|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$2,064.60
|
|
|
Service Code
|
NDC 49884-768-54
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,300.70 |
| Max. Negotiated Rate |
$1,858.14 |
| Rate for Payer: Aetna Commercial |
$1,754.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,341.99
|
| Rate for Payer: Cash Price |
$1,651.68
|
| Rate for Payer: Cofinity Commercial |
$1,445.22
|
| Rate for Payer: Cofinity Commercial |
$1,775.56
|
| Rate for Payer: Healthscope Commercial |
$1,858.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,754.91
|
| Rate for Payer: PHP Commercial |
$1,754.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,445.22
|
| Rate for Payer: Priority Health SBD |
$1,300.70
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 49884-768-52
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.07 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.20
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$144.52
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.49
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.52
|
| Rate for Payer: Priority Health SBD |
$130.07
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$302.56 |
| 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 |
$1,054.41
|
| 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) |
$332.82
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,864.79
|
| Rate for Payer: UHC Exchange |
$302.56
|
| Rate for Payer: UHC Medicare Advantage |
$2,950.73
|
| Rate for Payer: VA VA |
$2,864.79
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$15,835.74
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$289.79 |
| Max. Negotiated Rate |
$15,835.74 |
| Rate for Payer: Aetna Medicare |
$5,419.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,513.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,513.48
|
| Rate for Payer: BCBS Complete |
$2,993.07
|
| Rate for Payer: BCBS MAPPO |
$5,210.78
|
| Rate for Payer: BCBS Trust/PPO |
$1,563.91
|
| Rate for Payer: BCN Medicare Advantage |
$5,210.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,210.78
|
| Rate for Payer: Mclaren Medicaid |
$2,850.30
|
| Rate for Payer: Mclaren Medicare |
$5,210.78
|
| Rate for Payer: Meridian Medicaid |
$2,993.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,471.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,992.40
|
| Rate for Payer: PACE Medicare |
$4,950.24
|
| Rate for Payer: PACE SWMI |
$5,210.78
|
| Rate for Payer: PHP Medicare Advantage |
$5,210.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,850.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,835.74
|
| Rate for Payer: Priority Health Medicare |
$5,210.78
|
| Rate for Payer: Priority Health Narrow Network |
$12,668.59
|
| Rate for Payer: Railroad Medicare Medicare |
$5,210.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$318.77
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,210.78
|
| Rate for Payer: UHC Exchange |
$289.79
|
| Rate for Payer: UHC Medicare Advantage |
$5,367.10
|
| Rate for Payer: VA VA |
$5,210.78
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
|
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$254.75 |
| 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 |
$1,533.41
|
| 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) |
$280.22
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,864.79
|
| Rate for Payer: UHC Exchange |
$254.75
|
| Rate for Payer: UHC Medicare Advantage |
$2,950.73
|
| Rate for Payer: VA VA |
$2,864.79
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$15,835.74
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$267.52 |
| Max. Negotiated Rate |
$15,835.74 |
| Rate for Payer: Aetna Medicare |
$5,419.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,513.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,513.48
|
| Rate for Payer: BCBS Complete |
$2,993.07
|
| Rate for Payer: BCBS MAPPO |
$5,210.78
|
| Rate for Payer: BCBS Trust/PPO |
$1,627.21
|
| Rate for Payer: BCN Medicare Advantage |
$5,210.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,210.78
|
| Rate for Payer: Mclaren Medicaid |
$2,850.30
|
| Rate for Payer: Mclaren Medicare |
$5,210.78
|
| Rate for Payer: Meridian Medicaid |
$2,993.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,471.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,992.40
|
| Rate for Payer: PACE Medicare |
$4,950.24
|
| Rate for Payer: PACE SWMI |
$5,210.78
|
| Rate for Payer: PHP Medicare Advantage |
$5,210.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,850.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,835.74
|
| Rate for Payer: Priority Health Medicare |
$5,210.78
|
| Rate for Payer: Priority Health Narrow Network |
$12,668.59
|
| Rate for Payer: Railroad Medicare Medicare |
$5,210.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$294.27
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,210.78
|
| Rate for Payer: UHC Exchange |
$267.52
|
| Rate for Payer: UHC Medicare Advantage |
$5,367.10
|
| Rate for Payer: VA VA |
$5,210.78
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$383.80
|
|
|
Service Code
|
NDC 68084-344-01
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.79 |
| Max. Negotiated Rate |
$345.42 |
| Rate for Payer: Aetna Commercial |
$326.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$249.47
|
| Rate for Payer: Cash Price |
$307.04
|
| Rate for Payer: Cofinity Commercial |
$330.07
|
| Rate for Payer: Cofinity Commercial |
$268.66
|
| Rate for Payer: Healthscope Commercial |
$345.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$326.23
|
| Rate for Payer: PHP Commercial |
$326.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$268.66
|
| Rate for Payer: Priority Health SBD |
$241.79
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$383.80
|
|
|
Service Code
|
NDC 68084-344-11
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.79 |
| Max. Negotiated Rate |
$345.42 |
| Rate for Payer: Aetna Commercial |
$326.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$249.47
|
| Rate for Payer: Cash Price |
$307.04
|
| Rate for Payer: Cofinity Commercial |
$268.66
|
| Rate for Payer: Cofinity Commercial |
$330.07
|
| Rate for Payer: Healthscope Commercial |
$345.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$326.23
|
| Rate for Payer: PHP Commercial |
$326.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$268.66
|
| Rate for Payer: Priority Health SBD |
$241.79
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$215.65
|
|
|
Service Code
|
NDC 68084-342-01
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.86 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.17
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$150.96
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.30
|
| Rate for Payer: PHP Commercial |
$183.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.96
|
| Rate for Payer: Priority Health SBD |
$135.86
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$215.65
|
|
|
Service Code
|
NDC 68084-342-11
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.86 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.17
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$150.96
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.30
|
| Rate for Payer: PHP Commercial |
$183.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.96
|
| Rate for Payer: Priority Health SBD |
$135.86
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$470.00
|
|
|
Service Code
|
NDC 0904-6928-61
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$296.10 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Aetna Commercial |
$399.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.50
|
| Rate for Payer: Cash Price |
$376.00
|
| Rate for Payer: Cofinity Commercial |
$404.20
|
| Rate for Payer: Cofinity Commercial |
$329.00
|
| Rate for Payer: Healthscope Commercial |
$423.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$399.50
|
| Rate for Payer: PHP Commercial |
$399.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$329.00
|
| Rate for Payer: Priority Health SBD |
$296.10
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$1,353.09
|
|
|
Service Code
|
NDC 50458-639-65
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$852.45 |
| Max. Negotiated Rate |
$1,217.78 |
| Rate for Payer: Aetna Commercial |
$1,150.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$879.51
|
| Rate for Payer: Cash Price |
$1,082.47
|
| Rate for Payer: Cofinity Commercial |
$1,163.66
|
| Rate for Payer: Cofinity Commercial |
$947.16
|
| Rate for Payer: Healthscope Commercial |
$1,217.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,150.13
|
| Rate for Payer: PHP Commercial |
$1,150.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$947.16
|
| Rate for Payer: Priority Health SBD |
$852.45
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$50.76
|
|
|
Service Code
|
NDC 68382-138-14
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$45.68 |
| Rate for Payer: Aetna Commercial |
$43.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.99
|
| Rate for Payer: Cash Price |
$40.61
|
| Rate for Payer: Cofinity Commercial |
$35.53
|
| Rate for Payer: Cofinity Commercial |
$43.65
|
| Rate for Payer: Healthscope Commercial |
$45.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.15
|
| Rate for Payer: PHP Commercial |
$43.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.53
|
| Rate for Payer: Priority Health SBD |
$31.98
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$369.96
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
152057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.07 |
| Max. Negotiated Rate |
$332.96 |
| Rate for Payer: Aetna Commercial |
$314.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.47
|
| Rate for Payer: Cash Price |
$295.97
|
| Rate for Payer: Cofinity Commercial |
$258.97
|
| Rate for Payer: Cofinity Commercial |
$318.17
|
| Rate for Payer: Healthscope Commercial |
$332.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$314.47
|
| Rate for Payer: PHP Commercial |
$314.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.97
|
| Rate for Payer: Priority Health SBD |
$233.07
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$149.49
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
152057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$134.54 |
| Rate for Payer: Aetna Commercial |
$127.07
|
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Commercial |
$384.25
|
| Rate for Payer: Aetna Commercial |
$314.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.84
|
| Rate for Payer: BCBS Complete |
$42.35
|
| Rate for Payer: BCBS Complete |
$180.82
|
| Rate for Payer: BCBS Complete |
$59.80
|
| Rate for Payer: BCBS Complete |
$147.98
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: Cash Price |
$295.97
|
| Rate for Payer: Cash Price |
$84.70
|
| Rate for Payer: Cash Price |
$84.70
|
| Rate for Payer: Cash Price |
$119.59
|
| Rate for Payer: Cash Price |
$119.59
|
| Rate for Payer: Cash Price |
$295.97
|
| Rate for Payer: Cash Price |
$361.65
|
| Rate for Payer: Cash Price |
$361.65
|
| Rate for Payer: Cofinity Commercial |
$258.97
|
| Rate for Payer: Cofinity Commercial |
$316.44
|
| Rate for Payer: Cofinity Commercial |
$388.77
|
| Rate for Payer: Cofinity Commercial |
$74.12
|
| Rate for Payer: Cofinity Commercial |
$104.64
|
| Rate for Payer: Cofinity Commercial |
$91.06
|
| Rate for Payer: Cofinity Commercial |
$128.56
|
| Rate for Payer: Cofinity Commercial |
$318.17
|
| Rate for Payer: Healthscope Commercial |
$332.96
|
| Rate for Payer: Healthscope Commercial |
$134.54
|
| Rate for Payer: Healthscope Commercial |
$406.85
|
| Rate for Payer: Healthscope Commercial |
$95.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$314.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$384.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.07
|
| Rate for Payer: PHP Commercial |
$314.47
|
| Rate for Payer: PHP Commercial |
$90.00
|
| Rate for Payer: PHP Commercial |
$384.25
|
| Rate for Payer: PHP Commercial |
$127.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$316.44
|
| Rate for Payer: Priority Health SBD |
$94.18
|
| Rate for Payer: Priority Health SBD |
$66.70
|
| Rate for Payer: Priority Health SBD |
$284.80
|
| Rate for Payer: Priority Health SBD |
$233.07
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
|
IP
|
$199.75
|
|
|
Service Code
|
NDC 31722-530-01
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.84 |
| Max. Negotiated Rate |
$179.78 |
| Rate for Payer: Aetna Commercial |
$169.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.84
|
| Rate for Payer: Cash Price |
$159.80
|
| Rate for Payer: Cofinity Commercial |
$139.82
|
| Rate for Payer: Cofinity Commercial |
$171.78
|
| Rate for Payer: Healthscope Commercial |
$179.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$169.79
|
| Rate for Payer: PHP Commercial |
$169.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.82
|
| Rate for Payer: Priority Health SBD |
$125.84
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
|
IP
|
$103.08
|
|
|
Service Code
|
NDC 50268-755-15
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.94 |
| Max. Negotiated Rate |
$92.77 |
| Rate for Payer: Aetna Commercial |
$87.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.00
|
| Rate for Payer: Cash Price |
$82.46
|
| Rate for Payer: Cofinity Commercial |
$72.16
|
| Rate for Payer: Cofinity Commercial |
$88.65
|
| Rate for Payer: Healthscope Commercial |
$92.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.62
|
| Rate for Payer: PHP Commercial |
$87.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.16
|
| Rate for Payer: Priority Health SBD |
$64.94
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
|
IP
|
$2.07
|
|
|
Service Code
|
NDC 50268-755-11
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna Commercial |
$1.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.35
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cofinity Commercial |
$1.45
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Healthscope Commercial |
$1.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.76
|
| Rate for Payer: PHP Commercial |
$1.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.45
|
| Rate for Payer: Priority Health SBD |
$1.30
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
NDC 50111-916-01
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$299.25 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Aetna Commercial |
$403.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.75
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cofinity Commercial |
$332.50
|
| Rate for Payer: Cofinity Commercial |
$408.50
|
| Rate for Payer: Healthscope Commercial |
$427.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$403.75
|
| Rate for Payer: PHP Commercial |
$403.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.50
|
| Rate for Payer: Priority Health SBD |
$299.25
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$139.65
|
|
|
Service Code
|
NDC 50268-756-15
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.98 |
| Max. Negotiated Rate |
$125.68 |
| Rate for Payer: Aetna Commercial |
$118.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.77
|
| Rate for Payer: Cash Price |
$111.72
|
| Rate for Payer: Cofinity Commercial |
$120.10
|
| Rate for Payer: Cofinity Commercial |
$97.76
|
| Rate for Payer: Healthscope Commercial |
$125.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$118.70
|
| Rate for Payer: PHP Commercial |
$118.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.76
|
| Rate for Payer: Priority Health SBD |
$87.98
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$280.32
|
|
|
Service Code
|
NDC 50111-917-01
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.60 |
| Max. Negotiated Rate |
$252.29 |
| Rate for Payer: Aetna Commercial |
$238.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.21
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$241.08
|
| Rate for Payer: Healthscope Commercial |
$252.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$238.27
|
| Rate for Payer: PHP Commercial |
$238.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.22
|
| Rate for Payer: Priority Health SBD |
$176.60
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 50268-756-11
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna Commercial |
$2.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.82
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$2.41
|
| Rate for Payer: Cofinity Commercial |
$1.96
|
| Rate for Payer: Healthscope Commercial |
$2.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.38
|
| Rate for Payer: PHP Commercial |
$2.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.96
|
| Rate for Payer: Priority Health SBD |
$1.76
|
|
|
TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL
|
Facility
|
OP
|
$50,344.18
|
|
|
Service Code
|
CPT 22856
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,608.40 |
| Max. Negotiated Rate |
$50,344.18 |
| Rate for Payer: Aetna Medicare |
$17,245.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,727.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,727.79
|
| Rate for Payer: BCBS Complete |
$9,524.83
|
| Rate for Payer: BCBS MAPPO |
$16,582.23
|
| Rate for Payer: BCBS Trust/PPO |
$9,643.36
|
| Rate for Payer: BCN Medicare Advantage |
$16,582.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,582.23
|
| Rate for Payer: Mclaren Medicaid |
$9,070.48
|
| Rate for Payer: Mclaren Medicare |
$16,582.23
|
| Rate for Payer: Meridian Medicaid |
$9,524.83
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,411.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,069.56
|
| Rate for Payer: PACE Medicare |
$15,753.12
|
| Rate for Payer: PACE SWMI |
$16,582.23
|
| Rate for Payer: PHP Medicare Advantage |
$16,582.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,070.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$50,344.18
|
| Rate for Payer: Priority Health Medicare |
$16,582.23
|
| Rate for Payer: Priority Health Narrow Network |
$40,275.34
|
| Rate for Payer: Railroad Medicare Medicare |
$16,582.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,769.24
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,582.23
|
| Rate for Payer: UHC Exchange |
$1,608.40
|
| Rate for Payer: UHC Medicare Advantage |
$17,079.70
|
| Rate for Payer: VA VA |
$16,582.23
|
|
|
TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT ISTHMUSECTOMY
|
Facility
|
OP
|
$15,628.84
|
|
|
Service Code
|
CPT 60220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$697.78 |
| Max. Negotiated Rate |
$15,628.84 |
| Rate for Payer: Aetna Medicare |
$5,339.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,417.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,417.61
|
| Rate for Payer: BCBS Complete |
$2,949.02
|
| Rate for Payer: BCBS MAPPO |
$5,134.09
|
| Rate for Payer: BCBS Trust/PPO |
$3,378.70
|
| Rate for Payer: BCN Medicare Advantage |
$5,134.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,134.09
|
| Rate for Payer: Mclaren Medicaid |
$2,808.35
|
| Rate for Payer: Mclaren Medicare |
$5,134.09
|
| Rate for Payer: Meridian Medicaid |
$2,949.02
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,390.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,904.20
|
| Rate for Payer: PACE Medicare |
$4,877.39
|
| Rate for Payer: PACE SWMI |
$5,134.09
|
| Rate for Payer: PHP Medicare Advantage |
$5,134.09
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,808.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,628.84
|
| Rate for Payer: Priority Health Medicare |
$5,134.09
|
| Rate for Payer: Priority Health Narrow Network |
$12,503.07
|
| Rate for Payer: Railroad Medicare Medicare |
$5,134.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$767.56
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,134.09
|
| Rate for Payer: UHC Exchange |
$697.78
|
| Rate for Payer: UHC Medicare Advantage |
$5,288.11
|
| Rate for Payer: VA VA |
$5,134.09
|
|
|
TRABECTEDIN 1 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$14,468.63
|
|
|
Service Code
|
HCPCS J9352
|
| Hospital Charge Code |
175966
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,115.24 |
| Max. Negotiated Rate |
$13,021.77 |
| Rate for Payer: Aetna Commercial |
$12,298.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,404.61
|
| Rate for Payer: Cash Price |
$11,574.90
|
| Rate for Payer: Cofinity Commercial |
$10,128.04
|
| Rate for Payer: Cofinity Commercial |
$12,443.02
|
| Rate for Payer: Healthscope Commercial |
$13,021.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,298.34
|
| Rate for Payer: PHP Commercial |
$12,298.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,128.04
|
| Rate for Payer: Priority Health SBD |
$9,115.24
|
|
