|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$404.20
|
|
|
Service Code
|
NDC 59762-5000-5
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.65 |
| Max. Negotiated Rate |
$363.78 |
| Rate for Payer: Aetna Commercial |
$343.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.73
|
| Rate for Payer: Cash Price |
$323.36
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Commercial |
$347.61
|
| Rate for Payer: Healthscope Commercial |
$363.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$343.57
|
| Rate for Payer: PHP Commercial |
$343.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.94
|
| Rate for Payer: Priority Health SBD |
$254.65
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$753.12
|
|
|
Service Code
|
NDC 0013-0101-10
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$474.47 |
| Max. Negotiated Rate |
$677.81 |
| Rate for Payer: Aetna Commercial |
$640.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$489.53
|
| Rate for Payer: Cash Price |
$602.50
|
| Rate for Payer: Cofinity Commercial |
$527.18
|
| Rate for Payer: Cofinity Commercial |
$647.68
|
| Rate for Payer: Healthscope Commercial |
$677.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$640.15
|
| Rate for Payer: PHP Commercial |
$640.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$527.18
|
| Rate for Payer: Priority Health SBD |
$474.47
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$892.80
|
|
|
Service Code
|
NDC 62135-960-01
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$562.46 |
| Max. Negotiated Rate |
$803.52 |
| Rate for Payer: Aetna Commercial |
$758.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$580.32
|
| Rate for Payer: Cash Price |
$714.24
|
| Rate for Payer: Cofinity Commercial |
$624.96
|
| Rate for Payer: Cofinity Commercial |
$767.81
|
| Rate for Payer: Healthscope Commercial |
$803.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$758.88
|
| Rate for Payer: PHP Commercial |
$758.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$624.96
|
| Rate for Payer: Priority Health SBD |
$562.46
|
|
|
SULFASALAZINE 500 MG TABLET
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
NDC 50268-730-11
|
| Hospital Charge Code |
7562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.28
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cofinity Commercial |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$3.02
|
| Rate for Payer: Healthscope Commercial |
$3.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.98
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.46
|
| Rate for Payer: Priority Health SBD |
$2.21
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$21.65
|
|
|
Service Code
|
NDC 65862-148-36
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.64 |
| Max. Negotiated Rate |
$19.48 |
| Rate for Payer: Aetna Commercial |
$18.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.07
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cofinity Commercial |
$15.16
|
| Rate for Payer: Cofinity Commercial |
$18.62
|
| Rate for Payer: Healthscope Commercial |
$19.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.40
|
| Rate for Payer: PHP Commercial |
$18.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.16
|
| Rate for Payer: Priority Health SBD |
$13.64
|
|
|
SUMATRIPTAN 100 MG TABLET
|
Facility
|
IP
|
$7.92
|
|
|
Service Code
|
NDC 55111-293-09
|
| Hospital Charge Code |
13369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.99 |
| Max. Negotiated Rate |
$7.13 |
| Rate for Payer: Aetna Commercial |
$6.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.15
|
| Rate for Payer: Cash Price |
$6.34
|
| Rate for Payer: Cofinity Commercial |
$5.54
|
| Rate for Payer: Cofinity Commercial |
$6.81
|
| Rate for Payer: Healthscope Commercial |
$7.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.73
|
| Rate for Payer: PHP Commercial |
$6.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.54
|
| Rate for Payer: Priority Health SBD |
$4.99
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 62756-521-69
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.86 |
| Max. Negotiated Rate |
$64.08 |
| Rate for Payer: Aetna Commercial |
$60.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.28
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$49.84
|
| Rate for Payer: Cofinity Commercial |
$61.23
|
| Rate for Payer: Healthscope Commercial |
$64.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.52
|
| Rate for Payer: PHP Commercial |
$60.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.84
|
| Rate for Payer: Priority Health SBD |
$44.86
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$8.09
|
|
|
Service Code
|
NDC 55111-292-09
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$7.28 |
| Rate for Payer: Aetna Commercial |
$6.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.26
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Cofinity Commercial |
$6.96
|
| Rate for Payer: Cofinity Commercial |
$5.66
|
| Rate for Payer: Healthscope Commercial |
$7.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.88
|
| Rate for Payer: PHP Commercial |
$6.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.66
|
| Rate for Payer: Priority Health SBD |
$5.10
|
|
|
SUMATRIPTAN 50 MG TABLET
|
Facility
|
IP
|
$28.39
|
|
|
Service Code
|
NDC 65862-147-36
|
| Hospital Charge Code |
15328
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.89 |
| Max. Negotiated Rate |
$25.55 |
| Rate for Payer: Aetna Commercial |
$24.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.45
|
| Rate for Payer: Cash Price |
$22.71
|
| Rate for Payer: Cofinity Commercial |
$19.87
|
| Rate for Payer: Cofinity Commercial |
$24.42
|
| Rate for Payer: Healthscope Commercial |
$25.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.13
|
| Rate for Payer: PHP Commercial |
$24.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.87
|
| Rate for Payer: Priority Health SBD |
$17.89
|
|
|
SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$103.47
|
|
|
Service Code
|
HCPCS J3030
|
| Hospital Charge Code |
97342
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.19 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Aetna Commercial |
$87.95
|
| Rate for Payer: Aetna Commercial |
$23.11
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Commercial |
$21.15
|
| Rate for Payer: Aetna Commercial |
$189.41
|
| Rate for Payer: Aetna Commercial |
$22.42
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cash Price |
$178.27
|
| Rate for Payer: Cash Price |
$21.75
|
| Rate for Payer: Cash Price |
$82.78
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cofinity Commercial |
$18.47
|
| Rate for Payer: Cofinity Commercial |
$23.38
|
| Rate for Payer: Cofinity Commercial |
$72.43
|
| Rate for Payer: Cofinity Commercial |
$88.98
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$155.99
|
| Rate for Payer: Cofinity Commercial |
$191.64
|
| Rate for Payer: Cofinity Commercial |
$17.39
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Commercial |
$21.40
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Healthscope Commercial |
$23.74
|
| Rate for Payer: Healthscope Commercial |
$200.56
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$22.39
|
| Rate for Payer: Healthscope Commercial |
$93.12
|
| Rate for Payer: Healthscope Commercial |
$24.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$189.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.95
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: PHP Commercial |
$87.95
|
| Rate for Payer: PHP Commercial |
$23.11
|
| Rate for Payer: PHP Commercial |
$189.41
|
| Rate for Payer: PHP Commercial |
$22.42
|
| Rate for Payer: PHP Commercial |
$21.15
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.99
|
| Rate for Payer: Priority Health SBD |
$17.13
|
| Rate for Payer: Priority Health SBD |
$65.19
|
| Rate for Payer: Priority Health SBD |
$13.04
|
| Rate for Payer: Priority Health SBD |
$140.39
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$15.67
|
| Rate for Payer: Priority Health SBD |
$16.62
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$1,757.43
|
|
|
Service Code
|
CPT 15004
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$212.53 |
| Max. Negotiated Rate |
$1,757.43 |
| Rate for Payer: Aetna Medicare |
$581.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$698.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$698.54
|
| Rate for Payer: BCBS Complete |
$320.99
|
| Rate for Payer: BCBS MAPPO |
$558.83
|
| Rate for Payer: BCBS Trust/PPO |
$212.53
|
| Rate for Payer: BCN Medicare Advantage |
$558.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$558.83
|
| Rate for Payer: Mclaren Medicaid |
$305.68
|
| Rate for Payer: Mclaren Medicare |
$558.83
|
| Rate for Payer: Meridian Medicaid |
$320.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$586.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$642.65
|
| Rate for Payer: PACE Medicare |
$530.89
|
| Rate for Payer: PACE SWMI |
$558.83
|
| Rate for Payer: PHP Medicare Advantage |
$558.83
|
| Rate for Payer: Priority Health Choice Medicaid |
$305.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,757.43
|
| Rate for Payer: Priority Health Medicare |
$558.83
|
| Rate for Payer: Priority Health Narrow Network |
$1,405.94
|
| Rate for Payer: Railroad Medicare Medicare |
$558.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$277.71
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$558.83
|
| Rate for Payer: UHC Exchange |
$252.46
|
| Rate for Payer: UHC Medicare Advantage |
$575.59
|
| Rate for Payer: VA VA |
$558.83
|
|
|
SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN
|
Facility
|
OP
|
$5,175.07
|
|
|
Service Code
|
CPT 15002
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$213.82 |
| 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 |
$570.51
|
| 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) |
$235.20
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,622.64
|
| Rate for Payer: UHC Exchange |
$213.82
|
| Rate for Payer: UHC Medicare Advantage |
$1,671.32
|
| Rate for Payer: VA VA |
$1,622.64
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 46275
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$418.80 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,598.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,122.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,122.94
|
| Rate for Payer: BCBS Complete |
$1,435.05
|
| Rate for Payer: BCBS MAPPO |
$2,498.35
|
| Rate for Payer: BCBS Trust/PPO |
$1,303.31
|
| Rate for Payer: BCN Medicare Advantage |
$2,498.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,498.35
|
| Rate for Payer: Mclaren Medicaid |
$1,366.60
|
| Rate for Payer: Mclaren Medicare |
$2,498.35
|
| Rate for Payer: Meridian Medicaid |
$1,435.05
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,623.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,873.10
|
| Rate for Payer: PACE Medicare |
$2,373.43
|
| Rate for Payer: PACE SWMI |
$2,498.35
|
| Rate for Payer: PHP Medicare Advantage |
$2,498.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,366.60
|
| Rate for Payer: Priority Health Medicare |
$2,498.35
|
| Rate for Payer: Railroad Medicare Medicare |
$2,498.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$460.68
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,498.35
|
| Rate for Payer: UHC Exchange |
$418.80
|
| Rate for Payer: UHC Medicare Advantage |
$2,573.30
|
| Rate for Payer: VA VA |
$2,498.35
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 46285
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$420.11 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,598.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,122.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,122.94
|
| Rate for Payer: BCBS Complete |
$1,435.05
|
| Rate for Payer: BCBS MAPPO |
$2,498.35
|
| Rate for Payer: BCBS Trust/PPO |
$967.07
|
| Rate for Payer: BCN Medicare Advantage |
$2,498.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,498.35
|
| Rate for Payer: Mclaren Medicaid |
$1,366.60
|
| Rate for Payer: Mclaren Medicare |
$2,498.35
|
| Rate for Payer: Meridian Medicaid |
$1,435.05
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,623.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,873.10
|
| Rate for Payer: PACE Medicare |
$2,373.43
|
| Rate for Payer: PACE SWMI |
$2,498.35
|
| Rate for Payer: PHP Medicare Advantage |
$2,498.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,366.60
|
| Rate for Payer: Priority Health Medicare |
$2,498.35
|
| Rate for Payer: Railroad Medicare Medicare |
$2,498.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$462.12
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,498.35
|
| Rate for Payer: UHC Exchange |
$420.11
|
| Rate for Payer: UHC Medicare Advantage |
$2,573.30
|
| Rate for Payer: VA VA |
$2,498.35
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 46270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$397.84 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,598.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,122.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,122.94
|
| Rate for Payer: BCBS Complete |
$1,435.05
|
| Rate for Payer: BCBS MAPPO |
$2,498.35
|
| Rate for Payer: BCBS Trust/PPO |
$1,287.21
|
| Rate for Payer: BCN Medicare Advantage |
$2,498.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,498.35
|
| Rate for Payer: Mclaren Medicaid |
$1,366.60
|
| Rate for Payer: Mclaren Medicare |
$2,498.35
|
| Rate for Payer: Meridian Medicaid |
$1,435.05
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,623.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,873.10
|
| Rate for Payer: PACE Medicare |
$2,373.43
|
| Rate for Payer: PACE SWMI |
$2,498.35
|
| Rate for Payer: PHP Medicare Advantage |
$2,498.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,366.60
|
| Rate for Payer: Priority Health Medicare |
$2,498.35
|
| Rate for Payer: Railroad Medicare Medicare |
$2,498.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$437.62
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,498.35
|
| Rate for Payer: UHC Exchange |
$397.84
|
| Rate for Payer: UHC Medicare Advantage |
$2,573.30
|
| Rate for Payer: VA VA |
$2,498.35
|
|
|
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 46280
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$475.77 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,598.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,122.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,122.94
|
| Rate for Payer: BCBS Complete |
$1,435.05
|
| Rate for Payer: BCBS MAPPO |
$2,498.35
|
| Rate for Payer: BCBS Trust/PPO |
$1,695.21
|
| Rate for Payer: BCN Medicare Advantage |
$2,498.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,498.35
|
| Rate for Payer: Mclaren Medicaid |
$1,366.60
|
| Rate for Payer: Mclaren Medicare |
$2,498.35
|
| Rate for Payer: Meridian Medicaid |
$1,435.05
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,623.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,873.10
|
| Rate for Payer: PACE Medicare |
$2,373.43
|
| Rate for Payer: PACE SWMI |
$2,498.35
|
| Rate for Payer: PHP Medicare Advantage |
$2,498.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,366.60
|
| Rate for Payer: Priority Health Medicare |
$2,498.35
|
| Rate for Payer: Railroad Medicare Medicare |
$2,498.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$523.35
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,498.35
|
| Rate for Payer: UHC Exchange |
$475.77
|
| Rate for Payer: UHC Medicare Advantage |
$2,573.30
|
| Rate for Payer: VA VA |
$2,498.35
|
|
|
SURGICEL, OXIDIZED 2" X 1" MISC
|
Facility
|
IP
|
$310.06
|
|
|
Service Code
|
NDC 63713-0019-61
|
| Hospital Charge Code |
200200150
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$195.34 |
| Max. Negotiated Rate |
$279.05 |
| Rate for Payer: Aetna Commercial |
$263.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.54
|
| Rate for Payer: Cash Price |
$248.05
|
| Rate for Payer: Cofinity Commercial |
$217.04
|
| Rate for Payer: Cofinity Commercial |
$266.65
|
| Rate for Payer: Healthscope Commercial |
$279.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$263.55
|
| Rate for Payer: PHP Commercial |
$263.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.04
|
| Rate for Payer: Priority Health SBD |
$195.34
|
|
|
SUTURE OF INFRAPATELLAR TENDON; PRIMARY
|
Facility
|
OP
|
$19,502.65
|
|
|
Service Code
|
CPT 27380
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$621.81 |
| Max. Negotiated Rate |
$19,502.65 |
| Rate for Payer: Aetna Medicare |
$6,620.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,957.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,957.04
|
| Rate for Payer: BCBS Complete |
$3,656.42
|
| Rate for Payer: BCBS MAPPO |
$6,365.63
|
| Rate for Payer: BCBS Trust/PPO |
$2,758.56
|
| Rate for Payer: BCN Medicare Advantage |
$6,365.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,365.63
|
| Rate for Payer: Mclaren Medicaid |
$3,482.00
|
| Rate for Payer: Mclaren Medicare |
$6,365.63
|
| Rate for Payer: Meridian Medicaid |
$3,656.42
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,683.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,320.47
|
| Rate for Payer: PACE Medicare |
$6,047.35
|
| Rate for Payer: PACE SWMI |
$6,365.63
|
| Rate for Payer: PHP Medicare Advantage |
$6,365.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,482.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19,502.65
|
| Rate for Payer: Priority Health Medicare |
$6,365.63
|
| Rate for Payer: Priority Health Narrow Network |
$15,602.12
|
| Rate for Payer: Railroad Medicare Medicare |
$6,365.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$683.99
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,365.63
|
| Rate for Payer: UHC Exchange |
$621.81
|
| Rate for Payer: UHC Medicare Advantage |
$6,556.60
|
| Rate for Payer: VA VA |
$6,365.63
|
|
|
SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY
|
Facility
|
OP
|
$19,502.65
|
|
|
Service Code
|
CPT 27385
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$606.75 |
| Max. Negotiated Rate |
$19,502.65 |
| Rate for Payer: Aetna Medicare |
$6,620.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,957.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,957.04
|
| Rate for Payer: BCBS Complete |
$3,656.42
|
| Rate for Payer: BCBS MAPPO |
$6,365.63
|
| Rate for Payer: BCBS Trust/PPO |
$2,971.93
|
| Rate for Payer: BCN Medicare Advantage |
$6,365.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,365.63
|
| Rate for Payer: Mclaren Medicaid |
$3,482.00
|
| Rate for Payer: Mclaren Medicare |
$6,365.63
|
| Rate for Payer: Meridian Medicaid |
$3,656.42
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,683.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,320.47
|
| Rate for Payer: PACE Medicare |
$6,047.35
|
| Rate for Payer: PACE SWMI |
$6,365.63
|
| Rate for Payer: PHP Medicare Advantage |
$6,365.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,482.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19,502.65
|
| Rate for Payer: Priority Health Medicare |
$6,365.63
|
| Rate for Payer: Priority Health Narrow Network |
$15,602.12
|
| Rate for Payer: Railroad Medicare Medicare |
$6,365.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$667.42
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,365.63
|
| Rate for Payer: UHC Exchange |
$606.75
|
| Rate for Payer: UHC Medicare Advantage |
$6,556.60
|
| Rate for Payer: VA VA |
$6,365.63
|
|
|
SUVOREXANT 10 MG TABLET
|
Facility
|
IP
|
$509.61
|
|
|
Service Code
|
NDC 0006-0033-10
|
| Hospital Charge Code |
173275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.05 |
| Max. Negotiated Rate |
$458.65 |
| Rate for Payer: Aetna Commercial |
$433.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$331.25
|
| Rate for Payer: Cash Price |
$407.69
|
| Rate for Payer: Cofinity Commercial |
$438.26
|
| Rate for Payer: Cofinity Commercial |
$356.73
|
| Rate for Payer: Healthscope Commercial |
$458.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$433.17
|
| Rate for Payer: PHP Commercial |
$433.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.73
|
| Rate for Payer: Priority Health SBD |
$321.05
|
|
|
SUVOREXANT 10 MG TABLET
|
Facility
|
IP
|
$1,528.81
|
|
|
Service Code
|
NDC 0006-0033-30
|
| Hospital Charge Code |
173275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$963.15 |
| Max. Negotiated Rate |
$1,375.93 |
| Rate for Payer: Aetna Commercial |
$1,299.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$993.73
|
| Rate for Payer: Cash Price |
$1,223.05
|
| Rate for Payer: Cofinity Commercial |
$1,314.78
|
| Rate for Payer: Cofinity Commercial |
$1,070.17
|
| Rate for Payer: Healthscope Commercial |
$1,375.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,299.49
|
| Rate for Payer: PHP Commercial |
$1,299.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,070.17
|
| Rate for Payer: Priority Health SBD |
$963.15
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$15,316.40
|
|
|
Service Code
|
MS-DRG 312
|
| Min. Negotiated Rate |
$6,375.90 |
| Max. Negotiated Rate |
$15,316.40 |
| Rate for Payer: Aetna Medicare |
$6,979.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8,389.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8,389.34
|
| Rate for Payer: BCBS MAPPO |
$6,711.47
|
| Rate for Payer: BCBS Trust/PPO |
$15,316.40
|
| Rate for Payer: BCN Medicare Advantage |
$6,711.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,711.47
|
| Rate for Payer: Mclaren Medicare |
$6,711.47
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$7,047.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,718.19
|
| Rate for Payer: PACE Medicare |
$6,375.90
|
| Rate for Payer: PACE SWMI |
$6,711.47
|
| Rate for Payer: PHP Medicare Advantage |
$6,711.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12,391.16
|
| Rate for Payer: Priority Health Medicare |
$6,711.47
|
| Rate for Payer: Priority Health Narrow Network |
$9,912.93
|
| Rate for Payer: Railroad Medicare Medicare |
$6,711.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13,171.83
|
| Rate for Payer: UHC Core |
$8,082.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,711.47
|
| Rate for Payer: UHC Exchange |
$8,656.59
|
| Rate for Payer: UHC Medicare Advantage |
$6,912.81
|
| Rate for Payer: VA VA |
$6,711.47
|
|
|
TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE
|
Facility
|
IP
|
$348.96
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
24914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$219.84 |
| Max. Negotiated Rate |
$314.06 |
| Rate for Payer: Aetna Commercial |
$296.62
|
| Rate for Payer: Aetna Commercial |
$347.22
|
| Rate for Payer: Aetna Commercial |
$4.15
|
| Rate for Payer: Aetna Commercial |
$414.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$316.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.17
|
| Rate for Payer: Cash Price |
$389.76
|
| Rate for Payer: Cash Price |
$326.80
|
| Rate for Payer: Cash Price |
$279.17
|
| Rate for Payer: Cash Price |
$3.90
|
| Rate for Payer: Cofinity Commercial |
$351.31
|
| Rate for Payer: Cofinity Commercial |
$244.27
|
| Rate for Payer: Cofinity Commercial |
$4.20
|
| Rate for Payer: Cofinity Commercial |
$300.11
|
| Rate for Payer: Cofinity Commercial |
$285.95
|
| Rate for Payer: Cofinity Commercial |
$341.04
|
| Rate for Payer: Cofinity Commercial |
$418.99
|
| Rate for Payer: Cofinity Commercial |
$3.42
|
| Rate for Payer: Healthscope Commercial |
$367.65
|
| Rate for Payer: Healthscope Commercial |
$438.48
|
| Rate for Payer: Healthscope Commercial |
$314.06
|
| Rate for Payer: Healthscope Commercial |
$4.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$296.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$414.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$347.22
|
| Rate for Payer: PHP Commercial |
$296.62
|
| Rate for Payer: PHP Commercial |
$347.22
|
| Rate for Payer: PHP Commercial |
$4.15
|
| Rate for Payer: PHP Commercial |
$414.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$244.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$341.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.42
|
| Rate for Payer: Priority Health SBD |
$306.94
|
| Rate for Payer: Priority Health SBD |
$257.36
|
| Rate for Payer: Priority Health SBD |
$219.84
|
| Rate for Payer: Priority Health SBD |
$3.07
|
|
|
TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE
|
Facility
|
IP
|
$5.14
|
|
|
Service Code
|
HCPCS J7507
|
| Hospital Charge Code |
12933
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$4.37
|
| Rate for Payer: Aetna Commercial |
$421.46
|
| Rate for Payer: Aetna Commercial |
$436.15
|
| Rate for Payer: Aetna Commercial |
$348.02
|
| Rate for Payer: Aetna Commercial |
$478.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$365.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$322.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$266.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$333.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.34
|
| Rate for Payer: Cash Price |
$327.55
|
| Rate for Payer: Cash Price |
$4.11
|
| Rate for Payer: Cash Price |
$450.05
|
| Rate for Payer: Cash Price |
$396.67
|
| Rate for Payer: Cash Price |
$410.50
|
| Rate for Payer: Cofinity Commercial |
$347.09
|
| Rate for Payer: Cofinity Commercial |
$393.79
|
| Rate for Payer: Cofinity Commercial |
$483.80
|
| Rate for Payer: Cofinity Commercial |
$4.42
|
| Rate for Payer: Cofinity Commercial |
$3.60
|
| Rate for Payer: Cofinity Commercial |
$352.12
|
| Rate for Payer: Cofinity Commercial |
$286.61
|
| Rate for Payer: Cofinity Commercial |
$441.28
|
| Rate for Payer: Cofinity Commercial |
$359.18
|
| Rate for Payer: Cofinity Commercial |
$426.42
|
| Rate for Payer: Healthscope Commercial |
$506.30
|
| Rate for Payer: Healthscope Commercial |
$368.50
|
| Rate for Payer: Healthscope Commercial |
$446.26
|
| Rate for Payer: Healthscope Commercial |
$461.81
|
| Rate for Payer: Healthscope Commercial |
$4.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$348.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$421.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$478.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$436.15
|
| Rate for Payer: PHP Commercial |
$4.37
|
| Rate for Payer: PHP Commercial |
$421.46
|
| Rate for Payer: PHP Commercial |
$348.02
|
| Rate for Payer: PHP Commercial |
$478.18
|
| Rate for Payer: PHP Commercial |
$436.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$359.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$347.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$393.79
|
| Rate for Payer: Priority Health SBD |
$3.24
|
| Rate for Payer: Priority Health SBD |
$323.27
|
| Rate for Payer: Priority Health SBD |
$312.38
|
| Rate for Payer: Priority Health SBD |
$354.41
|
| Rate for Payer: Priority Health SBD |
$257.95
|
|
|
TACROLIMUS XR 1 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,982.83
|
|
|
Service Code
|
HCPCS J7503
|
| Hospital Charge Code |
175522
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,249.18 |
| Max. Negotiated Rate |
$1,784.55 |
| Rate for Payer: Aetna Commercial |
$1,685.41
|
| Rate for Payer: Aetna Commercial |
$505.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,288.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$386.65
|
| Rate for Payer: Cash Price |
$1,586.26
|
| Rate for Payer: Cash Price |
$475.88
|
| Rate for Payer: Cofinity Commercial |
$1,705.23
|
| Rate for Payer: Cofinity Commercial |
$1,387.98
|
| Rate for Payer: Cofinity Commercial |
$511.57
|
| Rate for Payer: Cofinity Commercial |
$416.40
|
| Rate for Payer: Healthscope Commercial |
$535.36
|
| Rate for Payer: Healthscope Commercial |
$1,784.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,685.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$505.62
|
| Rate for Payer: PHP Commercial |
$1,685.41
|
| Rate for Payer: PHP Commercial |
$505.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$416.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,387.98
|
| Rate for Payer: Priority Health SBD |
$1,249.18
|
| Rate for Payer: Priority Health SBD |
$374.76
|
|
