|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$19.58
|
|
|
Service Code
|
NDC 67877-124-05
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.34 |
| Max. Negotiated Rate |
$17.62 |
| Rate for Payer: Aetna Commercial |
$16.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.73
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cofinity Commercial |
$13.71
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Healthscope Commercial |
$17.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.64
|
| Rate for Payer: PHP Commercial |
$16.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.71
|
| Rate for Payer: Priority Health SBD |
$12.34
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 0904-5894-30
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.46 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: Aetna Commercial |
$8.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.67
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Healthscope Commercial |
$9.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.72
|
| Rate for Payer: PHP Commercial |
$8.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$25.94
|
|
|
Service Code
|
NDC 1990301022
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.34 |
| Max. Negotiated Rate |
$23.35 |
| Rate for Payer: Aetna Commercial |
$22.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.86
|
| Rate for Payer: Cash Price |
$20.75
|
| Rate for Payer: Cofinity Commercial |
$18.16
|
| Rate for Payer: Cofinity Commercial |
$22.31
|
| Rate for Payer: Healthscope Commercial |
$23.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.05
|
| Rate for Payer: PHP Commercial |
$22.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.16
|
| Rate for Payer: Priority Health SBD |
$16.34
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$9.05
|
|
|
Service Code
|
NDC 0536-1303-75
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$8.14 |
| Rate for Payer: Aetna Commercial |
$7.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.88
|
| Rate for Payer: Cash Price |
$7.24
|
| Rate for Payer: Cofinity Commercial |
$6.34
|
| Rate for Payer: Cofinity Commercial |
$7.78
|
| Rate for Payer: Healthscope Commercial |
$8.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.69
|
| Rate for Payer: PHP Commercial |
$7.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.34
|
| Rate for Payer: Priority Health SBD |
$5.70
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
NDC 62372-630-15
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.11
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.39
|
| Rate for Payer: Priority Health SBD |
$15.65
|
|
|
SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION
|
Facility
|
IP
|
$10.98
|
|
|
Service Code
|
NDC 0536-2220-75
|
| Hospital Charge Code |
7228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.92 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$9.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.14
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cofinity Commercial |
$7.69
|
| Rate for Payer: Cofinity Commercial |
$9.44
|
| Rate for Payer: Healthscope Commercial |
$9.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.33
|
| Rate for Payer: PHP Commercial |
$9.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.69
|
| Rate for Payer: Priority Health SBD |
$6.92
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$39.95
|
|
|
Service Code
|
NDC 0904-5068-60
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.17 |
| Max. Negotiated Rate |
$35.96 |
| Rate for Payer: Aetna Commercial |
$33.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.97
|
| Rate for Payer: Cash Price |
$31.96
|
| Rate for Payer: Cofinity Commercial |
$27.96
|
| Rate for Payer: Cofinity Commercial |
$34.36
|
| Rate for Payer: Healthscope Commercial |
$35.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.96
|
| Rate for Payer: PHP Commercial |
$33.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.96
|
| Rate for Payer: Priority Health SBD |
$25.17
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$103.40
|
|
|
Service Code
|
NDC 63739-225-10
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna Commercial |
$87.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.21
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Commercial |
$72.38
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.89
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.38
|
| Rate for Payer: Priority Health SBD |
$65.14
|
|
|
SIMETHICONE 80 MG CHEWABLE TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 70000-0434-1
|
| Hospital Charge Code |
7227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.86 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.28
|
| Rate for Payer: Priority Health SBD |
$48.86
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH CC
|
Facility
|
IP
|
$12,541.84
|
|
|
Service Code
|
MS-DRG 194
|
| Min. Negotiated Rate |
$6,093.34 |
| Max. Negotiated Rate |
$12,541.84 |
| Rate for Payer: Aetna Medicare |
$6,670.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,017.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,017.55
|
| Rate for Payer: BCBS MAPPO |
$6,414.04
|
| Rate for Payer: BCBS Trust/PPO |
$10,748.93
|
| Rate for Payer: BCN Medicare Advantage |
$6,414.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,414.04
|
| Rate for Payer: Mclaren Medicare |
$6,414.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,734.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,376.15
|
| Rate for Payer: PACE Medicare |
$6,093.34
|
| Rate for Payer: PACE SWMI |
$6,414.04
|
| Rate for Payer: PHP Medicare Advantage |
$6,414.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,798.50
|
| Rate for Payer: Priority Health Medicare |
$6,414.04
|
| Rate for Payer: Priority Health Narrow Network |
$9,438.80
|
| Rate for Payer: Railroad Medicare Medicare |
$6,414.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,541.84
|
| Rate for Payer: UHC Core |
$7,695.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,414.04
|
| Rate for Payer: UHC Exchange |
$8,242.56
|
| Rate for Payer: UHC Medicare Advantage |
$6,606.46
|
| Rate for Payer: VA VA |
$6,414.04
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITH MCC
|
Facility
|
IP
|
$20,235.96
|
|
|
Service Code
|
MS-DRG 193
|
| Min. Negotiated Rate |
$9,544.31 |
| Max. Negotiated Rate |
$20,235.96 |
| Rate for Payer: Aetna Medicare |
$10,448.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,558.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,558.30
|
| Rate for Payer: BCBS MAPPO |
$10,046.64
|
| Rate for Payer: BCBS Trust/PPO |
$16,866.71
|
| Rate for Payer: BCN Medicare Advantage |
$10,046.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10,046.64
|
| Rate for Payer: Mclaren Medicare |
$10,046.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,548.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,553.64
|
| Rate for Payer: PACE Medicare |
$9,544.31
|
| Rate for Payer: PACE SWMI |
$10,046.64
|
| Rate for Payer: PHP Medicare Advantage |
$10,046.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19,036.60
|
| Rate for Payer: Priority Health Medicare |
$10,046.64
|
| Rate for Payer: Priority Health Narrow Network |
$15,229.28
|
| Rate for Payer: Railroad Medicare Medicare |
$10,046.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20,235.96
|
| Rate for Payer: UHC Core |
$12,416.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$10,046.64
|
| Rate for Payer: UHC Exchange |
$13,299.17
|
| Rate for Payer: UHC Medicare Advantage |
$10,348.04
|
| Rate for Payer: VA VA |
$10,046.64
|
|
|
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC
|
Facility
|
IP
|
$9,542.90
|
|
|
Service Code
|
MS-DRG 195
|
| Min. Negotiated Rate |
$4,748.26 |
| Max. Negotiated Rate |
$9,542.90 |
| Rate for Payer: Aetna Medicare |
$5,198.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,247.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,247.71
|
| Rate for Payer: BCBS MAPPO |
$4,998.17
|
| Rate for Payer: BCBS Trust/PPO |
$7,292.58
|
| Rate for Payer: BCN Medicare Advantage |
$4,998.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,998.17
|
| Rate for Payer: Mclaren Medicare |
$4,998.17
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,248.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,747.90
|
| Rate for Payer: PACE Medicare |
$4,748.26
|
| Rate for Payer: PACE SWMI |
$4,998.17
|
| Rate for Payer: PHP Medicare Advantage |
$4,998.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,977.31
|
| Rate for Payer: Priority Health Medicare |
$4,998.17
|
| Rate for Payer: Priority Health Narrow Network |
$7,181.85
|
| Rate for Payer: Railroad Medicare Medicare |
$4,998.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9,542.90
|
| Rate for Payer: UHC Core |
$5,855.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,998.17
|
| Rate for Payer: UHC Exchange |
$6,271.64
|
| Rate for Payer: UHC Medicare Advantage |
$5,148.12
|
| Rate for Payer: VA VA |
$4,998.17
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 12011
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$54.36 |
| Max. Negotiated Rate |
$878.00 |
| 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 |
$79.92
|
| 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) |
$59.80
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$178.14
|
| Rate for Payer: UHC Exchange |
$54.36
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: VA VA |
$178.14
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 12013
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$56.65 |
| Max. Negotiated Rate |
$878.00 |
| 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 |
$108.25
|
| 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) |
$62.32
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$178.14
|
| Rate for Payer: UHC Exchange |
$56.65
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: VA VA |
$178.14
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 12001
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$43.88 |
| Max. Negotiated Rate |
$878.00 |
| 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 |
$77.91
|
| 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) |
$48.27
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$178.14
|
| Rate for Payer: UHC Exchange |
$43.88
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: VA VA |
$178.14
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 12002
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$57.63 |
| Max. Negotiated Rate |
$878.00 |
| 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 |
$93.93
|
| 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) |
$63.39
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$178.14
|
| Rate for Payer: UHC Exchange |
$57.63
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: VA VA |
$178.14
|
|
|
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 12004
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$72.04 |
| Max. Negotiated Rate |
$878.00 |
| 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 |
$122.43
|
| 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) |
$79.24
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$178.14
|
| Rate for Payer: UHC Exchange |
$72.04
|
| Rate for Payer: UHC Medicare Advantage |
$183.48
|
| Rate for Payer: VA VA |
$178.14
|
|
|
SIMPLE SYRUP
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
NDC 395266116
|
| Hospital Charge Code |
7242
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.72 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$122.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.60
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cofinity Commercial |
$100.80
|
| Rate for Payer: Cofinity Commercial |
$123.84
|
| Rate for Payer: Healthscope Commercial |
$129.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$122.40
|
| Rate for Payer: PHP Commercial |
$122.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.80
|
| Rate for Payer: Priority Health SBD |
$90.72
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
|
IP
|
$85,152.61
|
|
|
Service Code
|
MS-DRG 008
|
| Min. Negotiated Rate |
$36,467.07 |
| Max. Negotiated Rate |
$85,152.61 |
| Rate for Payer: Aetna Medicare |
$39,921.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47,982.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47,982.99
|
| Rate for Payer: BCBS MAPPO |
$38,386.39
|
| Rate for Payer: BCBS Trust/PPO |
$85,152.61
|
| Rate for Payer: BCN Medicare Advantage |
$38,386.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$38,386.39
|
| Rate for Payer: Mclaren Medicare |
$38,386.39
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$40,305.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44,144.35
|
| Rate for Payer: PACE Medicare |
$36,467.07
|
| Rate for Payer: PACE SWMI |
$38,386.39
|
| Rate for Payer: PHP Medicare Advantage |
$38,386.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75,504.97
|
| Rate for Payer: Priority Health Medicare |
$38,386.39
|
| Rate for Payer: Priority Health Narrow Network |
$60,403.98
|
| Rate for Payer: Railroad Medicare Medicare |
$38,386.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80,261.97
|
| Rate for Payer: UHC Core |
$49,249.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$38,386.39
|
| Rate for Payer: UHC Exchange |
$52,748.54
|
| Rate for Payer: UHC Medicare Advantage |
$39,537.98
|
| Rate for Payer: VA VA |
$38,386.39
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS
|
Facility
|
IP
|
$129,362.66
|
|
|
Service Code
|
MS-DRG 019
|
| Min. Negotiated Rate |
$55,157.24 |
| Max. Negotiated Rate |
$129,362.66 |
| Rate for Payer: Aetna Medicare |
$60,382.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$72,575.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$72,575.31
|
| Rate for Payer: BCBS MAPPO |
$58,060.25
|
| Rate for Payer: BCBS Trust/PPO |
$129,362.66
|
| Rate for Payer: BCN Medicare Advantage |
$58,060.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$58,060.25
|
| Rate for Payer: Mclaren Medicare |
$58,060.25
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$60,963.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66,769.29
|
| Rate for Payer: PACE Medicare |
$55,157.24
|
| Rate for Payer: PACE SWMI |
$58,060.25
|
| Rate for Payer: PHP Medicare Advantage |
$58,060.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$114,706.09
|
| Rate for Payer: Priority Health Medicare |
$58,060.25
|
| Rate for Payer: Priority Health Narrow Network |
$91,764.87
|
| Rate for Payer: Railroad Medicare Medicare |
$58,060.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$121,932.85
|
| Rate for Payer: UHC Core |
$74,819.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$58,060.25
|
| Rate for Payer: UHC Exchange |
$80,134.84
|
| Rate for Payer: UHC Medicare Advantage |
$59,802.06
|
| Rate for Payer: VA VA |
$58,060.25
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$430.73
|
|
|
Service Code
|
HCPCS J2805
|
| Hospital Charge Code |
11368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.36 |
| Max. Negotiated Rate |
$387.66 |
| Rate for Payer: Aetna Commercial |
$366.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$279.97
|
| Rate for Payer: Cash Price |
$344.58
|
| Rate for Payer: Cofinity Commercial |
$301.51
|
| Rate for Payer: Cofinity Commercial |
$370.43
|
| Rate for Payer: Healthscope Commercial |
$387.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$366.12
|
| Rate for Payer: PHP Commercial |
$366.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$301.51
|
| Rate for Payer: Priority Health SBD |
$271.36
|
|
|
SINUS AND MASTOID PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$40,455.13
|
|
|
Service Code
|
MS-DRG 135
|
| Min. Negotiated Rate |
$18,612.97 |
| Max. Negotiated Rate |
$40,455.13 |
| Rate for Payer: Aetna Medicare |
$20,376.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,490.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,490.75
|
| Rate for Payer: BCBS MAPPO |
$19,592.60
|
| Rate for Payer: BCBS Trust/PPO |
$30,843.61
|
| Rate for Payer: BCN Medicare Advantage |
$19,592.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,592.60
|
| Rate for Payer: Mclaren Medicare |
$19,592.60
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$20,572.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,531.49
|
| Rate for Payer: PACE Medicare |
$18,612.97
|
| Rate for Payer: PACE SWMI |
$19,592.60
|
| Rate for Payer: PHP Medicare Advantage |
$19,592.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38,057.42
|
| Rate for Payer: Priority Health Medicare |
$19,592.60
|
| Rate for Payer: Priority Health Narrow Network |
$30,445.94
|
| Rate for Payer: Railroad Medicare Medicare |
$19,592.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40,455.13
|
| Rate for Payer: UHC Core |
$24,823.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$19,592.60
|
| Rate for Payer: UHC Exchange |
$26,587.30
|
| Rate for Payer: UHC Medicare Advantage |
$20,180.38
|
| Rate for Payer: VA VA |
$19,592.60
|
|
|
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$18,287.46
|
|
|
Service Code
|
MS-DRG 136
|
| Min. Negotiated Rate |
$7,612.87 |
| Max. Negotiated Rate |
$18,287.46 |
| Rate for Payer: Aetna Medicare |
$8,334.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,016.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,016.94
|
| Rate for Payer: BCBS MAPPO |
$8,013.55
|
| Rate for Payer: BCBS Trust/PPO |
$18,287.46
|
| Rate for Payer: BCN Medicare Advantage |
$8,013.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,013.55
|
| Rate for Payer: Mclaren Medicare |
$8,013.55
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,414.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,215.58
|
| Rate for Payer: PACE Medicare |
$7,612.87
|
| Rate for Payer: PACE SWMI |
$8,013.55
|
| Rate for Payer: PHP Medicare Advantage |
$8,013.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,476.01
|
| Rate for Payer: Priority Health Medicare |
$8,013.55
|
| Rate for Payer: Priority Health Narrow Network |
$10,780.81
|
| Rate for Payer: Railroad Medicare Medicare |
$8,013.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,325.03
|
| Rate for Payer: UHC Core |
$8,789.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$8,013.55
|
| Rate for Payer: UHC Exchange |
$9,414.48
|
| Rate for Payer: UHC Medicare Advantage |
$8,253.96
|
| Rate for Payer: VA VA |
$8,013.55
|
|
|
SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION
|
Facility
|
OP
|
$317,963.84
|
|
|
Service Code
|
HCPCS Q2043
|
| Hospital Charge Code |
104852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29,224.38 |
| Max. Negotiated Rate |
$286,167.46 |
| Rate for Payer: Aetna Commercial |
$270,269.26
|
| Rate for Payer: Aetna Medicare |
$55,563.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206,676.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66,783.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66,783.32
|
| Rate for Payer: BCBS Complete |
$30,688.27
|
| Rate for Payer: BCBS MAPPO |
$53,426.66
|
| Rate for Payer: BCBS Trust/PPO |
$157,092.63
|
| Rate for Payer: BCN Medicare Advantage |
$53,426.66
|
| Rate for Payer: Cash Price |
$254,371.07
|
| Rate for Payer: Cash Price |
$254,371.07
|
| Rate for Payer: Cofinity Commercial |
$273,448.90
|
| Rate for Payer: Cofinity Commercial |
$222,574.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$53,426.66
|
| Rate for Payer: Healthscope Commercial |
$286,167.46
|
| Rate for Payer: Mclaren Medicaid |
$29,224.38
|
| Rate for Payer: Mclaren Medicare |
$53,426.66
|
| Rate for Payer: Meridian Medicaid |
$30,688.27
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$56,097.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61,440.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$270,269.26
|
| Rate for Payer: PACE Medicare |
$50,755.32
|
| Rate for Payer: PACE SWMI |
$53,426.66
|
| Rate for Payer: PHP Commercial |
$270,269.26
|
| Rate for Payer: PHP Medicare Advantage |
$53,426.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$29,224.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$222,574.69
|
| Rate for Payer: Priority Health Medicare |
$53,426.66
|
| Rate for Payer: Priority Health SBD |
$200,317.22
|
| Rate for Payer: Railroad Medicare Medicare |
$53,426.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$53,426.66
|
| Rate for Payer: UHC Medicare Advantage |
$55,029.46
|
| Rate for Payer: VA VA |
$53,426.66
|
|
|
SKIN CARE CONSULT
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS 00177
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: BCBS Complete |
$10.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.50
|
|
