|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$7.15
|
|
|
Service Code
|
NDC 68084069211
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.65
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cofinity Advantage |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$6.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.72
|
| Rate for Payer: Healthscope Commercial |
$6.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.36
|
| Rate for Payer: PHP Commercial |
$6.08
|
| Rate for Payer: Priority Health SBD |
$4.50
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$114.92
|
|
|
Service Code
|
NDC 57237001930
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.16 |
| Max. Negotiated Rate |
$103.43 |
| Rate for Payer: Aetna Commercial |
$97.68
|
| Rate for Payer: Aetna Medicare |
$57.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.70
|
| Rate for Payer: BCBS Complete |
$45.97
|
| Rate for Payer: Cash Price |
$91.94
|
| Rate for Payer: Cofinity Advantage |
$80.44
|
| Rate for Payer: Cofinity Commercial |
$98.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.94
|
| Rate for Payer: Healthscope Commercial |
$103.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$91.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$86.19
|
| Rate for Payer: PHP Commercial |
$97.68
|
| Rate for Payer: Priority Health SBD |
$72.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$74.70
|
| Rate for Payer: UHC Core |
$59.87
|
| Rate for Payer: UHC Exchange |
$45.16
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$3.42
|
|
|
Service Code
|
NDC 50268028811
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Aetna Medicare |
$1.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.22
|
| Rate for Payer: BCBS Complete |
$1.37
|
| Rate for Payer: Cash Price |
$2.74
|
| Rate for Payer: Cofinity Advantage |
$2.39
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.74
|
| Rate for Payer: Healthscope Commercial |
$3.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.56
|
| Rate for Payer: PHP Commercial |
$2.91
|
| Rate for Payer: Priority Health SBD |
$2.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.22
|
| Rate for Payer: UHC Core |
$1.78
|
| Rate for Payer: UHC Exchange |
$1.34
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$714.24
|
|
|
Service Code
|
NDC 68084069201
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$449.97 |
| Max. Negotiated Rate |
$642.82 |
| Rate for Payer: Aetna Commercial |
$607.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$464.26
|
| Rate for Payer: Cash Price |
$571.39
|
| Rate for Payer: Cofinity Advantage |
$499.97
|
| Rate for Payer: Cofinity Commercial |
$614.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$571.39
|
| Rate for Payer: Healthscope Commercial |
$642.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$607.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$535.68
|
| Rate for Payer: PHP Commercial |
$607.10
|
| Rate for Payer: Priority Health SBD |
$449.97
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$114.92
|
|
|
Service Code
|
NDC 68180029606
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.40 |
| Max. Negotiated Rate |
$103.43 |
| Rate for Payer: Aetna Commercial |
$97.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.70
|
| Rate for Payer: Cash Price |
$91.94
|
| Rate for Payer: Cofinity Advantage |
$80.44
|
| Rate for Payer: Cofinity Commercial |
$98.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.94
|
| Rate for Payer: Healthscope Commercial |
$103.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$86.19
|
| Rate for Payer: PHP Commercial |
$97.68
|
| Rate for Payer: Priority Health SBD |
$72.40
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$102.53
|
|
|
Service Code
|
NDC 50268028813
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.59 |
| Max. Negotiated Rate |
$92.28 |
| Rate for Payer: Aetna Commercial |
$87.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.64
|
| Rate for Payer: Cash Price |
$82.02
|
| Rate for Payer: Cofinity Advantage |
$71.77
|
| Rate for Payer: Cofinity Commercial |
$88.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.02
|
| Rate for Payer: Healthscope Commercial |
$92.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$76.90
|
| Rate for Payer: PHP Commercial |
$87.15
|
| Rate for Payer: Priority Health SBD |
$64.59
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19,765.12
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
183305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,452.03 |
| Max. Negotiated Rate |
$17,788.61 |
| Rate for Payer: Aetna Commercial |
$16,800.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,847.33
|
| Rate for Payer: Cash Price |
$15,812.10
|
| Rate for Payer: Cofinity Advantage |
$13,835.58
|
| Rate for Payer: Cofinity Commercial |
$16,998.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,812.10
|
| Rate for Payer: Healthscope Commercial |
$17,788.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,800.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,823.84
|
| Rate for Payer: PHP Commercial |
$16,800.35
|
| Rate for Payer: Priority Health SBD |
$12,452.03
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$4,743.64
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
183305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.06 |
| Max. Negotiated Rate |
$4,269.28 |
| Rate for Payer: Aetna Commercial |
$4,032.09
|
| Rate for Payer: Aetna Commercial |
$16,800.35
|
| Rate for Payer: Aetna Medicare |
$89.60
|
| Rate for Payer: Aetna Medicare |
$89.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,847.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,083.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$107.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$107.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$107.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$107.69
|
| Rate for Payer: BCBS Complete |
$47.31
|
| Rate for Payer: BCBS Complete |
$47.31
|
| Rate for Payer: BCBS MAPPO |
$86.15
|
| Rate for Payer: BCBS MAPPO |
$86.15
|
| Rate for Payer: BCBS Trust/PPO |
$216.42
|
| Rate for Payer: BCBS Trust/PPO |
$216.42
|
| Rate for Payer: BCN Commercial |
$216.42
|
| Rate for Payer: BCN Commercial |
$216.42
|
| Rate for Payer: BCN Medicare Advantage |
$86.15
|
| Rate for Payer: BCN Medicare Advantage |
$86.15
|
| Rate for Payer: Cash Price |
$15,812.10
|
| Rate for Payer: Cash Price |
$15,812.10
|
| Rate for Payer: Cash Price |
$3,794.91
|
| Rate for Payer: Cash Price |
$3,794.91
|
| Rate for Payer: Cofinity Advantage |
$3,320.55
|
| Rate for Payer: Cofinity Advantage |
$13,835.58
|
| Rate for Payer: Cofinity Commercial |
$4,079.53
|
| Rate for Payer: Cofinity Commercial |
$16,998.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,812.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,794.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$86.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$86.15
|
| Rate for Payer: Healthscope Commercial |
$17,788.61
|
| Rate for Payer: Healthscope Commercial |
$4,269.28
|
| Rate for Payer: Mclaren Medicaid |
$45.06
|
| Rate for Payer: Mclaren Medicaid |
$45.06
|
| Rate for Payer: Mclaren Medicare |
$86.15
|
| Rate for Payer: Mclaren Medicare |
$86.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$90.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$90.46
|
| Rate for Payer: Meridian Medicaid |
$90.46
|
| Rate for Payer: Meridian Medicaid |
$90.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$99.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$99.07
|
| Rate for Payer: Molina Medicare/Medicaid |
$94.77
|
| Rate for Payer: Molina Medicare/Medicaid |
$94.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,800.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,032.09
|
| Rate for Payer: Nomi Health Commercial |
$258.45
|
| Rate for Payer: Nomi Health Commercial |
$258.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,557.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14,823.84
|
| Rate for Payer: PACE Medicare |
$81.84
|
| Rate for Payer: PACE Medicare |
$81.84
|
| Rate for Payer: PACE SWMI |
$86.15
|
| Rate for Payer: PACE SWMI |
$86.15
|
| Rate for Payer: PHP Commercial |
$16,800.35
|
| Rate for Payer: PHP Commercial |
$4,032.09
|
| Rate for Payer: PHP Medicare Advantage |
$86.15
|
| Rate for Payer: PHP Medicare Advantage |
$86.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$45.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$45.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$268.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$268.45
|
| Rate for Payer: Priority Health Medicare |
$86.15
|
| Rate for Payer: Priority Health Medicare |
$86.15
|
| Rate for Payer: Priority Health SBD |
$2,988.49
|
| Rate for Payer: Priority Health SBD |
$12,452.03
|
| Rate for Payer: Priority Health Tiered Network |
$214.76
|
| Rate for Payer: Priority Health Tiered Network |
$214.76
|
| Rate for Payer: Railroad Medicare Medicare |
$86.15
|
| Rate for Payer: Railroad Medicare Medicare |
$86.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.35
|
| Rate for Payer: UHC Core |
$142.35
|
| Rate for Payer: UHC Core |
$142.35
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$86.15
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$86.15
|
| Rate for Payer: UHC Exchange |
$142.35
|
| Rate for Payer: UHC Exchange |
$142.35
|
| Rate for Payer: UHC Medicaid |
$45.06
|
| Rate for Payer: UHC Medicaid |
$45.06
|
| Rate for Payer: UHCCP Medicaid |
$45.06
|
| Rate for Payer: UHCCP Medicaid |
$45.06
|
| Rate for Payer: VA VA |
$86.15
|
| Rate for Payer: VA VA |
$86.15
|
|
|
DYSEQUILIBRIUM
|
Facility
|
IP
|
$15,142.64
|
|
|
Service Code
|
MSDRG 149
|
| Min. Negotiated Rate |
$6,068.16 |
| Max. Negotiated Rate |
$15,142.64 |
| Rate for Payer: Aetna Medicare |
$6,643.04
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,984.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,984.43
|
| Rate for Payer: BCBS MAPPO |
$6,387.54
|
| Rate for Payer: BCBS Trust/PPO |
$15,142.64
|
| Rate for Payer: BCN Commercial |
$15,142.64
|
| Rate for Payer: BCN Medicare Advantage |
$6,387.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,387.54
|
| Rate for Payer: Mclaren Medicare |
$6,387.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,706.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,345.67
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,026.29
|
| Rate for Payer: Nomi Health Commercial |
$9,695.64
|
| Rate for Payer: PACE Medicare |
$6,068.16
|
| Rate for Payer: PACE SWMI |
$6,387.54
|
| Rate for Payer: PHP Medicare Advantage |
$6,387.54
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$12,117.40
|
| Rate for Payer: Priority Health Medicare |
$6,387.54
|
| Rate for Payer: Priority Health Tiered Network |
$9,693.92
|
| Rate for Payer: Railroad Medicare Medicare |
$6,387.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,251.08
|
| Rate for Payer: UHC Core |
$10,249.57
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,387.54
|
| Rate for Payer: UHC Exchange |
$8,370.57
|
| Rate for Payer: VA VA |
$6,387.54
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC
|
Facility
|
IP
|
$22,958.57
|
|
|
Service Code
|
MSDRG 147
|
| Min. Negotiated Rate |
$9,885.15 |
| Max. Negotiated Rate |
$22,958.57 |
| Rate for Payer: Aetna Medicare |
$10,821.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,006.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,006.77
|
| Rate for Payer: BCBS MAPPO |
$10,405.42
|
| Rate for Payer: BCBS Trust/PPO |
$22,958.57
|
| Rate for Payer: BCN Commercial |
$22,958.57
|
| Rate for Payer: BCN Medicare Advantage |
$10,405.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,405.42
|
| Rate for Payer: Mclaren Medicare |
$10,405.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10,925.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,966.23
|
| Rate for Payer: Molina Medicare/Medicaid |
$11,445.96
|
| Rate for Payer: Nomi Health Commercial |
$16,402.35
|
| Rate for Payer: PACE Medicare |
$9,885.15
|
| Rate for Payer: PACE SWMI |
$10,405.42
|
| Rate for Payer: PHP Medicare Advantage |
$10,405.42
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$20,499.30
|
| Rate for Payer: Priority Health Medicare |
$10,405.42
|
| Rate for Payer: Priority Health Tiered Network |
$16,399.44
|
| Rate for Payer: Railroad Medicare Medicare |
$10,405.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20,725.45
|
| Rate for Payer: UHC Core |
$17,339.45
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$10,405.42
|
| Rate for Payer: UHC Exchange |
$14,160.70
|
| Rate for Payer: VA VA |
$10,405.42
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC
|
Facility
|
IP
|
$34,513.62
|
|
|
Service Code
|
MSDRG 146
|
| Min. Negotiated Rate |
$16,095.61 |
| Max. Negotiated Rate |
$34,513.62 |
| Rate for Payer: Aetna Medicare |
$17,620.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,178.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,178.44
|
| Rate for Payer: BCBS MAPPO |
$16,942.75
|
| Rate for Payer: BCBS Trust/PPO |
$30,662.14
|
| Rate for Payer: BCN Commercial |
$30,662.14
|
| Rate for Payer: BCN Medicare Advantage |
$16,942.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,942.75
|
| Rate for Payer: Mclaren Medicare |
$16,942.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17,789.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,484.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$18,637.03
|
| Rate for Payer: Nomi Health Commercial |
$27,314.46
|
| Rate for Payer: PACE Medicare |
$16,095.61
|
| Rate for Payer: PACE SWMI |
$16,942.75
|
| Rate for Payer: PHP Medicare Advantage |
$16,942.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$34,137.02
|
| Rate for Payer: Priority Health Medicare |
$16,942.75
|
| Rate for Payer: Priority Health Tiered Network |
$27,309.61
|
| Rate for Payer: Railroad Medicare Medicare |
$16,942.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34,513.62
|
| Rate for Payer: UHC Core |
$28,874.98
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$16,942.75
|
| Rate for Payer: UHC Exchange |
$23,581.48
|
| Rate for Payer: VA VA |
$16,942.75
|
|
|
EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$19,082.20
|
|
|
Service Code
|
MSDRG 148
|
| Min. Negotiated Rate |
$6,402.20 |
| Max. Negotiated Rate |
$19,082.20 |
| Rate for Payer: Aetna Medicare |
$7,008.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,423.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,423.95
|
| Rate for Payer: BCBS MAPPO |
$6,739.16
|
| Rate for Payer: BCBS Trust/PPO |
$19,082.20
|
| Rate for Payer: BCN Commercial |
$19,082.20
|
| Rate for Payer: BCN Medicare Advantage |
$6,739.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,739.16
|
| Rate for Payer: Mclaren Medicare |
$6,739.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,076.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,750.03
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,413.08
|
| Rate for Payer: Nomi Health Commercial |
$10,282.59
|
| Rate for Payer: PACE Medicare |
$6,402.20
|
| Rate for Payer: PACE SWMI |
$6,739.16
|
| Rate for Payer: PHP Medicare Advantage |
$6,739.16
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$12,850.96
|
| Rate for Payer: Priority Health Medicare |
$6,739.16
|
| Rate for Payer: Priority Health Tiered Network |
$10,280.76
|
| Rate for Payer: Railroad Medicare Medicare |
$6,739.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,992.73
|
| Rate for Payer: UHC Core |
$10,870.05
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,739.16
|
| Rate for Payer: UHC Exchange |
$8,877.30
|
| Rate for Payer: VA VA |
$6,739.16
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$13,934.63
|
|
|
Service Code
|
APR-DRG 1104
|
| Min. Negotiated Rate |
$13,271.08 |
| Max. Negotiated Rate |
$13,934.63 |
| Rate for Payer: BCBS Complete |
$13,934.63
|
| Rate for Payer: Mclaren Medicaid |
$13,271.08
|
| Rate for Payer: Meridian Medicaid |
$13,934.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$13,271.08
|
| Rate for Payer: UHC Medicaid |
$13,271.08
|
| Rate for Payer: UHCCP Medicaid |
$13,271.08
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$4,893.12
|
|
|
Service Code
|
APR-DRG 1101
|
| Min. Negotiated Rate |
$4,660.11 |
| Max. Negotiated Rate |
$4,893.12 |
| Rate for Payer: BCBS Complete |
$4,893.12
|
| Rate for Payer: Mclaren Medicaid |
$4,660.11
|
| Rate for Payer: Meridian Medicaid |
$4,893.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,660.11
|
| Rate for Payer: UHC Medicaid |
$4,660.11
|
| Rate for Payer: UHCCP Medicaid |
$4,660.11
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$5,412.53
|
|
|
Service Code
|
APR-DRG 1102
|
| Min. Negotiated Rate |
$5,154.79 |
| Max. Negotiated Rate |
$5,412.53 |
| Rate for Payer: BCBS Complete |
$5,412.53
|
| Rate for Payer: Mclaren Medicaid |
$5,154.79
|
| Rate for Payer: Meridian Medicaid |
$5,412.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,154.79
|
| Rate for Payer: UHC Medicaid |
$5,154.79
|
| Rate for Payer: UHCCP Medicaid |
$5,154.79
|
|
|
EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES
|
Facility
|
IP
|
$10,184.10
|
|
|
Service Code
|
APR-DRG 1103
|
| Min. Negotiated Rate |
$9,699.14 |
| Max. Negotiated Rate |
$10,184.10 |
| Rate for Payer: BCBS Complete |
$10,184.10
|
| Rate for Payer: Mclaren Medicaid |
$9,699.14
|
| Rate for Payer: Meridian Medicaid |
$10,184.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,699.14
|
| Rate for Payer: UHC Medicaid |
$9,699.14
|
| Rate for Payer: UHCCP Medicaid |
$9,699.14
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$5,717.52
|
|
|
Service Code
|
APR-DRG 7591
|
| Min. Negotiated Rate |
$5,445.26 |
| Max. Negotiated Rate |
$5,717.52 |
| Rate for Payer: BCBS Complete |
$5,717.52
|
| Rate for Payer: Mclaren Medicaid |
$5,445.26
|
| Rate for Payer: Meridian Medicaid |
$5,717.52
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,445.26
|
| Rate for Payer: UHC Medicaid |
$5,445.26
|
| Rate for Payer: UHCCP Medicaid |
$5,445.26
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$22,463.04
|
|
|
Service Code
|
APR-DRG 7594
|
| Min. Negotiated Rate |
$21,393.37 |
| Max. Negotiated Rate |
$22,463.04 |
| Rate for Payer: BCBS Complete |
$22,463.04
|
| Rate for Payer: Mclaren Medicaid |
$21,393.37
|
| Rate for Payer: Meridian Medicaid |
$22,463.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$21,393.37
|
| Rate for Payer: UHC Medicaid |
$21,393.37
|
| Rate for Payer: UHCCP Medicaid |
$21,393.37
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$11,115.14
|
|
|
Service Code
|
APR-DRG 7593
|
| Min. Negotiated Rate |
$10,585.85 |
| Max. Negotiated Rate |
$11,115.14 |
| Rate for Payer: BCBS Complete |
$11,115.14
|
| Rate for Payer: Mclaren Medicaid |
$10,585.85
|
| Rate for Payer: Meridian Medicaid |
$11,115.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,585.85
|
| Rate for Payer: UHC Medicaid |
$10,585.85
|
| Rate for Payer: UHCCP Medicaid |
$10,585.85
|
|
|
EATING DISORDERS
|
Facility
|
IP
|
$7,149.05
|
|
|
Service Code
|
APR-DRG 7592
|
| Min. Negotiated Rate |
$6,808.62 |
| Max. Negotiated Rate |
$7,149.05 |
| Rate for Payer: BCBS Complete |
$7,149.05
|
| Rate for Payer: Mclaren Medicaid |
$6,808.62
|
| Rate for Payer: Meridian Medicaid |
$7,149.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,808.62
|
| Rate for Payer: UHC Medicaid |
$6,808.62
|
| Rate for Payer: UHCCP Medicaid |
$6,808.62
|
|
|
ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$440,274.05
|
|
|
Service Code
|
MSDRG 003
|
| Min. Negotiated Rate |
$156,381.57 |
| Max. Negotiated Rate |
$440,274.05 |
| Rate for Payer: Aetna Medicare |
$171,196.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$205,765.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$205,765.23
|
| Rate for Payer: BCBS MAPPO |
$164,612.18
|
| Rate for Payer: BCBS Trust/PPO |
$440,274.05
|
| Rate for Payer: BCN Commercial |
$440,274.05
|
| Rate for Payer: BCN Medicare Advantage |
$164,612.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$164,612.18
|
| Rate for Payer: Mclaren Medicare |
$164,612.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$172,842.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$189,304.01
|
| Rate for Payer: Molina Medicare/Medicaid |
$181,073.40
|
| Rate for Payer: Nomi Health Commercial |
$273,805.08
|
| Rate for Payer: PACE Medicare |
$156,381.57
|
| Rate for Payer: PACE SWMI |
$164,612.18
|
| Rate for Payer: PHP Medicare Advantage |
$164,612.18
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$342,195.65
|
| Rate for Payer: Priority Health Medicare |
$164,612.18
|
| Rate for Payer: Priority Health Tiered Network |
$273,756.47
|
| Rate for Payer: Railroad Medicare Medicare |
$164,612.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$345,970.76
|
| Rate for Payer: UHC Core |
$289,448.05
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$164,612.18
|
| Rate for Payer: UHC Exchange |
$236,385.05
|
| Rate for Payer: VA VA |
$164,612.18
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$29,530.20
|
|
|
Service Code
|
HCPCS J1299
|
| Hospital Charge Code |
81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.38 |
| Max. Negotiated Rate |
$26,577.18 |
| Rate for Payer: Aetna Commercial |
$25,100.67
|
| Rate for Payer: Aetna Medicare |
$46.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,194.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$55.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$55.88
|
| Rate for Payer: BCBS Complete |
$24.55
|
| Rate for Payer: BCBS MAPPO |
$44.70
|
| Rate for Payer: BCBS Trust/PPO |
$112.95
|
| Rate for Payer: BCN Commercial |
$112.95
|
| Rate for Payer: BCN Medicare Advantage |
$44.70
|
| Rate for Payer: Cash Price |
$23,624.16
|
| Rate for Payer: Cash Price |
$23,624.16
|
| Rate for Payer: Cofinity Advantage |
$20,671.14
|
| Rate for Payer: Cofinity Commercial |
$25,395.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,624.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44.70
|
| Rate for Payer: Healthscope Commercial |
$26,577.18
|
| Rate for Payer: Mclaren Medicaid |
$23.38
|
| Rate for Payer: Mclaren Medicare |
$44.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$46.94
|
| Rate for Payer: Meridian Medicaid |
$46.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51.41
|
| Rate for Payer: Molina Medicare/Medicaid |
$49.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,100.67
|
| Rate for Payer: Nomi Health Commercial |
$134.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22,147.65
|
| Rate for Payer: PACE Medicare |
$42.47
|
| Rate for Payer: PACE SWMI |
$44.70
|
| Rate for Payer: PHP Commercial |
$25,100.67
|
| Rate for Payer: PHP Medicare Advantage |
$44.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$23.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$141.36
|
| Rate for Payer: Priority Health Medicare |
$44.70
|
| Rate for Payer: Priority Health SBD |
$18,604.03
|
| Rate for Payer: Priority Health Tiered Network |
$113.09
|
| Rate for Payer: Railroad Medicare Medicare |
$44.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$74.30
|
| Rate for Payer: UHC Core |
$74.30
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$44.70
|
| Rate for Payer: UHC Exchange |
$74.30
|
| Rate for Payer: UHC Medicaid |
$23.38
|
| Rate for Payer: UHCCP Medicaid |
$23.38
|
| Rate for Payer: VA VA |
$44.70
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$29,530.20
|
|
|
Service Code
|
HCPCS J1299
|
| Hospital Charge Code |
81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,604.03 |
| Max. Negotiated Rate |
$26,577.18 |
| Rate for Payer: Aetna Commercial |
$25,100.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,194.63
|
| Rate for Payer: Cash Price |
$23,624.16
|
| Rate for Payer: Cofinity Advantage |
$20,671.14
|
| Rate for Payer: Cofinity Commercial |
$25,395.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,624.16
|
| Rate for Payer: Healthscope Commercial |
$26,577.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,100.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22,147.65
|
| Rate for Payer: PHP Commercial |
$25,100.67
|
| Rate for Payer: Priority Health SBD |
$18,604.03
|
|
|
EFGARTIGIMOD ALFA-FCAB 20 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16,416.92
|
|
|
Service Code
|
HCPCS J9332
|
| Hospital Charge Code |
198972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.06 |
| Max. Negotiated Rate |
$14,775.23 |
| Rate for Payer: Aetna Commercial |
$13,954.38
|
| Rate for Payer: Aetna Medicare |
$33.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,671.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$40.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$40.76
|
| Rate for Payer: BCBS Complete |
$17.91
|
| Rate for Payer: BCBS MAPPO |
$32.61
|
| Rate for Payer: BCBS Trust/PPO |
$80.84
|
| Rate for Payer: BCN Commercial |
$80.84
|
| Rate for Payer: BCN Medicare Advantage |
$32.61
|
| Rate for Payer: Cash Price |
$13,133.54
|
| Rate for Payer: Cash Price |
$13,133.54
|
| Rate for Payer: Cofinity Advantage |
$11,491.84
|
| Rate for Payer: Cofinity Commercial |
$14,118.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,133.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$32.61
|
| Rate for Payer: Healthscope Commercial |
$14,775.23
|
| Rate for Payer: Mclaren Medicaid |
$17.06
|
| Rate for Payer: Mclaren Medicare |
$32.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$34.24
|
| Rate for Payer: Meridian Medicaid |
$34.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37.50
|
| Rate for Payer: Molina Medicare/Medicaid |
$35.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,954.38
|
| Rate for Payer: Nomi Health Commercial |
$97.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12,312.69
|
| Rate for Payer: PACE Medicare |
$30.98
|
| Rate for Payer: PACE SWMI |
$32.61
|
| Rate for Payer: PHP Commercial |
$13,954.38
|
| Rate for Payer: PHP Medicare Advantage |
$32.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$17.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$101.40
|
| Rate for Payer: Priority Health Medicare |
$32.61
|
| Rate for Payer: Priority Health SBD |
$10,342.66
|
| Rate for Payer: Priority Health Tiered Network |
$81.12
|
| Rate for Payer: Railroad Medicare Medicare |
$32.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$53.16
|
| Rate for Payer: UHC Core |
$53.16
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$32.61
|
| Rate for Payer: UHC Exchange |
$53.16
|
| Rate for Payer: UHC Medicaid |
$17.06
|
| Rate for Payer: UHCCP Medicaid |
$17.06
|
| Rate for Payer: VA VA |
$32.61
|
|
|
EFGARTIGIMOD ALFA-FCAB 20 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16,416.92
|
|
|
Service Code
|
HCPCS J9332
|
| Hospital Charge Code |
198972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,342.66 |
| Max. Negotiated Rate |
$14,775.23 |
| Rate for Payer: Aetna Commercial |
$13,954.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,671.00
|
| Rate for Payer: Cash Price |
$13,133.54
|
| Rate for Payer: Cofinity Advantage |
$11,491.84
|
| Rate for Payer: Cofinity Commercial |
$14,118.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,133.54
|
| Rate for Payer: Healthscope Commercial |
$14,775.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,954.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12,312.69
|
| Rate for Payer: PHP Commercial |
$13,954.38
|
| Rate for Payer: Priority Health SBD |
$10,342.66
|
|
