|
SPIRONOLACTONE 50 MG TABLET
|
Facility
|
IP
|
$2.61
|
|
|
Service Code
|
NDC 60687-476-11
|
| Hospital Charge Code |
11426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.22
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.64
|
|
|
SPIRONOLACTONE 50 MG TABLET
|
Facility
|
IP
|
$260.30
|
|
|
Service Code
|
NDC 60687-476-01
|
| Hospital Charge Code |
11426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.99 |
| Max. Negotiated Rate |
$234.27 |
| Rate for Payer: Aetna Commercial |
$221.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.20
|
| Rate for Payer: Cash Price |
$208.24
|
| Rate for Payer: Cofinity Commercial |
$182.21
|
| Rate for Payer: Cofinity Commercial |
$223.86
|
| Rate for Payer: Healthscope Commercial |
$234.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.26
|
| Rate for Payer: PHP Commercial |
$221.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: Priority Health SBD |
$163.99
|
|
|
SPLENIC PROCEDURES WITH CC
|
Facility
|
IP
|
$42,981.20
|
|
|
Service Code
|
MS-DRG 800
|
| Min. Negotiated Rate |
$19,745.96 |
| Max. Negotiated Rate |
$42,981.20 |
| Rate for Payer: Aetna Medicare |
$21,616.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25,981.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25,981.52
|
| Rate for Payer: BCBS MAPPO |
$20,785.22
|
| Rate for Payer: BCBS Trust/PPO |
$42,216.18
|
| Rate for Payer: BCN Medicare Advantage |
$20,785.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20,785.22
|
| Rate for Payer: Mclaren Medicare |
$20,785.22
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$21,824.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23,903.00
|
| Rate for Payer: PACE Medicare |
$19,745.96
|
| Rate for Payer: PACE SWMI |
$20,785.22
|
| Rate for Payer: PHP Medicare Advantage |
$20,785.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40,433.77
|
| Rate for Payer: Priority Health Medicare |
$20,785.22
|
| Rate for Payer: Priority Health Narrow Network |
$32,347.02
|
| Rate for Payer: Railroad Medicare Medicare |
$20,785.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42,981.20
|
| Rate for Payer: UHC Core |
$26,373.67
|
| Rate for Payer: UHC Dual Complete DSNP |
$20,785.22
|
| Rate for Payer: UHC Exchange |
$28,247.44
|
| Rate for Payer: UHC Medicare Advantage |
$21,408.78
|
| Rate for Payer: VA VA |
$20,785.22
|
|
|
SPLENIC PROCEDURES WITH MCC
|
Facility
|
IP
|
$75,577.47
|
|
|
Service Code
|
MS-DRG 799
|
| Min. Negotiated Rate |
$34,365.99 |
| Max. Negotiated Rate |
$75,577.47 |
| Rate for Payer: Aetna Medicare |
$37,621.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$45,218.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$45,218.41
|
| Rate for Payer: BCBS MAPPO |
$36,174.73
|
| Rate for Payer: BCBS Trust/PPO |
$58,015.68
|
| Rate for Payer: BCN Medicare Advantage |
$36,174.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$36,174.73
|
| Rate for Payer: Mclaren Medicare |
$36,174.73
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$37,983.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41,600.94
|
| Rate for Payer: PACE Medicare |
$34,365.99
|
| Rate for Payer: PACE SWMI |
$36,174.73
|
| Rate for Payer: PHP Medicare Advantage |
$36,174.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$71,098.11
|
| Rate for Payer: Priority Health Medicare |
$36,174.73
|
| Rate for Payer: Priority Health Narrow Network |
$56,878.49
|
| Rate for Payer: Railroad Medicare Medicare |
$36,174.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$75,577.47
|
| Rate for Payer: UHC Core |
$46,375.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$36,174.73
|
| Rate for Payer: UHC Exchange |
$49,669.87
|
| Rate for Payer: UHC Medicare Advantage |
$37,259.97
|
| Rate for Payer: VA VA |
$36,174.73
|
|
|
SPLENIC PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$40,852.52
|
|
|
Service Code
|
MS-DRG 801
|
| Min. Negotiated Rate |
$12,712.70 |
| Max. Negotiated Rate |
$40,852.52 |
| Rate for Payer: Aetna Medicare |
$13,917.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16,727.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16,727.24
|
| Rate for Payer: BCBS MAPPO |
$13,381.79
|
| Rate for Payer: BCBS Trust/PPO |
$40,852.52
|
| Rate for Payer: BCN Medicare Advantage |
$13,381.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,381.79
|
| Rate for Payer: Mclaren Medicare |
$13,381.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,050.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,389.06
|
| Rate for Payer: PACE Medicare |
$12,712.70
|
| Rate for Payer: PACE SWMI |
$13,381.79
|
| Rate for Payer: PHP Medicare Advantage |
$13,381.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25,682.05
|
| Rate for Payer: Priority Health Medicare |
$13,381.79
|
| Rate for Payer: Priority Health Narrow Network |
$20,545.64
|
| Rate for Payer: Railroad Medicare Medicare |
$13,381.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27,300.08
|
| Rate for Payer: UHC Core |
$16,751.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$13,381.79
|
| Rate for Payer: UHC Exchange |
$17,941.74
|
| Rate for Payer: UHC Medicare Advantage |
$13,783.24
|
| Rate for Payer: VA VA |
$13,381.79
|
|
|
SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)
|
Facility
|
OP
|
$9,754.38
|
|
|
Service Code
|
CPT 15120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$678.79 |
| Max. Negotiated Rate |
$9,754.38 |
| Rate for Payer: Aetna Medicare |
$3,319.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,990.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,990.30
|
| Rate for Payer: BCBS Complete |
$1,833.62
|
| Rate for Payer: BCBS MAPPO |
$3,192.24
|
| Rate for Payer: BCBS Trust/PPO |
$2,674.37
|
| Rate for Payer: BCN Medicare Advantage |
$3,192.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,192.24
|
| Rate for Payer: Mclaren Medicaid |
$1,746.16
|
| Rate for Payer: Mclaren Medicare |
$3,192.24
|
| Rate for Payer: Meridian Medicaid |
$1,833.62
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,351.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,671.08
|
| Rate for Payer: PACE Medicare |
$3,032.63
|
| Rate for Payer: PACE SWMI |
$3,192.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,192.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,746.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,754.38
|
| Rate for Payer: Priority Health Medicare |
$3,192.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,803.50
|
| Rate for Payer: Railroad Medicare Medicare |
$3,192.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$746.67
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,192.24
|
| Rate for Payer: UHC Exchange |
$678.79
|
| Rate for Payer: UHC Medicare Advantage |
$3,288.01
|
| Rate for Payer: VA VA |
$3,192.24
|
|
|
SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)
|
Facility
|
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 15100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$704.33 |
| Max. Negotiated Rate |
$5,175.07 |
| Rate for Payer: Aetna Medicare |
$1,687.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,028.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,028.30
|
| Rate for Payer: BCBS Complete |
$932.04
|
| Rate for Payer: BCBS MAPPO |
$1,622.64
|
| Rate for Payer: BCBS Trust/PPO |
$2,195.82
|
| Rate for Payer: BCN Medicare Advantage |
$1,622.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,622.64
|
| Rate for Payer: Mclaren Medicaid |
$887.58
|
| Rate for Payer: Mclaren Medicare |
$1,622.64
|
| Rate for Payer: Meridian Medicaid |
$932.04
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,703.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,866.04
|
| Rate for Payer: PACE Medicare |
$1,541.51
|
| Rate for Payer: PACE SWMI |
$1,622.64
|
| Rate for Payer: PHP Medicare Advantage |
$1,622.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$887.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,175.07
|
| Rate for Payer: Priority Health Medicare |
$1,622.64
|
| Rate for Payer: Priority Health Narrow Network |
$4,140.06
|
| Rate for Payer: Railroad Medicare Medicare |
$1,622.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$774.76
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$704.33
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC
|
Facility
|
IP
|
$26,704.34
|
|
|
Service Code
|
MS-DRG 537
|
| Min. Negotiated Rate |
$7,084.01 |
| Max. Negotiated Rate |
$26,704.34 |
| Rate for Payer: Aetna Medicare |
$7,755.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,321.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,321.06
|
| Rate for Payer: BCBS MAPPO |
$7,456.85
|
| Rate for Payer: BCBS Trust/PPO |
$26,704.34
|
| Rate for Payer: BCN Medicare Advantage |
$7,456.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,456.85
|
| Rate for Payer: Mclaren Medicare |
$7,456.85
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,829.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,575.38
|
| Rate for Payer: PACE Medicare |
$7,084.01
|
| Rate for Payer: PACE SWMI |
$7,456.85
|
| Rate for Payer: PHP Medicare Advantage |
$7,456.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13,876.37
|
| Rate for Payer: Priority Health Medicare |
$7,456.85
|
| Rate for Payer: Priority Health Narrow Network |
$11,101.10
|
| Rate for Payer: Railroad Medicare Medicare |
$7,456.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,750.62
|
| Rate for Payer: UHC Core |
$9,051.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$7,456.85
|
| Rate for Payer: UHC Exchange |
$9,694.18
|
| Rate for Payer: UHC Medicare Advantage |
$7,680.56
|
| Rate for Payer: VA VA |
$7,456.85
|
|
|
SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC
|
Facility
|
IP
|
$13,467.45
|
|
|
Service Code
|
MS-DRG 538
|
| Min. Negotiated Rate |
$5,319.54 |
| Max. Negotiated Rate |
$13,467.45 |
| Rate for Payer: Aetna Medicare |
$5,823.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,999.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,999.40
|
| Rate for Payer: BCBS MAPPO |
$5,599.52
|
| Rate for Payer: BCBS Trust/PPO |
$13,467.45
|
| Rate for Payer: BCN Medicare Advantage |
$5,599.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,599.52
|
| Rate for Payer: Mclaren Medicare |
$5,599.52
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,879.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,439.45
|
| Rate for Payer: PACE Medicare |
$5,319.54
|
| Rate for Payer: PACE SWMI |
$5,599.52
|
| Rate for Payer: PHP Medicare Advantage |
$5,599.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,175.53
|
| Rate for Payer: Priority Health Medicare |
$5,599.52
|
| Rate for Payer: Priority Health Narrow Network |
$8,140.42
|
| Rate for Payer: Railroad Medicare Medicare |
$5,599.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,816.61
|
| Rate for Payer: UHC Core |
$6,637.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,599.52
|
| Rate for Payer: UHC Exchange |
$7,108.73
|
| Rate for Payer: UHC Medicare Advantage |
$5,767.51
|
| Rate for Payer: VA VA |
$5,599.52
|
|
|
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; 10-20 STAB INCISIONS
|
Facility
|
OP
|
$8,913.25
|
|
|
Service Code
|
CPT 37765
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$261.30 |
| Max. Negotiated Rate |
$8,913.25 |
| Rate for Payer: Aetna Medicare |
$2,949.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,545.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,545.25
|
| Rate for Payer: BCBS Complete |
$1,629.11
|
| Rate for Payer: BCBS MAPPO |
$2,836.20
|
| Rate for Payer: BCBS Trust/PPO |
$1,862.15
|
| Rate for Payer: BCN Medicare Advantage |
$2,836.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,836.20
|
| Rate for Payer: Mclaren Medicaid |
$1,551.40
|
| Rate for Payer: Mclaren Medicare |
$2,836.20
|
| Rate for Payer: Meridian Medicaid |
$1,629.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,978.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,261.63
|
| Rate for Payer: PACE Medicare |
$2,694.39
|
| Rate for Payer: PACE SWMI |
$2,836.20
|
| Rate for Payer: PHP Medicare Advantage |
$2,836.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,551.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,913.25
|
| Rate for Payer: Priority Health Medicare |
$2,836.20
|
| Rate for Payer: Priority Health Narrow Network |
$7,130.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,836.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$287.43
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,836.20
|
| Rate for Payer: UHC Exchange |
$261.30
|
| Rate for Payer: UHC Medicare Advantage |
$2,921.29
|
| Rate for Payer: VA VA |
$2,836.20
|
|
|
STAB PHLEBECTOMY OF VARICOSE VEINS, 1 EXTREMITY; MORE THAN 20 INCISIONS
|
Facility
|
OP
|
$8,913.25
|
|
|
Service Code
|
CPT 37766
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$279.21 |
| Max. Negotiated Rate |
$8,913.25 |
| Rate for Payer: Aetna Medicare |
$2,949.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,545.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,545.25
|
| Rate for Payer: BCBS Complete |
$1,629.11
|
| Rate for Payer: BCBS MAPPO |
$2,836.20
|
| Rate for Payer: BCBS Trust/PPO |
$279.21
|
| Rate for Payer: BCN Medicare Advantage |
$2,836.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,836.20
|
| Rate for Payer: Mclaren Medicaid |
$1,551.40
|
| Rate for Payer: Mclaren Medicare |
$2,836.20
|
| Rate for Payer: Meridian Medicaid |
$1,629.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,978.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,261.63
|
| Rate for Payer: PACE Medicare |
$2,694.39
|
| Rate for Payer: PACE SWMI |
$2,836.20
|
| Rate for Payer: PHP Medicare Advantage |
$2,836.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,551.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,913.25
|
| Rate for Payer: Priority Health Medicare |
$2,836.20
|
| Rate for Payer: Priority Health Narrow Network |
$7,130.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,836.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$352.26
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,836.20
|
| Rate for Payer: UHC Exchange |
$320.24
|
| Rate for Payer: UHC Medicare Advantage |
$2,921.29
|
| Rate for Payer: VA VA |
$2,836.20
|
|
|
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL, EXTRADURAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 61782
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$167.98 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: BCBS Trust/PPO |
$357.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$184.78
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$167.98
|
|
|
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$878.00
|
|
|
Service Code
|
CPT 61783
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$226.92 |
| Max. Negotiated Rate |
$878.00 |
| Rate for Payer: BCBS Trust/PPO |
$480.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$249.61
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$226.92
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
IP
|
$443.75
|
|
|
Service Code
|
NDC 62327-333-03
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$279.56 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$310.62
|
| Rate for Payer: Priority Health SBD |
$279.56
|
|
|
STERILE TALC 3 GRAM INTRAPLEURAL AEROSOL POWDER
|
Facility
|
IP
|
$443.75
|
|
|
Service Code
|
NDC 62327-333-43
|
| Hospital Charge Code |
186167
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$279.56 |
| Max. Negotiated Rate |
$399.38 |
| Rate for Payer: Aetna Commercial |
$377.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.44
|
| Rate for Payer: Cash Price |
$355.00
|
| Rate for Payer: Cofinity Commercial |
$310.62
|
| Rate for Payer: Cofinity Commercial |
$381.62
|
| Rate for Payer: Healthscope Commercial |
$399.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$377.19
|
| Rate for Payer: PHP Commercial |
$377.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$310.62
|
| Rate for Payer: Priority Health SBD |
$279.56
|
|
|
STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC
|
Facility
|
IP
|
$42,407.22
|
|
|
Service Code
|
MS-DRG 327
|
| Min. Negotiated Rate |
$17,554.55 |
| Max. Negotiated Rate |
$42,407.22 |
| Rate for Payer: Aetna Medicare |
$19,217.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23,098.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23,098.09
|
| Rate for Payer: BCBS MAPPO |
$18,478.47
|
| Rate for Payer: BCBS Trust/PPO |
$42,407.22
|
| Rate for Payer: BCN Medicare Advantage |
$18,478.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18,478.47
|
| Rate for Payer: Mclaren Medicare |
$18,478.47
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19,402.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21,250.24
|
| Rate for Payer: PACE Medicare |
$17,554.55
|
| Rate for Payer: PACE SWMI |
$18,478.47
|
| Rate for Payer: PHP Medicare Advantage |
$18,478.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$35,837.49
|
| Rate for Payer: Priority Health Medicare |
$18,478.47
|
| Rate for Payer: Priority Health Narrow Network |
$28,669.99
|
| Rate for Payer: Railroad Medicare Medicare |
$18,478.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38,095.34
|
| Rate for Payer: UHC Core |
$23,375.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$18,478.47
|
| Rate for Payer: UHC Exchange |
$25,036.44
|
| Rate for Payer: UHC Medicare Advantage |
$19,032.82
|
| Rate for Payer: VA VA |
$18,478.47
|
|
|
STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC
|
Facility
|
IP
|
$79,482.80
|
|
|
Service Code
|
MS-DRG 326
|
| Min. Negotiated Rate |
$35,217.09 |
| Max. Negotiated Rate |
$79,482.80 |
| Rate for Payer: Aetna Medicare |
$38,553.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46,338.28
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46,338.28
|
| Rate for Payer: BCBS MAPPO |
$37,070.62
|
| Rate for Payer: BCBS Trust/PPO |
$79,482.80
|
| Rate for Payer: BCN Medicare Advantage |
$37,070.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37,070.62
|
| Rate for Payer: Mclaren Medicare |
$37,070.62
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$38,924.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42,631.21
|
| Rate for Payer: PACE Medicare |
$35,217.09
|
| Rate for Payer: PACE SWMI |
$37,070.62
|
| Rate for Payer: PHP Medicare Advantage |
$37,070.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$72,883.24
|
| Rate for Payer: Priority Health Medicare |
$37,070.62
|
| Rate for Payer: Priority Health Narrow Network |
$58,306.59
|
| Rate for Payer: Railroad Medicare Medicare |
$37,070.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77,475.07
|
| Rate for Payer: UHC Core |
$47,539.44
|
| Rate for Payer: UHC Dual Complete DSNP |
$37,070.62
|
| Rate for Payer: UHC Exchange |
$50,916.98
|
| Rate for Payer: UHC Medicare Advantage |
$38,182.74
|
| Rate for Payer: VA VA |
$37,070.62
|
|
|
STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$27,977.96
|
|
|
Service Code
|
MS-DRG 328
|
| Min. Negotiated Rate |
$11,396.34 |
| Max. Negotiated Rate |
$27,977.96 |
| Rate for Payer: Aetna Medicare |
$12,476.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,995.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,995.19
|
| Rate for Payer: BCBS MAPPO |
$11,996.15
|
| Rate for Payer: BCBS Trust/PPO |
$27,977.96
|
| Rate for Payer: BCN Medicare Advantage |
$11,996.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,996.15
|
| Rate for Payer: Mclaren Medicare |
$11,996.15
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,595.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,795.57
|
| Rate for Payer: PACE Medicare |
$11,396.34
|
| Rate for Payer: PACE SWMI |
$11,996.15
|
| Rate for Payer: PHP Medicare Advantage |
$11,996.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,921.13
|
| Rate for Payer: Priority Health Medicare |
$11,996.15
|
| Rate for Payer: Priority Health Narrow Network |
$18,336.90
|
| Rate for Payer: Railroad Medicare Medicare |
$11,996.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,365.21
|
| Rate for Payer: UHC Core |
$14,950.73
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,996.15
|
| Rate for Payer: UHC Exchange |
$16,012.93
|
| Rate for Payer: UHC Medicare Advantage |
$12,356.03
|
| Rate for Payer: VA VA |
$11,996.15
|
|
|
SUBMUCOSAL INJECTABLE COMPOSITION (ELEVIEW)
|
Facility
|
IP
|
$287.55
|
|
|
Service Code
|
NDC 9900-0010-87
|
| Hospital Charge Code |
200133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$181.16 |
| Max. Negotiated Rate |
$258.80 |
| Rate for Payer: Aetna Commercial |
$244.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.91
|
| Rate for Payer: Cash Price |
$230.04
|
| Rate for Payer: Cofinity Commercial |
$201.28
|
| Rate for Payer: Cofinity Commercial |
$247.29
|
| Rate for Payer: Healthscope Commercial |
$258.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$244.42
|
| Rate for Payer: PHP Commercial |
$244.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.28
|
| Rate for Payer: Priority Health SBD |
$181.16
|
|
|
SUBMUCOSAL INJECTABLE COMPOSITION (ELEVIEW)
|
Facility
|
IP
|
$287.55
|
|
|
Service Code
|
NDC 5391-5301-90
|
| Hospital Charge Code |
200133
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$181.16 |
| Max. Negotiated Rate |
$258.80 |
| Rate for Payer: Aetna Commercial |
$244.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.91
|
| Rate for Payer: Cash Price |
$230.04
|
| Rate for Payer: Cofinity Commercial |
$201.28
|
| Rate for Payer: Cofinity Commercial |
$247.29
|
| Rate for Payer: Healthscope Commercial |
$258.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$244.42
|
| Rate for Payer: PHP Commercial |
$244.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.28
|
| Rate for Payer: Priority Health SBD |
$181.16
|
|
|
SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 30140
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$174.53 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,979.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,580.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,580.99
|
| Rate for Payer: BCBS Complete |
$1,645.54
|
| Rate for Payer: BCBS MAPPO |
$2,864.79
|
| Rate for Payer: BCBS Trust/PPO |
$952.38
|
| Rate for Payer: BCN Medicare Advantage |
$2,864.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,864.79
|
| Rate for Payer: Mclaren Medicaid |
$1,567.04
|
| Rate for Payer: Mclaren Medicare |
$2,864.79
|
| Rate for Payer: Meridian Medicaid |
$1,645.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,008.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,294.51
|
| Rate for Payer: PACE Medicare |
$2,721.55
|
| Rate for Payer: PACE SWMI |
$2,864.79
|
| Rate for Payer: PHP Medicare Advantage |
$2,864.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,567.04
|
| Rate for Payer: Priority Health Medicare |
$2,864.79
|
| Rate for Payer: Railroad Medicare Medicare |
$2,864.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$191.98
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,864.79
|
| Rate for Payer: UHC Exchange |
$174.53
|
| Rate for Payer: UHC Medicare Advantage |
$2,950.73
|
| Rate for Payer: VA VA |
$2,864.79
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$24.20
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
163722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.25 |
| Max. Negotiated Rate |
$21.78 |
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Cash Price |
$19.36
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cofinity Commercial |
$16.94
|
| Rate for Payer: Cofinity Commercial |
$55.54
|
| Rate for Payer: Cofinity Commercial |
$20.26
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$20.81
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Healthscope Commercial |
$21.78
|
| Rate for Payer: Healthscope Commercial |
$71.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.57
|
| Rate for Payer: PHP Commercial |
$67.45
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: PHP Commercial |
$20.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.54
|
| Rate for Payer: Priority Health SBD |
$49.99
|
| Rate for Payer: Priority Health SBD |
$18.23
|
| Rate for Payer: Priority Health SBD |
$15.25
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$23.68
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
7536
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.92 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: Aetna Commercial |
$20.13
|
| Rate for Payer: Aetna Commercial |
$18.54
|
| Rate for Payer: Aetna Commercial |
$15.74
|
| Rate for Payer: Aetna Commercial |
$24.60
|
| Rate for Payer: Aetna Commercial |
$20.57
|
| Rate for Payer: Aetna Commercial |
$17.26
|
| Rate for Payer: Aetna Commercial |
$21.96
|
| Rate for Payer: Aetna Commercial |
$44.34
|
| Rate for Payer: Aetna Commercial |
$67.45
|
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.58
|
| Rate for Payer: Cash Price |
$63.48
|
| Rate for Payer: Cash Price |
$19.36
|
| Rate for Payer: Cash Price |
$14.82
|
| Rate for Payer: Cash Price |
$16.24
|
| Rate for Payer: Cash Price |
$41.73
|
| Rate for Payer: Cash Price |
$17.45
|
| Rate for Payer: Cash Price |
$17.65
|
| Rate for Payer: Cash Price |
$23.15
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cash Price |
$20.66
|
| Rate for Payer: Cofinity Commercial |
$36.51
|
| Rate for Payer: Cofinity Commercial |
$44.86
|
| Rate for Payer: Cofinity Commercial |
$18.08
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.97
|
| Rate for Payer: Cofinity Commercial |
$17.46
|
| Rate for Payer: Cofinity Commercial |
$16.94
|
| Rate for Payer: Cofinity Commercial |
$14.21
|
| Rate for Payer: Cofinity Commercial |
$55.54
|
| Rate for Payer: Cofinity Commercial |
$22.21
|
| Rate for Payer: Cofinity Commercial |
$68.24
|
| Rate for Payer: Cofinity Commercial |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$20.81
|
| Rate for Payer: Cofinity Commercial |
$16.58
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$18.76
|
| Rate for Payer: Cofinity Commercial |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$24.89
|
| Rate for Payer: Cofinity Commercial |
$20.26
|
| Rate for Payer: Healthscope Commercial |
$19.85
|
| Rate for Payer: Healthscope Commercial |
$16.67
|
| Rate for Payer: Healthscope Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$19.63
|
| Rate for Payer: Healthscope Commercial |
$21.31
|
| Rate for Payer: Healthscope Commercial |
$21.78
|
| Rate for Payer: Healthscope Commercial |
$23.25
|
| Rate for Payer: Healthscope Commercial |
$26.05
|
| Rate for Payer: Healthscope Commercial |
$46.94
|
| Rate for Payer: Healthscope Commercial |
$71.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.13
|
| Rate for Payer: PHP Commercial |
$21.96
|
| Rate for Payer: PHP Commercial |
$15.74
|
| Rate for Payer: PHP Commercial |
$67.45
|
| Rate for Payer: PHP Commercial |
$18.75
|
| Rate for Payer: PHP Commercial |
$24.60
|
| Rate for Payer: PHP Commercial |
$20.13
|
| Rate for Payer: PHP Commercial |
$18.54
|
| Rate for Payer: PHP Commercial |
$17.26
|
| Rate for Payer: PHP Commercial |
$20.57
|
| Rate for Payer: PHP Commercial |
$44.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.51
|
| Rate for Payer: Priority Health SBD |
$49.99
|
| Rate for Payer: Priority Health SBD |
$13.90
|
| Rate for Payer: Priority Health SBD |
$15.25
|
| Rate for Payer: Priority Health SBD |
$16.27
|
| Rate for Payer: Priority Health SBD |
$13.74
|
| Rate for Payer: Priority Health SBD |
$18.23
|
| Rate for Payer: Priority Health SBD |
$12.79
|
| Rate for Payer: Priority Health SBD |
$32.86
|
| Rate for Payer: Priority Health SBD |
$11.67
|
| Rate for Payer: Priority Health SBD |
$14.92
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$46.23
|
|
|
Service Code
|
NDC 66689-790-50
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$41.61 |
| Rate for Payer: Aetna Commercial |
$39.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.05
|
| Rate for Payer: Cash Price |
$36.98
|
| Rate for Payer: Cofinity Commercial |
$32.36
|
| Rate for Payer: Cofinity Commercial |
$39.76
|
| Rate for Payer: Healthscope Commercial |
$41.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.30
|
| Rate for Payer: PHP Commercial |
$39.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.36
|
| Rate for Payer: Priority Health SBD |
$29.12
|
|
|
SUCRALFATE 100 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$29.91
|
|
|
Service Code
|
NDC 60687-738-42
|
| Hospital Charge Code |
11441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.84 |
| Max. Negotiated Rate |
$26.92 |
| Rate for Payer: Aetna Commercial |
$25.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.44
|
| Rate for Payer: Cash Price |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$20.94
|
| Rate for Payer: Cofinity Commercial |
$25.72
|
| Rate for Payer: Healthscope Commercial |
$26.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.42
|
| Rate for Payer: PHP Commercial |
$25.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.94
|
| Rate for Payer: Priority Health SBD |
$18.84
|
|
