|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE
|
Facility
|
IP
|
$127.79
|
|
|
Service Code
|
HCPCS J1652
|
| Hospital Charge Code |
39803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.51 |
| Max. Negotiated Rate |
$115.01 |
| Rate for Payer: Aetna Commercial |
$108.62
|
| Rate for Payer: Aetna Commercial |
$163.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.06
|
| Rate for Payer: Cash Price |
$102.23
|
| Rate for Payer: Cash Price |
$154.25
|
| Rate for Payer: Cofinity Commercial |
$109.90
|
| Rate for Payer: Cofinity Commercial |
$89.45
|
| Rate for Payer: Cofinity Commercial |
$134.97
|
| Rate for Payer: Cofinity Commercial |
$165.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$89.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.25
|
| Rate for Payer: Healthscope Commercial |
$115.01
|
| Rate for Payer: Healthscope Commercial |
$173.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.62
|
| Rate for Payer: PHP Commercial |
$108.62
|
| Rate for Payer: PHP Commercial |
$163.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.06
|
| Rate for Payer: Priority Health SBD |
$80.51
|
| Rate for Payer: Priority Health SBD |
$121.47
|
|
|
FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL PATTERN FLAP, PARAMEDIAN FOREHEAD FLAP)
|
Facility
|
OP
|
$11,273.70
|
|
|
Service Code
|
CPT 15731
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,048.43 |
| Max. Negotiated Rate |
$11,273.70 |
| Rate for Payer: Aetna Medicare |
$3,730.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,483.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,483.69
|
| Rate for Payer: BCBS Complete |
$2,018.74
|
| Rate for Payer: BCBS MAPPO |
$3,586.95
|
| Rate for Payer: BCBS Trust/PPO |
$1,411.51
|
| Rate for Payer: BCN Commercial |
$1,411.51
|
| Rate for Payer: BCN Medicare Advantage |
$3,586.95
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,586.95
|
| Rate for Payer: Mclaren Medicaid |
$1,922.61
|
| Rate for Payer: Mclaren Medicare |
$3,586.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,766.30
|
| Rate for Payer: Meridian Medicaid |
$2,018.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,124.99
|
| Rate for Payer: Nomi Health Commercial |
$7,532.60
|
| Rate for Payer: PACE Medicare |
$3,407.60
|
| Rate for Payer: PACE SWMI |
$3,586.95
|
| Rate for Payer: PHP Medicare Advantage |
$3,586.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,922.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,273.70
|
| Rate for Payer: Priority Health Medicare |
$3,586.95
|
| Rate for Payer: Priority Health Narrow Network |
$9,018.96
|
| Rate for Payer: Railroad Medicare Medicare |
$3,586.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,048.43
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,586.95
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,586.95
|
| Rate for Payer: UHCCP Medicaid |
$2,019.45
|
| Rate for Payer: VA VA |
$3,586.95
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION
|
Facility
|
IP
|
$16.98
|
|
|
Service Code
|
HCPCS J7606
|
| Hospital Charge Code |
88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.70 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Aetna Commercial |
$14.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.04
|
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Cofinity Commercial |
$11.89
|
| Rate for Payer: Cofinity Commercial |
$14.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.58
|
| Rate for Payer: Healthscope Commercial |
$15.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.43
|
| Rate for Payer: PHP Commercial |
$14.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.04
|
| Rate for Payer: Priority Health SBD |
$10.70
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION
|
Facility
|
OP
|
$16.98
|
|
|
Service Code
|
HCPCS J7606
|
| Hospital Charge Code |
88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$15.28 |
| Rate for Payer: Aetna Commercial |
$14.43
|
| Rate for Payer: Aetna Medicare |
$8.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.04
|
| Rate for Payer: BCBS Complete |
$6.79
|
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Cofinity Commercial |
$14.60
|
| Rate for Payer: Cofinity Commercial |
$11.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.58
|
| Rate for Payer: Healthscope Commercial |
$15.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.43
|
| Rate for Payer: PHP Commercial |
$14.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.89
|
| Rate for Payer: Priority Health Narrow Network |
$1.51
|
| Rate for Payer: Priority Health SBD |
$10.70
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$255.75
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
106783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$230.18 |
| Rate for Payer: Aetna Commercial |
$217.39
|
| Rate for Payer: Aetna Commercial |
$181.59
|
| Rate for Payer: Aetna Commercial |
$442.42
|
| Rate for Payer: Aetna Commercial |
$159.49
|
| Rate for Payer: Aetna Commercial |
$1,256.31
|
| Rate for Payer: Aetna Commercial |
$364.53
|
| Rate for Payer: Aetna Commercial |
$320.10
|
| Rate for Payer: Aetna Medicare |
$188.30
|
| Rate for Payer: Aetna Medicare |
$106.82
|
| Rate for Payer: Aetna Medicare |
$739.00
|
| Rate for Payer: Aetna Medicare |
$127.88
|
| Rate for Payer: Aetna Medicare |
$93.82
|
| Rate for Payer: Aetna Medicare |
$260.25
|
| Rate for Payer: Aetna Medicare |
$214.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$244.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$960.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$338.32
|
| Rate for Payer: BCBS Complete |
$75.05
|
| Rate for Payer: BCBS Complete |
$591.20
|
| Rate for Payer: BCBS Complete |
$150.64
|
| Rate for Payer: BCBS Complete |
$171.54
|
| Rate for Payer: BCBS Complete |
$208.20
|
| Rate for Payer: BCBS Complete |
$85.45
|
| Rate for Payer: BCBS Complete |
$102.30
|
| Rate for Payer: BCBS Trust/PPO |
$0.69
|
| Rate for Payer: BCBS Trust/PPO |
$0.69
|
| Rate for Payer: BCBS Trust/PPO |
$0.69
|
| Rate for Payer: BCBS Trust/PPO |
$0.69
|
| Rate for Payer: BCBS Trust/PPO |
$0.69
|
| Rate for Payer: BCBS Trust/PPO |
$0.69
|
| Rate for Payer: BCBS Trust/PPO |
$0.69
|
| Rate for Payer: BCN Commercial |
$0.69
|
| Rate for Payer: BCN Commercial |
$0.69
|
| Rate for Payer: BCN Commercial |
$0.69
|
| Rate for Payer: BCN Commercial |
$0.69
|
| Rate for Payer: BCN Commercial |
$0.69
|
| Rate for Payer: BCN Commercial |
$0.69
|
| Rate for Payer: BCN Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$150.10
|
| Rate for Payer: Cash Price |
$1,182.41
|
| Rate for Payer: Cash Price |
$170.90
|
| Rate for Payer: Cash Price |
$150.10
|
| Rate for Payer: Cash Price |
$170.90
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cash Price |
$204.60
|
| Rate for Payer: Cash Price |
$1,182.41
|
| Rate for Payer: Cash Price |
$301.27
|
| Rate for Payer: Cash Price |
$301.27
|
| Rate for Payer: Cash Price |
$343.09
|
| Rate for Payer: Cash Price |
$343.09
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cofinity Commercial |
$219.94
|
| Rate for Payer: Cofinity Commercial |
$1,034.61
|
| Rate for Payer: Cofinity Commercial |
$1,271.09
|
| Rate for Payer: Cofinity Commercial |
$131.34
|
| Rate for Payer: Cofinity Commercial |
$161.36
|
| Rate for Payer: Cofinity Commercial |
$149.54
|
| Rate for Payer: Cofinity Commercial |
$183.72
|
| Rate for Payer: Cofinity Commercial |
$179.02
|
| Rate for Payer: Cofinity Commercial |
$447.63
|
| Rate for Payer: Cofinity Commercial |
$364.35
|
| Rate for Payer: Cofinity Commercial |
$263.61
|
| Rate for Payer: Cofinity Commercial |
$323.87
|
| Rate for Payer: Cofinity Commercial |
$368.82
|
| Rate for Payer: Cofinity Commercial |
$300.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$263.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,034.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$300.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$149.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$364.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,182.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$416.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$301.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.10
|
| Rate for Payer: Healthscope Commercial |
$338.93
|
| Rate for Payer: Healthscope Commercial |
$192.27
|
| Rate for Payer: Healthscope Commercial |
$230.18
|
| Rate for Payer: Healthscope Commercial |
$468.45
|
| Rate for Payer: Healthscope Commercial |
$168.87
|
| Rate for Payer: Healthscope Commercial |
$385.97
|
| Rate for Payer: Healthscope Commercial |
$1,330.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$320.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$442.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,256.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.59
|
| Rate for Payer: PHP Commercial |
$217.39
|
| Rate for Payer: PHP Commercial |
$159.49
|
| Rate for Payer: PHP Commercial |
$364.53
|
| Rate for Payer: PHP Commercial |
$442.42
|
| Rate for Payer: PHP Commercial |
$320.10
|
| Rate for Payer: PHP Commercial |
$181.59
|
| Rate for Payer: PHP Commercial |
$1,256.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$244.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$338.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$960.71
|
| Rate for Payer: Priority Health SBD |
$237.25
|
| Rate for Payer: Priority Health SBD |
$270.18
|
| Rate for Payer: Priority Health SBD |
$161.12
|
| Rate for Payer: Priority Health SBD |
$134.59
|
| Rate for Payer: Priority Health SBD |
$931.15
|
| Rate for Payer: Priority Health SBD |
$118.21
|
| Rate for Payer: Priority Health SBD |
$327.92
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$1,478.01
|
|
|
Service Code
|
HCPCS J1453
|
| Hospital Charge Code |
106783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$931.15 |
| Max. Negotiated Rate |
$1,330.21 |
| Rate for Payer: Aetna Commercial |
$1,256.31
|
| Rate for Payer: Aetna Commercial |
$159.49
|
| Rate for Payer: Aetna Commercial |
$181.59
|
| Rate for Payer: Aetna Commercial |
$364.53
|
| Rate for Payer: Aetna Commercial |
$442.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$960.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$338.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.96
|
| Rate for Payer: Cash Price |
$416.40
|
| Rate for Payer: Cash Price |
$150.10
|
| Rate for Payer: Cash Price |
$343.09
|
| Rate for Payer: Cash Price |
$170.90
|
| Rate for Payer: Cash Price |
$1,182.41
|
| Rate for Payer: Cofinity Commercial |
$131.34
|
| Rate for Payer: Cofinity Commercial |
$1,034.61
|
| Rate for Payer: Cofinity Commercial |
$1,271.09
|
| Rate for Payer: Cofinity Commercial |
$447.63
|
| Rate for Payer: Cofinity Commercial |
$364.35
|
| Rate for Payer: Cofinity Commercial |
$161.36
|
| Rate for Payer: Cofinity Commercial |
$368.82
|
| Rate for Payer: Cofinity Commercial |
$300.20
|
| Rate for Payer: Cofinity Commercial |
$149.54
|
| Rate for Payer: Cofinity Commercial |
$183.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$364.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,034.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$149.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$300.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,182.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$416.40
|
| Rate for Payer: Healthscope Commercial |
$192.27
|
| Rate for Payer: Healthscope Commercial |
$168.87
|
| Rate for Payer: Healthscope Commercial |
$1,330.21
|
| Rate for Payer: Healthscope Commercial |
$385.97
|
| Rate for Payer: Healthscope Commercial |
$468.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$442.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,256.31
|
| Rate for Payer: PHP Commercial |
$364.53
|
| Rate for Payer: PHP Commercial |
$442.42
|
| Rate for Payer: PHP Commercial |
$181.59
|
| Rate for Payer: PHP Commercial |
$159.49
|
| Rate for Payer: PHP Commercial |
$1,256.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$960.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$338.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.76
|
| Rate for Payer: Priority Health SBD |
$270.18
|
| Rate for Payer: Priority Health SBD |
$118.21
|
| Rate for Payer: Priority Health SBD |
$134.59
|
| Rate for Payer: Priority Health SBD |
$931.15
|
| Rate for Payer: Priority Health SBD |
$327.92
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$241.84
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.36 |
| Max. Negotiated Rate |
$217.66 |
| Rate for Payer: Aetna Commercial |
$205.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.20
|
| Rate for Payer: Cash Price |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$169.29
|
| Rate for Payer: Cofinity Commercial |
$207.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$169.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.47
|
| Rate for Payer: Healthscope Commercial |
$217.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.56
|
| Rate for Payer: PHP Commercial |
$205.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.20
|
| Rate for Payer: Priority Health SBD |
$152.36
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$241.84
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.74 |
| Max. Negotiated Rate |
$217.66 |
| Rate for Payer: Aetna Commercial |
$205.56
|
| Rate for Payer: Aetna Medicare |
$120.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.20
|
| Rate for Payer: BCBS Complete |
$96.74
|
| Rate for Payer: Cash Price |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$169.29
|
| Rate for Payer: Cofinity Commercial |
$207.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$169.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.47
|
| Rate for Payer: Healthscope Commercial |
$217.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.56
|
| Rate for Payer: PHP Commercial |
$205.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.20
|
| Rate for Payer: Priority Health SBD |
$152.36
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$167.32
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
17764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.41 |
| Max. Negotiated Rate |
$150.59 |
| Rate for Payer: Aetna Commercial |
$142.22
|
| Rate for Payer: Aetna Commercial |
$12.88
|
| Rate for Payer: Aetna Commercial |
$16.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.76
|
| Rate for Payer: Cash Price |
$133.86
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Cofinity Commercial |
$143.90
|
| Rate for Payer: Cofinity Commercial |
$13.03
|
| Rate for Payer: Cofinity Commercial |
$10.60
|
| Rate for Payer: Cofinity Commercial |
$117.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$117.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.90
|
| Rate for Payer: Healthscope Commercial |
$13.64
|
| Rate for Payer: Healthscope Commercial |
$150.59
|
| Rate for Payer: Healthscope Commercial |
$17.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.89
|
| Rate for Payer: PHP Commercial |
$12.88
|
| Rate for Payer: PHP Commercial |
$142.22
|
| Rate for Payer: PHP Commercial |
$16.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.92
|
| Rate for Payer: Priority Health SBD |
$12.52
|
| Rate for Payer: Priority Health SBD |
$9.54
|
| Rate for Payer: Priority Health SBD |
$105.41
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION
|
Facility
|
OP
|
$19.87
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
17764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: Aetna Commercial |
$16.89
|
| Rate for Payer: Aetna Commercial |
$12.88
|
| Rate for Payer: Aetna Commercial |
$142.22
|
| Rate for Payer: Aetna Medicare |
$7.58
|
| Rate for Payer: Aetna Medicare |
$83.66
|
| Rate for Payer: Aetna Medicare |
$9.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.92
|
| Rate for Payer: BCBS Complete |
$66.93
|
| Rate for Payer: BCBS Complete |
$6.06
|
| Rate for Payer: BCBS Complete |
$7.95
|
| Rate for Payer: BCBS Trust/PPO |
$0.89
|
| Rate for Payer: BCBS Trust/PPO |
$0.89
|
| Rate for Payer: BCBS Trust/PPO |
$0.89
|
| Rate for Payer: BCN Commercial |
$0.89
|
| Rate for Payer: BCN Commercial |
$0.89
|
| Rate for Payer: BCN Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$133.86
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$133.86
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cofinity Commercial |
$117.12
|
| Rate for Payer: Cofinity Commercial |
$10.60
|
| Rate for Payer: Cofinity Commercial |
$13.03
|
| Rate for Payer: Cofinity Commercial |
$143.90
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$117.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.90
|
| Rate for Payer: Healthscope Commercial |
$150.59
|
| Rate for Payer: Healthscope Commercial |
$13.64
|
| Rate for Payer: Healthscope Commercial |
$17.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.89
|
| Rate for Payer: PHP Commercial |
$142.22
|
| Rate for Payer: PHP Commercial |
$16.89
|
| Rate for Payer: PHP Commercial |
$12.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.85
|
| Rate for Payer: Priority Health SBD |
$9.54
|
| Rate for Payer: Priority Health SBD |
$12.52
|
| Rate for Payer: Priority Health SBD |
$105.41
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION
|
Facility
|
IP
|
$61.86
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.97 |
| Max. Negotiated Rate |
$55.67 |
| Rate for Payer: Aetna Commercial |
$52.58
|
| Rate for Payer: Aetna Commercial |
$340.37
|
| Rate for Payer: Aetna Commercial |
$79.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.54
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cash Price |
$74.51
|
| Rate for Payer: Cash Price |
$49.49
|
| Rate for Payer: Cofinity Commercial |
$280.31
|
| Rate for Payer: Cofinity Commercial |
$344.38
|
| Rate for Payer: Cofinity Commercial |
$43.30
|
| Rate for Payer: Cofinity Commercial |
$53.20
|
| Rate for Payer: Cofinity Commercial |
$65.20
|
| Rate for Payer: Cofinity Commercial |
$80.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$280.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.51
|
| Rate for Payer: Healthscope Commercial |
$360.40
|
| Rate for Payer: Healthscope Commercial |
$55.67
|
| Rate for Payer: Healthscope Commercial |
$83.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.17
|
| Rate for Payer: PHP Commercial |
$52.58
|
| Rate for Payer: PHP Commercial |
$79.17
|
| Rate for Payer: PHP Commercial |
$340.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.29
|
| Rate for Payer: Priority Health SBD |
$58.68
|
| Rate for Payer: Priority Health SBD |
$38.97
|
| Rate for Payer: Priority Health SBD |
$252.28
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION
|
Facility
|
OP
|
$93.14
|
|
|
Service Code
|
HCPCS Q2009
|
| Hospital Charge Code |
88010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$83.83 |
| Rate for Payer: Aetna Commercial |
$79.17
|
| Rate for Payer: Aetna Commercial |
$340.37
|
| Rate for Payer: Aetna Commercial |
$52.58
|
| Rate for Payer: Aetna Medicare |
$200.22
|
| Rate for Payer: Aetna Medicare |
$30.93
|
| Rate for Payer: Aetna Medicare |
$46.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.54
|
| Rate for Payer: BCBS Complete |
$24.74
|
| Rate for Payer: BCBS Complete |
$160.18
|
| Rate for Payer: BCBS Complete |
$37.26
|
| Rate for Payer: BCBS Trust/PPO |
$0.89
|
| Rate for Payer: BCBS Trust/PPO |
$0.89
|
| Rate for Payer: BCBS Trust/PPO |
$0.89
|
| Rate for Payer: BCN Commercial |
$0.89
|
| Rate for Payer: BCN Commercial |
$0.89
|
| Rate for Payer: BCN Commercial |
$0.89
|
| Rate for Payer: Cash Price |
$49.49
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cash Price |
$74.51
|
| Rate for Payer: Cash Price |
$49.49
|
| Rate for Payer: Cash Price |
$320.35
|
| Rate for Payer: Cash Price |
$74.51
|
| Rate for Payer: Cofinity Commercial |
$43.30
|
| Rate for Payer: Cofinity Commercial |
$280.31
|
| Rate for Payer: Cofinity Commercial |
$344.38
|
| Rate for Payer: Cofinity Commercial |
$53.20
|
| Rate for Payer: Cofinity Commercial |
$65.20
|
| Rate for Payer: Cofinity Commercial |
$80.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$280.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.51
|
| Rate for Payer: Healthscope Commercial |
$55.67
|
| Rate for Payer: Healthscope Commercial |
$360.40
|
| Rate for Payer: Healthscope Commercial |
$83.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.17
|
| Rate for Payer: PHP Commercial |
$52.58
|
| Rate for Payer: PHP Commercial |
$79.17
|
| Rate for Payer: PHP Commercial |
$340.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.29
|
| Rate for Payer: Priority Health SBD |
$252.28
|
| Rate for Payer: Priority Health SBD |
$58.68
|
| Rate for Payer: Priority Health SBD |
$38.97
|
|
|
FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC
|
Facility
|
OP
|
$9,986.81
|
|
|
Service Code
|
CPT 30930
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$123.79 |
| Max. Negotiated Rate |
$9,986.81 |
| Rate for Payer: Aetna Medicare |
$3,304.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,971.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,971.88
|
| Rate for Payer: BCBS Complete |
$1,788.30
|
| Rate for Payer: BCBS MAPPO |
$3,177.50
|
| Rate for Payer: BCBS Trust/PPO |
$980.72
|
| Rate for Payer: BCN Commercial |
$980.72
|
| Rate for Payer: BCN Medicare Advantage |
$3,177.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,177.50
|
| Rate for Payer: Mclaren Medicaid |
$1,703.14
|
| Rate for Payer: Mclaren Medicare |
$3,177.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,336.38
|
| Rate for Payer: Meridian Medicaid |
$1,788.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,654.12
|
| Rate for Payer: Nomi Health Commercial |
$6,672.75
|
| Rate for Payer: PACE Medicare |
$3,018.62
|
| Rate for Payer: PACE SWMI |
$3,177.50
|
| Rate for Payer: PHP Medicare Advantage |
$3,177.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,986.81
|
| Rate for Payer: Priority Health Medicare |
$3,177.50
|
| Rate for Payer: Priority Health Narrow Network |
$7,989.45
|
| Rate for Payer: Railroad Medicare Medicare |
$3,177.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.79
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,177.50
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,177.50
|
| Rate for Payer: UHCCP Medicaid |
$1,788.93
|
| Rate for Payer: VA VA |
$3,177.50
|
|
|
FRAXEL ARMS - BILATERAL
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00166
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$663.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
FRAXEL CHEST
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00155
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$530.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
|
FRAXEL FACE & NECK
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00162
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$5,000.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,000.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
FRAXEL FULL FACE
|
Professional
|
Both
|
$612.00
|
|
|
Service Code
|
HCPCS 00152
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$244.80 |
| Max. Negotiated Rate |
$397.80 |
| Rate for Payer: Aetna Medicare |
$306.00
|
| Rate for Payer: BCBS Complete |
$244.80
|
| Rate for Payer: Cash Price |
$489.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$397.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$397.80
|
|
|
FRAXEL HANDS
|
Professional
|
Both
|
$357.00
|
|
|
Service Code
|
HCPCS 00154
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$232.05 |
| Rate for Payer: Aetna Medicare |
$178.50
|
| Rate for Payer: BCBS Complete |
$142.80
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.05
|
|
|
FRAXEL LARGE SCAR
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00161
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$530.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
|
FRAXEL MEDIUM SCAR
|
Professional
|
Both
|
$306.00
|
|
|
Service Code
|
HCPCS 00160
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$5,000.00 |
| Rate for Payer: Aetna Medicare |
$153.00
|
| Rate for Payer: BCBS Complete |
$122.40
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,000.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.90
|
|
|
FRAXEL NECK
|
Professional
|
Both
|
$408.00
|
|
|
Service Code
|
HCPCS 00153
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$265.20 |
| Rate for Payer: Aetna Medicare |
$204.00
|
| Rate for Payer: BCBS Complete |
$163.20
|
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.20
|
|
|
FRAXEL NECK & CHEST
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00163
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna Medicare |
$612.00
|
| Rate for Payer: BCBS Complete |
$489.60
|
| Rate for Payer: Cash Price |
$979.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$795.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.60
|
|
|
FRAXEL PARTIAL TREATMENT - BILATERAL EYES
|
Professional
|
Both
|
$306.00
|
|
|
Service Code
|
HCPCS 00157
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$198.90 |
| Rate for Payer: Aetna Medicare |
$153.00
|
| Rate for Payer: BCBS Complete |
$122.40
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$198.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.90
|
|
|
FRAXEL PARTIAL TREATMENT - PERI-ORAL
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
HCPCS 00156
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$204.00 |
| Max. Negotiated Rate |
$331.50 |
| Rate for Payer: Aetna Medicare |
$255.00
|
| Rate for Payer: BCBS Complete |
$204.00
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$331.50
|
|
|
FRAXEL PARTIAL TREATMENT - UPPER LIP
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS 00158
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$165.75 |
| Rate for Payer: Aetna Medicare |
$127.50
|
| Rate for Payer: BCBS Complete |
$102.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.75
|
|
