|
MORPHINE VARIABLE DOSE
|
Facility
|
IP
|
$11.68
|
|
|
Service Code
|
HCPCS J2270
|
| Hospital Charge Code |
150710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: Aetna Commercial |
$9.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.59
|
| Rate for Payer: Cash Price |
$9.34
|
| Rate for Payer: Cofinity Commercial |
$10.04
|
| Rate for Payer: Cofinity Commercial |
$8.18
|
| Rate for Payer: Healthscope Commercial |
$10.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.93
|
| Rate for Payer: PHP Commercial |
$9.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.18
|
| Rate for Payer: Priority Health SBD |
$7.36
|
|
|
MOUTH PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$22,952.69
|
|
|
Service Code
|
MS-DRG 137
|
| Min. Negotiated Rate |
$10,762.81 |
| Max. Negotiated Rate |
$22,952.69 |
| Rate for Payer: Aetna Medicare |
$11,782.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,161.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,161.59
|
| Rate for Payer: BCBS MAPPO |
$11,329.27
|
| Rate for Payer: BCBS Trust/PPO |
$22,053.42
|
| Rate for Payer: BCN Medicare Advantage |
$11,329.27
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,329.27
|
| Rate for Payer: Mclaren Medicare |
$11,329.27
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$11,895.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,028.66
|
| Rate for Payer: PACE Medicare |
$10,762.81
|
| Rate for Payer: PACE SWMI |
$11,329.27
|
| Rate for Payer: PHP Medicare Advantage |
$11,329.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21,592.32
|
| Rate for Payer: Priority Health Medicare |
$11,329.27
|
| Rate for Payer: Priority Health Narrow Network |
$17,273.86
|
| Rate for Payer: Railroad Medicare Medicare |
$11,329.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22,952.69
|
| Rate for Payer: UHC Core |
$14,083.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,329.27
|
| Rate for Payer: UHC Exchange |
$15,084.62
|
| Rate for Payer: UHC Medicare Advantage |
$11,669.15
|
| Rate for Payer: VA VA |
$11,329.27
|
|
|
MOUTH PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$13,205.39
|
|
|
Service Code
|
MS-DRG 138
|
| Min. Negotiated Rate |
$6,390.96 |
| Max. Negotiated Rate |
$13,205.39 |
| Rate for Payer: Aetna Medicare |
$6,996.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,409.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,409.16
|
| Rate for Payer: BCBS MAPPO |
$6,727.33
|
| Rate for Payer: BCBS Trust/PPO |
$12,687.91
|
| Rate for Payer: BCN Medicare Advantage |
$6,727.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,727.33
|
| Rate for Payer: Mclaren Medicare |
$6,727.33
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,063.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,736.43
|
| Rate for Payer: PACE Medicare |
$6,390.96
|
| Rate for Payer: PACE SWMI |
$6,727.33
|
| Rate for Payer: PHP Medicare Advantage |
$6,727.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,422.73
|
| Rate for Payer: Priority Health Medicare |
$6,727.33
|
| Rate for Payer: Priority Health Narrow Network |
$9,938.18
|
| Rate for Payer: Railroad Medicare Medicare |
$6,727.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,205.39
|
| Rate for Payer: UHC Core |
$8,102.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,727.33
|
| Rate for Payer: UHC Exchange |
$8,678.64
|
| Rate for Payer: UHC Medicare Advantage |
$6,929.15
|
| Rate for Payer: VA VA |
$6,727.33
|
|
|
MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$190.24
|
|
|
Service Code
|
HCPCS J2280
|
| Hospital Charge Code |
31906
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.85 |
| Max. Negotiated Rate |
$171.22 |
| Rate for Payer: Aetna Commercial |
$161.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.66
|
| Rate for Payer: Cash Price |
$152.19
|
| Rate for Payer: Cofinity Commercial |
$163.61
|
| Rate for Payer: Cofinity Commercial |
$133.17
|
| Rate for Payer: Healthscope Commercial |
$171.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.70
|
| Rate for Payer: PHP Commercial |
$161.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.17
|
| Rate for Payer: Priority Health SBD |
$119.85
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC
|
Facility
|
IP
|
$25,459.26
|
|
|
Service Code
|
MS-DRG 059
|
| Min. Negotiated Rate |
$8,590.55 |
| Max. Negotiated Rate |
$25,459.26 |
| Rate for Payer: Aetna Medicare |
$9,404.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,303.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,303.35
|
| Rate for Payer: BCBS MAPPO |
$9,042.68
|
| Rate for Payer: BCBS Trust/PPO |
$25,459.26
|
| Rate for Payer: BCN Medicare Advantage |
$9,042.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,042.68
|
| Rate for Payer: Mclaren Medicare |
$9,042.68
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,494.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,399.08
|
| Rate for Payer: PACE Medicare |
$8,590.55
|
| Rate for Payer: PACE SWMI |
$9,042.68
|
| Rate for Payer: PHP Medicare Advantage |
$9,042.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,036.23
|
| Rate for Payer: Priority Health Medicare |
$9,042.68
|
| Rate for Payer: Priority Health Narrow Network |
$13,628.98
|
| Rate for Payer: Railroad Medicare Medicare |
$9,042.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18,109.55
|
| Rate for Payer: UHC Core |
$11,112.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,042.68
|
| Rate for Payer: UHC Exchange |
$11,901.68
|
| Rate for Payer: UHC Medicare Advantage |
$9,313.96
|
| Rate for Payer: VA VA |
$9,042.68
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC
|
Facility
|
IP
|
$26,570.39
|
|
|
Service Code
|
MS-DRG 058
|
| Min. Negotiated Rate |
$12,289.86 |
| Max. Negotiated Rate |
$26,570.39 |
| Rate for Payer: Aetna Medicare |
$13,454.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16,170.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16,170.88
|
| Rate for Payer: BCBS MAPPO |
$12,936.70
|
| Rate for Payer: BCBS Trust/PPO |
$26,570.39
|
| Rate for Payer: BCN Medicare Advantage |
$12,936.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,936.70
|
| Rate for Payer: Mclaren Medicare |
$12,936.70
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$13,583.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,877.20
|
| Rate for Payer: PACE Medicare |
$12,289.86
|
| Rate for Payer: PACE SWMI |
$12,936.70
|
| Rate for Payer: PHP Medicare Advantage |
$12,936.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24,795.23
|
| Rate for Payer: Priority Health Medicare |
$12,936.70
|
| Rate for Payer: Priority Health Narrow Network |
$19,836.18
|
| Rate for Payer: Railroad Medicare Medicare |
$12,936.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26,357.39
|
| Rate for Payer: UHC Core |
$16,173.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,936.70
|
| Rate for Payer: UHC Exchange |
$17,322.20
|
| Rate for Payer: UHC Medicare Advantage |
$13,324.80
|
| Rate for Payer: VA VA |
$12,936.70
|
|
|
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC
|
Facility
|
IP
|
$16,787.66
|
|
|
Service Code
|
MS-DRG 060
|
| Min. Negotiated Rate |
$6,607.85 |
| Max. Negotiated Rate |
$16,787.66 |
| Rate for Payer: Aetna Medicare |
$7,233.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,694.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,694.54
|
| Rate for Payer: BCBS MAPPO |
$6,955.63
|
| Rate for Payer: BCBS Trust/PPO |
$16,787.66
|
| Rate for Payer: BCN Medicare Advantage |
$6,955.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,955.63
|
| Rate for Payer: Mclaren Medicare |
$6,955.63
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,303.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,998.97
|
| Rate for Payer: PACE Medicare |
$6,607.85
|
| Rate for Payer: PACE SWMI |
$6,955.63
|
| Rate for Payer: PHP Medicare Advantage |
$6,955.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,877.62
|
| Rate for Payer: Priority Health Medicare |
$6,955.63
|
| Rate for Payer: Priority Health Narrow Network |
$10,302.10
|
| Rate for Payer: Railroad Medicare Medicare |
$6,955.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,688.94
|
| Rate for Payer: UHC Core |
$8,399.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,955.63
|
| Rate for Payer: UHC Exchange |
$8,996.44
|
| Rate for Payer: UHC Medicare Advantage |
$7,164.30
|
| Rate for Payer: VA VA |
$6,955.63
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET
|
Facility
|
IP
|
$275.60
|
|
|
Service Code
|
NDC 4098522368
|
| Hospital Charge Code |
118929
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.63 |
| Max. Negotiated Rate |
$248.04 |
| Rate for Payer: Aetna Commercial |
$234.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.14
|
| Rate for Payer: Cash Price |
$220.48
|
| Rate for Payer: Cofinity Commercial |
$192.92
|
| Rate for Payer: Cofinity Commercial |
$237.02
|
| Rate for Payer: Healthscope Commercial |
$248.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.26
|
| Rate for Payer: PHP Commercial |
$234.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.92
|
| Rate for Payer: Priority Health SBD |
$173.63
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET
|
Facility
|
IP
|
$187.20
|
|
|
Service Code
|
NDC 8068116000
|
| Hospital Charge Code |
118929
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.94 |
| Max. Negotiated Rate |
$168.48 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.68
|
| Rate for Payer: Cash Price |
$149.76
|
| Rate for Payer: Cofinity Commercial |
$131.04
|
| Rate for Payer: Cofinity Commercial |
$160.99
|
| Rate for Payer: Healthscope Commercial |
$168.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$159.12
|
| Rate for Payer: PHP Commercial |
$159.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.04
|
| Rate for Payer: Priority Health SBD |
$117.94
|
|
|
MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
NDC 904549261
|
| Hospital Charge Code |
118929
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.40 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cofinity Commercial |
$126.00
|
| Rate for Payer: Cofinity Commercial |
$154.80
|
| Rate for Payer: Healthscope Commercial |
$162.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$153.00
|
| Rate for Payer: PHP Commercial |
$153.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.00
|
| Rate for Payer: Priority Health SBD |
$113.40
|
|
|
MULTIVITAMIN-MINERALS-IRON FUMARATE 19 MG-FOLIC ACID 400 MCG TABLET
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
NDC 9629512782
|
| Hospital Charge Code |
196928
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.04 |
| Max. Negotiated Rate |
$187.20 |
| Rate for Payer: Aetna Commercial |
$176.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.20
|
| Rate for Payer: Cash Price |
$166.40
|
| Rate for Payer: Cofinity Commercial |
$145.60
|
| Rate for Payer: Cofinity Commercial |
$178.88
|
| Rate for Payer: Healthscope Commercial |
$187.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$176.80
|
| Rate for Payer: PHP Commercial |
$176.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.60
|
| Rate for Payer: Priority Health SBD |
$131.04
|
|
|
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID
|
Facility
|
IP
|
$12.29
|
|
|
Service Code
|
NDC 9900-0008-00
|
| Hospital Charge Code |
119617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.74 |
| Max. Negotiated Rate |
$11.06 |
| Rate for Payer: Aetna Commercial |
$10.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.99
|
| Rate for Payer: Cash Price |
$9.83
|
| Rate for Payer: Cofinity Commercial |
$10.57
|
| Rate for Payer: Cofinity Commercial |
$8.60
|
| Rate for Payer: Healthscope Commercial |
$11.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.45
|
| Rate for Payer: PHP Commercial |
$10.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.60
|
| Rate for Payer: Priority Health SBD |
$7.74
|
|
|
MULTIVIT AND MINERALS-FERROUS GLUCONATE 9 MG IRON/15 ML ORAL LIQUID
|
Facility
|
IP
|
$24.60
|
|
|
Service Code
|
NDC 5434462
|
| Hospital Charge Code |
119617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$22.14 |
| Rate for Payer: Aetna Commercial |
$20.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.99
|
| Rate for Payer: Cash Price |
$19.68
|
| Rate for Payer: Cofinity Commercial |
$17.22
|
| Rate for Payer: Cofinity Commercial |
$21.16
|
| Rate for Payer: Healthscope Commercial |
$22.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.91
|
| Rate for Payer: PHP Commercial |
$20.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.22
|
| Rate for Payer: Priority Health SBD |
$15.50
|
|
|
MUPIROCIN 2 % TOPICAL OINTMENT
|
Facility
|
IP
|
$20.20
|
|
|
Service Code
|
NDC 51672-1312-0
|
| Hospital Charge Code |
10674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.73 |
| Max. Negotiated Rate |
$18.18 |
| Rate for Payer: Aetna Commercial |
$17.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.13
|
| Rate for Payer: Cash Price |
$16.16
|
| Rate for Payer: Cofinity Commercial |
$14.14
|
| Rate for Payer: Cofinity Commercial |
$17.37
|
| Rate for Payer: Healthscope Commercial |
$18.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.17
|
| Rate for Payer: PHP Commercial |
$17.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.14
|
| Rate for Payer: Priority Health SBD |
$12.73
|
|
|
MUPIROCIN 2 % TOPICAL OINTMENT
|
Facility
|
IP
|
$29.96
|
|
|
Service Code
|
NDC 68462-180-22
|
| Hospital Charge Code |
10674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.87 |
| Max. Negotiated Rate |
$26.96 |
| Rate for Payer: Aetna Commercial |
$25.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.47
|
| Rate for Payer: Cash Price |
$23.97
|
| Rate for Payer: Cofinity Commercial |
$20.97
|
| Rate for Payer: Cofinity Commercial |
$25.77
|
| Rate for Payer: Healthscope Commercial |
$26.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.47
|
| Rate for Payer: PHP Commercial |
$25.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.97
|
| Rate for Payer: Priority Health SBD |
$18.87
|
|
|
MUPIROCIN 2 % TOPICAL OINTMENT
|
Facility
|
IP
|
$29.96
|
|
|
Service Code
|
NDC 45802-112-22
|
| Hospital Charge Code |
10674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.87 |
| Max. Negotiated Rate |
$26.96 |
| Rate for Payer: Aetna Commercial |
$25.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.47
|
| Rate for Payer: Cash Price |
$23.97
|
| Rate for Payer: Cofinity Commercial |
$20.97
|
| Rate for Payer: Cofinity Commercial |
$25.77
|
| Rate for Payer: Healthscope Commercial |
$26.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.47
|
| Rate for Payer: PHP Commercial |
$25.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.97
|
| Rate for Payer: Priority Health SBD |
$18.87
|
|
|
MUPIROCIN 2 % TOPICAL OINTMENT
|
Facility
|
IP
|
$106.65
|
|
|
Service Code
|
NDC 0093-1010-42
|
| Hospital Charge Code |
10674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.19 |
| Max. Negotiated Rate |
$95.98 |
| Rate for Payer: Aetna Commercial |
$90.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.32
|
| Rate for Payer: Cash Price |
$85.32
|
| Rate for Payer: Cofinity Commercial |
$74.66
|
| Rate for Payer: Cofinity Commercial |
$91.72
|
| Rate for Payer: Healthscope Commercial |
$95.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.65
|
| Rate for Payer: PHP Commercial |
$90.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.66
|
| Rate for Payer: Priority Health SBD |
$67.19
|
|
|
MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK WITH NAMED VASCULAR PEDICLE (IE, BUCCINATORS, GENIOGLOSSUS, TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)
|
Facility
|
OP
|
$5,427.00
|
|
|
Service Code
|
CPT 15733
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,010.16 |
| Max. Negotiated Rate |
$5,427.00 |
| 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 |
$2,545.67
|
| 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 Medicare |
$3,192.24
|
| Rate for Payer: Railroad Medicare Medicare |
$3,192.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,111.18
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,192.24
|
| Rate for Payer: UHC Exchange |
$1,010.16
|
| Rate for Payer: UHC Medicare Advantage |
$3,288.01
|
| Rate for Payer: VA VA |
$3,192.24
|
|
|
MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY
|
Facility
|
OP
|
$5,427.00
|
|
|
Service Code
|
CPT 15738
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,243.95 |
| Max. Negotiated Rate |
$5,427.00 |
| 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 |
$1,370.72
|
| 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 Medicare |
$3,192.24
|
| Rate for Payer: Railroad Medicare Medicare |
$3,192.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,368.34
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,192.24
|
| Rate for Payer: UHC Exchange |
$1,243.95
|
| Rate for Payer: UHC Medicare Advantage |
$3,288.01
|
| Rate for Payer: VA VA |
$3,192.24
|
|
|
MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK
|
Facility
|
OP
|
$5,427.00
|
|
|
Service Code
|
CPT 15734
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,370.72 |
| Max. Negotiated Rate |
$5,427.00 |
| 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 |
$1,370.72
|
| 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 Medicare |
$3,192.24
|
| Rate for Payer: Railroad Medicare Medicare |
$3,192.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,621.20
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,192.24
|
| Rate for Payer: UHC Exchange |
$1,473.82
|
| Rate for Payer: UHC Medicare Advantage |
$3,288.01
|
| Rate for Payer: VA VA |
$3,192.24
|
|
|
MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$33.78
|
|
|
Service Code
|
NDC 54643-5649-1
|
| Hospital Charge Code |
161578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Aetna Commercial |
$28.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.96
|
| Rate for Payer: Cash Price |
$27.02
|
| Rate for Payer: Cofinity Commercial |
$23.65
|
| Rate for Payer: Cofinity Commercial |
$29.05
|
| Rate for Payer: Healthscope Commercial |
$30.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.71
|
| Rate for Payer: PHP Commercial |
$28.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.65
|
| Rate for Payer: Priority Health SBD |
$21.28
|
|
|
MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$239.36
|
|
|
Service Code
|
HCPCS J7519
|
| Hospital Charge Code |
23968
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.80 |
| Max. Negotiated Rate |
$215.42 |
| Rate for Payer: Aetna Commercial |
$203.46
|
| Rate for Payer: Aetna Commercial |
$113.76
|
| Rate for Payer: Aetna Commercial |
$193.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.58
|
| Rate for Payer: Cash Price |
$191.49
|
| Rate for Payer: Cash Price |
$107.07
|
| Rate for Payer: Cash Price |
$182.53
|
| Rate for Payer: Cofinity Commercial |
$93.69
|
| Rate for Payer: Cofinity Commercial |
$115.10
|
| Rate for Payer: Cofinity Commercial |
$159.71
|
| Rate for Payer: Cofinity Commercial |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$205.85
|
| Rate for Payer: Cofinity Commercial |
$167.55
|
| Rate for Payer: Healthscope Commercial |
$215.42
|
| Rate for Payer: Healthscope Commercial |
$120.46
|
| Rate for Payer: Healthscope Commercial |
$205.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$203.46
|
| Rate for Payer: PHP Commercial |
$113.76
|
| Rate for Payer: PHP Commercial |
$193.94
|
| Rate for Payer: PHP Commercial |
$203.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.55
|
| Rate for Payer: Priority Health SBD |
$84.32
|
| Rate for Payer: Priority Health SBD |
$143.74
|
| Rate for Payer: Priority Health SBD |
$150.80
|
|
|
MYCOPHENOLATE MOFETIL 250 MG CAPSULE
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
15113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.79
|
| Rate for Payer: Aetna Commercial |
$378.72
|
| Rate for Payer: Aetna Commercial |
$314.92
|
| Rate for Payer: Aetna Commercial |
$381.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$289.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.90
|
| Rate for Payer: Cash Price |
$356.44
|
| Rate for Payer: Cash Price |
$359.08
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Cofinity Commercial |
$311.88
|
| Rate for Payer: Cofinity Commercial |
$383.17
|
| Rate for Payer: Cofinity Commercial |
$318.63
|
| Rate for Payer: Cofinity Commercial |
$314.20
|
| Rate for Payer: Cofinity Commercial |
$259.35
|
| Rate for Payer: Cofinity Commercial |
$3.12
|
| Rate for Payer: Cofinity Commercial |
$3.84
|
| Rate for Payer: Healthscope Commercial |
$4.01
|
| Rate for Payer: Healthscope Commercial |
$333.45
|
| Rate for Payer: Healthscope Commercial |
$401.00
|
| Rate for Payer: Healthscope Commercial |
$403.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$378.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$314.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$381.52
|
| Rate for Payer: PHP Commercial |
$378.72
|
| Rate for Payer: PHP Commercial |
$314.92
|
| Rate for Payer: PHP Commercial |
$3.79
|
| Rate for Payer: PHP Commercial |
$381.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$259.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$311.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$314.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.12
|
| Rate for Payer: Priority Health SBD |
$282.78
|
| Rate for Payer: Priority Health SBD |
$233.42
|
| Rate for Payer: Priority Health SBD |
$2.81
|
| Rate for Payer: Priority Health SBD |
$280.70
|
|
|
MYCOPHENOLATE MOFETIL 500 MG TABLET
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
HCPCS J7517
|
| Hospital Charge Code |
21374
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$4.08
|
| Rate for Payer: Aetna Commercial |
$168.77
|
| Rate for Payer: Aetna Commercial |
$288.86
|
| Rate for Payer: Aetna Commercial |
$212.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$220.90
|
| Rate for Payer: Cash Price |
$271.87
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cash Price |
$199.88
|
| Rate for Payer: Cash Price |
$158.84
|
| Rate for Payer: Cofinity Commercial |
$3.36
|
| Rate for Payer: Cofinity Commercial |
$237.89
|
| Rate for Payer: Cofinity Commercial |
$138.98
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| Rate for Payer: Cofinity Commercial |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$292.26
|
| Rate for Payer: Cofinity Commercial |
$174.90
|
| Rate for Payer: Cofinity Commercial |
$214.87
|
| Rate for Payer: Healthscope Commercial |
$4.32
|
| Rate for Payer: Healthscope Commercial |
$224.86
|
| Rate for Payer: Healthscope Commercial |
$305.86
|
| Rate for Payer: Healthscope Commercial |
$178.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$288.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$168.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.37
|
| Rate for Payer: PHP Commercial |
$4.08
|
| Rate for Payer: PHP Commercial |
$168.77
|
| Rate for Payer: PHP Commercial |
$212.37
|
| Rate for Payer: PHP Commercial |
$288.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.36
|
| Rate for Payer: Priority Health SBD |
$3.02
|
| Rate for Payer: Priority Health SBD |
$125.09
|
| Rate for Payer: Priority Health SBD |
$214.10
|
| Rate for Payer: Priority Health SBD |
$157.41
|
|
|
MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$1,811.08
|
|
|
Service Code
|
NDC 60505-2966-7
|
| Hospital Charge Code |
38063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,140.98 |
| Max. Negotiated Rate |
$1,629.97 |
| Rate for Payer: Aetna Commercial |
$1,539.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,177.20
|
| Rate for Payer: Cash Price |
$1,448.86
|
| Rate for Payer: Cofinity Commercial |
$1,267.76
|
| Rate for Payer: Cofinity Commercial |
$1,557.53
|
| Rate for Payer: Healthscope Commercial |
$1,629.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,539.42
|
| Rate for Payer: PHP Commercial |
$1,539.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,267.76
|
| Rate for Payer: Priority Health SBD |
$1,140.98
|
|
