|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$173.90
|
|
|
Service Code
|
NDC 0172-4096-60
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.56 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.73
|
| Rate for Payer: Priority Health SBD |
$109.56
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$331.55
|
|
|
Service Code
|
NDC 0904-6475-61
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.88 |
| Max. Negotiated Rate |
$298.40 |
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.08
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Healthscope Commercial |
$298.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.08
|
| Rate for Payer: Priority Health SBD |
$208.88
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$3.07
|
|
|
Service Code
|
NDC 50268-106-11
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.00
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$2.15
|
| Rate for Payer: Cofinity Commercial |
$2.64
|
| Rate for Payer: Healthscope Commercial |
$2.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.61
|
| Rate for Payer: PHP Commercial |
$2.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.15
|
| Rate for Payer: Priority Health SBD |
$1.93
|
|
|
BACLOFEN 20 MG TABLET
|
Facility
IP
|
$243.84
|
|
|
Service Code
|
NDC 0904-6476-61
|
| Hospital Charge Code |
861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.62 |
| Max. Negotiated Rate |
$219.46 |
| Rate for Payer: Aetna Commercial |
$207.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.50
|
| Rate for Payer: Cash Price |
$195.07
|
| Rate for Payer: Cofinity Commercial |
$170.69
|
| Rate for Payer: Cofinity Commercial |
$209.70
|
| Rate for Payer: Healthscope Commercial |
$219.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.26
|
| Rate for Payer: PHP Commercial |
$207.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.69
|
| Rate for Payer: Priority Health SBD |
$153.62
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
IP
|
$5.13
|
|
|
Service Code
|
NDC 50268-105-11
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$4.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.33
|
| Rate for Payer: Cash Price |
$4.10
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Cofinity Commercial |
$4.41
|
| Rate for Payer: Healthscope Commercial |
$4.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.36
|
| Rate for Payer: PHP Commercial |
$4.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.59
|
| Rate for Payer: Priority Health SBD |
$3.23
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
IP
|
$256.08
|
|
|
Service Code
|
NDC 50268-105-15
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.33 |
| Max. Negotiated Rate |
$230.47 |
| Rate for Payer: Aetna Commercial |
$217.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.45
|
| Rate for Payer: Cash Price |
$204.86
|
| Rate for Payer: Cofinity Commercial |
$179.26
|
| Rate for Payer: Cofinity Commercial |
$220.23
|
| Rate for Payer: Healthscope Commercial |
$230.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.67
|
| Rate for Payer: PHP Commercial |
$217.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.26
|
| Rate for Payer: Priority Health SBD |
$161.33
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC
|
Facility
IP
|
$54,403.42
|
|
|
Service Code
|
MS-DRG 095
|
| Min. Negotiated Rate |
$16,780.09 |
| Max. Negotiated Rate |
$54,403.42 |
| Rate for Payer: Aetna Medicare |
$18,369.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22,079.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22,079.06
|
| Rate for Payer: BCBS MAPPO |
$17,663.25
|
| Rate for Payer: BCBS Trust/PPO |
$54,403.42
|
| Rate for Payer: BCN Medicare Advantage |
$17,663.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,663.25
|
| Rate for Payer: Mclaren Medicare |
$17,663.25
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$18,546.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20,312.74
|
| Rate for Payer: PACE Medicare |
$16,780.09
|
| Rate for Payer: PACE SWMI |
$17,663.25
|
| Rate for Payer: PHP Medicare Advantage |
$17,663.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34,213.08
|
| Rate for Payer: Priority Health Medicare |
$17,663.25
|
| Rate for Payer: Priority Health Narrow Network |
$27,370.46
|
| Rate for Payer: Railroad Medicare Medicare |
$17,663.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36,368.59
|
| Rate for Payer: UHC Core |
$22,316.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$17,663.25
|
| Rate for Payer: UHC Exchange |
$23,901.61
|
| Rate for Payer: UHC Medicare Advantage |
$18,193.15
|
| Rate for Payer: VA VA |
$17,663.25
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC
|
Facility
IP
|
$64,203.72
|
|
|
Service Code
|
MS-DRG 094
|
| Min. Negotiated Rate |
$25,253.53 |
| Max. Negotiated Rate |
$64,203.72 |
| Rate for Payer: Aetna Medicare |
$27,645.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33,228.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33,228.32
|
| Rate for Payer: BCBS MAPPO |
$26,582.66
|
| Rate for Payer: BCBS Trust/PPO |
$64,203.72
|
| Rate for Payer: BCN Medicare Advantage |
$26,582.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26,582.66
|
| Rate for Payer: Mclaren Medicare |
$26,582.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$27,911.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30,570.06
|
| Rate for Payer: PACE Medicare |
$25,253.53
|
| Rate for Payer: PACE SWMI |
$26,582.66
|
| Rate for Payer: PHP Medicare Advantage |
$26,582.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$51,985.46
|
| Rate for Payer: Priority Health Medicare |
$26,582.66
|
| Rate for Payer: Priority Health Narrow Network |
$41,588.37
|
| Rate for Payer: Railroad Medicare Medicare |
$26,582.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55,260.67
|
| Rate for Payer: UHC Core |
$33,908.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$26,582.66
|
| Rate for Payer: UHC Exchange |
$36,317.57
|
| Rate for Payer: UHC Medicare Advantage |
$27,380.14
|
| Rate for Payer: VA VA |
$26,582.66
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC
|
Facility
IP
|
$38,204.27
|
|
|
Service Code
|
MS-DRG 096
|
| Min. Negotiated Rate |
$15,380.96 |
| Max. Negotiated Rate |
$38,204.27 |
| Rate for Payer: Aetna Medicare |
$16,838.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,238.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,238.10
|
| Rate for Payer: BCBS MAPPO |
$16,190.48
|
| Rate for Payer: BCBS Trust/PPO |
$38,204.27
|
| Rate for Payer: BCN Medicare Advantage |
$16,190.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,190.48
|
| Rate for Payer: Mclaren Medicare |
$16,190.48
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,000.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18,619.05
|
| Rate for Payer: PACE Medicare |
$15,380.96
|
| Rate for Payer: PACE SWMI |
$16,190.48
|
| Rate for Payer: PHP Medicare Advantage |
$16,190.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31,278.52
|
| Rate for Payer: Priority Health Medicare |
$16,190.48
|
| Rate for Payer: Priority Health Narrow Network |
$25,022.82
|
| Rate for Payer: Railroad Medicare Medicare |
$16,190.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33,249.14
|
| Rate for Payer: UHC Core |
$20,401.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,190.48
|
| Rate for Payer: UHC Exchange |
$21,851.49
|
| Rate for Payer: UHC Medicare Advantage |
$16,676.19
|
| Rate for Payer: VA VA |
$16,190.48
|
|
|
BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH
|
Facility
IP
|
$88.62
|
|
|
Service Code
|
NDC 0065-0530-01
|
| Hospital Charge Code |
10780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$79.76 |
| Rate for Payer: Aetna Commercial |
$75.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.60
|
| Rate for Payer: Cash Price |
$70.90
|
| Rate for Payer: Cofinity Commercial |
$62.03
|
| Rate for Payer: Cofinity Commercial |
$76.21
|
| Rate for Payer: Healthscope Commercial |
$79.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.33
|
| Rate for Payer: PHP Commercial |
$75.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.03
|
| Rate for Payer: Priority Health SBD |
$55.83
|
|
|
BARICITINIB 2 MG TABLET
|
Facility
IP
|
$9,317.01
|
|
|
Service Code
|
NDC 0002-4182-30
|
| Hospital Charge Code |
186973
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,869.72 |
| Max. Negotiated Rate |
$8,385.31 |
| Rate for Payer: Aetna Commercial |
$7,919.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,056.06
|
| Rate for Payer: Cash Price |
$7,453.61
|
| Rate for Payer: Cofinity Commercial |
$6,521.91
|
| Rate for Payer: Cofinity Commercial |
$8,012.63
|
| Rate for Payer: Healthscope Commercial |
$8,385.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,919.46
|
| Rate for Payer: PHP Commercial |
$7,919.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,521.91
|
| Rate for Payer: Priority Health SBD |
$5,869.72
|
|
|
BARIUM SULFATE (BULK) POWDER
|
Facility
IP
|
$681.00
|
|
|
Service Code
|
NDC 0395-0200-01
|
| Hospital Charge Code |
916
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$429.03 |
| Max. Negotiated Rate |
$612.90 |
| Rate for Payer: Aetna Commercial |
$578.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$442.65
|
| Rate for Payer: Cash Price |
$544.80
|
| Rate for Payer: Cofinity Commercial |
$476.70
|
| Rate for Payer: Cofinity Commercial |
$585.66
|
| Rate for Payer: Healthscope Commercial |
$612.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$578.85
|
| Rate for Payer: PHP Commercial |
$578.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$476.70
|
| Rate for Payer: Priority Health SBD |
$429.03
|
|
|
BBC JOINT COCKTAIL COMPOUND (INTRA-OP)
|
Facility
IP
|
$283.83
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
300231
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.81 |
| Max. Negotiated Rate |
$255.45 |
| Rate for Payer: Aetna Commercial |
$241.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.49
|
| Rate for Payer: Cash Price |
$227.06
|
| Rate for Payer: Cofinity Commercial |
$198.68
|
| Rate for Payer: Cofinity Commercial |
$244.09
|
| Rate for Payer: Healthscope Commercial |
$255.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.26
|
| Rate for Payer: PHP Commercial |
$241.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.68
|
| Rate for Payer: Priority Health SBD |
$178.81
|
|
|
BBC JOINT COCKTAIL COMPOUND WITHOUT KETOROLAC (INTRA-OP)
|
Facility
IP
|
$283.83
|
|
|
Service Code
|
HCPCS J2795
|
| Hospital Charge Code |
300230
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.81 |
| Max. Negotiated Rate |
$255.45 |
| Rate for Payer: Aetna Commercial |
$241.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.49
|
| Rate for Payer: Cash Price |
$227.06
|
| Rate for Payer: Cofinity Commercial |
$198.68
|
| Rate for Payer: Cofinity Commercial |
$244.09
|
| Rate for Payer: Healthscope Commercial |
$255.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.26
|
| Rate for Payer: PHP Commercial |
$241.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.68
|
| Rate for Payer: Priority Health SBD |
$178.81
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION
|
Facility
OP
|
$451.25
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
116210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.54 |
| Max. Negotiated Rate |
$406.12 |
| Rate for Payer: Aetna Commercial |
$383.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.31
|
| Rate for Payer: BCBS Complete |
$180.50
|
| Rate for Payer: BCBS Trust/PPO |
$8.54
|
| Rate for Payer: Cash Price |
$361.00
|
| Rate for Payer: Cash Price |
$361.00
|
| Rate for Payer: Cofinity Commercial |
$388.08
|
| Rate for Payer: Cofinity Commercial |
$315.88
|
| Rate for Payer: Healthscope Commercial |
$406.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$383.56
|
| Rate for Payer: PHP Commercial |
$383.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$315.88
|
| Rate for Payer: Priority Health SBD |
$284.29
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION
|
Facility
IP
|
$451.25
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
116210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$284.29 |
| Max. Negotiated Rate |
$406.12 |
| Rate for Payer: Aetna Commercial |
$383.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.31
|
| Rate for Payer: Cash Price |
$361.00
|
| Rate for Payer: Cofinity Commercial |
$315.88
|
| Rate for Payer: Cofinity Commercial |
$388.08
|
| Rate for Payer: Healthscope Commercial |
$406.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$383.56
|
| Rate for Payer: PHP Commercial |
$383.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$315.88
|
| Rate for Payer: Priority Health SBD |
$284.29
|
|
|
BEHAVIORAL AND DEVELOPMENTAL DISORDERS
|
Facility
IP
|
$25,652.65
|
|
|
Service Code
|
MS-DRG 886
|
| Min. Negotiated Rate |
$11,973.79 |
| Max. Negotiated Rate |
$25,652.65 |
| Rate for Payer: Aetna Medicare |
$13,108.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,754.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,754.99
|
| Rate for Payer: BCBS MAPPO |
$12,603.99
|
| Rate for Payer: BCBS Trust/PPO |
$18,832.04
|
| Rate for Payer: BCN Medicare Advantage |
$12,603.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,603.99
|
| Rate for Payer: Mclaren Medicare |
$12,603.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$13,234.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,494.59
|
| Rate for Payer: PACE Medicare |
$11,973.79
|
| Rate for Payer: PACE SWMI |
$12,603.99
|
| Rate for Payer: PHP Medicare Advantage |
$12,603.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24,132.26
|
| Rate for Payer: Priority Health Medicare |
$12,603.99
|
| Rate for Payer: Priority Health Narrow Network |
$19,305.81
|
| Rate for Payer: Railroad Medicare Medicare |
$12,603.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25,652.65
|
| Rate for Payer: UHC Core |
$15,740.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,603.99
|
| Rate for Payer: UHC Exchange |
$16,859.04
|
| Rate for Payer: UHC Medicare Advantage |
$12,982.11
|
| Rate for Payer: VA VA |
$12,603.99
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$2,650.15
|
|
|
Service Code
|
HCPCS J0485
|
| Hospital Charge Code |
152968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,669.59 |
| Max. Negotiated Rate |
$2,385.14 |
| Rate for Payer: Aetna Commercial |
$2,252.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,722.60
|
| Rate for Payer: Cash Price |
$2,120.12
|
| Rate for Payer: Cofinity Commercial |
$1,855.10
|
| Rate for Payer: Cofinity Commercial |
$2,279.13
|
| Rate for Payer: Healthscope Commercial |
$2,385.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,252.63
|
| Rate for Payer: PHP Commercial |
$2,252.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,855.10
|
| Rate for Payer: Priority Health SBD |
$1,669.59
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$1,961.92
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
152250
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,236.01 |
| Max. Negotiated Rate |
$1,765.73 |
| Rate for Payer: Aetna Commercial |
$1,667.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,275.25
|
| Rate for Payer: Cash Price |
$1,569.54
|
| Rate for Payer: Cofinity Commercial |
$1,687.25
|
| Rate for Payer: Cofinity Commercial |
$1,373.34
|
| Rate for Payer: Healthscope Commercial |
$1,765.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,667.63
|
| Rate for Payer: PHP Commercial |
$1,667.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,373.34
|
| Rate for Payer: Priority Health SBD |
$1,236.01
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$5,313.29
|
|
|
Service Code
|
HCPCS J0490
|
| Hospital Charge Code |
152251
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,347.37 |
| Max. Negotiated Rate |
$4,781.96 |
| Rate for Payer: Aetna Commercial |
$4,516.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,453.64
|
| Rate for Payer: Cash Price |
$4,250.63
|
| Rate for Payer: Cofinity Commercial |
$4,569.43
|
| Rate for Payer: Cofinity Commercial |
$3,719.30
|
| Rate for Payer: Healthscope Commercial |
$4,781.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,516.30
|
| Rate for Payer: PHP Commercial |
$4,516.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,719.30
|
| Rate for Payer: Priority Health SBD |
$3,347.37
|
|
|
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$9,530.12
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
176654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,003.98 |
| Max. Negotiated Rate |
$8,577.11 |
| Rate for Payer: Aetna Commercial |
$8,100.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,194.58
|
| Rate for Payer: Cash Price |
$7,624.10
|
| Rate for Payer: Cofinity Commercial |
$6,671.08
|
| Rate for Payer: Cofinity Commercial |
$8,195.90
|
| Rate for Payer: Healthscope Commercial |
$8,577.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8,100.60
|
| Rate for Payer: PHP Commercial |
$8,100.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,671.08
|
| Rate for Payer: Priority Health SBD |
$6,003.98
|
|
|
BENDAMUSTINE (BENDEKA) 25 MG/ML INTRAVENOUS SOLUTION
|
Facility
OP
|
$9,530.12
|
|
|
Service Code
|
HCPCS J9034
|
| Hospital Charge Code |
176654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$8,577.11 |
| Rate for Payer: Aetna Commercial |
$8,100.60
|
| Rate for Payer: Aetna Commercial |
$7,879.47
|
| Rate for Payer: Aetna Medicare |
$15.35
|
| Rate for Payer: Aetna Medicare |
$15.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,025.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,194.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18.44
|
| Rate for Payer: BCBS Complete |
$8.48
|
| Rate for Payer: BCBS Complete |
$8.48
|
| Rate for Payer: BCBS MAPPO |
$14.76
|
| Rate for Payer: BCBS MAPPO |
$14.76
|
| Rate for Payer: BCBS Trust/PPO |
$43.67
|
| Rate for Payer: BCBS Trust/PPO |
$43.67
|
| Rate for Payer: BCN Medicare Advantage |
$14.76
|
| Rate for Payer: BCN Medicare Advantage |
$14.76
|
| Rate for Payer: Cash Price |
$7,624.10
|
| Rate for Payer: Cash Price |
$7,415.98
|
| Rate for Payer: Cash Price |
$7,624.10
|
| Rate for Payer: Cash Price |
$7,415.98
|
| Rate for Payer: Cofinity Commercial |
$6,488.98
|
| Rate for Payer: Cofinity Commercial |
$8,195.90
|
| Rate for Payer: Cofinity Commercial |
$6,671.08
|
| Rate for Payer: Cofinity Commercial |
$7,972.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.76
|
| Rate for Payer: Healthscope Commercial |
$8,342.97
|
| Rate for Payer: Healthscope Commercial |
$8,577.11
|
| Rate for Payer: Mclaren Medicaid |
$8.07
|
| Rate for Payer: Mclaren Medicaid |
$8.07
|
| Rate for Payer: Mclaren Medicare |
$14.76
|
| Rate for Payer: Mclaren Medicare |
$14.76
|
| Rate for Payer: Meridian Medicaid |
$8.48
|
| Rate for Payer: Meridian Medicaid |
$8.48
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15.49
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,879.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8,100.60
|
| Rate for Payer: PACE Medicare |
$14.02
|
| Rate for Payer: PACE Medicare |
$14.02
|
| Rate for Payer: PACE SWMI |
$14.76
|
| Rate for Payer: PACE SWMI |
$14.76
|
| Rate for Payer: PHP Commercial |
$7,879.47
|
| Rate for Payer: PHP Commercial |
$8,100.60
|
| Rate for Payer: PHP Medicare Advantage |
$14.76
|
| Rate for Payer: PHP Medicare Advantage |
$14.76
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,488.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,671.08
|
| Rate for Payer: Priority Health Medicare |
$14.76
|
| Rate for Payer: Priority Health Medicare |
$14.76
|
| Rate for Payer: Priority Health SBD |
$6,003.98
|
| Rate for Payer: Priority Health SBD |
$5,840.08
|
| Rate for Payer: Railroad Medicare Medicare |
$14.76
|
| Rate for Payer: Railroad Medicare Medicare |
$14.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$14.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$14.76
|
| Rate for Payer: UHC Medicare Advantage |
$15.20
|
| Rate for Payer: UHC Medicare Advantage |
$15.20
|
| Rate for Payer: VA VA |
$14.76
|
| Rate for Payer: VA VA |
$14.76
|
|
|
BENIGN PROSTATIC HYPERTROPHY WITH MCC
|
Facility
IP
|
$19,969.51
|
|
|
Service Code
|
MS-DRG 725
|
| Min. Negotiated Rate |
$8,957.97 |
| Max. Negotiated Rate |
$19,969.51 |
| Rate for Payer: Aetna Medicare |
$9,806.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,786.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,786.80
|
| Rate for Payer: BCBS MAPPO |
$9,429.44
|
| Rate for Payer: BCBS Trust/PPO |
$19,969.51
|
| Rate for Payer: BCN Medicare Advantage |
$9,429.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,429.44
|
| Rate for Payer: Mclaren Medicare |
$9,429.44
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,900.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,843.86
|
| Rate for Payer: PACE Medicare |
$8,957.97
|
| Rate for Payer: PACE SWMI |
$9,429.44
|
| Rate for Payer: PHP Medicare Advantage |
$9,429.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,806.82
|
| Rate for Payer: Priority Health Medicare |
$9,429.44
|
| Rate for Payer: Priority Health Narrow Network |
$14,245.46
|
| Rate for Payer: Railroad Medicare Medicare |
$9,429.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18,928.69
|
| Rate for Payer: UHC Core |
$11,614.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,429.44
|
| Rate for Payer: UHC Exchange |
$12,440.02
|
| Rate for Payer: UHC Medicare Advantage |
$9,712.32
|
| Rate for Payer: VA VA |
$9,429.44
|
|
|
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC
|
Facility
IP
|
$11,761.24
|
|
|
Service Code
|
MS-DRG 726
|
| Min. Negotiated Rate |
$5,468.69 |
| Max. Negotiated Rate |
$11,761.24 |
| Rate for Payer: Aetna Medicare |
$5,986.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,195.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,195.65
|
| Rate for Payer: BCBS MAPPO |
$5,756.52
|
| Rate for Payer: BCBS Trust/PPO |
$11,761.24
|
| Rate for Payer: BCN Medicare Advantage |
$5,756.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,756.52
|
| Rate for Payer: Mclaren Medicare |
$5,756.52
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,044.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,620.00
|
| Rate for Payer: PACE Medicare |
$5,468.69
|
| Rate for Payer: PACE SWMI |
$5,756.52
|
| Rate for Payer: PHP Medicare Advantage |
$5,756.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,488.36
|
| Rate for Payer: Priority Health Medicare |
$5,756.52
|
| Rate for Payer: Priority Health Narrow Network |
$8,390.69
|
| Rate for Payer: Railroad Medicare Medicare |
$5,756.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,149.15
|
| Rate for Payer: UHC Core |
$6,841.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,756.52
|
| Rate for Payer: UHC Exchange |
$7,327.27
|
| Rate for Payer: UHC Medicare Advantage |
$5,929.22
|
| Rate for Payer: VA VA |
$5,756.52
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
IP
|
$18,588.51
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
185161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,710.76 |
| Max. Negotiated Rate |
$16,729.66 |
| Rate for Payer: Aetna Commercial |
$15,800.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,082.53
|
| Rate for Payer: Cash Price |
$14,870.81
|
| Rate for Payer: Cofinity Commercial |
$13,011.96
|
| Rate for Payer: Cofinity Commercial |
$15,986.12
|
| Rate for Payer: Healthscope Commercial |
$16,729.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15,800.23
|
| Rate for Payer: PHP Commercial |
$15,800.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,011.96
|
| Rate for Payer: Priority Health SBD |
$11,710.76
|
|
