|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$1,911.87
|
|
|
Service Code
|
NDC 70954-188-10
|
| Hospital Charge Code |
8970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,204.48 |
| Max. Negotiated Rate |
$1,720.68 |
| Rate for Payer: Aetna Commercial |
$1,625.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,242.72
|
| Rate for Payer: Cash Price |
$1,529.50
|
| Rate for Payer: Cofinity Commercial |
$1,338.31
|
| Rate for Payer: Cofinity Commercial |
$1,644.21
|
| Rate for Payer: Healthscope Commercial |
$1,720.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,625.09
|
| Rate for Payer: PHP Commercial |
$1,625.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,338.31
|
| Rate for Payer: Priority Health SBD |
$1,204.48
|
|
|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$1,589.28
|
|
|
Service Code
|
NDC 0472-0082-16
|
| Hospital Charge Code |
8970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,001.25 |
| Max. Negotiated Rate |
$1,430.35 |
| Rate for Payer: Aetna Commercial |
$1,350.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,033.03
|
| Rate for Payer: Cash Price |
$1,271.42
|
| Rate for Payer: Cofinity Commercial |
$1,112.50
|
| Rate for Payer: Cofinity Commercial |
$1,366.78
|
| Rate for Payer: Healthscope Commercial |
$1,430.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,350.89
|
| Rate for Payer: PHP Commercial |
$1,350.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,112.50
|
| Rate for Payer: Priority Health SBD |
$1,001.25
|
|
|
ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$1,367.21
|
|
|
Service Code
|
NDC 50383-810-16
|
| Hospital Charge Code |
8970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$861.34 |
| Max. Negotiated Rate |
$1,230.49 |
| Rate for Payer: Aetna Commercial |
$1,162.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$888.69
|
| Rate for Payer: Cash Price |
$1,093.77
|
| Rate for Payer: Cofinity Commercial |
$1,175.80
|
| Rate for Payer: Cofinity Commercial |
$957.05
|
| Rate for Payer: Healthscope Commercial |
$1,230.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,162.13
|
| Rate for Payer: PHP Commercial |
$1,162.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$957.05
|
| Rate for Payer: Priority Health SBD |
$861.34
|
|
|
ACYCLOVIR 400 MG TABLET
|
Facility
IP
|
$197.60
|
|
|
Service Code
|
NDC 0904-5790-61
|
| Hospital Charge Code |
8971
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.49 |
| Max. Negotiated Rate |
$177.84 |
| Rate for Payer: Aetna Commercial |
$167.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.44
|
| Rate for Payer: Cash Price |
$158.08
|
| Rate for Payer: Cofinity Commercial |
$138.32
|
| Rate for Payer: Cofinity Commercial |
$169.94
|
| Rate for Payer: Healthscope Commercial |
$177.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$167.96
|
| Rate for Payer: PHP Commercial |
$167.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.32
|
| Rate for Payer: Priority Health SBD |
$124.49
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$16.65
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
23128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.49 |
| Max. Negotiated Rate |
$14.98 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Aetna Commercial |
$17.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.04
|
| Rate for Payer: Cash Price |
$16.05
|
| Rate for Payer: Cash Price |
$13.32
|
| Rate for Payer: Cash Price |
$18.12
|
| Rate for Payer: Cofinity Commercial |
$11.66
|
| Rate for Payer: Cofinity Commercial |
$19.48
|
| Rate for Payer: Cofinity Commercial |
$15.86
|
| Rate for Payer: Cofinity Commercial |
$14.04
|
| Rate for Payer: Cofinity Commercial |
$17.25
|
| Rate for Payer: Cofinity Commercial |
$14.32
|
| Rate for Payer: Healthscope Commercial |
$18.05
|
| Rate for Payer: Healthscope Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$20.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.15
|
| Rate for Payer: PHP Commercial |
$19.25
|
| Rate for Payer: PHP Commercial |
$17.05
|
| Rate for Payer: PHP Commercial |
$14.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.86
|
| Rate for Payer: Priority Health SBD |
$10.49
|
| Rate for Payer: Priority Health SBD |
$12.64
|
| Rate for Payer: Priority Health SBD |
$14.27
|
|
|
ADALIMUMAB 40 MG/0.8 ML SUBCUTANEOUS SYRINGE KIT
|
Facility
IP
|
$17,548.83
|
|
|
Service Code
|
HCPCS J0135
|
| Hospital Charge Code |
34652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,055.76 |
| Max. Negotiated Rate |
$15,793.95 |
| Rate for Payer: Aetna Commercial |
$14,916.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,406.74
|
| Rate for Payer: Cash Price |
$14,039.06
|
| Rate for Payer: Cofinity Commercial |
$12,284.18
|
| Rate for Payer: Cofinity Commercial |
$15,091.99
|
| Rate for Payer: Healthscope Commercial |
$15,793.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14,916.51
|
| Rate for Payer: PHP Commercial |
$14,916.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,284.18
|
| Rate for Payer: Priority Health SBD |
$11,055.76
|
|
|
ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER
|
Facility
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 42831
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$230.85 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,979.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,580.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,580.99
|
| Rate for Payer: BCBS Complete |
$1,645.54
|
| Rate for Payer: BCBS MAPPO |
$2,864.79
|
| Rate for Payer: BCBS Trust/PPO |
$1,549.67
|
| Rate for Payer: BCN Medicare Advantage |
$2,864.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,864.79
|
| Rate for Payer: Mclaren Medicaid |
$1,567.04
|
| Rate for Payer: Mclaren Medicare |
$2,864.79
|
| Rate for Payer: Meridian Medicaid |
$1,645.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,008.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,294.51
|
| Rate for Payer: PACE Medicare |
$2,721.55
|
| Rate for Payer: PACE SWMI |
$2,864.79
|
| Rate for Payer: PHP Medicare Advantage |
$2,864.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,567.04
|
| Rate for Payer: Priority Health Medicare |
$2,864.79
|
| Rate for Payer: Railroad Medicare Medicare |
$2,864.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$253.94
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,864.79
|
| Rate for Payer: UHC Exchange |
$230.85
|
| Rate for Payer: UHC Medicare Advantage |
$2,950.73
|
| Rate for Payer: VA VA |
$2,864.79
|
|
|
ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12
|
Facility
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 42830
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$212.51 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,979.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,580.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,580.99
|
| Rate for Payer: BCBS Complete |
$1,645.54
|
| Rate for Payer: BCBS MAPPO |
$2,864.79
|
| Rate for Payer: BCBS Trust/PPO |
$1,267.68
|
| Rate for Payer: BCN Medicare Advantage |
$2,864.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,864.79
|
| Rate for Payer: Mclaren Medicaid |
$1,567.04
|
| Rate for Payer: Mclaren Medicare |
$2,864.79
|
| Rate for Payer: Meridian Medicaid |
$1,645.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,008.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,294.51
|
| Rate for Payer: PACE Medicare |
$2,721.55
|
| Rate for Payer: PACE SWMI |
$2,864.79
|
| Rate for Payer: PHP Medicare Advantage |
$2,864.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,567.04
|
| Rate for Payer: Priority Health Medicare |
$2,864.79
|
| Rate for Payer: Railroad Medicare Medicare |
$2,864.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$233.76
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,864.79
|
| Rate for Payer: UHC Exchange |
$212.51
|
| Rate for Payer: UHC Medicare Advantage |
$2,950.73
|
| Rate for Payer: VA VA |
$2,864.79
|
|
|
ADENOIDECTOMY, SECONDARY; YOUNGER THAN AGE 12
|
Facility
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 42835
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$198.43 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,979.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,580.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,580.99
|
| Rate for Payer: BCBS Complete |
$1,645.54
|
| Rate for Payer: BCBS MAPPO |
$2,864.79
|
| Rate for Payer: BCBS Trust/PPO |
$952.38
|
| Rate for Payer: BCN Medicare Advantage |
$2,864.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,864.79
|
| Rate for Payer: Mclaren Medicaid |
$1,567.04
|
| Rate for Payer: Mclaren Medicare |
$2,864.79
|
| Rate for Payer: Meridian Medicaid |
$1,645.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,008.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,294.51
|
| Rate for Payer: PACE Medicare |
$2,721.55
|
| Rate for Payer: PACE SWMI |
$2,864.79
|
| Rate for Payer: PHP Medicare Advantage |
$2,864.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,567.04
|
| Rate for Payer: Priority Health Medicare |
$2,864.79
|
| Rate for Payer: Railroad Medicare Medicare |
$2,864.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$218.27
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,864.79
|
| Rate for Payer: UHC Exchange |
$198.43
|
| Rate for Payer: UHC Medicare Advantage |
$2,950.73
|
| Rate for Payer: VA VA |
$2,864.79
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$24.74
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
8975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.59 |
| Max. Negotiated Rate |
$22.27 |
| Rate for Payer: Aetna Commercial |
$21.03
|
| Rate for Payer: Aetna Commercial |
$14.67
|
| Rate for Payer: Aetna Commercial |
$21.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.22
|
| Rate for Payer: Cash Price |
$20.23
|
| Rate for Payer: Cash Price |
$19.79
|
| Rate for Payer: Cash Price |
$13.81
|
| Rate for Payer: Cofinity Commercial |
$17.70
|
| Rate for Payer: Cofinity Commercial |
$12.08
|
| Rate for Payer: Cofinity Commercial |
$14.84
|
| Rate for Payer: Cofinity Commercial |
$17.32
|
| Rate for Payer: Cofinity Commercial |
$21.28
|
| Rate for Payer: Cofinity Commercial |
$21.75
|
| Rate for Payer: Healthscope Commercial |
$22.27
|
| Rate for Payer: Healthscope Commercial |
$15.53
|
| Rate for Payer: Healthscope Commercial |
$22.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.03
|
| Rate for Payer: PHP Commercial |
$21.50
|
| Rate for Payer: PHP Commercial |
$14.67
|
| Rate for Payer: PHP Commercial |
$21.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.70
|
| Rate for Payer: Priority Health SBD |
$10.87
|
| Rate for Payer: Priority Health SBD |
$15.93
|
| Rate for Payer: Priority Health SBD |
$15.59
|
|
|
ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE
|
Facility
IP
|
$39.13
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
39477
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$35.22 |
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.43
|
| Rate for Payer: Cash Price |
$31.30
|
| Rate for Payer: Cofinity Commercial |
$33.65
|
| Rate for Payer: Cofinity Commercial |
$27.39
|
| Rate for Payer: Healthscope Commercial |
$35.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.26
|
| Rate for Payer: PHP Commercial |
$33.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.39
|
| Rate for Payer: Priority Health SBD |
$24.65
|
|
|
ADENOSINE 3 MG/ML IV (CODE)
|
Facility
IP
|
$25.29
|
|
|
Service Code
|
HCPCS J0153
|
| Hospital Charge Code |
163702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.93 |
| Max. Negotiated Rate |
$22.76 |
| Rate for Payer: Aetna Commercial |
$21.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.44
|
| Rate for Payer: Cash Price |
$20.23
|
| Rate for Payer: Cofinity Commercial |
$17.70
|
| Rate for Payer: Cofinity Commercial |
$21.75
|
| Rate for Payer: Healthscope Commercial |
$22.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.50
|
| Rate for Payer: PHP Commercial |
$21.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.70
|
| Rate for Payer: Priority Health SBD |
$15.93
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM
|
Facility
OP
|
$9,754.38
|
|
|
Service Code
|
CPT 14301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$852.99 |
| Max. Negotiated Rate |
$9,754.38 |
| Rate for Payer: Aetna Medicare |
$3,319.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,990.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,990.30
|
| Rate for Payer: BCBS Complete |
$1,833.62
|
| Rate for Payer: BCBS MAPPO |
$3,192.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,174.90
|
| Rate for Payer: BCN Medicare Advantage |
$3,192.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,192.24
|
| Rate for Payer: Mclaren Medicaid |
$1,746.16
|
| Rate for Payer: Mclaren Medicare |
$3,192.24
|
| Rate for Payer: Meridian Medicaid |
$1,833.62
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,351.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,671.08
|
| Rate for Payer: PACE Medicare |
$3,032.63
|
| Rate for Payer: PACE SWMI |
$3,192.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,192.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,746.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,754.38
|
| Rate for Payer: Priority Health Medicare |
$3,192.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,803.50
|
| Rate for Payer: Railroad Medicare Medicare |
$3,192.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$938.29
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,192.24
|
| Rate for Payer: UHC Exchange |
$852.99
|
| Rate for Payer: UHC Medicare Advantage |
$3,288.01
|
| Rate for Payer: VA VA |
$3,192.24
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM
|
Facility
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 14061
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$803.22 |
| Max. Negotiated Rate |
$5,175.07 |
| Rate for Payer: Aetna Medicare |
$1,687.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,028.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,028.30
|
| Rate for Payer: BCBS Complete |
$932.04
|
| Rate for Payer: BCBS MAPPO |
$1,622.64
|
| Rate for Payer: BCBS Trust/PPO |
$1,515.50
|
| Rate for Payer: BCN Medicare Advantage |
$1,622.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,622.64
|
| Rate for Payer: Mclaren Medicaid |
$887.58
|
| Rate for Payer: Mclaren Medicare |
$1,622.64
|
| Rate for Payer: Meridian Medicaid |
$932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,703.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,866.04
|
| Rate for Payer: PACE Medicare |
$1,541.51
|
| Rate for Payer: PACE SWMI |
$1,622.64
|
| Rate for Payer: PHP Medicare Advantage |
$1,622.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$887.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,175.07
|
| Rate for Payer: Priority Health Medicare |
$1,622.64
|
| Rate for Payer: Priority Health Narrow Network |
$4,140.06
|
| Rate for Payer: Railroad Medicare Medicare |
$1,622.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$883.54
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$803.22
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS
|
Facility
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 14060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$653.25 |
| Max. Negotiated Rate |
$5,175.07 |
| Rate for Payer: Aetna Medicare |
$1,687.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,028.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,028.30
|
| Rate for Payer: BCBS Complete |
$932.04
|
| Rate for Payer: BCBS MAPPO |
$1,622.64
|
| Rate for Payer: BCBS Trust/PPO |
$796.18
|
| Rate for Payer: BCN Medicare Advantage |
$1,622.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,622.64
|
| Rate for Payer: Mclaren Medicaid |
$887.58
|
| Rate for Payer: Mclaren Medicare |
$1,622.64
|
| Rate for Payer: Meridian Medicaid |
$932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,703.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,866.04
|
| Rate for Payer: PACE Medicare |
$1,541.51
|
| Rate for Payer: PACE SWMI |
$1,622.64
|
| Rate for Payer: PHP Medicare Advantage |
$1,622.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$887.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,175.07
|
| Rate for Payer: Priority Health Medicare |
$1,622.64
|
| Rate for Payer: Priority Health Narrow Network |
$4,140.06
|
| Rate for Payer: Railroad Medicare Medicare |
$1,622.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$718.58
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$653.25
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS
|
Facility
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 14020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$558.62 |
| Max. Negotiated Rate |
$5,175.07 |
| Rate for Payer: Aetna Medicare |
$1,687.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,028.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,028.30
|
| Rate for Payer: BCBS Complete |
$932.04
|
| Rate for Payer: BCBS MAPPO |
$1,622.64
|
| Rate for Payer: BCBS Trust/PPO |
$796.18
|
| Rate for Payer: BCN Medicare Advantage |
$1,622.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,622.64
|
| Rate for Payer: Mclaren Medicaid |
$887.58
|
| Rate for Payer: Mclaren Medicare |
$1,622.64
|
| Rate for Payer: Meridian Medicaid |
$932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,703.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,866.04
|
| Rate for Payer: PACE Medicare |
$1,541.51
|
| Rate for Payer: PACE SWMI |
$1,622.64
|
| Rate for Payer: PHP Medicare Advantage |
$1,622.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$887.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,175.07
|
| Rate for Payer: Priority Health Medicare |
$1,622.64
|
| Rate for Payer: Priority Health Narrow Network |
$4,140.06
|
| Rate for Payer: Railroad Medicare Medicare |
$1,622.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$614.48
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$558.62
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM
|
Facility
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 14001
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$643.75 |
| Max. Negotiated Rate |
$5,175.07 |
| Rate for Payer: Aetna Medicare |
$1,687.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,028.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,028.30
|
| Rate for Payer: BCBS Complete |
$932.04
|
| Rate for Payer: BCBS MAPPO |
$1,622.64
|
| Rate for Payer: BCBS Trust/PPO |
$796.18
|
| Rate for Payer: BCN Medicare Advantage |
$1,622.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,622.64
|
| Rate for Payer: Mclaren Medicaid |
$887.58
|
| Rate for Payer: Mclaren Medicare |
$1,622.64
|
| Rate for Payer: Meridian Medicaid |
$932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,703.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,866.04
|
| Rate for Payer: PACE Medicare |
$1,541.51
|
| Rate for Payer: PACE SWMI |
$1,622.64
|
| Rate for Payer: PHP Medicare Advantage |
$1,622.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$887.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,175.07
|
| Rate for Payer: Priority Health Medicare |
$1,622.64
|
| Rate for Payer: Priority Health Narrow Network |
$4,140.06
|
| Rate for Payer: Railroad Medicare Medicare |
$1,622.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$708.12
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$643.75
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS
|
Facility
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 14000
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$497.71 |
| Max. Negotiated Rate |
$5,175.07 |
| Rate for Payer: Aetna Medicare |
$1,687.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,028.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,028.30
|
| Rate for Payer: BCBS Complete |
$932.04
|
| Rate for Payer: BCBS MAPPO |
$1,622.64
|
| Rate for Payer: BCBS Trust/PPO |
$796.18
|
| Rate for Payer: BCN Medicare Advantage |
$1,622.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,622.64
|
| Rate for Payer: Mclaren Medicaid |
$887.58
|
| Rate for Payer: Mclaren Medicare |
$1,622.64
|
| Rate for Payer: Meridian Medicaid |
$932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,703.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,866.04
|
| Rate for Payer: PACE Medicare |
$1,541.51
|
| Rate for Payer: PACE SWMI |
$1,622.64
|
| Rate for Payer: PHP Medicare Advantage |
$1,622.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$887.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,175.07
|
| Rate for Payer: Priority Health Medicare |
$1,622.64
|
| Rate for Payer: Priority Health Narrow Network |
$4,140.06
|
| Rate for Payer: Railroad Medicare Medicare |
$1,622.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$547.48
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$497.71
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$17,473.96
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
165224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,008.59 |
| Max. Negotiated Rate |
$15,726.56 |
| Rate for Payer: Aetna Commercial |
$14,852.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,358.07
|
| Rate for Payer: Cash Price |
$13,979.17
|
| Rate for Payer: Cofinity Commercial |
$12,231.77
|
| Rate for Payer: Cofinity Commercial |
$15,027.61
|
| Rate for Payer: Healthscope Commercial |
$15,726.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14,852.87
|
| Rate for Payer: PHP Commercial |
$14,852.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,231.77
|
| Rate for Payer: Priority Health SBD |
$11,008.59
|
|
|
ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION
|
Facility
OP
|
$17,473.96
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
165224
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.99 |
| Max. Negotiated Rate |
$15,726.56 |
| Rate for Payer: Aetna Commercial |
$14,852.87
|
| Rate for Payer: Aetna Medicare |
$39.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,358.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47.96
|
| Rate for Payer: BCBS Complete |
$22.04
|
| Rate for Payer: BCBS MAPPO |
$38.37
|
| Rate for Payer: BCBS Trust/PPO |
$113.58
|
| Rate for Payer: BCN Medicare Advantage |
$38.37
|
| Rate for Payer: Cash Price |
$13,979.17
|
| Rate for Payer: Cash Price |
$13,979.17
|
| Rate for Payer: Cofinity Commercial |
$15,027.61
|
| Rate for Payer: Cofinity Commercial |
$12,231.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$38.37
|
| Rate for Payer: Healthscope Commercial |
$15,726.56
|
| Rate for Payer: Mclaren Medicaid |
$20.99
|
| Rate for Payer: Mclaren Medicare |
$38.37
|
| Rate for Payer: Meridian Medicaid |
$22.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$40.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14,852.87
|
| Rate for Payer: PACE Medicare |
$36.45
|
| Rate for Payer: PACE SWMI |
$38.37
|
| Rate for Payer: PHP Commercial |
$14,852.87
|
| Rate for Payer: PHP Medicare Advantage |
$38.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$20.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,231.77
|
| Rate for Payer: Priority Health Medicare |
$38.37
|
| Rate for Payer: Priority Health SBD |
$11,008.59
|
| Rate for Payer: Railroad Medicare Medicare |
$38.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$38.37
|
| Rate for Payer: UHC Medicare Advantage |
$39.52
|
| Rate for Payer: VA VA |
$38.37
|
|
|
ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION
|
Facility
OP
|
$27,958.29
|
|
|
Service Code
|
HCPCS J9354
|
| Hospital Charge Code |
165225
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.99 |
| Max. Negotiated Rate |
$25,162.46 |
| Rate for Payer: Aetna Commercial |
$23,764.55
|
| Rate for Payer: Aetna Medicare |
$39.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18,172.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47.96
|
| Rate for Payer: BCBS Complete |
$22.04
|
| Rate for Payer: BCBS MAPPO |
$38.37
|
| Rate for Payer: BCBS Trust/PPO |
$113.58
|
| Rate for Payer: BCN Medicare Advantage |
$38.37
|
| Rate for Payer: Cash Price |
$22,366.63
|
| Rate for Payer: Cash Price |
$22,366.63
|
| Rate for Payer: Cofinity Commercial |
$24,044.13
|
| Rate for Payer: Cofinity Commercial |
$19,570.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$38.37
|
| Rate for Payer: Healthscope Commercial |
$25,162.46
|
| Rate for Payer: Mclaren Medicaid |
$20.99
|
| Rate for Payer: Mclaren Medicare |
$38.37
|
| Rate for Payer: Meridian Medicaid |
$22.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$40.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23,764.55
|
| Rate for Payer: PACE Medicare |
$36.45
|
| Rate for Payer: PACE SWMI |
$38.37
|
| Rate for Payer: PHP Commercial |
$23,764.55
|
| Rate for Payer: PHP Medicare Advantage |
$38.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$20.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,570.80
|
| Rate for Payer: Priority Health Medicare |
$38.37
|
| Rate for Payer: Priority Health SBD |
$17,613.72
|
| Rate for Payer: Railroad Medicare Medicare |
$38.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$38.37
|
| Rate for Payer: UHC Medicare Advantage |
$39.52
|
| Rate for Payer: VA VA |
$38.37
|
|
|
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC
|
Facility
IP
|
$53,268.14
|
|
|
Service Code
|
MS-DRG 614
|
| Min. Negotiated Rate |
$15,878.36 |
| Max. Negotiated Rate |
$53,268.14 |
| Rate for Payer: Aetna Medicare |
$17,382.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,892.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,892.58
|
| Rate for Payer: BCBS MAPPO |
$16,714.06
|
| Rate for Payer: BCBS Trust/PPO |
$53,268.14
|
| Rate for Payer: BCN Medicare Advantage |
$16,714.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,714.06
|
| Rate for Payer: Mclaren Medicare |
$16,714.06
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,549.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,221.17
|
| Rate for Payer: PACE Medicare |
$15,878.36
|
| Rate for Payer: PACE SWMI |
$16,714.06
|
| Rate for Payer: PHP Medicare Advantage |
$16,714.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32,321.76
|
| Rate for Payer: Priority Health Medicare |
$16,714.06
|
| Rate for Payer: Priority Health Narrow Network |
$25,857.41
|
| Rate for Payer: Railroad Medicare Medicare |
$16,714.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34,358.11
|
| Rate for Payer: UHC Core |
$21,082.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,714.06
|
| Rate for Payer: UHC Exchange |
$22,580.31
|
| Rate for Payer: UHC Medicare Advantage |
$17,215.48
|
| Rate for Payer: VA VA |
$16,714.06
|
|
|
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC
|
Facility
IP
|
$32,503.71
|
|
|
Service Code
|
MS-DRG 615
|
| Min. Negotiated Rate |
$10,532.92 |
| Max. Negotiated Rate |
$32,503.71 |
| Rate for Payer: Aetna Medicare |
$11,530.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,859.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,859.10
|
| Rate for Payer: BCBS MAPPO |
$11,087.28
|
| Rate for Payer: BCBS Trust/PPO |
$32,503.71
|
| Rate for Payer: BCN Medicare Advantage |
$11,087.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,087.28
|
| Rate for Payer: Mclaren Medicare |
$11,087.28
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,641.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,750.37
|
| Rate for Payer: PACE Medicare |
$10,532.92
|
| Rate for Payer: PACE SWMI |
$11,087.28
|
| Rate for Payer: PHP Medicare Advantage |
$11,087.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21,110.17
|
| Rate for Payer: Priority Health Medicare |
$11,087.28
|
| Rate for Payer: Priority Health Narrow Network |
$16,888.14
|
| Rate for Payer: Railroad Medicare Medicare |
$11,087.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22,440.16
|
| Rate for Payer: UHC Core |
$13,769.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,087.28
|
| Rate for Payer: UHC Exchange |
$14,747.78
|
| Rate for Payer: UHC Medicare Advantage |
$11,419.90
|
| Rate for Payer: VA VA |
$11,087.28
|
|
|
AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC
|
Facility
IP
|
$17,269.05
|
|
|
Service Code
|
MS-DRG 560
|
| Min. Negotiated Rate |
$8,213.59 |
| Max. Negotiated Rate |
$17,269.05 |
| Rate for Payer: Aetna Medicare |
$8,991.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,807.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,807.35
|
| Rate for Payer: BCBS MAPPO |
$8,645.88
|
| Rate for Payer: BCBS Trust/PPO |
$16,789.85
|
| Rate for Payer: BCN Medicare Advantage |
$8,645.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,645.88
|
| Rate for Payer: Mclaren Medicare |
$8,645.88
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,078.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,942.76
|
| Rate for Payer: PACE Medicare |
$8,213.59
|
| Rate for Payer: PACE SWMI |
$8,645.88
|
| Rate for Payer: PHP Medicare Advantage |
$8,645.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,245.54
|
| Rate for Payer: Priority Health Medicare |
$8,645.88
|
| Rate for Payer: Priority Health Narrow Network |
$12,996.43
|
| Rate for Payer: Railroad Medicare Medicare |
$8,645.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,269.05
|
| Rate for Payer: UHC Core |
$10,596.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$8,645.88
|
| Rate for Payer: UHC Exchange |
$11,349.30
|
| Rate for Payer: UHC Medicare Advantage |
$8,905.26
|
| Rate for Payer: VA VA |
$8,645.88
|
|
|
AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
IP
|
$41,770.41
|
|
|
Service Code
|
MS-DRG 559
|
| Min. Negotiated Rate |
$13,128.66 |
| Max. Negotiated Rate |
$41,770.41 |
| Rate for Payer: Aetna Medicare |
$14,372.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,274.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,274.55
|
| Rate for Payer: BCBS MAPPO |
$13,819.64
|
| Rate for Payer: BCBS Trust/PPO |
$41,770.41
|
| Rate for Payer: BCN Medicare Advantage |
$13,819.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,819.64
|
| Rate for Payer: Mclaren Medicare |
$13,819.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,510.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,892.59
|
| Rate for Payer: PACE Medicare |
$13,128.66
|
| Rate for Payer: PACE SWMI |
$13,819.64
|
| Rate for Payer: PHP Medicare Advantage |
$13,819.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26,554.53
|
| Rate for Payer: Priority Health Medicare |
$13,819.64
|
| Rate for Payer: Priority Health Narrow Network |
$21,243.62
|
| Rate for Payer: Railroad Medicare Medicare |
$13,819.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28,227.53
|
| Rate for Payer: UHC Core |
$17,320.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$13,819.64
|
| Rate for Payer: UHC Exchange |
$18,551.26
|
| Rate for Payer: UHC Medicare Advantage |
$14,234.23
|
| Rate for Payer: VA VA |
$13,819.64
|
|
