|
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION
|
Facility
|
OP
|
$13.81
|
|
|
Service Code
|
NDC 37000003201
|
| Hospital Charge Code |
1090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.52 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Aetna Commercial |
$11.74
|
| Rate for Payer: Aetna Medicare |
$6.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.98
|
| Rate for Payer: BCBS Complete |
$5.52
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cofinity Commercial |
$11.88
|
| Rate for Payer: Cofinity Commercial |
$9.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.05
|
| Rate for Payer: Healthscope Commercial |
$12.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.74
|
| Rate for Payer: PHP Commercial |
$11.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.98
|
| Rate for Payer: Priority Health SBD |
$8.70
|
|
|
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION
|
Facility
|
OP
|
$24.84
|
|
|
Service Code
|
NDC 01490003916
|
| Hospital Charge Code |
1090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.94 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$15.65
|
|
|
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION
|
Facility
|
IP
|
$13.81
|
|
|
Service Code
|
NDC 37000003201
|
| Hospital Charge Code |
1090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$12.43 |
| Rate for Payer: Aetna Commercial |
$11.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.98
|
| Rate for Payer: Cash Price |
$11.05
|
| Rate for Payer: Cofinity Commercial |
$11.88
|
| Rate for Payer: Cofinity Commercial |
$9.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.05
|
| Rate for Payer: Healthscope Commercial |
$12.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.74
|
| Rate for Payer: PHP Commercial |
$11.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.98
|
| Rate for Payer: Priority Health SBD |
$8.70
|
|
|
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION
|
Facility
|
OP
|
$2.88
|
|
|
Service Code
|
NDC 09900000728
|
| Hospital Charge Code |
1090
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.59 |
| Rate for Payer: Aetna Commercial |
$2.45
|
| Rate for Payer: Aetna Medicare |
$1.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.87
|
| Rate for Payer: BCBS Complete |
$1.15
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cofinity Commercial |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$2.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.30
|
| Rate for Payer: Healthscope Commercial |
$2.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.45
|
| Rate for Payer: PHP Commercial |
$2.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.87
|
| Rate for Payer: Priority Health SBD |
$1.81
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET
|
Facility
|
OP
|
$236.16
|
|
|
Service Code
|
NDC 50268012715
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.46 |
| Max. Negotiated Rate |
$212.54 |
| Rate for Payer: Aetna Commercial |
$200.74
|
| Rate for Payer: Aetna Medicare |
$118.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.50
|
| Rate for Payer: BCBS Complete |
$94.46
|
| Rate for Payer: Cash Price |
$188.93
|
| Rate for Payer: Cofinity Commercial |
$165.31
|
| Rate for Payer: Cofinity Commercial |
$203.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$165.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.93
|
| Rate for Payer: Healthscope Commercial |
$212.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$200.74
|
| Rate for Payer: PHP Commercial |
$200.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.50
|
| Rate for Payer: Priority Health SBD |
$148.78
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 50268012711
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$4.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.07
|
| Rate for Payer: Cash Price |
$3.78
|
| Rate for Payer: Cofinity Commercial |
$3.31
|
| Rate for Payer: Cofinity Commercial |
$4.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.78
|
| Rate for Payer: Healthscope Commercial |
$4.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.02
|
| Rate for Payer: PHP Commercial |
$4.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.07
|
| Rate for Payer: Priority Health SBD |
$2.98
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 50268012711
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$4.02
|
| Rate for Payer: Aetna Medicare |
$2.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.07
|
| Rate for Payer: BCBS Complete |
$1.89
|
| Rate for Payer: Cash Price |
$3.78
|
| Rate for Payer: Cofinity Commercial |
$3.31
|
| Rate for Payer: Cofinity Commercial |
$4.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.78
|
| Rate for Payer: Healthscope Commercial |
$4.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.02
|
| Rate for Payer: PHP Commercial |
$4.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.07
|
| Rate for Payer: Priority Health SBD |
$2.98
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET
|
Facility
|
OP
|
$415.95
|
|
|
Service Code
|
NDC 52817027010
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.38 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: Aetna Medicare |
$207.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$270.37
|
| Rate for Payer: BCBS Complete |
$166.38
|
| Rate for Payer: Cash Price |
$332.76
|
| Rate for Payer: Cofinity Commercial |
$291.17
|
| Rate for Payer: Cofinity Commercial |
$357.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$291.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.76
|
| Rate for Payer: Healthscope Commercial |
$374.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.56
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.37
|
| Rate for Payer: Priority Health SBD |
$262.05
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET
|
Facility
|
IP
|
$470.00
|
|
|
Service Code
|
NDC 29300012601
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$296.10 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Aetna Commercial |
$399.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.50
|
| Rate for Payer: Cash Price |
$376.00
|
| Rate for Payer: Cofinity Commercial |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$404.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$329.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.00
|
| Rate for Payer: Healthscope Commercial |
$423.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.50
|
| Rate for Payer: PHP Commercial |
$399.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.50
|
| Rate for Payer: Priority Health SBD |
$296.10
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET
|
Facility
|
OP
|
$470.00
|
|
|
Service Code
|
NDC 29300012601
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.00 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Aetna Commercial |
$399.50
|
| Rate for Payer: Aetna Medicare |
$235.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.50
|
| Rate for Payer: BCBS Complete |
$188.00
|
| Rate for Payer: Cash Price |
$376.00
|
| Rate for Payer: Cofinity Commercial |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$404.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$329.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.00
|
| Rate for Payer: Healthscope Commercial |
$423.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.50
|
| Rate for Payer: PHP Commercial |
$399.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.50
|
| Rate for Payer: Priority Health SBD |
$296.10
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET
|
Facility
|
IP
|
$236.16
|
|
|
Service Code
|
NDC 50268012715
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.78 |
| Max. Negotiated Rate |
$212.54 |
| Rate for Payer: Aetna Commercial |
$200.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.50
|
| Rate for Payer: Cash Price |
$188.93
|
| Rate for Payer: Cofinity Commercial |
$165.31
|
| Rate for Payer: Cofinity Commercial |
$203.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$165.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.93
|
| Rate for Payer: Healthscope Commercial |
$212.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$200.74
|
| Rate for Payer: PHP Commercial |
$200.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.50
|
| Rate for Payer: Priority Health SBD |
$148.78
|
|
|
BISOPROLOL FUMARATE 5 MG TABLET
|
Facility
|
IP
|
$415.95
|
|
|
Service Code
|
NDC 52817027010
|
| Hospital Charge Code |
18288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.05 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$270.37
|
| Rate for Payer: Cash Price |
$332.76
|
| Rate for Payer: Cofinity Commercial |
$291.17
|
| Rate for Payer: Cofinity Commercial |
$357.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$291.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.76
|
| Rate for Payer: Healthscope Commercial |
$374.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.56
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.37
|
| Rate for Payer: Priority Health SBD |
$262.05
|
|
|
BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING RETENTION TIME)
|
Facility
|
OP
|
$1,832.42
|
|
|
Service Code
|
CPT 51720
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$348.92 |
| Max. Negotiated Rate |
$1,832.42 |
| Rate for Payer: Aetna Medicare |
$677.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$813.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$813.71
|
| Rate for Payer: BCBS Complete |
$366.37
|
| Rate for Payer: BCBS MAPPO |
$650.97
|
| Rate for Payer: BCN Medicare Advantage |
$650.97
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$650.97
|
| Rate for Payer: Mclaren Medicaid |
$348.92
|
| Rate for Payer: Mclaren Medicare |
$650.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$683.52
|
| Rate for Payer: Meridian Medicaid |
$366.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$748.62
|
| Rate for Payer: PACE Medicare |
$618.42
|
| Rate for Payer: PACE SWMI |
$650.97
|
| Rate for Payer: PHP Medicare Advantage |
$650.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$348.92
|
| Rate for Payer: Priority Health Medicare |
$650.97
|
| Rate for Payer: Railroad Medicare Medicare |
$650.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,832.42
|
| Rate for Payer: UHC Dual Complete DSNP |
$650.97
|
| Rate for Payer: UHC Medicare Advantage |
$650.97
|
| Rate for Payer: UHCCP Medicaid |
$366.50
|
| Rate for Payer: VA VA |
$650.97
|
|
|
BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION
|
Facility
|
OP
|
$667.69
|
|
|
Service Code
|
CPT 51700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$127.14 |
| Max. Negotiated Rate |
$667.69 |
| Rate for Payer: Aetna Medicare |
$246.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$296.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$296.50
|
| Rate for Payer: BCBS Complete |
$133.50
|
| Rate for Payer: BCBS MAPPO |
$237.20
|
| Rate for Payer: BCN Medicare Advantage |
$237.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$237.20
|
| Rate for Payer: Mclaren Medicaid |
$127.14
|
| Rate for Payer: Mclaren Medicare |
$237.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$249.06
|
| Rate for Payer: Meridian Medicaid |
$133.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$272.78
|
| Rate for Payer: PACE Medicare |
$225.34
|
| Rate for Payer: PACE SWMI |
$237.20
|
| Rate for Payer: PHP Medicare Advantage |
$237.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$127.14
|
| Rate for Payer: Priority Health Medicare |
$237.20
|
| Rate for Payer: Railroad Medicare Medicare |
$237.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$667.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$237.20
|
| Rate for Payer: UHC Medicare Advantage |
$237.20
|
| Rate for Payer: UHCCP Medicaid |
$133.54
|
| Rate for Payer: VA VA |
$237.20
|
|
|
BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION
|
Facility
|
OP
|
$480.52
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
9289
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$192.21 |
| Max. Negotiated Rate |
$432.47 |
| Rate for Payer: Aetna Commercial |
$408.44
|
| Rate for Payer: Aetna Commercial |
$233.15
|
| Rate for Payer: Aetna Commercial |
$418.29
|
| Rate for Payer: Aetna Medicare |
$137.15
|
| Rate for Payer: Aetna Medicare |
$246.05
|
| Rate for Payer: Aetna Medicare |
$240.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$319.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$312.34
|
| Rate for Payer: BCBS Complete |
$109.72
|
| Rate for Payer: BCBS Complete |
$192.21
|
| Rate for Payer: BCBS Complete |
$196.84
|
| Rate for Payer: Cash Price |
$219.43
|
| Rate for Payer: Cash Price |
$384.42
|
| Rate for Payer: Cash Price |
$393.68
|
| Rate for Payer: Cofinity Commercial |
$344.47
|
| Rate for Payer: Cofinity Commercial |
$423.21
|
| Rate for Payer: Cofinity Commercial |
$336.36
|
| Rate for Payer: Cofinity Commercial |
$413.25
|
| Rate for Payer: Cofinity Commercial |
$235.89
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$336.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$344.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$192.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$384.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$393.68
|
| Rate for Payer: Healthscope Commercial |
$246.86
|
| Rate for Payer: Healthscope Commercial |
$432.47
|
| Rate for Payer: Healthscope Commercial |
$442.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$418.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$233.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$408.44
|
| Rate for Payer: PHP Commercial |
$233.15
|
| Rate for Payer: PHP Commercial |
$408.44
|
| Rate for Payer: PHP Commercial |
$418.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$319.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$312.34
|
| Rate for Payer: Priority Health SBD |
$302.73
|
| Rate for Payer: Priority Health SBD |
$172.80
|
| Rate for Payer: Priority Health SBD |
$310.02
|
|
|
BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION
|
Facility
|
OP
|
$912.70
|
|
|
Service Code
|
HCPCS J9040
|
| Hospital Charge Code |
17012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$365.08 |
| Max. Negotiated Rate |
$821.43 |
| Rate for Payer: Aetna Commercial |
$775.79
|
| Rate for Payer: Aetna Commercial |
$455.87
|
| Rate for Payer: Aetna Medicare |
$268.16
|
| Rate for Payer: Aetna Medicare |
$456.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$593.25
|
| Rate for Payer: BCBS Complete |
$214.53
|
| Rate for Payer: BCBS Complete |
$365.08
|
| Rate for Payer: Cash Price |
$429.06
|
| Rate for Payer: Cash Price |
$730.16
|
| Rate for Payer: Cofinity Commercial |
$638.89
|
| Rate for Payer: Cofinity Commercial |
$375.42
|
| Rate for Payer: Cofinity Commercial |
$784.92
|
| Rate for Payer: Cofinity Commercial |
$461.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$638.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$375.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$429.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$730.16
|
| Rate for Payer: Healthscope Commercial |
$482.69
|
| Rate for Payer: Healthscope Commercial |
$821.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$775.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$455.87
|
| Rate for Payer: PHP Commercial |
$455.87
|
| Rate for Payer: PHP Commercial |
$775.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$348.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$593.25
|
| Rate for Payer: Priority Health SBD |
$337.88
|
| Rate for Payer: Priority Health SBD |
$575.00
|
|
|
BLEPHAROPLASTY, UPPER EYELID;
|
Facility
|
OP
|
$5,021.81
|
|
|
Service Code
|
CPT 15822
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$956.23 |
| Max. Negotiated Rate |
$5,021.81 |
| Rate for Payer: Aetna Medicare |
$1,855.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,230.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,230.01
|
| Rate for Payer: BCBS Complete |
$1,004.04
|
| Rate for Payer: BCBS MAPPO |
$1,784.01
|
| Rate for Payer: BCN Medicare Advantage |
$1,784.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,784.01
|
| Rate for Payer: Mclaren Medicaid |
$956.23
|
| Rate for Payer: Mclaren Medicare |
$1,784.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,873.21
|
| Rate for Payer: Meridian Medicaid |
$1,004.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,051.61
|
| Rate for Payer: PACE Medicare |
$1,694.81
|
| Rate for Payer: PACE SWMI |
$1,784.01
|
| Rate for Payer: PHP Medicare Advantage |
$1,784.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$956.23
|
| Rate for Payer: Priority Health Medicare |
$1,784.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1,784.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,021.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,784.01
|
| Rate for Payer: UHC Medicare Advantage |
$1,784.01
|
| Rate for Payer: UHCCP Medicaid |
$1,004.40
|
| Rate for Payer: VA VA |
$1,784.01
|
|
|
BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID
|
Facility
|
OP
|
$5,021.81
|
|
|
Service Code
|
CPT 15823
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$956.23 |
| Max. Negotiated Rate |
$5,021.81 |
| Rate for Payer: Aetna Medicare |
$1,855.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,230.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,230.01
|
| Rate for Payer: BCBS Complete |
$1,004.04
|
| Rate for Payer: BCBS MAPPO |
$1,784.01
|
| Rate for Payer: BCN Medicare Advantage |
$1,784.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,784.01
|
| Rate for Payer: Mclaren Medicaid |
$956.23
|
| Rate for Payer: Mclaren Medicare |
$1,784.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,873.21
|
| Rate for Payer: Meridian Medicaid |
$1,004.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,051.61
|
| Rate for Payer: PACE Medicare |
$1,694.81
|
| Rate for Payer: PACE SWMI |
$1,784.01
|
| Rate for Payer: PHP Medicare Advantage |
$1,784.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$956.23
|
| Rate for Payer: Priority Health Medicare |
$1,784.01
|
| Rate for Payer: Railroad Medicare Medicare |
$1,784.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,021.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,784.01
|
| Rate for Payer: UHC Medicare Advantage |
$1,784.01
|
| Rate for Payer: UHCCP Medicaid |
$1,004.40
|
| Rate for Payer: VA VA |
$1,784.01
|
|
|
BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE
|
Facility
|
OP
|
$19,611.80
|
|
|
Service Code
|
CPT 20902
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,734.39 |
| Max. Negotiated Rate |
$19,611.80 |
| Rate for Payer: Aetna Medicare |
$7,245.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,708.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,708.92
|
| Rate for Payer: BCBS Complete |
$3,921.11
|
| Rate for Payer: BCBS MAPPO |
$6,967.14
|
| Rate for Payer: BCN Medicare Advantage |
$6,967.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,967.14
|
| Rate for Payer: Mclaren Medicaid |
$3,734.39
|
| Rate for Payer: Mclaren Medicare |
$6,967.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,315.50
|
| Rate for Payer: Meridian Medicaid |
$3,921.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,012.21
|
| Rate for Payer: PACE Medicare |
$6,618.78
|
| Rate for Payer: PACE SWMI |
$6,967.14
|
| Rate for Payer: PHP Medicare Advantage |
$6,967.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,734.39
|
| Rate for Payer: Priority Health Medicare |
$6,967.14
|
| Rate for Payer: Railroad Medicare Medicare |
$6,967.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,611.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,967.14
|
| Rate for Payer: UHC Medicare Advantage |
$6,967.14
|
| Rate for Payer: UHCCP Medicaid |
$3,922.50
|
| Rate for Payer: VA VA |
$6,967.14
|
|
|
BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION
|
Facility
|
OP
|
$192.88
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
35839
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.15 |
| Max. Negotiated Rate |
$173.59 |
| Rate for Payer: Aetna Commercial |
$163.95
|
| Rate for Payer: Aetna Medicare |
$96.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.37
|
| Rate for Payer: BCBS Complete |
$77.15
|
| Rate for Payer: Cash Price |
$154.30
|
| Rate for Payer: Cofinity Commercial |
$135.02
|
| Rate for Payer: Cofinity Commercial |
$165.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.30
|
| Rate for Payer: Healthscope Commercial |
$173.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.95
|
| Rate for Payer: PHP Commercial |
$163.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.37
|
| Rate for Payer: Priority Health SBD |
$121.51
|
|
|
BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$192.88
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
185652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.15 |
| Max. Negotiated Rate |
$173.59 |
| Rate for Payer: Aetna Commercial |
$163.95
|
| Rate for Payer: Aetna Medicare |
$96.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.37
|
| Rate for Payer: BCBS Complete |
$77.15
|
| Rate for Payer: Cash Price |
$154.30
|
| Rate for Payer: Cofinity Commercial |
$135.02
|
| Rate for Payer: Cofinity Commercial |
$165.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.30
|
| Rate for Payer: Healthscope Commercial |
$173.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.95
|
| Rate for Payer: PHP Commercial |
$163.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.37
|
| Rate for Payer: Priority Health SBD |
$121.51
|
|
|
BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$6,907.69
|
|
|
Service Code
|
HCPCS J9048
|
| Hospital Charge Code |
185652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$6,216.92 |
| Rate for Payer: Aetna Commercial |
$5,871.54
|
| Rate for Payer: Aetna Medicare |
$17.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,490.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20.62
|
| Rate for Payer: BCBS Complete |
$9.29
|
| Rate for Payer: BCBS MAPPO |
$16.50
|
| Rate for Payer: BCN Medicare Advantage |
$16.50
|
| Rate for Payer: Cash Price |
$5,526.15
|
| Rate for Payer: Cash Price |
$5,526.15
|
| Rate for Payer: Cofinity Commercial |
$5,940.61
|
| Rate for Payer: Cofinity Commercial |
$4,835.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,835.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,526.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16.50
|
| Rate for Payer: Healthscope Commercial |
$6,216.92
|
| Rate for Payer: Mclaren Medicaid |
$8.84
|
| Rate for Payer: Mclaren Medicare |
$16.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.32
|
| Rate for Payer: Meridian Medicaid |
$9.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,871.54
|
| Rate for Payer: PACE Medicare |
$15.68
|
| Rate for Payer: PACE SWMI |
$16.50
|
| Rate for Payer: PHP Commercial |
$5,871.54
|
| Rate for Payer: PHP Medicare Advantage |
$16.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,490.00
|
| Rate for Payer: Priority Health Medicare |
$16.50
|
| Rate for Payer: Priority Health SBD |
$4,351.84
|
| Rate for Payer: Railroad Medicare Medicare |
$16.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$16.50
|
| Rate for Payer: UHC Medicare Advantage |
$16.50
|
| Rate for Payer: UHCCP Medicaid |
$9.29
|
| Rate for Payer: VA VA |
$16.50
|
|
|
BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$6,907.69
|
|
|
Service Code
|
HCPCS J9048
|
| Hospital Charge Code |
185652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,351.84 |
| Max. Negotiated Rate |
$6,216.92 |
| Rate for Payer: Aetna Commercial |
$5,871.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,490.00
|
| Rate for Payer: Cash Price |
$5,526.15
|
| Rate for Payer: Cofinity Commercial |
$4,835.38
|
| Rate for Payer: Cofinity Commercial |
$5,940.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,835.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,526.15
|
| Rate for Payer: Healthscope Commercial |
$6,216.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,871.54
|
| Rate for Payer: PHP Commercial |
$5,871.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,490.00
|
| Rate for Payer: Priority Health SBD |
$4,351.84
|
|
|
BORTEZOMIB 3.5 MG SUBCUTANEOUS INJECTION
|
Facility
|
OP
|
$192.88
|
|
|
Service Code
|
HCPCS J9041
|
| Hospital Charge Code |
151057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.15 |
| Max. Negotiated Rate |
$173.59 |
| Rate for Payer: Aetna Commercial |
$163.95
|
| Rate for Payer: Aetna Medicare |
$96.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.37
|
| Rate for Payer: BCBS Complete |
$77.15
|
| Rate for Payer: Cash Price |
$154.30
|
| Rate for Payer: Cofinity Commercial |
$135.02
|
| Rate for Payer: Cofinity Commercial |
$165.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.30
|
| Rate for Payer: Healthscope Commercial |
$173.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.95
|
| Rate for Payer: PHP Commercial |
$163.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.37
|
| Rate for Payer: Priority Health SBD |
$121.51
|
|
|
BREAST REDUCTION
|
Facility
|
OP
|
$17,903.47
|
|
|
Service Code
|
CPT 19318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,409.09 |
| Max. Negotiated Rate |
$17,903.47 |
| Rate for Payer: Aetna Medicare |
$6,614.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,950.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,950.31
|
| Rate for Payer: BCBS Complete |
$3,579.55
|
| Rate for Payer: BCBS MAPPO |
$6,360.25
|
| Rate for Payer: BCN Medicare Advantage |
$6,360.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,360.25
|
| Rate for Payer: Mclaren Medicaid |
$3,409.09
|
| Rate for Payer: Mclaren Medicare |
$6,360.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,678.26
|
| Rate for Payer: Meridian Medicaid |
$3,579.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,314.29
|
| Rate for Payer: PACE Medicare |
$6,042.24
|
| Rate for Payer: PACE SWMI |
$6,360.25
|
| Rate for Payer: PHP Medicare Advantage |
$6,360.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,409.09
|
| Rate for Payer: Priority Health Medicare |
$6,360.25
|
| Rate for Payer: Railroad Medicare Medicare |
$6,360.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,903.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,360.25
|
| Rate for Payer: UHC Medicare Advantage |
$6,360.25
|
| Rate for Payer: UHCCP Medicaid |
$3,580.82
|
| Rate for Payer: VA VA |
$6,360.25
|
|
