|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$2.85
|
|
|
Service Code
|
NDC 68084-808-11
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna Commercial |
$2.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.85
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cofinity Commercial |
$2.00
|
| Rate for Payer: Cofinity Commercial |
$2.45
|
| Rate for Payer: Healthscope Commercial |
$2.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.42
|
| Rate for Payer: PHP Commercial |
$2.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.00
|
| Rate for Payer: Priority Health SBD |
$1.80
|
|
|
TRAMADOL 50 MG TABLET
|
Facility
IP
|
$1,269.00
|
|
|
Service Code
|
NDC 65162-627-11
|
| Hospital Charge Code |
14632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$799.47 |
| Max. Negotiated Rate |
$1,142.10 |
| Rate for Payer: Aetna Commercial |
$1,078.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$824.85
|
| Rate for Payer: Cash Price |
$1,015.20
|
| Rate for Payer: Cofinity Commercial |
$1,091.34
|
| Rate for Payer: Cofinity Commercial |
$888.30
|
| Rate for Payer: Healthscope Commercial |
$1,142.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,078.65
|
| Rate for Payer: PHP Commercial |
$1,078.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$888.30
|
| Rate for Payer: Priority Health SBD |
$799.47
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$18.21
|
|
|
Service Code
|
NDC 0013-1114-21
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$16.39 |
| Rate for Payer: Aetna Commercial |
$15.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.84
|
| Rate for Payer: Cash Price |
$14.57
|
| Rate for Payer: Cofinity Commercial |
$12.75
|
| Rate for Payer: Cofinity Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$16.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.48
|
| Rate for Payer: PHP Commercial |
$15.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.75
|
| Rate for Payer: Priority Health SBD |
$11.47
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$38.59
|
|
|
Service Code
|
NDC 63323-563-01
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.31 |
| Max. Negotiated Rate |
$34.73 |
| Rate for Payer: Aetna Commercial |
$32.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.08
|
| Rate for Payer: Cash Price |
$30.87
|
| Rate for Payer: Cofinity Commercial |
$27.01
|
| Rate for Payer: Cofinity Commercial |
$33.19
|
| Rate for Payer: Healthscope Commercial |
$34.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.80
|
| Rate for Payer: PHP Commercial |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.01
|
| Rate for Payer: Priority Health SBD |
$24.31
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$25.90
|
|
|
Service Code
|
NDC 60505-6169-0
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Commercial |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.02
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.13
|
| Rate for Payer: Priority Health SBD |
$16.32
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$15.91
|
|
|
Service Code
|
NDC 55150-188-10
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.02 |
| Max. Negotiated Rate |
$14.32 |
| Rate for Payer: Aetna Commercial |
$13.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.34
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cofinity Commercial |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$13.68
|
| Rate for Payer: Healthscope Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.52
|
| Rate for Payer: PHP Commercial |
$13.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.14
|
| Rate for Payer: Priority Health SBD |
$10.02
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$18.21
|
|
|
Service Code
|
NDC 0013-1114-20
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.47 |
| Max. Negotiated Rate |
$16.39 |
| Rate for Payer: Aetna Commercial |
$15.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.84
|
| Rate for Payer: Cash Price |
$14.57
|
| Rate for Payer: Cofinity Commercial |
$12.75
|
| Rate for Payer: Cofinity Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$16.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.48
|
| Rate for Payer: PHP Commercial |
$15.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.75
|
| Rate for Payer: Priority Health SBD |
$11.47
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$23.31
|
|
|
Service Code
|
NDC 0013-1114-01
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$20.98 |
| Rate for Payer: Aetna Commercial |
$19.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.15
|
| Rate for Payer: Cash Price |
$18.65
|
| Rate for Payer: Cofinity Commercial |
$16.32
|
| Rate for Payer: Cofinity Commercial |
$20.05
|
| Rate for Payer: Healthscope Commercial |
$20.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.81
|
| Rate for Payer: PHP Commercial |
$19.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.32
|
| Rate for Payer: Priority Health SBD |
$14.69
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$24.05
|
|
|
Service Code
|
NDC 72485-107-01
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$21.64 |
| Rate for Payer: Aetna Commercial |
$20.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.63
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Cofinity Commercial |
$20.68
|
| Rate for Payer: Healthscope Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.44
|
| Rate for Payer: PHP Commercial |
$20.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.84
|
| Rate for Payer: Priority Health SBD |
$15.15
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$25.90
|
|
|
Service Code
|
NDC 60505-6169-1
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Commercial |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.02
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.13
|
| Rate for Payer: Priority Health SBD |
$16.32
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$31.07
|
|
|
Service Code
|
NDC 0517-0960-01
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.57 |
| Max. Negotiated Rate |
$27.96 |
| Rate for Payer: Aetna Commercial |
$26.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.20
|
| Rate for Payer: Cash Price |
$24.86
|
| Rate for Payer: Cofinity Commercial |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$26.72
|
| Rate for Payer: Healthscope Commercial |
$27.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.41
|
| Rate for Payer: PHP Commercial |
$26.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.75
|
| Rate for Payer: Priority Health SBD |
$19.57
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$31.07
|
|
|
Service Code
|
NDC 0517-0960-10
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.57 |
| Max. Negotiated Rate |
$27.96 |
| Rate for Payer: Aetna Commercial |
$26.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.20
|
| Rate for Payer: Cash Price |
$24.86
|
| Rate for Payer: Cofinity Commercial |
$21.75
|
| Rate for Payer: Cofinity Commercial |
$26.72
|
| Rate for Payer: Healthscope Commercial |
$27.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.41
|
| Rate for Payer: PHP Commercial |
$26.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.75
|
| Rate for Payer: Priority Health SBD |
$19.57
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$23.99
|
|
|
Service Code
|
NDC 39822-1000-1
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.11 |
| Max. Negotiated Rate |
$21.59 |
| Rate for Payer: Aetna Commercial |
$20.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.59
|
| Rate for Payer: Cash Price |
$19.19
|
| Rate for Payer: Cofinity Commercial |
$16.79
|
| Rate for Payer: Cofinity Commercial |
$20.63
|
| Rate for Payer: Healthscope Commercial |
$21.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.39
|
| Rate for Payer: PHP Commercial |
$20.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.79
|
| Rate for Payer: Priority Health SBD |
$15.11
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$38.59
|
|
|
Service Code
|
NDC 63323-563-10
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.31 |
| Max. Negotiated Rate |
$34.73 |
| Rate for Payer: Aetna Commercial |
$32.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.08
|
| Rate for Payer: Cash Price |
$30.87
|
| Rate for Payer: Cofinity Commercial |
$27.01
|
| Rate for Payer: Cofinity Commercial |
$33.19
|
| Rate for Payer: Healthscope Commercial |
$34.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.80
|
| Rate for Payer: PHP Commercial |
$32.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.01
|
| Rate for Payer: Priority Health SBD |
$24.31
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$24.05
|
|
|
Service Code
|
NDC 72485-107-10
|
| Hospital Charge Code |
155937
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$21.64 |
| Rate for Payer: Aetna Commercial |
$20.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.63
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Cofinity Commercial |
$20.68
|
| Rate for Payer: Healthscope Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.44
|
| Rate for Payer: PHP Commercial |
$20.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.84
|
| Rate for Payer: Priority Health SBD |
$15.15
|
|
|
TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) SOLUTION CUSTOM
|
Facility
IP
|
$25.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
300870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna Commercial |
$20.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Cash Price |
$19.24
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Commercial |
$20.68
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Cofinity Commercial |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$16.84
|
| Rate for Payer: Healthscope Commercial |
$21.64
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.02
|
| Rate for Payer: PHP Commercial |
$20.44
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.84
|
| Rate for Payer: Priority Health SBD |
$15.15
|
| Rate for Payer: Priority Health SBD |
$16.32
|
|
|
TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVE DISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONARY), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ALL ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL ARTERY
|
Facility
OP
|
$31,275.01
|
|
|
Service Code
|
CPT 37236
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$420.44 |
| Max. Negotiated Rate |
$31,275.01 |
| Rate for Payer: Aetna Medicare |
$10,180.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,235.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,235.94
|
| Rate for Payer: BCBS Complete |
$5,622.66
|
| Rate for Payer: BCBS MAPPO |
$9,788.75
|
| Rate for Payer: BCBS Trust/PPO |
$6,543.60
|
| Rate for Payer: BCN Medicare Advantage |
$9,788.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,788.75
|
| Rate for Payer: Mclaren Medicaid |
$5,354.45
|
| Rate for Payer: Mclaren Medicare |
$9,788.75
|
| Rate for Payer: Meridian Medicaid |
$5,622.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,278.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,257.06
|
| Rate for Payer: PACE Medicare |
$9,299.31
|
| Rate for Payer: PACE SWMI |
$9,788.75
|
| Rate for Payer: PHP Medicare Advantage |
$9,788.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,354.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31,275.01
|
| Rate for Payer: Priority Health Medicare |
$9,788.75
|
| Rate for Payer: Priority Health Narrow Network |
$25,020.01
|
| Rate for Payer: Railroad Medicare Medicare |
$9,788.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$462.48
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,788.75
|
| Rate for Payer: UHC Exchange |
$420.44
|
| Rate for Payer: UHC Medicare Advantage |
$10,082.41
|
| Rate for Payer: VA VA |
$9,788.75
|
|
|
TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INITIAL VEIN
|
Facility
OP
|
$31,275.01
|
|
|
Service Code
|
CPT 37238
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.73 |
| Max. Negotiated Rate |
$31,275.01 |
| Rate for Payer: Aetna Medicare |
$10,180.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,235.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,235.94
|
| Rate for Payer: BCBS Complete |
$5,622.66
|
| Rate for Payer: BCBS MAPPO |
$9,788.75
|
| Rate for Payer: BCBS Trust/PPO |
$8,503.67
|
| Rate for Payer: BCN Medicare Advantage |
$9,788.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,788.75
|
| Rate for Payer: Mclaren Medicaid |
$5,354.45
|
| Rate for Payer: Mclaren Medicare |
$9,788.75
|
| Rate for Payer: Meridian Medicaid |
$5,622.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,278.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,257.06
|
| Rate for Payer: PACE Medicare |
$9,299.31
|
| Rate for Payer: PACE SWMI |
$9,788.75
|
| Rate for Payer: PHP Medicare Advantage |
$9,788.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,354.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31,275.01
|
| Rate for Payer: Priority Health Medicare |
$9,788.75
|
| Rate for Payer: Priority Health Narrow Network |
$25,020.01
|
| Rate for Payer: Railroad Medicare Medicare |
$9,788.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$322.00
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,788.75
|
| Rate for Payer: UHC Exchange |
$292.73
|
| Rate for Payer: UHC Medicare Advantage |
$10,082.41
|
| Rate for Payer: VA VA |
$9,788.75
|
|
|
TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE STENTING, AND ALL ANGIOPLASTY IN THE CENTRAL DIALYSIS SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$5,340.42
|
|
|
Service Code
|
CPT 36908
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$197.45 |
| Max. Negotiated Rate |
$5,340.42 |
| Rate for Payer: BCBS Trust/PPO |
$5,340.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$217.20
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$197.45
|
|
|
TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)
|
Facility
OP
|
$19,834.21
|
|
|
Service Code
|
CPT 27691
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$737.40 |
| Max. Negotiated Rate |
$19,834.21 |
| 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 |
$2,299.99
|
| 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 |
$19,834.21
|
| Rate for Payer: Priority Health Medicare |
$6,365.63
|
| Rate for Payer: Priority Health Narrow Network |
$15,867.37
|
| Rate for Payer: Railroad Medicare Medicare |
$6,365.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$811.14
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,365.63
|
| Rate for Payer: UHC Exchange |
$737.40
|
| Rate for Payer: UHC Medicare Advantage |
$6,556.60
|
| Rate for Payer: VA VA |
$6,365.63
|
|
|
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC
|
Facility
IP
|
$16,010.31
|
|
|
Service Code
|
MS-DRG 069
|
| Min. Negotiated Rate |
$5,932.57 |
| Max. Negotiated Rate |
$16,010.31 |
| Rate for Payer: Aetna Medicare |
$6,494.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,806.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,806.01
|
| Rate for Payer: BCBS MAPPO |
$6,244.81
|
| Rate for Payer: BCBS Trust/PPO |
$16,010.31
|
| Rate for Payer: BCN Medicare Advantage |
$6,244.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,244.81
|
| Rate for Payer: Mclaren Medicare |
$6,244.81
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$6,557.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,181.53
|
| Rate for Payer: PACE Medicare |
$5,932.57
|
| Rate for Payer: PACE SWMI |
$6,244.81
|
| Rate for Payer: PHP Medicare Advantage |
$6,244.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,461.28
|
| Rate for Payer: Priority Health Medicare |
$6,244.81
|
| Rate for Payer: Priority Health Narrow Network |
$9,169.02
|
| Rate for Payer: Railroad Medicare Medicare |
$6,244.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12,183.37
|
| Rate for Payer: UHC Core |
$7,475.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,244.81
|
| Rate for Payer: UHC Exchange |
$8,006.97
|
| Rate for Payer: UHC Medicare Advantage |
$6,432.15
|
| Rate for Payer: VA VA |
$6,244.81
|
|
|
TRANSLUMINAL BALLOON ANGIOPLASTY, CENTRAL DIALYSIS SEGMENT, PERFORMED THROUGH DIALYSIS CIRCUIT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION REQUIRED TO PERFORM THE ANGIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
OP
|
$1,449.89
|
|
|
Service Code
|
CPT 36907
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$139.16 |
| Max. Negotiated Rate |
$1,449.89 |
| Rate for Payer: BCBS Trust/PPO |
$1,449.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$153.08
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Exchange |
$139.16
|
|
|
TRANSLUMINAL BALLOON ANGIOPLASTY (EXCEPT DIALYSIS CIRCUIT), OPEN OR PERCUTANEOUS, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY WITHIN THE SAME VEIN; INITIAL VEIN
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
CPT 37248
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$283.24 |
| Max. Negotiated Rate |
$7,632.00 |
| Rate for Payer: Aetna Medicare |
$5,289.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,357.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,357.20
|
| Rate for Payer: BCBS Complete |
$2,921.26
|
| Rate for Payer: BCBS MAPPO |
$5,085.76
|
| Rate for Payer: BCBS Trust/PPO |
$4,471.08
|
| Rate for Payer: BCN Medicare Advantage |
$5,085.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,085.76
|
| Rate for Payer: Mclaren Medicaid |
$2,781.91
|
| Rate for Payer: Mclaren Medicare |
$5,085.76
|
| Rate for Payer: Meridian Medicaid |
$2,921.26
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,340.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,848.62
|
| Rate for Payer: PACE Medicare |
$4,831.47
|
| Rate for Payer: PACE SWMI |
$5,085.76
|
| Rate for Payer: PHP Medicare Advantage |
$5,085.76
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,781.91
|
| Rate for Payer: Priority Health Medicare |
$5,085.76
|
| Rate for Payer: Railroad Medicare Medicare |
$5,085.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$311.56
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,085.76
|
| Rate for Payer: UHC Exchange |
$283.24
|
| Rate for Payer: UHC Medicare Advantage |
$5,238.33
|
| Rate for Payer: VA VA |
$5,085.76
|
|
|
TRANSPERINEAL PLACEMENT OF BIODEGRADABLE MATERIAL, PERI-PROSTATIC, SINGLE OR MULTIPLE INJECTION(S), INCLUDING IMAGE GUIDANCE, WHEN PERFORMED
|
Facility
OP
|
$7,632.00
|
|
|
Service Code
|
CPT 55874
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$159.46 |
| Max. Negotiated Rate |
$7,632.00 |
| Rate for Payer: Aetna Medicare |
$4,788.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5,755.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5,755.12
|
| Rate for Payer: BCBS Complete |
$2,644.60
|
| Rate for Payer: BCBS MAPPO |
$4,604.10
|
| Rate for Payer: BCBS Trust/PPO |
$4,808.08
|
| Rate for Payer: BCN Medicare Advantage |
$4,604.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,604.10
|
| Rate for Payer: Mclaren Medicaid |
$2,518.44
|
| Rate for Payer: Mclaren Medicare |
$4,604.10
|
| Rate for Payer: Meridian Medicaid |
$2,644.60
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$4,834.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,294.72
|
| Rate for Payer: PACE Medicare |
$4,373.90
|
| Rate for Payer: PACE SWMI |
$4,604.10
|
| Rate for Payer: PHP Medicare Advantage |
$4,604.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,518.44
|
| Rate for Payer: Priority Health Medicare |
$4,604.10
|
| Rate for Payer: Railroad Medicare Medicare |
$4,604.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.41
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,604.10
|
| Rate for Payer: UHC Exchange |
$159.46
|
| Rate for Payer: UHC Medicare Advantage |
$4,742.22
|
| Rate for Payer: VA VA |
$4,604.10
|
|
|
TRANSTRACHEAL (PERCUTANEOUS) INTRODUCTION OF NEEDLE WIRE DILATOR/STENT OR INDWELLING TUBE FOR OXYGEN THERAPY
|
Facility
OP
|
$4,658.40
|
|
|
Service Code
|
CPT 31730
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$143.75 |
| Max. Negotiated Rate |
$4,658.40 |
| Rate for Payer: Aetna Medicare |
$1,570.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,887.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,887.76
|
| Rate for Payer: BCBS Complete |
$867.46
|
| Rate for Payer: BCBS MAPPO |
$1,510.21
|
| Rate for Payer: BCBS Trust/PPO |
$494.11
|
| Rate for Payer: BCN Medicare Advantage |
$1,510.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,510.21
|
| Rate for Payer: Mclaren Medicaid |
$826.08
|
| Rate for Payer: Mclaren Medicare |
$1,510.21
|
| Rate for Payer: Meridian Medicaid |
$867.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,585.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,736.74
|
| Rate for Payer: PACE Medicare |
$1,434.70
|
| Rate for Payer: PACE SWMI |
$1,510.21
|
| Rate for Payer: PHP Medicare Advantage |
$1,510.21
|
| Rate for Payer: Priority Health Choice Medicaid |
$826.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,658.40
|
| Rate for Payer: Priority Health Medicare |
$1,510.21
|
| Rate for Payer: Priority Health Narrow Network |
$3,726.72
|
| Rate for Payer: Railroad Medicare Medicare |
$1,510.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$158.12
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,510.21
|
| Rate for Payer: UHC Exchange |
$143.75
|
| Rate for Payer: UHC Medicare Advantage |
$1,555.52
|
| Rate for Payer: VA VA |
$1,510.21
|
|
