|
PLEURAL DRAINAGE, PERCUTANEOUS, WITH INSERTION OF INDWELLING CATHETER; WITHOUT IMAGING GUIDANCE
|
Facility
|
OP
|
$5,222.22
|
|
|
Service Code
|
CPT 32556
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$119.84 |
| Max. Negotiated Rate |
$5,222.22 |
| Rate for Payer: Aetna Medicare |
$1,760.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,116.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,116.40
|
| Rate for Payer: BCBS Complete |
$972.53
|
| Rate for Payer: BCBS MAPPO |
$1,693.12
|
| Rate for Payer: BCBS Trust/PPO |
$527.94
|
| Rate for Payer: BCN Medicare Advantage |
$1,693.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,693.12
|
| Rate for Payer: Mclaren Medicaid |
$926.14
|
| Rate for Payer: Mclaren Medicare |
$1,693.12
|
| Rate for Payer: Meridian Medicaid |
$972.53
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,777.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,947.09
|
| Rate for Payer: PACE Medicare |
$1,608.46
|
| Rate for Payer: PACE SWMI |
$1,693.12
|
| Rate for Payer: PHP Medicare Advantage |
$1,693.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$926.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,222.22
|
| Rate for Payer: Priority Health Medicare |
$1,693.12
|
| Rate for Payer: Priority Health Narrow Network |
$4,177.77
|
| Rate for Payer: Railroad Medicare Medicare |
$1,693.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$131.82
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,693.12
|
| Rate for Payer: UHC Exchange |
$119.84
|
| Rate for Payer: UHC Medicare Advantage |
$1,743.91
|
| Rate for Payer: VA VA |
$1,693.12
|
|
|
PLEURAL EFFUSION WITH CC
|
Facility
|
IP
|
$15,588.69
|
|
|
Service Code
|
MS-DRG 187
|
| Min. Negotiated Rate |
$7,284.48 |
| Max. Negotiated Rate |
$15,588.69 |
| Rate for Payer: Aetna Medicare |
$7,974.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,584.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,584.84
|
| Rate for Payer: BCBS MAPPO |
$7,667.87
|
| Rate for Payer: BCBS Trust/PPO |
$15,588.69
|
| Rate for Payer: BCN Medicare Advantage |
$7,667.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,667.87
|
| Rate for Payer: Mclaren Medicare |
$7,667.87
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,051.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,818.05
|
| Rate for Payer: PACE Medicare |
$7,284.48
|
| Rate for Payer: PACE SWMI |
$7,667.87
|
| Rate for Payer: PHP Medicare Advantage |
$7,667.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14,296.83
|
| Rate for Payer: Priority Health Medicare |
$7,667.87
|
| Rate for Payer: Priority Health Narrow Network |
$11,437.46
|
| Rate for Payer: Railroad Medicare Medicare |
$7,667.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15,197.56
|
| Rate for Payer: UHC Core |
$9,325.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$7,667.87
|
| Rate for Payer: UHC Exchange |
$9,987.91
|
| Rate for Payer: UHC Medicare Advantage |
$7,897.91
|
| Rate for Payer: VA VA |
$7,667.87
|
|
|
PLEURAL EFFUSION WITH MCC
|
Facility
|
IP
|
$23,675.73
|
|
|
Service Code
|
MS-DRG 186
|
| Min. Negotiated Rate |
$11,087.10 |
| Max. Negotiated Rate |
$23,675.73 |
| Rate for Payer: Aetna Medicare |
$12,137.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,588.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,588.29
|
| Rate for Payer: BCBS MAPPO |
$11,670.63
|
| Rate for Payer: BCBS Trust/PPO |
$23,313.87
|
| Rate for Payer: BCN Medicare Advantage |
$11,670.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,670.63
|
| Rate for Payer: Mclaren Medicare |
$11,670.63
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,254.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,421.22
|
| Rate for Payer: PACE Medicare |
$11,087.10
|
| Rate for Payer: PACE SWMI |
$11,670.63
|
| Rate for Payer: PHP Medicare Advantage |
$11,670.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,272.51
|
| Rate for Payer: Priority Health Medicare |
$11,670.63
|
| Rate for Payer: Priority Health Narrow Network |
$17,818.01
|
| Rate for Payer: Railroad Medicare Medicare |
$11,670.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23,675.73
|
| Rate for Payer: UHC Core |
$14,527.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,670.63
|
| Rate for Payer: UHC Exchange |
$15,559.80
|
| Rate for Payer: UHC Medicare Advantage |
$12,020.75
|
| Rate for Payer: VA VA |
$11,670.63
|
|
|
PLEURAL EFFUSION WITHOUT CC/MCC
|
Facility
|
IP
|
$11,679.99
|
|
|
Service Code
|
MS-DRG 188
|
| Min. Negotiated Rate |
$5,575.42 |
| Max. Negotiated Rate |
$11,679.99 |
| Rate for Payer: Aetna Medicare |
$6,103.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,336.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,336.08
|
| Rate for Payer: BCBS MAPPO |
$5,868.86
|
| Rate for Payer: BCBS Trust/PPO |
$11,679.99
|
| Rate for Payer: BCN Medicare Advantage |
$5,868.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,868.86
|
| Rate for Payer: Mclaren Medicare |
$5,868.86
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,162.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,749.19
|
| Rate for Payer: PACE Medicare |
$5,575.42
|
| Rate for Payer: PACE SWMI |
$5,868.86
|
| Rate for Payer: PHP Medicare Advantage |
$5,868.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,712.22
|
| Rate for Payer: Priority Health Medicare |
$5,868.86
|
| Rate for Payer: Priority Health Narrow Network |
$8,569.78
|
| Rate for Payer: Railroad Medicare Medicare |
$5,868.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11,387.11
|
| Rate for Payer: UHC Core |
$6,987.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,868.86
|
| Rate for Payer: UHC Exchange |
$7,483.66
|
| Rate for Payer: UHC Medicare Advantage |
$6,044.93
|
| Rate for Payer: VA VA |
$5,868.86
|
|
|
PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE
|
Facility
|
OP
|
$673.24
|
|
|
Service Code
|
HCPCS 90670
|
| Hospital Charge Code |
103895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$269.30 |
| Max. Negotiated Rate |
$784.54 |
| Rate for Payer: Aetna Commercial |
$572.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$437.61
|
| Rate for Payer: BCBS Complete |
$269.30
|
| Rate for Payer: BCBS Trust/PPO |
$784.54
|
| Rate for Payer: Cash Price |
$538.59
|
| Rate for Payer: Cash Price |
$538.59
|
| Rate for Payer: Cofinity Commercial |
$471.27
|
| Rate for Payer: Cofinity Commercial |
$578.99
|
| Rate for Payer: Healthscope Commercial |
$605.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$572.25
|
| Rate for Payer: PHP Commercial |
$572.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$471.27
|
| Rate for Payer: Priority Health SBD |
$424.14
|
|
|
PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE
|
Facility
|
IP
|
$673.24
|
|
|
Service Code
|
HCPCS 90670
|
| Hospital Charge Code |
103895
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$424.14 |
| Max. Negotiated Rate |
$605.92 |
| Rate for Payer: Aetna Commercial |
$572.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$437.61
|
| Rate for Payer: Cash Price |
$538.59
|
| Rate for Payer: Cofinity Commercial |
$471.27
|
| Rate for Payer: Cofinity Commercial |
$578.99
|
| Rate for Payer: Healthscope Commercial |
$605.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$572.25
|
| Rate for Payer: PHP Commercial |
$572.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$471.27
|
| Rate for Payer: Priority Health SBD |
$424.14
|
|
|
PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE
|
Facility
|
IP
|
$761.16
|
|
|
Service Code
|
HCPCS 90677
|
| Hospital Charge Code |
197781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$479.53 |
| Max. Negotiated Rate |
$685.04 |
| Rate for Payer: Aetna Commercial |
$646.99
|
| Rate for Payer: Aetna Commercial |
$667.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$494.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$510.24
|
| Rate for Payer: Cash Price |
$627.98
|
| Rate for Payer: Cash Price |
$608.93
|
| Rate for Payer: Cofinity Commercial |
$675.08
|
| Rate for Payer: Cofinity Commercial |
$654.60
|
| Rate for Payer: Cofinity Commercial |
$532.81
|
| Rate for Payer: Cofinity Commercial |
$549.49
|
| Rate for Payer: Healthscope Commercial |
$706.48
|
| Rate for Payer: Healthscope Commercial |
$685.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$667.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$646.99
|
| Rate for Payer: PHP Commercial |
$646.99
|
| Rate for Payer: PHP Commercial |
$667.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$532.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$549.49
|
| Rate for Payer: Priority Health SBD |
$494.54
|
| Rate for Payer: Priority Health SBD |
$479.53
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SOLUTION
|
Facility
|
OP
|
$374.95
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
11037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.98 |
| Max. Negotiated Rate |
$402.61 |
| Rate for Payer: Aetna Commercial |
$318.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.72
|
| Rate for Payer: BCBS Complete |
$149.98
|
| Rate for Payer: BCBS Trust/PPO |
$402.61
|
| Rate for Payer: Cash Price |
$299.96
|
| Rate for Payer: Cash Price |
$299.96
|
| Rate for Payer: Cofinity Commercial |
$322.46
|
| Rate for Payer: Cofinity Commercial |
$262.46
|
| Rate for Payer: Healthscope Commercial |
$337.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$318.71
|
| Rate for Payer: PHP Commercial |
$318.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.46
|
| Rate for Payer: Priority Health SBD |
$236.22
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SOLUTION
|
Facility
|
IP
|
$374.95
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
11037
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$236.22 |
| Max. Negotiated Rate |
$337.46 |
| Rate for Payer: Aetna Commercial |
$318.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.72
|
| Rate for Payer: Cash Price |
$299.96
|
| Rate for Payer: Cofinity Commercial |
$322.46
|
| Rate for Payer: Cofinity Commercial |
$262.46
|
| Rate for Payer: Healthscope Commercial |
$337.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$318.71
|
| Rate for Payer: PHP Commercial |
$318.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.46
|
| Rate for Payer: Priority Health SBD |
$236.22
|
|
|
PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE
|
Facility
|
IP
|
$347.89
|
|
|
Service Code
|
HCPCS 90732
|
| Hospital Charge Code |
111964
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$219.17 |
| Max. Negotiated Rate |
$313.10 |
| Rate for Payer: Aetna Commercial |
$295.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.13
|
| Rate for Payer: Cash Price |
$278.31
|
| Rate for Payer: Cofinity Commercial |
$243.52
|
| Rate for Payer: Cofinity Commercial |
$299.19
|
| Rate for Payer: Healthscope Commercial |
$313.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$295.71
|
| Rate for Payer: PHP Commercial |
$295.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.52
|
| Rate for Payer: Priority Health SBD |
$219.17
|
|
|
PNEUMOTHORAX WITH CC
|
Facility
|
IP
|
$16,428.56
|
|
|
Service Code
|
MS-DRG 200
|
| Min. Negotiated Rate |
$7,836.61 |
| Max. Negotiated Rate |
$16,428.56 |
| Rate for Payer: Aetna Medicare |
$8,579.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,311.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,311.32
|
| Rate for Payer: BCBS MAPPO |
$8,249.06
|
| Rate for Payer: BCBS Trust/PPO |
$15,322.99
|
| Rate for Payer: BCN Medicare Advantage |
$8,249.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,249.06
|
| Rate for Payer: Mclaren Medicare |
$8,249.06
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,661.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,486.42
|
| Rate for Payer: PACE Medicare |
$7,836.61
|
| Rate for Payer: PACE SWMI |
$8,249.06
|
| Rate for Payer: PHP Medicare Advantage |
$8,249.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,454.86
|
| Rate for Payer: Priority Health Medicare |
$8,249.06
|
| Rate for Payer: Priority Health Narrow Network |
$12,363.89
|
| Rate for Payer: Railroad Medicare Medicare |
$8,249.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,428.56
|
| Rate for Payer: UHC Core |
$10,080.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$8,249.06
|
| Rate for Payer: UHC Exchange |
$10,796.93
|
| Rate for Payer: UHC Medicare Advantage |
$8,496.53
|
| Rate for Payer: VA VA |
$8,249.06
|
|
|
PNEUMOTHORAX WITH MCC
|
Facility
|
IP
|
$27,062.12
|
|
|
Service Code
|
MS-DRG 199
|
| Min. Negotiated Rate |
$12,605.96 |
| Max. Negotiated Rate |
$27,062.12 |
| Rate for Payer: Aetna Medicare |
$13,800.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16,586.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16,586.79
|
| Rate for Payer: BCBS MAPPO |
$13,269.43
|
| Rate for Payer: BCBS Trust/PPO |
$21,203.61
|
| Rate for Payer: BCN Medicare Advantage |
$13,269.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,269.43
|
| Rate for Payer: Mclaren Medicare |
$13,269.43
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$13,932.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,259.84
|
| Rate for Payer: PACE Medicare |
$12,605.96
|
| Rate for Payer: PACE SWMI |
$13,269.43
|
| Rate for Payer: PHP Medicare Advantage |
$13,269.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25,458.19
|
| Rate for Payer: Priority Health Medicare |
$13,269.43
|
| Rate for Payer: Priority Health Narrow Network |
$20,366.55
|
| Rate for Payer: Railroad Medicare Medicare |
$13,269.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27,062.12
|
| Rate for Payer: UHC Core |
$16,605.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$13,269.43
|
| Rate for Payer: UHC Exchange |
$17,785.35
|
| Rate for Payer: UHC Medicare Advantage |
$13,667.51
|
| Rate for Payer: VA VA |
$13,269.43
|
|
|
PNEUMOTHORAX WITHOUT CC/MCC
|
Facility
|
IP
|
$10,770.85
|
|
|
Service Code
|
MS-DRG 201
|
| Min. Negotiated Rate |
$5,299.02 |
| Max. Negotiated Rate |
$10,770.85 |
| Rate for Payer: Aetna Medicare |
$5,801.04
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,972.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,972.40
|
| Rate for Payer: BCBS MAPPO |
$5,577.92
|
| Rate for Payer: BCBS Trust/PPO |
$10,423.94
|
| Rate for Payer: BCN Medicare Advantage |
$5,577.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,577.92
|
| Rate for Payer: Mclaren Medicare |
$5,577.92
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,856.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,414.61
|
| Rate for Payer: PACE Medicare |
$5,299.02
|
| Rate for Payer: PACE SWMI |
$5,577.92
|
| Rate for Payer: PHP Medicare Advantage |
$5,577.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,132.48
|
| Rate for Payer: Priority Health Medicare |
$5,577.92
|
| Rate for Payer: Priority Health Narrow Network |
$8,105.98
|
| Rate for Payer: Railroad Medicare Medicare |
$5,577.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,770.85
|
| Rate for Payer: UHC Core |
$6,609.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,577.92
|
| Rate for Payer: UHC Exchange |
$7,078.65
|
| Rate for Payer: UHC Medicare Advantage |
$5,745.26
|
| Rate for Payer: VA VA |
$5,577.92
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC
|
Facility
|
IP
|
$24,343.86
|
|
|
Service Code
|
MS-DRG 917
|
| Min. Negotiated Rate |
$11,386.76 |
| Max. Negotiated Rate |
$24,343.86 |
| Rate for Payer: Aetna Medicare |
$12,465.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,982.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,982.58
|
| Rate for Payer: BCBS MAPPO |
$11,986.06
|
| Rate for Payer: BCBS Trust/PPO |
$22,846.14
|
| Rate for Payer: BCN Medicare Advantage |
$11,986.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,986.06
|
| Rate for Payer: Mclaren Medicare |
$11,986.06
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,585.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,783.97
|
| Rate for Payer: PACE Medicare |
$11,386.76
|
| Rate for Payer: PACE SWMI |
$11,986.06
|
| Rate for Payer: PHP Medicare Advantage |
$11,986.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,901.04
|
| Rate for Payer: Priority Health Medicare |
$11,986.06
|
| Rate for Payer: Priority Health Narrow Network |
$18,320.83
|
| Rate for Payer: Railroad Medicare Medicare |
$11,986.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,343.86
|
| Rate for Payer: UHC Core |
$14,937.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,986.06
|
| Rate for Payer: UHC Exchange |
$15,998.90
|
| Rate for Payer: UHC Medicare Advantage |
$12,345.64
|
| Rate for Payer: VA VA |
$11,986.06
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC
|
Facility
|
IP
|
$13,132.17
|
|
|
Service Code
|
MS-DRG 918
|
| Min. Negotiated Rate |
$6,358.11 |
| Max. Negotiated Rate |
$13,132.17 |
| Rate for Payer: Aetna Medicare |
$6,960.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,365.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,365.94
|
| Rate for Payer: BCBS MAPPO |
$6,692.75
|
| Rate for Payer: BCBS Trust/PPO |
$9,336.97
|
| Rate for Payer: BCN Medicare Advantage |
$6,692.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,692.75
|
| Rate for Payer: Mclaren Medicare |
$6,692.75
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,027.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,696.66
|
| Rate for Payer: PACE Medicare |
$6,358.11
|
| Rate for Payer: PACE SWMI |
$6,692.75
|
| Rate for Payer: PHP Medicare Advantage |
$6,692.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,353.85
|
| Rate for Payer: Priority Health Medicare |
$6,692.75
|
| Rate for Payer: Priority Health Narrow Network |
$9,883.08
|
| Rate for Payer: Railroad Medicare Medicare |
$6,692.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,132.17
|
| Rate for Payer: UHC Core |
$8,058.02
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,692.75
|
| Rate for Payer: UHC Exchange |
$8,630.52
|
| Rate for Payer: UHC Medicare Advantage |
$6,893.53
|
| Rate for Payer: VA VA |
$6,692.75
|
|
|
POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16,878.95
|
|
|
Service Code
|
HCPCS J9309
|
| Hospital Charge Code |
195050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.99 |
| Max. Negotiated Rate |
$15,191.06 |
| Rate for Payer: Aetna Commercial |
$14,347.11
|
| Rate for Payer: Aetna Medicare |
$129.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,971.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$155.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$155.36
|
| Rate for Payer: BCBS Complete |
$71.39
|
| Rate for Payer: BCBS MAPPO |
$124.29
|
| Rate for Payer: BCBS Trust/PPO |
$367.95
|
| Rate for Payer: BCN Medicare Advantage |
$124.29
|
| Rate for Payer: Cash Price |
$13,503.16
|
| Rate for Payer: Cash Price |
$13,503.16
|
| Rate for Payer: Cofinity Commercial |
$14,515.90
|
| Rate for Payer: Cofinity Commercial |
$11,815.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$124.29
|
| Rate for Payer: Healthscope Commercial |
$15,191.06
|
| Rate for Payer: Mclaren Medicaid |
$67.99
|
| Rate for Payer: Mclaren Medicare |
$124.29
|
| Rate for Payer: Meridian Medicaid |
$71.39
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$130.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$142.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14,347.11
|
| Rate for Payer: PACE Medicare |
$118.07
|
| Rate for Payer: PACE SWMI |
$124.29
|
| Rate for Payer: PHP Commercial |
$14,347.11
|
| Rate for Payer: PHP Medicare Advantage |
$124.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,815.26
|
| Rate for Payer: Priority Health Medicare |
$124.29
|
| Rate for Payer: Priority Health SBD |
$10,633.74
|
| Rate for Payer: Railroad Medicare Medicare |
$124.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$124.29
|
| Rate for Payer: UHC Medicare Advantage |
$128.02
|
| Rate for Payer: VA VA |
$124.29
|
|
|
POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
NDC 46783-221-52
|
| Hospital Charge Code |
155488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.07 |
| Max. Negotiated Rate |
$80.10 |
| Rate for Payer: Aetna Commercial |
$75.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.85
|
| Rate for Payer: Cash Price |
$71.20
|
| Rate for Payer: Cofinity Commercial |
$62.30
|
| Rate for Payer: Cofinity Commercial |
$76.54
|
| Rate for Payer: Healthscope Commercial |
$80.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.65
|
| Rate for Payer: PHP Commercial |
$75.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.30
|
| Rate for Payer: Priority Health SBD |
$56.07
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$11.25
|
|
|
Service Code
|
NDC 9629513543
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.31
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cofinity Commercial |
$7.88
|
| Rate for Payer: Cofinity Commercial |
$9.68
|
| Rate for Payer: Healthscope Commercial |
$10.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.56
|
| Rate for Payer: PHP Commercial |
$9.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health SBD |
$7.09
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$17.14
|
|
|
Service Code
|
NDC 45802-868-01
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$15.43 |
| Rate for Payer: Aetna Commercial |
$14.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.14
|
| Rate for Payer: Cash Price |
$13.71
|
| Rate for Payer: Cofinity Commercial |
$14.74
|
| Rate for Payer: Cofinity Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$15.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.57
|
| Rate for Payer: PHP Commercial |
$14.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.00
|
| Rate for Payer: Priority Health SBD |
$10.80
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER
|
Facility
|
IP
|
$25.83
|
|
|
Service Code
|
NDC 4110082076
|
| Hospital Charge Code |
24984
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.27 |
| Max. Negotiated Rate |
$23.25 |
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cofinity Commercial |
$18.08
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.96
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.08
|
| Rate for Payer: Priority Health SBD |
$16.27
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$69.89
|
|
|
Service Code
|
NDC 68084-430-98
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.03 |
| Max. Negotiated Rate |
$62.90 |
| Rate for Payer: Aetna Commercial |
$59.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.43
|
| Rate for Payer: Cash Price |
$55.91
|
| Rate for Payer: Cofinity Commercial |
$48.92
|
| Rate for Payer: Cofinity Commercial |
$60.11
|
| Rate for Payer: Healthscope Commercial |
$62.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.41
|
| Rate for Payer: PHP Commercial |
$59.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.92
|
| Rate for Payer: Priority Health SBD |
$44.03
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$90.86
|
|
|
Service Code
|
NDC 0904-6931-26
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.24 |
| Max. Negotiated Rate |
$81.77 |
| Rate for Payer: Aetna Commercial |
$77.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.06
|
| Rate for Payer: Cash Price |
$72.69
|
| Rate for Payer: Cofinity Commercial |
$63.60
|
| Rate for Payer: Cofinity Commercial |
$78.14
|
| Rate for Payer: Healthscope Commercial |
$81.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.23
|
| Rate for Payer: PHP Commercial |
$77.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.60
|
| Rate for Payer: Priority Health SBD |
$57.24
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$100.20
|
|
|
Service Code
|
NDC 45802-868-66
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.13 |
| Max. Negotiated Rate |
$90.18 |
| Rate for Payer: Aetna Commercial |
$85.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.13
|
| Rate for Payer: Cash Price |
$80.16
|
| Rate for Payer: Cofinity Commercial |
$70.14
|
| Rate for Payer: Cofinity Commercial |
$86.17
|
| Rate for Payer: Healthscope Commercial |
$90.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.17
|
| Rate for Payer: PHP Commercial |
$85.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.14
|
| Rate for Payer: Priority Health SBD |
$63.13
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$201.60
|
|
|
Service Code
|
NDC 51079-306-30
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.01 |
| Max. Negotiated Rate |
$181.44 |
| Rate for Payer: Aetna Commercial |
$171.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.04
|
| Rate for Payer: Cash Price |
$161.28
|
| Rate for Payer: Cofinity Commercial |
$141.12
|
| Rate for Payer: Cofinity Commercial |
$173.38
|
| Rate for Payer: Healthscope Commercial |
$181.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.36
|
| Rate for Payer: PHP Commercial |
$171.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.12
|
| Rate for Payer: Priority Health SBD |
$127.01
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$1,105.19
|
|
|
Service Code
|
NDC 69784-180-10
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$696.27 |
| Max. Negotiated Rate |
$994.67 |
| Rate for Payer: Aetna Commercial |
$939.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$718.37
|
| Rate for Payer: Cash Price |
$884.15
|
| Rate for Payer: Cofinity Commercial |
$773.63
|
| Rate for Payer: Cofinity Commercial |
$950.46
|
| Rate for Payer: Healthscope Commercial |
$994.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$939.41
|
| Rate for Payer: PHP Commercial |
$939.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$773.63
|
| Rate for Payer: Priority Health SBD |
$696.27
|
|
