|
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC
|
Facility
|
IP
|
$60,477.28
|
|
|
Service Code
|
MS-DRG 480
|
| Min. Negotiated Rate |
$20,643.60 |
| Max. Negotiated Rate |
$60,477.28 |
| Rate for Payer: Aetna Medicare |
$22,599.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27,162.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27,162.62
|
| Rate for Payer: BCBS MAPPO |
$21,730.10
|
| Rate for Payer: BCBS Trust/PPO |
$60,477.28
|
| Rate for Payer: BCN Medicare Advantage |
$21,730.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21,730.10
|
| Rate for Payer: Mclaren Medicare |
$21,730.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$22,816.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24,989.62
|
| Rate for Payer: PACE Medicare |
$20,643.60
|
| Rate for Payer: PACE SWMI |
$21,730.10
|
| Rate for Payer: PHP Medicare Advantage |
$21,730.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$42,316.48
|
| Rate for Payer: Priority Health Medicare |
$21,730.10
|
| Rate for Payer: Priority Health Narrow Network |
$33,853.18
|
| Rate for Payer: Railroad Medicare Medicare |
$21,730.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$44,982.52
|
| Rate for Payer: UHC Core |
$27,601.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$21,730.10
|
| Rate for Payer: UHC Exchange |
$29,562.72
|
| Rate for Payer: UHC Medicare Advantage |
$22,382.00
|
| Rate for Payer: VA VA |
$21,730.10
|
|
|
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC
|
Facility
|
IP
|
$28,010.90
|
|
|
Service Code
|
MS-DRG 482
|
| Min. Negotiated Rate |
$11,335.44 |
| Max. Negotiated Rate |
$28,010.90 |
| Rate for Payer: Aetna Medicare |
$12,409.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,915.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,915.05
|
| Rate for Payer: BCBS MAPPO |
$11,932.04
|
| Rate for Payer: BCBS Trust/PPO |
$28,010.90
|
| Rate for Payer: BCN Medicare Advantage |
$11,932.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,932.04
|
| Rate for Payer: Mclaren Medicare |
$11,932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,528.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,721.85
|
| Rate for Payer: PACE Medicare |
$11,335.44
|
| Rate for Payer: PACE SWMI |
$11,932.04
|
| Rate for Payer: PHP Medicare Advantage |
$11,932.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,793.41
|
| Rate for Payer: Priority Health Medicare |
$11,932.04
|
| Rate for Payer: Priority Health Narrow Network |
$18,234.73
|
| Rate for Payer: Railroad Medicare Medicare |
$11,932.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,229.45
|
| Rate for Payer: UHC Core |
$14,867.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,932.04
|
| Rate for Payer: UHC Exchange |
$15,923.71
|
| Rate for Payer: UHC Medicare Advantage |
$12,290.00
|
| Rate for Payer: VA VA |
$11,932.04
|
|
|
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC
|
Facility
|
IP
|
$71,256.96
|
|
|
Service Code
|
MS-DRG 521
|
| Min. Negotiated Rate |
$20,953.51 |
| Max. Negotiated Rate |
$71,256.96 |
| Rate for Payer: Aetna Medicare |
$22,938.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27,570.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27,570.41
|
| Rate for Payer: BCBS MAPPO |
$22,056.33
|
| Rate for Payer: BCBS Trust/PPO |
$71,256.96
|
| Rate for Payer: BCN Medicare Advantage |
$22,056.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22,056.33
|
| Rate for Payer: Mclaren Medicare |
$22,056.33
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$23,159.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25,364.78
|
| Rate for Payer: PACE Medicare |
$20,953.51
|
| Rate for Payer: PACE SWMI |
$22,056.33
|
| Rate for Payer: PHP Medicare Advantage |
$22,056.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$42,966.53
|
| Rate for Payer: Priority Health Medicare |
$22,056.33
|
| Rate for Payer: Priority Health Narrow Network |
$34,373.22
|
| Rate for Payer: Railroad Medicare Medicare |
$22,056.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45,673.53
|
| Rate for Payer: UHC Core |
$28,025.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$22,056.33
|
| Rate for Payer: UHC Exchange |
$30,016.86
|
| Rate for Payer: UHC Medicare Advantage |
$22,718.02
|
| Rate for Payer: VA VA |
$22,056.33
|
|
|
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC
|
Facility
|
IP
|
$39,690.89
|
|
|
Service Code
|
MS-DRG 522
|
| Min. Negotiated Rate |
$14,919.13 |
| Max. Negotiated Rate |
$39,690.89 |
| Rate for Payer: Aetna Medicare |
$16,332.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19,630.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19,630.44
|
| Rate for Payer: BCBS MAPPO |
$15,704.35
|
| Rate for Payer: BCBS Trust/PPO |
$39,690.89
|
| Rate for Payer: BCN Medicare Advantage |
$15,704.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15,704.35
|
| Rate for Payer: Mclaren Medicare |
$15,704.35
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$16,489.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18,060.00
|
| Rate for Payer: PACE Medicare |
$14,919.13
|
| Rate for Payer: PACE SWMI |
$15,704.35
|
| Rate for Payer: PHP Medicare Advantage |
$15,704.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$30,309.90
|
| Rate for Payer: Priority Health Medicare |
$15,704.35
|
| Rate for Payer: Priority Health Narrow Network |
$24,247.92
|
| Rate for Payer: Railroad Medicare Medicare |
$15,704.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32,219.50
|
| Rate for Payer: UHC Core |
$19,770.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$15,704.35
|
| Rate for Payer: UHC Exchange |
$21,174.81
|
| Rate for Payer: UHC Medicare Advantage |
$16,175.48
|
| Rate for Payer: VA VA |
$15,704.35
|
|
|
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$123,644.54
|
|
|
Service Code
|
MS-DRG 969
|
| Min. Negotiated Rate |
$47,488.39 |
| Max. Negotiated Rate |
$123,644.54 |
| Rate for Payer: Aetna Medicare |
$51,987.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62,484.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62,484.72
|
| Rate for Payer: BCBS MAPPO |
$49,987.78
|
| Rate for Payer: BCBS Trust/PPO |
$123,644.54
|
| Rate for Payer: BCN Medicare Advantage |
$49,987.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49,987.78
|
| Rate for Payer: Mclaren Medicare |
$49,987.78
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$52,487.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57,485.95
|
| Rate for Payer: PACE Medicare |
$47,488.39
|
| Rate for Payer: PACE SWMI |
$49,987.78
|
| Rate for Payer: PHP Medicare Advantage |
$49,987.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$98,621.26
|
| Rate for Payer: Priority Health Medicare |
$49,987.78
|
| Rate for Payer: Priority Health Narrow Network |
$78,897.01
|
| Rate for Payer: Railroad Medicare Medicare |
$49,987.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104,834.64
|
| Rate for Payer: UHC Core |
$64,327.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$49,987.78
|
| Rate for Payer: UHC Exchange |
$68,897.82
|
| Rate for Payer: UHC Medicare Advantage |
$51,487.41
|
| Rate for Payer: VA VA |
$49,987.78
|
|
|
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC
|
Facility
|
IP
|
$40,033.45
|
|
|
Service Code
|
MS-DRG 970
|
| Min. Negotiated Rate |
$19,485.29 |
| Max. Negotiated Rate |
$40,033.45 |
| Rate for Payer: Aetna Medicare |
$21,331.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25,638.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25,638.54
|
| Rate for Payer: BCBS MAPPO |
$20,510.83
|
| Rate for Payer: BCBS Trust/PPO |
$40,033.45
|
| Rate for Payer: BCN Medicare Advantage |
$20,510.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20,510.83
|
| Rate for Payer: Mclaren Medicare |
$20,510.83
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$21,536.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23,587.45
|
| Rate for Payer: PACE Medicare |
$19,485.29
|
| Rate for Payer: PACE SWMI |
$20,510.83
|
| Rate for Payer: PHP Medicare Advantage |
$20,510.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34,502.95
|
| Rate for Payer: Priority Health Medicare |
$20,510.83
|
| Rate for Payer: Priority Health Narrow Network |
$27,602.36
|
| Rate for Payer: Railroad Medicare Medicare |
$20,510.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36,676.72
|
| Rate for Payer: UHC Core |
$22,505.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$20,510.83
|
| Rate for Payer: UHC Exchange |
$24,104.11
|
| Rate for Payer: UHC Medicare Advantage |
$21,126.15
|
| Rate for Payer: VA VA |
$20,510.83
|
|
|
HIV WITH MAJOR RELATED CONDITION WITH CC
|
Facility
|
IP
|
$20,795.78
|
|
|
Service Code
|
MS-DRG 975
|
| Min. Negotiated Rate |
$9,795.38 |
| Max. Negotiated Rate |
$20,795.78 |
| Rate for Payer: Aetna Medicare |
$10,723.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,888.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,888.66
|
| Rate for Payer: BCBS MAPPO |
$10,310.93
|
| Rate for Payer: BCBS Trust/PPO |
$12,505.65
|
| Rate for Payer: BCN Medicare Advantage |
$10,310.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,310.93
|
| Rate for Payer: Mclaren Medicare |
$10,310.93
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,826.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,857.57
|
| Rate for Payer: PACE Medicare |
$9,795.38
|
| Rate for Payer: PACE SWMI |
$10,310.93
|
| Rate for Payer: PHP Medicare Advantage |
$10,310.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19,563.25
|
| Rate for Payer: Priority Health Medicare |
$10,310.93
|
| Rate for Payer: Priority Health Narrow Network |
$15,650.60
|
| Rate for Payer: Railroad Medicare Medicare |
$10,310.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20,795.78
|
| Rate for Payer: UHC Core |
$12,760.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,310.93
|
| Rate for Payer: UHC Exchange |
$13,667.08
|
| Rate for Payer: UHC Medicare Advantage |
$10,620.26
|
| Rate for Payer: VA VA |
$10,310.93
|
|
|
HIV WITH MAJOR RELATED CONDITION WITH MCC
|
Facility
|
IP
|
$47,631.27
|
|
|
Service Code
|
MS-DRG 974
|
| Min. Negotiated Rate |
$20,421.92 |
| Max. Negotiated Rate |
$47,631.27 |
| Rate for Payer: Aetna Medicare |
$22,356.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$26,870.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$26,870.95
|
| Rate for Payer: BCBS MAPPO |
$21,496.76
|
| Rate for Payer: BCBS Trust/PPO |
$47,631.27
|
| Rate for Payer: BCN Medicare Advantage |
$21,496.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21,496.76
|
| Rate for Payer: Mclaren Medicare |
$21,496.76
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$22,571.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24,721.27
|
| Rate for Payer: PACE Medicare |
$20,421.92
|
| Rate for Payer: PACE SWMI |
$21,496.76
|
| Rate for Payer: PHP Medicare Advantage |
$21,496.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$41,851.54
|
| Rate for Payer: Priority Health Medicare |
$21,496.76
|
| Rate for Payer: Priority Health Narrow Network |
$33,481.23
|
| Rate for Payer: Railroad Medicare Medicare |
$21,496.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$44,488.29
|
| Rate for Payer: UHC Core |
$27,298.44
|
| Rate for Payer: UHC Dual Complete DSNP |
$21,496.76
|
| Rate for Payer: UHC Exchange |
$29,237.91
|
| Rate for Payer: UHC Medicare Advantage |
$22,141.66
|
| Rate for Payer: VA VA |
$21,496.76
|
|
|
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC
|
Facility
|
IP
|
$12,894.21
|
|
|
Service Code
|
MS-DRG 976
|
| Min. Negotiated Rate |
$6,251.38 |
| Max. Negotiated Rate |
$12,894.21 |
| Rate for Payer: Aetna Medicare |
$6,843.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,225.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,225.50
|
| Rate for Payer: BCBS MAPPO |
$6,580.40
|
| Rate for Payer: BCBS Trust/PPO |
$12,143.33
|
| Rate for Payer: BCN Medicare Advantage |
$6,580.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,580.40
|
| Rate for Payer: Mclaren Medicare |
$6,580.40
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,909.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,567.46
|
| Rate for Payer: PACE Medicare |
$6,251.38
|
| Rate for Payer: PACE SWMI |
$6,580.40
|
| Rate for Payer: PHP Medicare Advantage |
$6,580.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,129.99
|
| Rate for Payer: Priority Health Medicare |
$6,580.40
|
| Rate for Payer: Priority Health Narrow Network |
$9,703.99
|
| Rate for Payer: Railroad Medicare Medicare |
$6,580.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,894.21
|
| Rate for Payer: UHC Core |
$7,912.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,580.40
|
| Rate for Payer: UHC Exchange |
$8,474.13
|
| Rate for Payer: UHC Medicare Advantage |
$6,777.81
|
| Rate for Payer: VA VA |
$6,580.40
|
|
|
HIV WITH OR WITHOUT OTHER RELATED CONDITION
|
Facility
|
IP
|
$21,601.19
|
|
|
Service Code
|
MS-DRG 977
|
| Min. Negotiated Rate |
$10,156.63 |
| Max. Negotiated Rate |
$21,601.19 |
| Rate for Payer: Aetna Medicare |
$11,118.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,363.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,363.99
|
| Rate for Payer: BCBS MAPPO |
$10,691.19
|
| Rate for Payer: BCBS Trust/PPO |
$18,594.88
|
| Rate for Payer: BCN Medicare Advantage |
$10,691.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,691.19
|
| Rate for Payer: Mclaren Medicare |
$10,691.19
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,225.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,294.87
|
| Rate for Payer: PACE Medicare |
$10,156.63
|
| Rate for Payer: PACE SWMI |
$10,691.19
|
| Rate for Payer: PHP Medicare Advantage |
$10,691.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,320.92
|
| Rate for Payer: Priority Health Medicare |
$10,691.19
|
| Rate for Payer: Priority Health Narrow Network |
$16,256.74
|
| Rate for Payer: Railroad Medicare Medicare |
$10,691.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21,601.19
|
| Rate for Payer: UHC Core |
$13,254.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,691.19
|
| Rate for Payer: UHC Exchange |
$14,196.40
|
| Rate for Payer: UHC Medicare Advantage |
$11,011.93
|
| Rate for Payer: VA VA |
$10,691.19
|
|
|
HONEY 100 % TOPICAL PASTE
|
Facility
|
IP
|
$56.21
|
|
|
Service Code
|
NDC 995803361
|
| Hospital Charge Code |
166117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.41 |
| Max. Negotiated Rate |
$50.59 |
| Rate for Payer: Aetna Commercial |
$47.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.54
|
| Rate for Payer: Cash Price |
$44.97
|
| Rate for Payer: Cofinity Commercial |
$39.35
|
| Rate for Payer: Cofinity Commercial |
$48.34
|
| Rate for Payer: Healthscope Commercial |
$50.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.78
|
| Rate for Payer: PHP Commercial |
$47.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.35
|
| Rate for Payer: Priority Health SBD |
$35.41
|
|
|
HONEY 100 % TOPICAL PASTE
|
Facility
|
IP
|
$56.21
|
|
|
Service Code
|
NDC 995803360
|
| Hospital Charge Code |
166117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.41 |
| Max. Negotiated Rate |
$50.59 |
| Rate for Payer: Aetna Commercial |
$47.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.54
|
| Rate for Payer: Cash Price |
$44.97
|
| Rate for Payer: Cofinity Commercial |
$48.34
|
| Rate for Payer: Cofinity Commercial |
$39.35
|
| Rate for Payer: Healthscope Commercial |
$50.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.78
|
| Rate for Payer: PHP Commercial |
$47.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.35
|
| Rate for Payer: Priority Health SBD |
$35.41
|
|
|
HONEY 80 % TOPICAL GEL
|
Facility
|
IP
|
$56.21
|
|
|
Service Code
|
NDC 995803471
|
| Hospital Charge Code |
164073
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.41 |
| Max. Negotiated Rate |
$50.59 |
| Rate for Payer: Aetna Commercial |
$47.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.54
|
| Rate for Payer: Cash Price |
$44.97
|
| Rate for Payer: Cofinity Commercial |
$39.35
|
| Rate for Payer: Cofinity Commercial |
$48.34
|
| Rate for Payer: Healthscope Commercial |
$50.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.78
|
| Rate for Payer: PHP Commercial |
$47.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.35
|
| Rate for Payer: Priority Health SBD |
$35.41
|
|
|
HUM PROTHROMBIN CPLX (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION
|
Facility
|
IP
|
$4.93
|
|
|
Service Code
|
HCPCS J7168
|
| Hospital Charge Code |
170850
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$4.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.20
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cofinity Commercial |
$4.24
|
| Rate for Payer: Cofinity Commercial |
$3.45
|
| Rate for Payer: Healthscope Commercial |
$4.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.19
|
| Rate for Payer: PHP Commercial |
$4.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.45
|
| Rate for Payer: Priority Health SBD |
$3.11
|
|
|
HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION
|
Facility
|
IP
|
$165.57
|
|
|
Service Code
|
HCPCS J3473
|
| Hospital Charge Code |
76338
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.31 |
| Max. Negotiated Rate |
$149.01 |
| Rate for Payer: Aetna Commercial |
$140.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.62
|
| Rate for Payer: Cash Price |
$132.46
|
| Rate for Payer: Cofinity Commercial |
$115.90
|
| Rate for Payer: Cofinity Commercial |
$142.39
|
| Rate for Payer: Healthscope Commercial |
$149.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$140.73
|
| Rate for Payer: PHP Commercial |
$140.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.90
|
| Rate for Payer: Priority Health SBD |
$104.31
|
|
|
HYDRALAZINE 100 MG TABLET
|
Facility
|
IP
|
$453.55
|
|
|
Service Code
|
NDC 0904-6443-61
|
| Hospital Charge Code |
3699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.74 |
| Max. Negotiated Rate |
$408.20 |
| Rate for Payer: Aetna Commercial |
$385.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$294.81
|
| Rate for Payer: Cash Price |
$362.84
|
| Rate for Payer: Cofinity Commercial |
$317.48
|
| Rate for Payer: Cofinity Commercial |
$390.05
|
| Rate for Payer: Healthscope Commercial |
$408.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$385.52
|
| Rate for Payer: PHP Commercial |
$385.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.48
|
| Rate for Payer: Priority Health SBD |
$285.74
|
|
|
HYDRALAZINE 10 MG TABLET
|
Facility
|
IP
|
$3.86
|
|
|
Service Code
|
NDC 51079-074-01
|
| Hospital Charge Code |
3698
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.47 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.51
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Cofinity Commercial |
$2.70
|
| Rate for Payer: Cofinity Commercial |
$3.32
|
| Rate for Payer: Healthscope Commercial |
$3.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.28
|
| Rate for Payer: PHP Commercial |
$3.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.70
|
| Rate for Payer: Priority Health SBD |
$2.43
|
|
|
HYDRALAZINE 10 MG TABLET
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 68084-447-01
|
| Hospital Charge Code |
3698
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$217.63 |
| Max. Negotiated Rate |
$310.90 |
| Rate for Payer: Aetna Commercial |
$293.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.54
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$241.82
|
| Rate for Payer: Cofinity Commercial |
$297.09
|
| Rate for Payer: Healthscope Commercial |
$310.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.63
|
| Rate for Payer: PHP Commercial |
$293.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.82
|
| Rate for Payer: Priority Health SBD |
$217.63
|
|
|
HYDRALAZINE 10 MG TABLET
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 51079-074-20
|
| Hospital Charge Code |
3698
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.80 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.51
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$269.78
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.78
|
| Rate for Payer: Priority Health SBD |
$242.80
|
|
|
HYDRALAZINE 10 MG TABLET
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 68084-447-11
|
| Hospital Charge Code |
3698
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$217.63 |
| Max. Negotiated Rate |
$310.90 |
| Rate for Payer: Aetna Commercial |
$293.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.54
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$241.82
|
| Rate for Payer: Cofinity Commercial |
$297.09
|
| Rate for Payer: Healthscope Commercial |
$310.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.63
|
| Rate for Payer: PHP Commercial |
$293.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.82
|
| Rate for Payer: Priority Health SBD |
$217.63
|
|
|
HYDRALAZINE 10 MG TABLET
|
Facility
|
IP
|
$227.95
|
|
|
Service Code
|
NDC 0904-6440-61
|
| Hospital Charge Code |
3698
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.61 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$193.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.17
|
| Rate for Payer: Cash Price |
$182.36
|
| Rate for Payer: Cofinity Commercial |
$196.04
|
| Rate for Payer: Cofinity Commercial |
$159.56
|
| Rate for Payer: Healthscope Commercial |
$205.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.76
|
| Rate for Payer: PHP Commercial |
$193.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.56
|
| Rate for Payer: Priority Health SBD |
$143.61
|
|
|
HYDRALAZINE 20 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$175.41
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
3697
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.51 |
| Max. Negotiated Rate |
$157.87 |
| Rate for Payer: Aetna Commercial |
$149.10
|
| Rate for Payer: Aetna Commercial |
$19.78
|
| Rate for Payer: Aetna Commercial |
$31.60
|
| Rate for Payer: Aetna Commercial |
$23.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.78
|
| Rate for Payer: Cash Price |
$21.89
|
| Rate for Payer: Cash Price |
$140.33
|
| Rate for Payer: Cash Price |
$18.62
|
| Rate for Payer: Cash Price |
$29.74
|
| Rate for Payer: Cofinity Commercial |
$23.53
|
| Rate for Payer: Cofinity Commercial |
$26.03
|
| Rate for Payer: Cofinity Commercial |
$20.01
|
| Rate for Payer: Cofinity Commercial |
$150.85
|
| Rate for Payer: Cofinity Commercial |
$19.15
|
| Rate for Payer: Cofinity Commercial |
$16.29
|
| Rate for Payer: Cofinity Commercial |
$122.79
|
| Rate for Payer: Cofinity Commercial |
$31.97
|
| Rate for Payer: Healthscope Commercial |
$24.62
|
| Rate for Payer: Healthscope Commercial |
$20.94
|
| Rate for Payer: Healthscope Commercial |
$157.87
|
| Rate for Payer: Healthscope Commercial |
$33.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$149.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.26
|
| Rate for Payer: PHP Commercial |
$31.60
|
| Rate for Payer: PHP Commercial |
$149.10
|
| Rate for Payer: PHP Commercial |
$23.26
|
| Rate for Payer: PHP Commercial |
$19.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.15
|
| Rate for Payer: Priority Health SBD |
$17.24
|
| Rate for Payer: Priority Health SBD |
$110.51
|
| Rate for Payer: Priority Health SBD |
$14.66
|
| Rate for Payer: Priority Health SBD |
$23.42
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
IP
|
$4.21
|
|
|
Service Code
|
NDC 51079-075-01
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$3.79 |
| Rate for Payer: Aetna Commercial |
$3.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.74
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cofinity Commercial |
$2.95
|
| Rate for Payer: Cofinity Commercial |
$3.62
|
| Rate for Payer: Healthscope Commercial |
$3.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.58
|
| Rate for Payer: PHP Commercial |
$3.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.95
|
| Rate for Payer: Priority Health SBD |
$2.65
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
IP
|
$258.50
|
|
|
Service Code
|
NDC 0904-6441-61
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.86 |
| Max. Negotiated Rate |
$232.65 |
| Rate for Payer: Aetna Commercial |
$219.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.02
|
| Rate for Payer: Cash Price |
$206.80
|
| Rate for Payer: Cofinity Commercial |
$180.95
|
| Rate for Payer: Cofinity Commercial |
$222.31
|
| Rate for Payer: Healthscope Commercial |
$232.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$219.72
|
| Rate for Payer: PHP Commercial |
$219.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.95
|
| Rate for Payer: Priority Health SBD |
$162.86
|
|
|
HYDRALAZINE 25 MG TABLET
|
Facility
|
IP
|
$84.60
|
|
|
Service Code
|
NDC 23155-833-01
|
| Hospital Charge Code |
3700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.30 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Commercial |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.91
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.22
|
| Rate for Payer: Priority Health SBD |
$53.30
|
|
