|
NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL HEMORRHAGE
|
Facility
|
OP
|
$4,793.34
|
|
|
Service Code
|
CPT 31238
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$164.05 |
| Max. Negotiated Rate |
$4,793.34 |
| Rate for Payer: Aetna Medicare |
$1,570.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,887.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,887.76
|
| Rate for Payer: BCBS Complete |
$867.46
|
| Rate for Payer: BCBS MAPPO |
$1,510.21
|
| Rate for Payer: BCBS Trust/PPO |
$1,131.76
|
| Rate for Payer: BCN Medicare Advantage |
$1,510.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,510.21
|
| Rate for Payer: Mclaren Medicaid |
$826.08
|
| Rate for Payer: Mclaren Medicare |
$1,510.21
|
| Rate for Payer: Meridian Medicaid |
$867.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,585.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,736.74
|
| Rate for Payer: PACE Medicare |
$1,434.70
|
| Rate for Payer: PACE SWMI |
$1,510.21
|
| Rate for Payer: PHP Medicare Advantage |
$1,510.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$826.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,793.34
|
| Rate for Payer: Priority Health Medicare |
$1,510.21
|
| Rate for Payer: Priority Health Narrow Network |
$3,834.67
|
| Rate for Payer: Railroad Medicare Medicare |
$1,510.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$180.46
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,510.21
|
| Rate for Payer: UHC Exchange |
$164.05
|
| Rate for Payer: UHC Medicare Advantage |
$1,555.52
|
| Rate for Payer: VA VA |
$1,510.21
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)
|
Facility
|
OP
|
$18,552.19
|
|
|
Service Code
|
CPT 31254
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$237.40 |
| Max. Negotiated Rate |
$18,552.19 |
| Rate for Payer: Aetna Medicare |
$6,333.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,612.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,612.51
|
| Rate for Payer: BCBS Complete |
$3,498.10
|
| Rate for Payer: BCBS MAPPO |
$6,090.01
|
| Rate for Payer: BCBS Trust/PPO |
$2,525.75
|
| Rate for Payer: BCN Medicare Advantage |
$6,090.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,090.01
|
| Rate for Payer: Mclaren Medicaid |
$3,331.24
|
| Rate for Payer: Mclaren Medicare |
$6,090.01
|
| Rate for Payer: Meridian Medicaid |
$3,498.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,394.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,003.51
|
| Rate for Payer: PACE Medicare |
$5,785.51
|
| Rate for Payer: PACE SWMI |
$6,090.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,090.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,331.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,552.19
|
| Rate for Payer: Priority Health Medicare |
$6,090.01
|
| Rate for Payer: Priority Health Narrow Network |
$14,841.75
|
| Rate for Payer: Railroad Medicare Medicare |
$6,090.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.14
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,090.01
|
| Rate for Payer: UHC Exchange |
$237.40
|
| Rate for Payer: UHC Medicare Advantage |
$6,272.71
|
| Rate for Payer: VA VA |
$6,090.01
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)
|
Facility
|
OP
|
$18,552.19
|
|
|
Service Code
|
CPT 31255
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.33 |
| Max. Negotiated Rate |
$18,552.19 |
| Rate for Payer: Aetna Medicare |
$6,333.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,612.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,612.51
|
| Rate for Payer: BCBS Complete |
$3,498.10
|
| Rate for Payer: BCBS MAPPO |
$6,090.01
|
| Rate for Payer: BCBS Trust/PPO |
$2,540.43
|
| Rate for Payer: BCN Medicare Advantage |
$6,090.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,090.01
|
| Rate for Payer: Mclaren Medicaid |
$3,331.24
|
| Rate for Payer: Mclaren Medicare |
$6,090.01
|
| Rate for Payer: Meridian Medicaid |
$3,498.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,394.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,003.51
|
| Rate for Payer: PACE Medicare |
$5,785.51
|
| Rate for Payer: PACE SWMI |
$6,090.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,090.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,331.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,552.19
|
| Rate for Payer: Priority Health Medicare |
$6,090.01
|
| Rate for Payer: Priority Health Narrow Network |
$14,841.75
|
| Rate for Payer: Railroad Medicare Medicare |
$6,090.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$346.86
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,090.01
|
| Rate for Payer: UHC Exchange |
$315.33
|
| Rate for Payer: UHC Medicare Advantage |
$6,272.71
|
| Rate for Payer: VA VA |
$6,090.01
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED
|
Facility
|
OP
|
$18,552.19
|
|
|
Service Code
|
CPT 31253
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$487.23 |
| Max. Negotiated Rate |
$18,552.19 |
| Rate for Payer: Aetna Medicare |
$6,333.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,612.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,612.51
|
| Rate for Payer: BCBS Complete |
$3,498.10
|
| Rate for Payer: BCBS MAPPO |
$6,090.01
|
| Rate for Payer: BCBS Trust/PPO |
$2,958.69
|
| Rate for Payer: BCN Medicare Advantage |
$6,090.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,090.01
|
| Rate for Payer: Mclaren Medicaid |
$3,331.24
|
| Rate for Payer: Mclaren Medicare |
$6,090.01
|
| Rate for Payer: Meridian Medicaid |
$3,498.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,394.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,003.51
|
| Rate for Payer: PACE Medicare |
$5,785.51
|
| Rate for Payer: PACE SWMI |
$6,090.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,090.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,331.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,552.19
|
| Rate for Payer: Priority Health Medicare |
$6,090.01
|
| Rate for Payer: Priority Health Narrow Network |
$14,841.75
|
| Rate for Payer: Railroad Medicare Medicare |
$6,090.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$535.95
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,090.01
|
| Rate for Payer: UHC Exchange |
$487.23
|
| Rate for Payer: UHC Medicare Advantage |
$6,272.71
|
| Rate for Payer: VA VA |
$6,090.01
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY
|
Facility
|
OP
|
$18,552.19
|
|
|
Service Code
|
CPT 31257
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$434.84 |
| Max. Negotiated Rate |
$18,552.19 |
| Rate for Payer: Aetna Medicare |
$6,333.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,612.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,612.51
|
| Rate for Payer: BCBS Complete |
$3,498.10
|
| Rate for Payer: BCBS MAPPO |
$6,090.01
|
| Rate for Payer: BCBS Trust/PPO |
$1,789.52
|
| Rate for Payer: BCN Medicare Advantage |
$6,090.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,090.01
|
| Rate for Payer: Mclaren Medicaid |
$3,331.24
|
| Rate for Payer: Mclaren Medicare |
$6,090.01
|
| Rate for Payer: Meridian Medicaid |
$3,498.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,394.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,003.51
|
| Rate for Payer: PACE Medicare |
$5,785.51
|
| Rate for Payer: PACE SWMI |
$6,090.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,090.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,331.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,552.19
|
| Rate for Payer: Priority Health Medicare |
$6,090.01
|
| Rate for Payer: Priority Health Narrow Network |
$14,841.75
|
| Rate for Payer: Railroad Medicare Medicare |
$6,090.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$478.32
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,090.01
|
| Rate for Payer: UHC Exchange |
$434.84
|
| Rate for Payer: UHC Medicare Advantage |
$6,272.71
|
| Rate for Payer: VA VA |
$6,090.01
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS
|
Facility
|
OP
|
$18,552.19
|
|
|
Service Code
|
CPT 31259
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$459.40 |
| Max. Negotiated Rate |
$18,552.19 |
| Rate for Payer: Aetna Medicare |
$6,333.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,612.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,612.51
|
| Rate for Payer: BCBS Complete |
$3,498.10
|
| Rate for Payer: BCBS MAPPO |
$6,090.01
|
| Rate for Payer: BCBS Trust/PPO |
$3,130.36
|
| Rate for Payer: BCN Medicare Advantage |
$6,090.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,090.01
|
| Rate for Payer: Mclaren Medicaid |
$3,331.24
|
| Rate for Payer: Mclaren Medicare |
$6,090.01
|
| Rate for Payer: Meridian Medicaid |
$3,498.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,394.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,003.51
|
| Rate for Payer: PACE Medicare |
$5,785.51
|
| Rate for Payer: PACE SWMI |
$6,090.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,090.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,331.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,552.19
|
| Rate for Payer: Priority Health Medicare |
$6,090.01
|
| Rate for Payer: Priority Health Narrow Network |
$14,841.75
|
| Rate for Payer: Railroad Medicare Medicare |
$6,090.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$505.34
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,090.01
|
| Rate for Payer: UHC Exchange |
$459.40
|
| Rate for Payer: UHC Medicare Advantage |
$6,272.71
|
| Rate for Payer: VA VA |
$6,090.01
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED
|
Facility
|
OP
|
$18,552.19
|
|
|
Service Code
|
CPT 31276
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$369.03 |
| Max. Negotiated Rate |
$18,552.19 |
| Rate for Payer: Aetna Medicare |
$6,333.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,612.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,612.51
|
| Rate for Payer: BCBS Complete |
$3,498.10
|
| Rate for Payer: BCBS MAPPO |
$6,090.01
|
| Rate for Payer: BCBS Trust/PPO |
$1,731.54
|
| Rate for Payer: BCN Medicare Advantage |
$6,090.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,090.01
|
| Rate for Payer: Mclaren Medicaid |
$3,331.24
|
| Rate for Payer: Mclaren Medicare |
$6,090.01
|
| Rate for Payer: Meridian Medicaid |
$3,498.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,394.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,003.51
|
| Rate for Payer: PACE Medicare |
$5,785.51
|
| Rate for Payer: PACE SWMI |
$6,090.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,090.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,331.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,552.19
|
| Rate for Payer: Priority Health Medicare |
$6,090.01
|
| Rate for Payer: Priority Health Narrow Network |
$14,841.75
|
| Rate for Payer: Railroad Medicare Medicare |
$6,090.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$405.93
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,090.01
|
| Rate for Payer: UHC Exchange |
$369.03
|
| Rate for Payer: UHC Medicare Advantage |
$6,272.71
|
| Rate for Payer: VA VA |
$6,090.01
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;
|
Facility
|
OP
|
$9,996.07
|
|
|
Service Code
|
CPT 31256
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$175.84 |
| Max. Negotiated Rate |
$9,996.07 |
| Rate for Payer: Aetna Medicare |
$3,465.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,165.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,165.16
|
| Rate for Payer: BCBS Complete |
$1,913.98
|
| Rate for Payer: BCBS MAPPO |
$3,332.13
|
| Rate for Payer: BCBS Trust/PPO |
$1,131.94
|
| Rate for Payer: BCN Medicare Advantage |
$3,332.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,332.13
|
| Rate for Payer: Mclaren Medicaid |
$1,822.68
|
| Rate for Payer: Mclaren Medicare |
$3,332.13
|
| Rate for Payer: Meridian Medicaid |
$1,913.98
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,498.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,831.95
|
| Rate for Payer: PACE Medicare |
$3,165.52
|
| Rate for Payer: PACE SWMI |
$3,332.13
|
| Rate for Payer: PHP Medicare Advantage |
$3,332.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,822.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,996.07
|
| Rate for Payer: Priority Health Medicare |
$3,332.13
|
| Rate for Payer: Priority Health Narrow Network |
$7,996.86
|
| Rate for Payer: Railroad Medicare Medicare |
$3,332.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$193.42
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,332.13
|
| Rate for Payer: UHC Exchange |
$175.84
|
| Rate for Payer: UHC Medicare Advantage |
$3,432.09
|
| Rate for Payer: VA VA |
$3,332.13
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS
|
Facility
|
OP
|
$18,552.19
|
|
|
Service Code
|
CPT 31267
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$259.33 |
| Max. Negotiated Rate |
$18,552.19 |
| Rate for Payer: Aetna Medicare |
$6,333.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,612.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,612.51
|
| Rate for Payer: BCBS Complete |
$3,498.10
|
| Rate for Payer: BCBS MAPPO |
$6,090.01
|
| Rate for Payer: BCBS Trust/PPO |
$2,342.98
|
| Rate for Payer: BCN Medicare Advantage |
$6,090.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,090.01
|
| Rate for Payer: Mclaren Medicaid |
$3,331.24
|
| Rate for Payer: Mclaren Medicare |
$6,090.01
|
| Rate for Payer: Meridian Medicaid |
$3,498.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,394.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,003.51
|
| Rate for Payer: PACE Medicare |
$5,785.51
|
| Rate for Payer: PACE SWMI |
$6,090.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,090.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,331.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,552.19
|
| Rate for Payer: Priority Health Medicare |
$6,090.01
|
| Rate for Payer: Priority Health Narrow Network |
$14,841.75
|
| Rate for Payer: Railroad Medicare Medicare |
$6,090.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$285.26
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,090.01
|
| Rate for Payer: UHC Exchange |
$259.33
|
| Rate for Payer: UHC Medicare Advantage |
$6,272.71
|
| Rate for Payer: VA VA |
$6,090.01
|
|
|
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY;
|
Facility
|
OP
|
$18,552.19
|
|
|
Service Code
|
CPT 31287
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$196.47 |
| Max. Negotiated Rate |
$18,552.19 |
| Rate for Payer: Aetna Medicare |
$6,333.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,612.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,612.51
|
| Rate for Payer: BCBS Complete |
$3,498.10
|
| Rate for Payer: BCBS MAPPO |
$6,090.01
|
| Rate for Payer: BCBS Trust/PPO |
$1,484.17
|
| Rate for Payer: BCN Medicare Advantage |
$6,090.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,090.01
|
| Rate for Payer: Mclaren Medicaid |
$3,331.24
|
| Rate for Payer: Mclaren Medicare |
$6,090.01
|
| Rate for Payer: Meridian Medicaid |
$3,498.10
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,394.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,003.51
|
| Rate for Payer: PACE Medicare |
$5,785.51
|
| Rate for Payer: PACE SWMI |
$6,090.01
|
| Rate for Payer: PHP Medicare Advantage |
$6,090.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,331.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,552.19
|
| Rate for Payer: Priority Health Medicare |
$6,090.01
|
| Rate for Payer: Priority Health Narrow Network |
$14,841.75
|
| Rate for Payer: Railroad Medicare Medicare |
$6,090.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$216.12
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,090.01
|
| Rate for Payer: UHC Exchange |
$196.47
|
| Rate for Payer: UHC Medicare Advantage |
$6,272.71
|
| Rate for Payer: VA VA |
$6,090.01
|
|
|
NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL
|
Facility
|
OP
|
$6,837.00
|
|
|
Service Code
|
CPT 69706
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$237.40 |
| Max. Negotiated Rate |
$6,837.00 |
| Rate for Payer: Aetna Medicare |
$5,419.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,513.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,513.48
|
| Rate for Payer: BCBS Complete |
$2,993.07
|
| Rate for Payer: BCBS MAPPO |
$5,210.78
|
| Rate for Payer: BCBS Trust/PPO |
$4,149.91
|
| Rate for Payer: BCN Medicare Advantage |
$5,210.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,210.78
|
| Rate for Payer: Mclaren Medicaid |
$2,850.30
|
| Rate for Payer: Mclaren Medicare |
$5,210.78
|
| Rate for Payer: Meridian Medicaid |
$2,993.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,471.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,992.40
|
| Rate for Payer: PACE Medicare |
$4,950.24
|
| Rate for Payer: PACE SWMI |
$5,210.78
|
| Rate for Payer: PHP Medicare Advantage |
$5,210.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,850.30
|
| Rate for Payer: Priority Health Medicare |
$5,210.78
|
| Rate for Payer: Railroad Medicare Medicare |
$5,210.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.14
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,210.78
|
| Rate for Payer: UHC Exchange |
$237.40
|
| Rate for Payer: UHC Medicare Advantage |
$5,367.10
|
| Rate for Payer: VA VA |
$5,210.78
|
|
|
NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$21,344.31
|
|
|
Service Code
|
HCPCS J2323
|
| Hospital Charge Code |
40120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,446.92 |
| Max. Negotiated Rate |
$19,209.88 |
| Rate for Payer: Aetna Commercial |
$18,142.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13,873.80
|
| Rate for Payer: Cash Price |
$17,075.45
|
| Rate for Payer: Cofinity Commercial |
$14,941.02
|
| Rate for Payer: Cofinity Commercial |
$18,356.11
|
| Rate for Payer: Healthscope Commercial |
$19,209.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18,142.66
|
| Rate for Payer: PHP Commercial |
$18,142.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14,941.02
|
| Rate for Payer: Priority Health SBD |
$13,446.92
|
|
|
NECITUMUMAB 800 MG/50 ML (16 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19,440.58
|
|
|
Service Code
|
HCPCS J9295
|
| Hospital Charge Code |
176602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,247.57 |
| Max. Negotiated Rate |
$17,496.52 |
| Rate for Payer: Aetna Commercial |
$16,524.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,636.38
|
| Rate for Payer: Cash Price |
$15,552.46
|
| Rate for Payer: Cofinity Commercial |
$13,608.41
|
| Rate for Payer: Cofinity Commercial |
$16,718.90
|
| Rate for Payer: Healthscope Commercial |
$17,496.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16,524.49
|
| Rate for Payer: PHP Commercial |
$16,524.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,608.41
|
| Rate for Payer: Priority Health SBD |
$12,247.57
|
|
|
NECITUMUMAB 800 MG/50 ML (16 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19,440.58
|
|
|
Service Code
|
HCPCS J9295
|
| Hospital Charge Code |
176602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$17,496.52 |
| Rate for Payer: Aetna Commercial |
$16,524.49
|
| Rate for Payer: Aetna Medicare |
$5.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,636.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.17
|
| Rate for Payer: BCBS Complete |
$3.30
|
| Rate for Payer: BCBS MAPPO |
$5.74
|
| Rate for Payer: BCBS Trust/PPO |
$16.97
|
| Rate for Payer: BCN Medicare Advantage |
$5.74
|
| Rate for Payer: Cash Price |
$15,552.46
|
| Rate for Payer: Cash Price |
$15,552.46
|
| Rate for Payer: Cofinity Commercial |
$13,608.41
|
| Rate for Payer: Cofinity Commercial |
$16,718.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.74
|
| Rate for Payer: Healthscope Commercial |
$17,496.52
|
| Rate for Payer: Mclaren Medicaid |
$3.14
|
| Rate for Payer: Mclaren Medicare |
$5.74
|
| Rate for Payer: Meridian Medicaid |
$3.30
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16,524.49
|
| Rate for Payer: PACE Medicare |
$5.45
|
| Rate for Payer: PACE SWMI |
$5.74
|
| Rate for Payer: PHP Commercial |
$16,524.49
|
| Rate for Payer: PHP Medicare Advantage |
$5.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,608.41
|
| Rate for Payer: Priority Health Medicare |
$5.74
|
| Rate for Payer: Priority Health SBD |
$12,247.57
|
| Rate for Payer: Railroad Medicare Medicare |
$5.74
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.74
|
| Rate for Payer: UHC Medicare Advantage |
$5.91
|
| Rate for Payer: VA VA |
$5.74
|
|
|
NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS
|
Facility
|
OP
|
$1,076.20
|
|
|
Service Code
|
CPT 97607
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$20.63 |
| Max. Negotiated Rate |
$1,076.20 |
| Rate for Payer: Aetna Medicare |
$368.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$443.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$443.50
|
| Rate for Payer: BCBS Complete |
$203.80
|
| Rate for Payer: BCBS MAPPO |
$354.80
|
| Rate for Payer: BCBS Trust/PPO |
$366.58
|
| Rate for Payer: BCN Medicare Advantage |
$354.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$354.80
|
| Rate for Payer: Mclaren Medicaid |
$194.08
|
| Rate for Payer: Mclaren Medicare |
$354.80
|
| Rate for Payer: Meridian Medicaid |
$203.80
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$372.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$408.02
|
| Rate for Payer: PACE Medicare |
$337.06
|
| Rate for Payer: PACE SWMI |
$354.80
|
| Rate for Payer: PHP Medicare Advantage |
$354.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$194.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,076.20
|
| Rate for Payer: Priority Health Medicare |
$354.80
|
| Rate for Payer: Priority Health Narrow Network |
$860.96
|
| Rate for Payer: Railroad Medicare Medicare |
$354.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$354.80
|
| Rate for Payer: UHC Exchange |
$20.63
|
| Rate for Payer: UHC Medicare Advantage |
$365.44
|
| Rate for Payer: VA VA |
$354.80
|
|
|
NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS
|
Facility
|
OP
|
$541.49
|
|
|
Service Code
|
CPT 97605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$23.58 |
| Max. Negotiated Rate |
$541.49 |
| Rate for Payer: Aetna Medicare |
$185.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$222.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$222.68
|
| Rate for Payer: BCBS Complete |
$102.32
|
| Rate for Payer: BCBS MAPPO |
$178.14
|
| Rate for Payer: BCBS Trust/PPO |
$47.60
|
| Rate for Payer: BCN Medicare Advantage |
$178.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$178.14
|
| Rate for Payer: Mclaren Medicaid |
$97.44
|
| Rate for Payer: Mclaren Medicare |
$178.14
|
| Rate for Payer: Meridian Medicaid |
$102.32
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$187.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$204.86
|
| Rate for Payer: PACE Medicare |
$169.23
|
| Rate for Payer: PACE SWMI |
$178.14
|
| Rate for Payer: PHP Medicare Advantage |
$178.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$97.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$541.49
|
| Rate for Payer: Priority Health Medicare |
$178.14
|
| Rate for Payer: Priority Health Narrow Network |
$433.19
|
| Rate for Payer: Railroad Medicare Medicare |
$178.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$178.14
|
| Rate for Payer: UHC Exchange |
$23.58
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: VA VA |
$178.14
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS
|
Facility
|
IP
|
$153.76
|
|
|
Service Code
|
NDC 24208-790-62
|
| Hospital Charge Code |
5474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.87 |
| Max. Negotiated Rate |
$138.38 |
| Rate for Payer: Aetna Commercial |
$130.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.94
|
| Rate for Payer: Cash Price |
$123.01
|
| Rate for Payer: Cofinity Commercial |
$107.63
|
| Rate for Payer: Cofinity Commercial |
$132.23
|
| Rate for Payer: Healthscope Commercial |
$138.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.70
|
| Rate for Payer: PHP Commercial |
$130.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.63
|
| Rate for Payer: Priority Health SBD |
$96.87
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$45.82
|
|
|
Service Code
|
NDC 24208-795-35
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.87 |
| Max. Negotiated Rate |
$41.24 |
| Rate for Payer: Aetna Commercial |
$38.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.78
|
| Rate for Payer: Cash Price |
$36.66
|
| Rate for Payer: Cofinity Commercial |
$32.07
|
| Rate for Payer: Cofinity Commercial |
$39.41
|
| Rate for Payer: Healthscope Commercial |
$41.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.95
|
| Rate for Payer: PHP Commercial |
$38.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.07
|
| Rate for Payer: Priority Health SBD |
$28.87
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$58.60
|
|
|
Service Code
|
NDC 61314-631-36
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.92 |
| Max. Negotiated Rate |
$52.74 |
| Rate for Payer: Aetna Commercial |
$49.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.09
|
| Rate for Payer: Cash Price |
$46.88
|
| Rate for Payer: Cofinity Commercial |
$41.02
|
| Rate for Payer: Cofinity Commercial |
$50.40
|
| Rate for Payer: Healthscope Commercial |
$52.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.81
|
| Rate for Payer: PHP Commercial |
$49.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.02
|
| Rate for Payer: Priority Health SBD |
$36.92
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 39822-1201-1
|
| Hospital Charge Code |
70678
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$40.70 |
| Rate for Payer: Aetna Commercial |
$38.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.39
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cofinity Commercial |
$31.65
|
| Rate for Payer: Cofinity Commercial |
$38.89
|
| Rate for Payer: Healthscope Commercial |
$40.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.44
|
| Rate for Payer: PHP Commercial |
$38.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.65
|
| Rate for Payer: Priority Health SBD |
$28.49
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION
|
Facility
|
IP
|
$42.53
|
|
|
Service Code
|
NDC 39822-1201-5
|
| Hospital Charge Code |
70678
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$38.28 |
| Rate for Payer: Aetna Commercial |
$36.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.64
|
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Cofinity Commercial |
$29.77
|
| Rate for Payer: Cofinity Commercial |
$36.58
|
| Rate for Payer: Healthscope Commercial |
$38.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$36.15
|
| Rate for Payer: PHP Commercial |
$36.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.77
|
| Rate for Payer: Priority Health SBD |
$26.79
|
|
|
NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION
|
Facility
|
IP
|
$45.22
|
|
|
Service Code
|
NDC 39822-1201-2
|
| Hospital Charge Code |
70678
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.49 |
| Max. Negotiated Rate |
$40.70 |
| Rate for Payer: Aetna Commercial |
$38.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.39
|
| Rate for Payer: Cash Price |
$36.18
|
| Rate for Payer: Cofinity Commercial |
$31.65
|
| Rate for Payer: Cofinity Commercial |
$38.89
|
| Rate for Payer: Healthscope Commercial |
$40.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.44
|
| Rate for Payer: PHP Commercial |
$38.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.65
|
| Rate for Payer: Priority Health SBD |
$28.49
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
IP
|
$420.96
|
|
|
Service Code
|
NDC 39822-0310-5
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$265.20 |
| Max. Negotiated Rate |
$378.86 |
| Rate for Payer: Aetna Commercial |
$357.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.62
|
| Rate for Payer: Cash Price |
$336.77
|
| Rate for Payer: Cofinity Commercial |
$294.67
|
| Rate for Payer: Cofinity Commercial |
$362.03
|
| Rate for Payer: Healthscope Commercial |
$378.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$357.82
|
| Rate for Payer: PHP Commercial |
$357.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$294.67
|
| Rate for Payer: Priority Health SBD |
$265.20
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
IP
|
$4.21
|
|
|
Service Code
|
NDC 39822-0310-7
|
| Hospital Charge Code |
5472
|
|
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
|
|
|
NEOMYCIN 500 MG TABLET
|
Facility
|
IP
|
$454.56
|
|
|
Service Code
|
NDC 50383-565-10
|
| Hospital Charge Code |
5472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.37 |
| Max. Negotiated Rate |
$409.10 |
| Rate for Payer: Aetna Commercial |
$386.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$295.46
|
| Rate for Payer: Cash Price |
$363.65
|
| Rate for Payer: Cofinity Commercial |
$318.19
|
| Rate for Payer: Cofinity Commercial |
$390.92
|
| Rate for Payer: Healthscope Commercial |
$409.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$386.38
|
| Rate for Payer: PHP Commercial |
$386.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$318.19
|
| Rate for Payer: Priority Health SBD |
$286.37
|
|
