|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$9,648.34
|
|
|
Service Code
|
APR-DRG 2044
|
| Min. Negotiated Rate |
$8,723.25 |
| Max. Negotiated Rate |
$9,648.34 |
| Rate for Payer: BCBS Complete |
$9,648.34
|
| Rate for Payer: Mclaren Medicaid |
$9,188.90
|
| Rate for Payer: Meridian Medicaid |
$9,648.34
|
| Rate for Payer: PHP Medicaid |
$8,723.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,188.90
|
| Rate for Payer: UHC Medicaid |
$9,188.90
|
| Rate for Payer: UHCCP Medicaid |
$9,188.90
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$3,908.38
|
|
|
Service Code
|
APR-DRG 2041
|
| Min. Negotiated Rate |
$3,533.64 |
| Max. Negotiated Rate |
$3,908.38 |
| Rate for Payer: BCBS Complete |
$3,908.38
|
| Rate for Payer: Mclaren Medicaid |
$3,722.27
|
| Rate for Payer: Meridian Medicaid |
$3,908.38
|
| Rate for Payer: PHP Medicaid |
$3,533.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,722.27
|
| Rate for Payer: UHC Medicaid |
$3,722.27
|
| Rate for Payer: UHCCP Medicaid |
$3,722.27
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$12,448.14
|
|
|
Service Code
|
MSDRG 312
|
| Min. Negotiated Rate |
$7,629.51 |
| Max. Negotiated Rate |
$12,448.14 |
| Rate for Payer: Aetna Medicare |
$8,031.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,038.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,038.83
|
| Rate for Payer: BCBS MAPPO |
$8,031.06
|
| Rate for Payer: BCN Medicare Advantage |
$8,031.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,031.06
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,031.06
|
| Rate for Payer: Mclaren Medicare |
$8,031.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,432.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,235.72
|
| Rate for Payer: Molina Medicare/Medicaid |
$8,834.17
|
| Rate for Payer: PACE Medicare |
$7,629.51
|
| Rate for Payer: PACE SWMI |
$8,031.06
|
| Rate for Payer: PHP Commercial |
$8,834.17
|
| Rate for Payer: PHP Medicare Advantage |
$8,031.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$11,974.74
|
| Rate for Payer: Priority Health Medicare |
$8,031.06
|
| Rate for Payer: Priority Health Narrow Network |
$9,579.79
|
| Rate for Payer: Railroad Medicare Medicare |
$8,031.06
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,031.06
|
| Rate for Payer: UHC Exchange |
$12,448.14
|
| Rate for Payer: UHCCP DNSP |
$8,031.06
|
| Rate for Payer: VA VA |
$8,031.06
|
|
|
SYNCOPE AND COLLAPSE
|
Facility
|
IP
|
$4,772.13
|
|
|
Service Code
|
APR-DRG 2042
|
| Min. Negotiated Rate |
$4,314.57 |
| Max. Negotiated Rate |
$4,772.13 |
| Rate for Payer: BCBS Complete |
$4,772.13
|
| Rate for Payer: Mclaren Medicaid |
$4,544.88
|
| Rate for Payer: Meridian Medicaid |
$4,772.13
|
| Rate for Payer: PHP Medicaid |
$4,314.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,544.88
|
| Rate for Payer: UHC Medicaid |
$4,544.88
|
| Rate for Payer: UHCCP Medicaid |
$4,544.88
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$169.20
|
|
|
Service Code
|
NDC 65862059801
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.90 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna Commercial |
$152.28
|
| Rate for Payer: ASR ASR |
$164.12
|
| Rate for Payer: BCBS Trust/PPO |
$138.95
|
| Rate for Payer: BCN Commercial |
$138.95
|
| Rate for Payer: Cash Price |
$135.36
|
| Rate for Payer: Cofinity Commercial |
$159.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.36
|
| Rate for Payer: Healthscope Commercial |
$164.12
|
| Rate for Payer: Healthscope Whirlpool |
$169.20
|
| Rate for Payer: Mclaren Commercial |
$152.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.82
|
| Rate for Payer: Nomi Health Commercial |
$138.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$148.90
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$243.20
|
|
|
Service Code
|
NDC 68382013201
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.98 |
| Max. Negotiated Rate |
$243.20 |
| Rate for Payer: Aetna Commercial |
$218.88
|
| Rate for Payer: Aetna Medicare |
$89.98
|
| Rate for Payer: ASR ASR |
$235.90
|
| Rate for Payer: BCBS Complete |
$97.28
|
| Rate for Payer: BCBS Trust/PPO |
$200.52
|
| Rate for Payer: BCN Commercial |
$200.52
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Commercial |
$228.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$235.90
|
| Rate for Payer: Healthscope Whirlpool |
$243.20
|
| Rate for Payer: Mclaren Commercial |
$218.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$194.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.72
|
| Rate for Payer: Nomi Health Commercial |
$199.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$182.40
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$213.09
|
| Rate for Payer: Priority Health Narrow Network |
$170.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$214.02
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$234.65
|
|
|
Service Code
|
NDC 904738361
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.99 |
| Max. Negotiated Rate |
$234.65 |
| Rate for Payer: Aetna Commercial |
$211.19
|
| Rate for Payer: ASR ASR |
$227.61
|
| Rate for Payer: BCBS Trust/PPO |
$192.69
|
| Rate for Payer: BCN Commercial |
$192.69
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$220.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$227.61
|
| Rate for Payer: Healthscope Whirlpool |
$234.65
|
| Rate for Payer: Mclaren Commercial |
$211.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$199.45
|
| Rate for Payer: Nomi Health Commercial |
$192.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$175.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$206.49
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$234.65
|
|
|
Service Code
|
NDC 904738361
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.82 |
| Max. Negotiated Rate |
$234.65 |
| Rate for Payer: Aetna Commercial |
$211.19
|
| Rate for Payer: Aetna Medicare |
$86.82
|
| Rate for Payer: ASR ASR |
$227.61
|
| Rate for Payer: BCBS Complete |
$93.86
|
| Rate for Payer: BCBS Trust/PPO |
$193.47
|
| Rate for Payer: BCN Commercial |
$193.47
|
| Rate for Payer: Cash Price |
$187.72
|
| Rate for Payer: Cofinity Commercial |
$220.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$187.72
|
| Rate for Payer: Healthscope Commercial |
$227.61
|
| Rate for Payer: Healthscope Whirlpool |
$234.65
|
| Rate for Payer: Mclaren Commercial |
$211.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$187.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$199.45
|
| Rate for Payer: Nomi Health Commercial |
$192.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$175.99
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$205.60
|
| Rate for Payer: Priority Health Narrow Network |
$164.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$206.49
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$192.85
|
|
|
Service Code
|
NDC 904640161
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.64 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna Commercial |
$173.56
|
| Rate for Payer: ASR ASR |
$187.06
|
| Rate for Payer: BCBS Trust/PPO |
$158.37
|
| Rate for Payer: BCN Commercial |
$158.37
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$181.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$187.06
|
| Rate for Payer: Healthscope Whirlpool |
$192.85
|
| Rate for Payer: Mclaren Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: Nomi Health Commercial |
$158.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$144.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$169.71
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$192.85
|
|
|
Service Code
|
NDC 904640161
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.35 |
| Max. Negotiated Rate |
$192.85 |
| Rate for Payer: Aetna Commercial |
$173.56
|
| Rate for Payer: Aetna Medicare |
$71.35
|
| Rate for Payer: ASR ASR |
$187.06
|
| Rate for Payer: BCBS Complete |
$77.14
|
| Rate for Payer: BCBS Trust/PPO |
$159.00
|
| Rate for Payer: BCN Commercial |
$159.00
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$181.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$187.06
|
| Rate for Payer: Healthscope Whirlpool |
$192.85
|
| Rate for Payer: Mclaren Commercial |
$173.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$154.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: Nomi Health Commercial |
$158.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$144.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$168.98
|
| Rate for Payer: Priority Health Narrow Network |
$135.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$169.71
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$243.20
|
|
|
Service Code
|
NDC 68382013201
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.40 |
| Max. Negotiated Rate |
$243.20 |
| Rate for Payer: Aetna Commercial |
$218.88
|
| Rate for Payer: ASR ASR |
$235.90
|
| Rate for Payer: BCBS Trust/PPO |
$199.72
|
| Rate for Payer: BCN Commercial |
$199.72
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Commercial |
$228.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$235.90
|
| Rate for Payer: Healthscope Whirlpool |
$243.20
|
| Rate for Payer: Mclaren Commercial |
$218.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.72
|
| Rate for Payer: Nomi Health Commercial |
$199.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$182.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$214.02
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$169.20
|
|
|
Service Code
|
NDC 65862059801
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.60 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna Commercial |
$152.28
|
| Rate for Payer: Aetna Medicare |
$62.60
|
| Rate for Payer: ASR ASR |
$164.12
|
| Rate for Payer: BCBS Complete |
$67.68
|
| Rate for Payer: BCBS Trust/PPO |
$139.51
|
| Rate for Payer: BCN Commercial |
$139.51
|
| Rate for Payer: Cash Price |
$135.36
|
| Rate for Payer: Cofinity Commercial |
$159.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.36
|
| Rate for Payer: Healthscope Commercial |
$164.12
|
| Rate for Payer: Healthscope Whirlpool |
$169.20
|
| Rate for Payer: Mclaren Commercial |
$152.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.82
|
| Rate for Payer: Nomi Health Commercial |
$138.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$148.25
|
| Rate for Payer: Priority Health Narrow Network |
$118.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$148.90
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
IP
|
$2.89
|
|
|
Service Code
|
NDC 51079029401
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna Commercial |
$2.60
|
| Rate for Payer: ASR ASR |
$2.80
|
| Rate for Payer: BCBS Trust/PPO |
$2.37
|
| Rate for Payer: BCN Commercial |
$2.37
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.31
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Healthscope Whirlpool |
$2.89
|
| Rate for Payer: Mclaren Commercial |
$2.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.45
|
| Rate for Payer: Nomi Health Commercial |
$2.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.54
|
|
|
TAMSULOSIN 0.4 MG CAPSULE
|
Facility
|
OP
|
$2.89
|
|
|
Service Code
|
NDC 51079029401
|
| Hospital Charge Code |
103890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Aetna Commercial |
$2.60
|
| Rate for Payer: Aetna Medicare |
$1.07
|
| Rate for Payer: ASR ASR |
$2.80
|
| Rate for Payer: BCBS Complete |
$1.16
|
| Rate for Payer: BCBS Trust/PPO |
$2.38
|
| Rate for Payer: BCN Commercial |
$2.38
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.31
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Healthscope Whirlpool |
$2.89
|
| Rate for Payer: Mclaren Commercial |
$2.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.45
|
| Rate for Payer: Nomi Health Commercial |
$2.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.53
|
| Rate for Payer: Priority Health Narrow Network |
$2.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.54
|
|
|
TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$657.25
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
168855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$657.25 |
| Rate for Payer: Aetna Commercial |
$591.52
|
| Rate for Payer: ASR ASR |
$637.53
|
| Rate for Payer: BCBS Trust/PPO |
$539.73
|
| Rate for Payer: BCN Commercial |
$539.73
|
| Rate for Payer: Cash Price |
$525.80
|
| Rate for Payer: Cofinity Commercial |
$617.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$525.80
|
| Rate for Payer: Healthscope Commercial |
$637.53
|
| Rate for Payer: Healthscope Whirlpool |
$657.25
|
| Rate for Payer: Mclaren Commercial |
$591.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$558.66
|
| Rate for Payer: Nomi Health Commercial |
$538.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$492.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$578.38
|
|
|
TBO-FILGRASTIM 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$657.25
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
168855
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$657.25 |
| Rate for Payer: Aetna Commercial |
$591.52
|
| Rate for Payer: Aetna Medicare |
$0.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.31
|
| Rate for Payer: ASR ASR |
$637.53
|
| Rate for Payer: BCBS Complete |
$0.14
|
| Rate for Payer: BCBS MAPPO |
$0.25
|
| Rate for Payer: BCBS Trust/PPO |
$541.90
|
| Rate for Payer: BCN Commercial |
$541.90
|
| Rate for Payer: BCN Medicare Advantage |
$0.25
|
| Rate for Payer: Cash Price |
$525.80
|
| Rate for Payer: Cash Price |
$525.80
|
| Rate for Payer: Cofinity Commercial |
$617.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$525.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.25
|
| Rate for Payer: Healthscope Commercial |
$637.53
|
| Rate for Payer: Healthscope Whirlpool |
$657.25
|
| Rate for Payer: Humana Choice PPO Medicare |
$0.25
|
| Rate for Payer: Mclaren Commercial |
$591.52
|
| Rate for Payer: Mclaren Medicaid |
$0.25
|
| Rate for Payer: Mclaren Medicare |
$0.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.26
|
| Rate for Payer: Meridian Medicaid |
$0.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.29
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$558.66
|
| Rate for Payer: Nomi Health Commercial |
$538.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$492.94
|
| Rate for Payer: PACE Medicare |
$0.24
|
| Rate for Payer: PACE SWMI |
$0.25
|
| Rate for Payer: PHP Commercial |
$0.28
|
| Rate for Payer: PHP Medicaid |
$0.13
|
| Rate for Payer: PHP Medicare Advantage |
$0.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.13
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.26
|
| Rate for Payer: Priority Health Medicare |
$0.25
|
| Rate for Payer: Priority Health Narrow Network |
$0.21
|
| Rate for Payer: Railroad Medicare Medicare |
$0.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$578.38
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$0.25
|
| Rate for Payer: UHC Exchange |
$0.39
|
| Rate for Payer: UHC Medicaid |
$0.13
|
| Rate for Payer: UHCCP DNSP |
$0.25
|
| Rate for Payer: UHCCP Medicaid |
$0.13
|
| Rate for Payer: VA VA |
$0.25
|
|
|
TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$1,051.94
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
168856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$1,051.94 |
| Rate for Payer: Aetna Commercial |
$946.74
|
| Rate for Payer: Aetna Medicare |
$0.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.31
|
| Rate for Payer: ASR ASR |
$1,020.38
|
| Rate for Payer: BCBS Complete |
$0.14
|
| Rate for Payer: BCBS MAPPO |
$0.25
|
| Rate for Payer: BCBS Trust/PPO |
$867.32
|
| Rate for Payer: BCN Commercial |
$867.32
|
| Rate for Payer: BCN Medicare Advantage |
$0.25
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cofinity Commercial |
$988.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$841.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.25
|
| Rate for Payer: Healthscope Commercial |
$1,020.38
|
| Rate for Payer: Healthscope Whirlpool |
$1,051.94
|
| Rate for Payer: Humana Choice PPO Medicare |
$0.25
|
| Rate for Payer: Mclaren Commercial |
$946.74
|
| Rate for Payer: Mclaren Medicaid |
$0.25
|
| Rate for Payer: Mclaren Medicare |
$0.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.26
|
| Rate for Payer: Meridian Medicaid |
$0.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.29
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$894.15
|
| Rate for Payer: Nomi Health Commercial |
$862.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$788.95
|
| Rate for Payer: PACE Medicare |
$0.24
|
| Rate for Payer: PACE SWMI |
$0.25
|
| Rate for Payer: PHP Commercial |
$0.28
|
| Rate for Payer: PHP Medicaid |
$0.13
|
| Rate for Payer: PHP Medicare Advantage |
$0.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.13
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.26
|
| Rate for Payer: Priority Health Medicare |
$0.25
|
| Rate for Payer: Priority Health Narrow Network |
$0.21
|
| Rate for Payer: Railroad Medicare Medicare |
$0.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$925.70
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$0.25
|
| Rate for Payer: UHC Exchange |
$0.39
|
| Rate for Payer: UHC Medicaid |
$0.13
|
| Rate for Payer: UHCCP DNSP |
$0.25
|
| Rate for Payer: UHCCP Medicaid |
$0.13
|
| Rate for Payer: VA VA |
$0.25
|
|
|
TBO-FILGRASTIM 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$1,051.94
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
168856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$788.95 |
| Max. Negotiated Rate |
$1,051.94 |
| Rate for Payer: Aetna Commercial |
$946.74
|
| Rate for Payer: ASR ASR |
$1,020.38
|
| Rate for Payer: BCBS Trust/PPO |
$863.85
|
| Rate for Payer: BCN Commercial |
$863.85
|
| Rate for Payer: Cash Price |
$841.55
|
| Rate for Payer: Cofinity Commercial |
$988.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$841.55
|
| Rate for Payer: Healthscope Commercial |
$1,020.38
|
| Rate for Payer: Healthscope Whirlpool |
$1,051.94
|
| Rate for Payer: Mclaren Commercial |
$946.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$894.15
|
| Rate for Payer: Nomi Health Commercial |
$862.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$788.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$925.70
|
|
|
TELMISARTAN 20 MG TABLET
|
Facility
|
OP
|
$67.83
|
|
|
Service Code
|
NDC 378292093
|
| Hospital Charge Code |
29176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.10 |
| Max. Negotiated Rate |
$67.83 |
| Rate for Payer: Aetna Commercial |
$61.05
|
| Rate for Payer: Aetna Medicare |
$25.10
|
| Rate for Payer: ASR ASR |
$65.80
|
| Rate for Payer: BCBS Complete |
$27.13
|
| Rate for Payer: BCBS Trust/PPO |
$55.93
|
| Rate for Payer: BCN Commercial |
$55.93
|
| Rate for Payer: Cash Price |
$54.26
|
| Rate for Payer: Cofinity Commercial |
$63.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.26
|
| Rate for Payer: Healthscope Commercial |
$65.80
|
| Rate for Payer: Healthscope Whirlpool |
$67.83
|
| Rate for Payer: Mclaren Commercial |
$61.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$54.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.66
|
| Rate for Payer: Nomi Health Commercial |
$55.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$59.43
|
| Rate for Payer: Priority Health Narrow Network |
$47.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.69
|
|
|
TELMISARTAN 20 MG TABLET
|
Facility
|
IP
|
$67.83
|
|
|
Service Code
|
NDC 378292093
|
| Hospital Charge Code |
29176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.87 |
| Max. Negotiated Rate |
$67.83 |
| Rate for Payer: Aetna Commercial |
$61.05
|
| Rate for Payer: ASR ASR |
$65.80
|
| Rate for Payer: BCBS Trust/PPO |
$55.70
|
| Rate for Payer: BCN Commercial |
$55.70
|
| Rate for Payer: Cash Price |
$54.26
|
| Rate for Payer: Cofinity Commercial |
$63.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.26
|
| Rate for Payer: Healthscope Commercial |
$65.80
|
| Rate for Payer: Healthscope Whirlpool |
$67.83
|
| Rate for Payer: Mclaren Commercial |
$61.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.66
|
| Rate for Payer: Nomi Health Commercial |
$55.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.69
|
|
|
TELMISARTAN 40 MG TABLET
|
Facility
|
IP
|
$483.52
|
|
|
Service Code
|
NDC 597004037
|
| Hospital Charge Code |
24335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$362.64 |
| Max. Negotiated Rate |
$483.52 |
| Rate for Payer: Aetna Commercial |
$435.16
|
| Rate for Payer: ASR ASR |
$469.01
|
| Rate for Payer: BCBS Trust/PPO |
$397.06
|
| Rate for Payer: BCN Commercial |
$397.06
|
| Rate for Payer: Cash Price |
$386.81
|
| Rate for Payer: Cofinity Commercial |
$454.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$386.81
|
| Rate for Payer: Healthscope Commercial |
$469.01
|
| Rate for Payer: Healthscope Whirlpool |
$483.52
|
| Rate for Payer: Mclaren Commercial |
$435.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$410.99
|
| Rate for Payer: Nomi Health Commercial |
$396.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$362.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$425.49
|
|
|
TELMISARTAN 40 MG TABLET
|
Facility
|
OP
|
$483.52
|
|
|
Service Code
|
NDC 597004037
|
| Hospital Charge Code |
24335
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.90 |
| Max. Negotiated Rate |
$483.52 |
| Rate for Payer: Aetna Commercial |
$435.16
|
| Rate for Payer: Aetna Medicare |
$178.90
|
| Rate for Payer: ASR ASR |
$469.01
|
| Rate for Payer: BCBS Complete |
$193.41
|
| Rate for Payer: BCBS Trust/PPO |
$398.66
|
| Rate for Payer: BCN Commercial |
$398.66
|
| Rate for Payer: Cash Price |
$386.81
|
| Rate for Payer: Cofinity Commercial |
$454.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$386.81
|
| Rate for Payer: Healthscope Commercial |
$469.01
|
| Rate for Payer: Healthscope Whirlpool |
$483.52
|
| Rate for Payer: Mclaren Commercial |
$435.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$386.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$410.99
|
| Rate for Payer: Nomi Health Commercial |
$396.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$362.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$423.66
|
| Rate for Payer: Priority Health Narrow Network |
$338.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$425.49
|
|
|
TENDONITIS, MYOSITIS AND BURSITIS WITH MCC
|
Facility
|
IP
|
$20,428.22
|
|
|
Service Code
|
MSDRG 557
|
| Min. Negotiated Rate |
$11,838.89 |
| Max. Negotiated Rate |
$20,428.22 |
| Rate for Payer: Aetna Medicare |
$12,461.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,577.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,577.49
|
| Rate for Payer: BCBS MAPPO |
$12,461.99
|
| Rate for Payer: BCN Medicare Advantage |
$12,461.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,461.99
|
| Rate for Payer: Humana Choice PPO Medicare |
$12,461.99
|
| Rate for Payer: Mclaren Medicare |
$12,461.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,085.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,331.29
|
| Rate for Payer: Molina Medicare/Medicaid |
$13,708.19
|
| Rate for Payer: PACE Medicare |
$11,838.89
|
| Rate for Payer: PACE SWMI |
$12,461.99
|
| Rate for Payer: PHP Commercial |
$13,708.19
|
| Rate for Payer: PHP Medicare Advantage |
$12,461.99
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$20,428.22
|
| Rate for Payer: Priority Health Medicare |
$12,461.99
|
| Rate for Payer: Priority Health Narrow Network |
$16,342.58
|
| Rate for Payer: Railroad Medicare Medicare |
$12,461.99
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12,461.99
|
| Rate for Payer: UHC Exchange |
$19,316.08
|
| Rate for Payer: UHCCP DNSP |
$12,461.99
|
| Rate for Payer: VA VA |
$12,461.99
|
|
|
TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC
|
Facility
|
IP
|
$12,689.25
|
|
|
Service Code
|
MSDRG 558
|
| Min. Negotiated Rate |
$7,777.28 |
| Max. Negotiated Rate |
$12,689.25 |
| Rate for Payer: Aetna Medicare |
$8,186.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,233.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,233.26
|
| Rate for Payer: BCBS MAPPO |
$8,186.61
|
| Rate for Payer: BCN Medicare Advantage |
$8,186.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,186.61
|
| Rate for Payer: Humana Choice PPO Medicare |
$8,186.61
|
| Rate for Payer: Mclaren Medicare |
$8,186.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,595.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,414.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$9,005.27
|
| Rate for Payer: PACE Medicare |
$7,777.28
|
| Rate for Payer: PACE SWMI |
$8,186.61
|
| Rate for Payer: PHP Commercial |
$9,005.27
|
| Rate for Payer: PHP Medicare Advantage |
$8,186.61
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$12,271.50
|
| Rate for Payer: Priority Health Medicare |
$8,186.61
|
| Rate for Payer: Priority Health Narrow Network |
$9,817.20
|
| Rate for Payer: Railroad Medicare Medicare |
$8,186.61
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8,186.61
|
| Rate for Payer: UHC Exchange |
$12,689.25
|
| Rate for Payer: UHCCP DNSP |
$8,186.61
|
| Rate for Payer: VA VA |
$8,186.61
|
|
|
TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES
|
Facility
|
IP
|
$17,870.00
|
|
|
Service Code
|
APR-DRG 3174
|
| Min. Negotiated Rate |
$16,156.62 |
| Max. Negotiated Rate |
$17,870.00 |
| Rate for Payer: BCBS Complete |
$17,870.00
|
| Rate for Payer: Mclaren Medicaid |
$17,019.05
|
| Rate for Payer: Meridian Medicaid |
$17,870.00
|
| Rate for Payer: PHP Medicaid |
$16,156.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$17,019.05
|
| Rate for Payer: UHC Medicaid |
$17,019.05
|
| Rate for Payer: UHCCP Medicaid |
$17,019.05
|
|
