|
SIROLIMUS 0.5 MG TABLET
|
Facility
|
IP
|
$1,498.50
|
|
|
Service Code
|
NDC 59762-1001-1
|
| Hospital Charge Code |
104764
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$659.34 |
| Max. Negotiated Rate |
$1,348.65 |
| Rate for Payer: Aetna American Axle |
$974.02
|
| Rate for Payer: Aetna Commercial |
$1,273.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$974.02
|
| Rate for Payer: Cash Price |
$1,198.80
|
| Rate for Payer: Cofinity Commercial |
$1,048.95
|
| Rate for Payer: Cofinity Commercial |
$1,288.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,198.80
|
| Rate for Payer: Healthscope Commercial |
$1,348.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,048.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,123.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,273.72
|
| Rate for Payer: PHP Commercial |
$1,273.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,048.95
|
| Rate for Payer: Priority Health SBD |
$944.06
|
| Rate for Payer: UMR Bronson Commercial |
$659.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,123.88
|
|
|
SIROLIMUS 1 MG TABLET
|
Facility
|
IP
|
$11,827.79
|
|
|
Service Code
|
HCPCS J7520
|
| Hospital Charge Code |
28958
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,204.23 |
| Max. Negotiated Rate |
$10,645.01 |
| Rate for Payer: Aetna American Axle |
$7,688.06
|
| Rate for Payer: Aetna American Axle |
$562.99
|
| Rate for Payer: Aetna Commercial |
$736.22
|
| Rate for Payer: Aetna Commercial |
$10,053.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,688.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$562.99
|
| Rate for Payer: Cash Price |
$692.91
|
| Rate for Payer: Cash Price |
$9,462.23
|
| Rate for Payer: Cofinity Commercial |
$10,171.90
|
| Rate for Payer: Cofinity Commercial |
$744.88
|
| Rate for Payer: Cofinity Commercial |
$606.30
|
| Rate for Payer: Cofinity Commercial |
$8,279.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,462.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$692.91
|
| Rate for Payer: Healthscope Commercial |
$779.53
|
| Rate for Payer: Healthscope Commercial |
$10,645.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,279.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$606.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$649.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,870.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10,053.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$736.22
|
| Rate for Payer: PHP Commercial |
$10,053.62
|
| Rate for Payer: PHP Commercial |
$736.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8,279.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$606.30
|
| Rate for Payer: Priority Health SBD |
$7,451.51
|
| Rate for Payer: Priority Health SBD |
$545.67
|
| Rate for Payer: UMR Bronson Commercial |
$5,204.23
|
| Rate for Payer: UMR Bronson Commercial |
$381.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,870.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$649.60
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET
|
Facility
|
IP
|
$65.73
|
|
|
Service Code
|
NDC 0006-0277-01
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.92 |
| Max. Negotiated Rate |
$59.16 |
| Rate for Payer: Aetna American Axle |
$42.72
|
| Rate for Payer: Aetna Commercial |
$55.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.72
|
| Rate for Payer: Cash Price |
$52.58
|
| Rate for Payer: Cofinity Commercial |
$46.01
|
| Rate for Payer: Cofinity Commercial |
$56.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.58
|
| Rate for Payer: Healthscope Commercial |
$59.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.87
|
| Rate for Payer: PHP Commercial |
$55.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.01
|
| Rate for Payer: Priority Health SBD |
$41.41
|
| Rate for Payer: UMR Bronson Commercial |
$28.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.30
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET
|
Facility
|
IP
|
$6,572.31
|
|
|
Service Code
|
NDC 0006-0277-28
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,891.82 |
| Max. Negotiated Rate |
$5,915.08 |
| Rate for Payer: Aetna American Axle |
$4,272.00
|
| Rate for Payer: Aetna Commercial |
$5,586.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,272.00
|
| Rate for Payer: Cash Price |
$5,257.85
|
| Rate for Payer: Cofinity Commercial |
$4,600.62
|
| Rate for Payer: Cofinity Commercial |
$5,652.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,257.85
|
| Rate for Payer: Healthscope Commercial |
$5,915.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,600.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,929.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,586.46
|
| Rate for Payer: PHP Commercial |
$5,586.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,600.62
|
| Rate for Payer: Priority Health SBD |
$4,140.56
|
| Rate for Payer: UMR Bronson Commercial |
$2,891.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,929.23
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET
|
Facility
|
IP
|
$1,971.48
|
|
|
Service Code
|
NDC 0006-0277-31
|
| Hospital Charge Code |
77617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$867.45 |
| Max. Negotiated Rate |
$1,774.33 |
| Rate for Payer: Aetna American Axle |
$1,281.46
|
| Rate for Payer: Aetna Commercial |
$1,675.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,281.46
|
| Rate for Payer: Cash Price |
$1,577.18
|
| Rate for Payer: Cofinity Commercial |
$1,380.04
|
| Rate for Payer: Cofinity Commercial |
$1,695.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,577.18
|
| Rate for Payer: Healthscope Commercial |
$1,774.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,380.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,478.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,675.76
|
| Rate for Payer: PHP Commercial |
$1,675.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,380.04
|
| Rate for Payer: Priority Health SBD |
$1,242.03
|
| Rate for Payer: UMR Bronson Commercial |
$867.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,478.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET
|
Facility
|
IP
|
$1,971.48
|
|
|
Service Code
|
NDC 0006-0112-31
|
| Hospital Charge Code |
77616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$867.45 |
| Max. Negotiated Rate |
$1,774.33 |
| Rate for Payer: Aetna American Axle |
$1,281.46
|
| Rate for Payer: Aetna Commercial |
$1,675.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,281.46
|
| Rate for Payer: Cash Price |
$1,577.18
|
| Rate for Payer: Cofinity Commercial |
$1,380.04
|
| Rate for Payer: Cofinity Commercial |
$1,695.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,577.18
|
| Rate for Payer: Healthscope Commercial |
$1,774.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,380.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,478.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,675.76
|
| Rate for Payer: PHP Commercial |
$1,675.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,380.04
|
| Rate for Payer: Priority Health SBD |
$1,242.03
|
| Rate for Payer: UMR Bronson Commercial |
$867.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,478.61
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET
|
Facility
|
IP
|
$6,572.31
|
|
|
Service Code
|
NDC 0006-0112-28
|
| Hospital Charge Code |
77616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,891.82 |
| Max. Negotiated Rate |
$5,915.08 |
| Rate for Payer: Aetna American Axle |
$4,272.00
|
| Rate for Payer: Aetna Commercial |
$5,586.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,272.00
|
| Rate for Payer: Cash Price |
$5,257.85
|
| Rate for Payer: Cofinity Commercial |
$4,600.62
|
| Rate for Payer: Cofinity Commercial |
$5,652.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,257.85
|
| Rate for Payer: Healthscope Commercial |
$5,915.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,600.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,929.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,586.46
|
| Rate for Payer: PHP Commercial |
$5,586.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,600.62
|
| Rate for Payer: Priority Health SBD |
$4,140.56
|
| Rate for Payer: UMR Bronson Commercial |
$2,891.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,929.23
|
|
|
SKIN CARE CONSULT
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS 00177
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$17.50 |
| Rate for Payer: BCBS Complete |
$10.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.50
|
| Rate for Payer: UMR Bronson Commercial |
$11.50
|
|
|
SKIN DEBRIDEMENT WITH CC
|
Facility
|
IP
|
$30,232.70
|
|
|
Service Code
|
MS-DRG 571
|
| Min. Negotiated Rate |
$12,872.67 |
| Max. Negotiated Rate |
$30,232.70 |
| Rate for Payer: Aetna Medicare |
$14,092.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16,937.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16,937.72
|
| Rate for Payer: BCBS MAPPO |
$13,550.18
|
| Rate for Payer: BCBS Trust/PPO |
$30,232.70
|
| Rate for Payer: BCN Medicare Advantage |
$13,550.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,550.18
|
| Rate for Payer: Mclaren Medicare |
$13,550.18
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,227.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,582.71
|
| Rate for Payer: PACE Medicare |
$12,872.67
|
| Rate for Payer: PACE SWMI |
$13,550.18
|
| Rate for Payer: PHP Medicare Advantage |
$13,550.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24,278.63
|
| Rate for Payer: Priority Health Medicare |
$13,550.18
|
| Rate for Payer: Priority Health Narrow Network |
$19,422.90
|
| Rate for Payer: Railroad Medicare Medicare |
$13,550.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25,808.24
|
| Rate for Payer: UHC Core |
$21,162.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$13,550.18
|
| Rate for Payer: UHC Exchange |
$16,824.25
|
| Rate for Payer: UHC Medicare Advantage |
$13,956.69
|
| Rate for Payer: VA VA |
$13,550.18
|
|
|
SKIN DEBRIDEMENT WITH MCC
|
Facility
|
IP
|
$44,575.24
|
|
|
Service Code
|
MS-DRG 570
|
| Min. Negotiated Rate |
$21,879.38 |
| Max. Negotiated Rate |
$44,575.24 |
| Rate for Payer: Aetna Medicare |
$23,952.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28,788.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28,788.66
|
| Rate for Payer: BCBS MAPPO |
$23,030.93
|
| Rate for Payer: BCBS Trust/PPO |
$38,748.92
|
| Rate for Payer: BCN Medicare Advantage |
$23,030.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23,030.93
|
| Rate for Payer: Mclaren Medicare |
$23,030.93
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$24,182.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26,485.57
|
| Rate for Payer: PACE Medicare |
$21,879.38
|
| Rate for Payer: PACE SWMI |
$23,030.93
|
| Rate for Payer: PHP Medicare Advantage |
$23,030.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$41,933.34
|
| Rate for Payer: Priority Health Medicare |
$23,030.93
|
| Rate for Payer: Priority Health Narrow Network |
$33,546.67
|
| Rate for Payer: Railroad Medicare Medicare |
$23,030.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$44,575.24
|
| Rate for Payer: UHC Core |
$36,550.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$23,030.93
|
| Rate for Payer: UHC Exchange |
$29,058.36
|
| Rate for Payer: UHC Medicare Advantage |
$23,721.86
|
| Rate for Payer: VA VA |
$23,030.93
|
|
|
SKIN DEBRIDEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$20,362.03
|
|
|
Service Code
|
MS-DRG 572
|
| Min. Negotiated Rate |
$8,829.43 |
| Max. Negotiated Rate |
$20,362.03 |
| Rate for Payer: Aetna Medicare |
$9,665.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,617.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,617.68
|
| Rate for Payer: BCBS MAPPO |
$9,294.14
|
| Rate for Payer: BCBS Trust/PPO |
$20,362.03
|
| Rate for Payer: BCN Medicare Advantage |
$9,294.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,294.14
|
| Rate for Payer: Mclaren Medicare |
$9,294.14
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,758.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,688.26
|
| Rate for Payer: PACE Medicare |
$8,829.43
|
| Rate for Payer: PACE SWMI |
$9,294.14
|
| Rate for Payer: PHP Medicare Advantage |
$9,294.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,353.17
|
| Rate for Payer: Priority Health Medicare |
$9,294.14
|
| Rate for Payer: Priority Health Narrow Network |
$13,082.54
|
| Rate for Payer: Railroad Medicare Medicare |
$9,294.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,383.46
|
| Rate for Payer: UHC Core |
$14,254.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,294.14
|
| Rate for Payer: UHC Exchange |
$11,332.18
|
| Rate for Payer: UHC Medicare Advantage |
$9,572.96
|
| Rate for Payer: VA VA |
$9,294.14
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$73,421.91
|
|
|
Service Code
|
MS-DRG 577
|
| Min. Negotiated Rate |
$19,880.09 |
| Max. Negotiated Rate |
$73,421.91 |
| Rate for Payer: Aetna Medicare |
$21,763.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$26,158.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$26,158.01
|
| Rate for Payer: BCBS MAPPO |
$20,926.41
|
| Rate for Payer: BCBS Trust/PPO |
$73,421.91
|
| Rate for Payer: BCN Medicare Advantage |
$20,926.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20,926.41
|
| Rate for Payer: Mclaren Medicare |
$20,926.41
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$21,972.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24,065.37
|
| Rate for Payer: PACE Medicare |
$19,880.09
|
| Rate for Payer: PACE SWMI |
$20,926.41
|
| Rate for Payer: PHP Medicare Advantage |
$20,926.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38,014.37
|
| Rate for Payer: Priority Health Medicare |
$20,926.41
|
| Rate for Payer: Priority Health Narrow Network |
$30,411.50
|
| Rate for Payer: Railroad Medicare Medicare |
$20,926.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40,409.37
|
| Rate for Payer: UHC Core |
$33,134.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$20,926.41
|
| Rate for Payer: UHC Exchange |
$26,342.65
|
| Rate for Payer: UHC Medicare Advantage |
$21,554.20
|
| Rate for Payer: VA VA |
$20,926.41
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$114,485.21
|
|
|
Service Code
|
MS-DRG 576
|
| Min. Negotiated Rate |
$42,091.18 |
| Max. Negotiated Rate |
$114,485.21 |
| Rate for Payer: Aetna Medicare |
$46,078.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$55,383.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$55,383.14
|
| Rate for Payer: BCBS MAPPO |
$44,306.51
|
| Rate for Payer: BCBS Trust/PPO |
$114,485.21
|
| Rate for Payer: BCN Medicare Advantage |
$44,306.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44,306.51
|
| Rate for Payer: Mclaren Medicare |
$44,306.51
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$46,521.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$50,952.49
|
| Rate for Payer: PACE Medicare |
$42,091.18
|
| Rate for Payer: PACE SWMI |
$44,306.51
|
| Rate for Payer: PHP Medicare Advantage |
$44,306.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$81,552.03
|
| Rate for Payer: Priority Health Medicare |
$44,306.51
|
| Rate for Payer: Priority Health Narrow Network |
$65,241.62
|
| Rate for Payer: Railroad Medicare Medicare |
$44,306.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$86,690.01
|
| Rate for Payer: UHC Core |
$71,084.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$44,306.51
|
| Rate for Payer: UHC Exchange |
$56,512.75
|
| Rate for Payer: UHC Medicare Advantage |
$45,635.71
|
| Rate for Payer: VA VA |
$44,306.51
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$36,469.72
|
|
|
Service Code
|
MS-DRG 578
|
| Min. Negotiated Rate |
$12,276.76 |
| Max. Negotiated Rate |
$36,469.72 |
| Rate for Payer: Aetna Medicare |
$13,439.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16,153.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16,153.64
|
| Rate for Payer: BCBS MAPPO |
$12,922.91
|
| Rate for Payer: BCBS Trust/PPO |
$36,469.72
|
| Rate for Payer: BCN Medicare Advantage |
$12,922.91
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,922.91
|
| Rate for Payer: Mclaren Medicare |
$12,922.91
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$13,569.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,861.35
|
| Rate for Payer: PACE Medicare |
$12,276.76
|
| Rate for Payer: PACE SWMI |
$12,922.91
|
| Rate for Payer: PHP Medicare Advantage |
$12,922.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23,110.55
|
| Rate for Payer: Priority Health Medicare |
$12,922.91
|
| Rate for Payer: Priority Health Narrow Network |
$18,488.44
|
| Rate for Payer: Railroad Medicare Medicare |
$12,922.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,566.57
|
| Rate for Payer: UHC Core |
$20,144.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,922.91
|
| Rate for Payer: UHC Exchange |
$16,014.81
|
| Rate for Payer: UHC Medicare Advantage |
$13,310.60
|
| Rate for Payer: VA VA |
$12,922.91
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$51,952.07
|
|
|
Service Code
|
MS-DRG 574
|
| Min. Negotiated Rate |
$25,419.68 |
| Max. Negotiated Rate |
$51,952.07 |
| Rate for Payer: Aetna Medicare |
$27,827.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$33,446.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$33,446.95
|
| Rate for Payer: BCBS MAPPO |
$26,757.56
|
| Rate for Payer: BCBS Trust/PPO |
$44,533.61
|
| Rate for Payer: BCN Medicare Advantage |
$26,757.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$26,757.56
|
| Rate for Payer: Mclaren Medicare |
$26,757.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$28,095.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30,771.19
|
| Rate for Payer: PACE Medicare |
$25,419.68
|
| Rate for Payer: PACE SWMI |
$26,757.56
|
| Rate for Payer: PHP Medicare Advantage |
$26,757.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$48,872.96
|
| Rate for Payer: Priority Health Medicare |
$26,757.56
|
| Rate for Payer: Priority Health Narrow Network |
$39,098.37
|
| Rate for Payer: Railroad Medicare Medicare |
$26,757.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51,952.07
|
| Rate for Payer: UHC Core |
$42,599.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$26,757.56
|
| Rate for Payer: UHC Exchange |
$33,867.28
|
| Rate for Payer: UHC Medicare Advantage |
$27,560.29
|
| Rate for Payer: VA VA |
$26,757.56
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$129,949.60
|
|
|
Service Code
|
MS-DRG 573
|
| Min. Negotiated Rate |
$46,007.78 |
| Max. Negotiated Rate |
$129,949.60 |
| Rate for Payer: Aetna Medicare |
$50,366.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$60,536.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$60,536.55
|
| Rate for Payer: BCBS MAPPO |
$48,429.24
|
| Rate for Payer: BCBS Trust/PPO |
$129,949.60
|
| Rate for Payer: BCN Medicare Advantage |
$48,429.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48,429.24
|
| Rate for Payer: Mclaren Medicare |
$48,429.24
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$50,850.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55,693.63
|
| Rate for Payer: PACE Medicare |
$46,007.78
|
| Rate for Payer: PACE SWMI |
$48,429.24
|
| Rate for Payer: PHP Medicare Advantage |
$48,429.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$89,229.24
|
| Rate for Payer: Priority Health Medicare |
$48,429.24
|
| Rate for Payer: Priority Health Narrow Network |
$71,383.39
|
| Rate for Payer: Railroad Medicare Medicare |
$48,429.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$94,850.90
|
| Rate for Payer: UHC Core |
$77,775.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$48,429.24
|
| Rate for Payer: UHC Exchange |
$61,832.79
|
| Rate for Payer: UHC Medicare Advantage |
$49,882.12
|
| Rate for Payer: VA VA |
$48,429.24
|
|
|
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$31,209.68
|
|
|
Service Code
|
MS-DRG 575
|
| Min. Negotiated Rate |
$15,464.96 |
| Max. Negotiated Rate |
$31,209.68 |
| Rate for Payer: Aetna Medicare |
$16,930.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,348.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,348.62
|
| Rate for Payer: BCBS MAPPO |
$16,278.90
|
| Rate for Payer: BCBS Trust/PPO |
$26,752.33
|
| Rate for Payer: BCN Medicare Advantage |
$16,278.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,278.90
|
| Rate for Payer: Mclaren Medicare |
$16,278.90
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,092.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18,720.74
|
| Rate for Payer: PACE Medicare |
$15,464.96
|
| Rate for Payer: PACE SWMI |
$16,278.90
|
| Rate for Payer: PHP Medicare Advantage |
$16,278.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$29,359.94
|
| Rate for Payer: Priority Health Medicare |
$16,278.90
|
| Rate for Payer: Priority Health Narrow Network |
$23,487.95
|
| Rate for Payer: Railroad Medicare Medicare |
$16,278.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31,209.68
|
| Rate for Payer: UHC Core |
$25,591.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,278.90
|
| Rate for Payer: UHC Exchange |
$20,345.42
|
| Rate for Payer: UHC Medicare Advantage |
$16,767.27
|
| Rate for Payer: VA VA |
$16,278.90
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC
|
Facility
|
IP
|
$29,162.20
|
|
|
Service Code
|
MS-DRG 623
|
| Min. Negotiated Rate |
$14,113.56 |
| Max. Negotiated Rate |
$29,162.20 |
| Rate for Payer: Aetna Medicare |
$15,450.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18,570.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18,570.48
|
| Rate for Payer: BCBS MAPPO |
$14,856.38
|
| Rate for Payer: BCBS Trust/PPO |
$29,162.20
|
| Rate for Payer: BCN Medicare Advantage |
$14,856.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14,856.38
|
| Rate for Payer: Mclaren Medicare |
$14,856.38
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$15,599.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17,084.84
|
| Rate for Payer: PACE Medicare |
$14,113.56
|
| Rate for Payer: PACE SWMI |
$14,856.38
|
| Rate for Payer: PHP Medicare Advantage |
$14,856.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26,710.94
|
| Rate for Payer: Priority Health Medicare |
$14,856.38
|
| Rate for Payer: Priority Health Narrow Network |
$21,368.75
|
| Rate for Payer: Railroad Medicare Medicare |
$14,856.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28,393.80
|
| Rate for Payer: UHC Core |
$23,282.39
|
| Rate for Payer: UHC Dual Complete DSNP |
$14,856.38
|
| Rate for Payer: UHC Exchange |
$18,509.76
|
| Rate for Payer: UHC Medicare Advantage |
$15,302.07
|
| Rate for Payer: VA VA |
$14,856.38
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC
|
Facility
|
IP
|
$58,355.70
|
|
|
Service Code
|
MS-DRG 622
|
| Min. Negotiated Rate |
$28,492.93 |
| Max. Negotiated Rate |
$58,355.70 |
| Rate for Payer: Aetna Medicare |
$31,192.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$37,490.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$37,490.70
|
| Rate for Payer: BCBS MAPPO |
$29,992.56
|
| Rate for Payer: BCBS Trust/PPO |
$46,207.21
|
| Rate for Payer: BCN Medicare Advantage |
$29,992.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29,992.56
|
| Rate for Payer: Mclaren Medicare |
$29,992.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$31,492.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34,491.44
|
| Rate for Payer: PACE Medicare |
$28,492.93
|
| Rate for Payer: PACE SWMI |
$29,992.56
|
| Rate for Payer: PHP Medicare Advantage |
$29,992.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$54,897.05
|
| Rate for Payer: Priority Health Medicare |
$29,992.56
|
| Rate for Payer: Priority Health Narrow Network |
$43,917.64
|
| Rate for Payer: Railroad Medicare Medicare |
$29,992.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58,355.70
|
| Rate for Payer: UHC Core |
$47,850.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$29,992.56
|
| Rate for Payer: UHC Exchange |
$38,041.77
|
| Rate for Payer: UHC Medicare Advantage |
$30,892.34
|
| Rate for Payer: VA VA |
$29,992.56
|
|
|
SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$20,995.28
|
|
|
Service Code
|
MS-DRG 624
|
| Min. Negotiated Rate |
$8,645.69 |
| Max. Negotiated Rate |
$20,995.28 |
| Rate for Payer: Aetna Medicare |
$9,464.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,375.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,375.91
|
| Rate for Payer: BCBS MAPPO |
$9,100.73
|
| Rate for Payer: BCBS Trust/PPO |
$20,995.28
|
| Rate for Payer: BCN Medicare Advantage |
$9,100.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,100.73
|
| Rate for Payer: Mclaren Medicare |
$9,100.73
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$9,555.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,465.84
|
| Rate for Payer: PACE Medicare |
$8,645.69
|
| Rate for Payer: PACE SWMI |
$9,100.73
|
| Rate for Payer: PHP Medicare Advantage |
$9,100.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,992.99
|
| Rate for Payer: Priority Health Medicare |
$9,100.73
|
| Rate for Payer: Priority Health Narrow Network |
$12,794.39
|
| Rate for Payer: Railroad Medicare Medicare |
$9,100.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,000.58
|
| Rate for Payer: UHC Core |
$13,940.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,100.73
|
| Rate for Payer: UHC Exchange |
$11,082.59
|
| Rate for Payer: UHC Medicare Advantage |
$9,373.75
|
| Rate for Payer: VA VA |
$9,100.73
|
|
|
SKIN GRAFTS FOR INJURIES WITH CC/MCC
|
Facility
|
IP
|
$63,453.24
|
|
|
Service Code
|
MS-DRG 904
|
| Min. Negotiated Rate |
$24,324.50 |
| Max. Negotiated Rate |
$63,453.24 |
| Rate for Payer: Aetna Medicare |
$26,628.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$32,005.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$32,005.92
|
| Rate for Payer: BCBS MAPPO |
$25,604.74
|
| Rate for Payer: BCBS Trust/PPO |
$63,453.24
|
| Rate for Payer: BCN Medicare Advantage |
$25,604.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25,604.74
|
| Rate for Payer: Mclaren Medicare |
$25,604.74
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$26,884.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29,445.45
|
| Rate for Payer: PACE Medicare |
$24,324.50
|
| Rate for Payer: PACE SWMI |
$25,604.74
|
| Rate for Payer: PHP Medicare Advantage |
$25,604.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$46,726.21
|
| Rate for Payer: Priority Health Medicare |
$25,604.74
|
| Rate for Payer: Priority Health Narrow Network |
$37,380.97
|
| Rate for Payer: Railroad Medicare Medicare |
$25,604.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49,670.07
|
| Rate for Payer: UHC Core |
$40,728.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$25,604.74
|
| Rate for Payer: UHC Exchange |
$32,379.65
|
| Rate for Payer: UHC Medicare Advantage |
$26,372.88
|
| Rate for Payer: VA VA |
$25,604.74
|
|
|
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC
|
Facility
|
IP
|
$28,337.97
|
|
|
Service Code
|
MS-DRG 905
|
| Min. Negotiated Rate |
$12,080.58 |
| Max. Negotiated Rate |
$28,337.97 |
| Rate for Payer: Aetna Medicare |
$13,225.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,895.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,895.50
|
| Rate for Payer: BCBS MAPPO |
$12,716.40
|
| Rate for Payer: BCBS Trust/PPO |
$28,337.97
|
| Rate for Payer: BCN Medicare Advantage |
$12,716.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,716.40
|
| Rate for Payer: Mclaren Medicare |
$12,716.40
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$13,352.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,623.86
|
| Rate for Payer: PACE Medicare |
$12,080.58
|
| Rate for Payer: PACE SWMI |
$12,716.40
|
| Rate for Payer: PHP Medicare Advantage |
$12,716.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22,725.97
|
| Rate for Payer: Priority Health Medicare |
$12,716.40
|
| Rate for Payer: Priority Health Narrow Network |
$18,180.78
|
| Rate for Payer: Railroad Medicare Medicare |
$12,716.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24,157.76
|
| Rate for Payer: UHC Core |
$19,808.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,716.40
|
| Rate for Payer: UHC Exchange |
$15,748.31
|
| Rate for Payer: UHC Medicare Advantage |
$13,097.89
|
| Rate for Payer: VA VA |
$12,716.40
|
|
|
SKIN SUBSTITUTE, INTEGRA MESHED BILAYER WOUND MATRIX, PER SQUARE CENTIMETER
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT C9363
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
|
|
SKIN ULCERS WITH CC
|
Facility
|
IP
|
$18,455.81
|
|
|
Service Code
|
MS-DRG 593
|
| Min. Negotiated Rate |
$9,344.09 |
| Max. Negotiated Rate |
$18,455.81 |
| Rate for Payer: Aetna Medicare |
$10,229.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,294.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,294.85
|
| Rate for Payer: BCBS MAPPO |
$9,835.88
|
| Rate for Payer: BCBS Trust/PPO |
$15,904.14
|
| Rate for Payer: BCN Medicare Advantage |
$9,835.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,835.88
|
| Rate for Payer: Mclaren Medicare |
$9,835.88
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$10,327.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,311.26
|
| Rate for Payer: PACE Medicare |
$9,344.09
|
| Rate for Payer: PACE SWMI |
$9,835.88
|
| Rate for Payer: PHP Medicare Advantage |
$9,835.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,361.97
|
| Rate for Payer: Priority Health Medicare |
$9,835.88
|
| Rate for Payer: Priority Health Narrow Network |
$13,889.58
|
| Rate for Payer: Railroad Medicare Medicare |
$9,835.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18,455.81
|
| Rate for Payer: UHC Core |
$15,133.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,835.88
|
| Rate for Payer: UHC Exchange |
$12,031.25
|
| Rate for Payer: UHC Medicare Advantage |
$10,130.96
|
| Rate for Payer: VA VA |
$9,835.88
|
|
|
SKIN ULCERS WITH MCC
|
Facility
|
IP
|
$31,882.39
|
|
|
Service Code
|
MS-DRG 592
|
| Min. Negotiated Rate |
$15,787.81 |
| Max. Negotiated Rate |
$31,882.39 |
| Rate for Payer: Aetna Medicare |
$17,283.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$20,773.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$20,773.44
|
| Rate for Payer: BCBS MAPPO |
$16,618.75
|
| Rate for Payer: BCBS Trust/PPO |
$26,669.41
|
| Rate for Payer: BCN Medicare Advantage |
$16,618.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,618.75
|
| Rate for Payer: Mclaren Medicare |
$16,618.75
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$17,449.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,111.56
|
| Rate for Payer: PACE Medicare |
$15,787.81
|
| Rate for Payer: PACE SWMI |
$16,618.75
|
| Rate for Payer: PHP Medicare Advantage |
$16,618.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$29,992.77
|
| Rate for Payer: Priority Health Medicare |
$16,618.75
|
| Rate for Payer: Priority Health Narrow Network |
$23,994.22
|
| Rate for Payer: Railroad Medicare Medicare |
$16,618.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31,882.39
|
| Rate for Payer: UHC Core |
$26,142.97
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,618.75
|
| Rate for Payer: UHC Exchange |
$20,783.95
|
| Rate for Payer: UHC Medicare Advantage |
$17,117.31
|
| Rate for Payer: VA VA |
$16,618.75
|
|
