|
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$44,792.40
|
|
|
Service Code
|
MSDRG 468
|
| Min. Negotiated Rate |
$20,725.36 |
| Max. Negotiated Rate |
$44,792.40 |
| Rate for Payer: Aetna Medicare |
$22,688.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27,270.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27,270.21
|
| Rate for Payer: BCBS MAPPO |
$21,816.17
|
| Rate for Payer: BCBS Trust/PPO |
$44,664.80
|
| Rate for Payer: BCN Commercial |
$44,664.80
|
| Rate for Payer: BCN Medicare Advantage |
$21,816.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21,816.17
|
| Rate for Payer: Mclaren Medicare |
$21,816.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$22,906.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25,088.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$23,997.79
|
| Rate for Payer: Nomi Health Commercial |
$35,449.20
|
| Rate for Payer: PACE Medicare |
$20,725.36
|
| Rate for Payer: PACE SWMI |
$21,816.17
|
| Rate for Payer: PHP Medicare Advantage |
$21,816.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$44,303.64
|
| Rate for Payer: Priority Health Medicare |
$21,816.17
|
| Rate for Payer: Priority Health Tiered Network |
$35,442.91
|
| Rate for Payer: Railroad Medicare Medicare |
$21,816.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$44,792.40
|
| Rate for Payer: UHC Core |
$37,474.48
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$21,816.17
|
| Rate for Payer: UHC Exchange |
$30,604.48
|
| Rate for Payer: VA VA |
$21,816.17
|
|
|
REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT
|
Facility
|
OP
|
$41,369.85
|
|
|
Service Code
|
CPT 27134
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,690.48 |
| Max. Negotiated Rate |
$41,369.85 |
| Rate for Payer: Priority Health Medicare |
$12,792.51
|
| Rate for Payer: Aetna Medicare |
$13,304.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,990.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,990.64
|
| Rate for Payer: BCBS Complete |
$7,025.65
|
| Rate for Payer: BCBS MAPPO |
$12,792.51
|
| Rate for Payer: BCBS Trust/PPO |
$8,437.75
|
| Rate for Payer: BCN Commercial |
$8,437.75
|
| Rate for Payer: BCN Medicare Advantage |
$12,792.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,792.51
|
| Rate for Payer: Mclaren Medicaid |
$6,690.48
|
| Rate for Payer: Mclaren Medicare |
$12,792.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,432.14
|
| Rate for Payer: Meridian Medicaid |
$13,432.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,711.39
|
| Rate for Payer: Molina Medicare/Medicaid |
$14,071.76
|
| Rate for Payer: Nomi Health Commercial |
$38,377.53
|
| Rate for Payer: PACE Medicare |
$12,152.88
|
| Rate for Payer: PACE SWMI |
$12,792.51
|
| Rate for Payer: PHP Medicare Advantage |
$12,792.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,690.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$41,369.85
|
| Rate for Payer: Priority Health Tiered Network |
$33,095.88
|
| Rate for Payer: Railroad Medicare Medicare |
$12,792.51
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12,792.51
|
| Rate for Payer: UHC Medicaid |
$6,690.48
|
| Rate for Payer: UHCCP Medicaid |
$6,690.48
|
| Rate for Payer: VA VA |
$12,792.51
|
|
|
REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT
|
Facility
|
OP
|
$41,369.85
|
|
|
Service Code
|
CPT 27486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,469.76 |
| Max. Negotiated Rate |
$41,369.85 |
| Rate for Payer: Aetna Medicare |
$13,304.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,990.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,990.64
|
| Rate for Payer: BCBS Complete |
$7,025.65
|
| Rate for Payer: BCBS MAPPO |
$12,792.51
|
| Rate for Payer: BCBS Trust/PPO |
$5,469.76
|
| Rate for Payer: BCN Commercial |
$5,469.76
|
| Rate for Payer: BCN Medicare Advantage |
$12,792.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,792.51
|
| Rate for Payer: Mclaren Medicaid |
$6,690.48
|
| Rate for Payer: Mclaren Medicare |
$12,792.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,432.14
|
| Rate for Payer: Meridian Medicaid |
$13,432.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,711.39
|
| Rate for Payer: Molina Medicare/Medicaid |
$14,071.76
|
| Rate for Payer: Nomi Health Commercial |
$38,377.53
|
| Rate for Payer: PACE Medicare |
$12,152.88
|
| Rate for Payer: PACE SWMI |
$12,792.51
|
| Rate for Payer: PHP Medicare Advantage |
$12,792.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,690.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$41,369.85
|
| Rate for Payer: Priority Health Medicare |
$12,792.51
|
| Rate for Payer: Priority Health Tiered Network |
$33,095.88
|
| Rate for Payer: Railroad Medicare Medicare |
$12,792.51
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12,792.51
|
| Rate for Payer: UHC Medicaid |
$6,690.48
|
| Rate for Payer: UHCCP Medicaid |
$6,690.48
|
| Rate for Payer: VA VA |
$12,792.51
|
|
|
REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT
|
Facility
|
OP
|
$56,498.90
|
|
|
Service Code
|
CPT 27487
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$9,137.21 |
| Max. Negotiated Rate |
$56,498.90 |
| Rate for Payer: Aetna Medicare |
$18,169.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,838.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,838.46
|
| Rate for Payer: BCBS Complete |
$9,594.95
|
| Rate for Payer: BCBS MAPPO |
$17,470.77
|
| Rate for Payer: BCBS Trust/PPO |
$10,051.34
|
| Rate for Payer: BCN Commercial |
$10,051.34
|
| Rate for Payer: BCN Medicare Advantage |
$17,470.77
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,470.77
|
| Rate for Payer: Mclaren Medicaid |
$9,137.21
|
| Rate for Payer: Mclaren Medicare |
$17,470.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18,344.31
|
| Rate for Payer: Meridian Medicaid |
$18,344.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20,091.39
|
| Rate for Payer: Molina Medicare/Medicaid |
$19,217.85
|
| Rate for Payer: Nomi Health Commercial |
$52,412.31
|
| Rate for Payer: PACE Medicare |
$16,597.23
|
| Rate for Payer: PACE SWMI |
$17,470.77
|
| Rate for Payer: PHP Medicare Advantage |
$17,470.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,137.21
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$56,498.90
|
| Rate for Payer: Priority Health Medicare |
$17,470.77
|
| Rate for Payer: Priority Health Tiered Network |
$45,199.12
|
| Rate for Payer: Railroad Medicare Medicare |
$17,470.77
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$17,470.77
|
| Rate for Payer: UHC Medicaid |
$9,137.21
|
| Rate for Payer: UHCCP Medicaid |
$9,137.21
|
| Rate for Payer: VA VA |
$17,470.77
|
|
|
REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT
|
Facility
|
OP
|
$41,369.85
|
|
|
Service Code
|
CPT 23473
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,254.24 |
| Max. Negotiated Rate |
$41,369.85 |
| Rate for Payer: Aetna Medicare |
$13,304.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,990.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,990.64
|
| Rate for Payer: BCBS Complete |
$7,025.65
|
| Rate for Payer: BCBS MAPPO |
$12,792.51
|
| Rate for Payer: BCBS Trust/PPO |
$5,254.24
|
| Rate for Payer: BCN Commercial |
$5,254.24
|
| Rate for Payer: BCN Medicare Advantage |
$12,792.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,792.51
|
| Rate for Payer: Mclaren Medicaid |
$6,690.48
|
| Rate for Payer: Mclaren Medicare |
$12,792.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,432.14
|
| Rate for Payer: Meridian Medicaid |
$13,432.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,711.39
|
| Rate for Payer: Molina Medicare/Medicaid |
$14,071.76
|
| Rate for Payer: Nomi Health Commercial |
$38,377.53
|
| Rate for Payer: PACE Medicare |
$12,152.88
|
| Rate for Payer: PACE SWMI |
$12,792.51
|
| Rate for Payer: PHP Medicare Advantage |
$12,792.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,690.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$41,369.85
|
| Rate for Payer: Priority Health Medicare |
$12,792.51
|
| Rate for Payer: Priority Health Tiered Network |
$33,095.88
|
| Rate for Payer: Railroad Medicare Medicare |
$12,792.51
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$12,792.51
|
| Rate for Payer: UHC Medicaid |
$6,690.48
|
| Rate for Payer: UHCCP Medicaid |
$6,690.48
|
| Rate for Payer: VA VA |
$12,792.51
|
|
|
REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$17,930.33
|
|
|
Service Code
|
CPT 36832
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,899.76 |
| Max. Negotiated Rate |
$17,930.33 |
| Rate for Payer: Aetna Medicare |
$5,766.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,930.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,930.60
|
| Rate for Payer: BCBS Complete |
$3,045.03
|
| Rate for Payer: BCBS MAPPO |
$5,544.48
|
| Rate for Payer: BCBS Trust/PPO |
$4,260.97
|
| Rate for Payer: BCN Commercial |
$4,260.97
|
| Rate for Payer: BCN Medicare Advantage |
$5,544.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,544.48
|
| Rate for Payer: Mclaren Medicaid |
$2,899.76
|
| Rate for Payer: Mclaren Medicare |
$5,544.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,821.70
|
| Rate for Payer: Meridian Medicaid |
$5,821.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,376.15
|
| Rate for Payer: Molina Medicare/Medicaid |
$6,098.93
|
| Rate for Payer: Nomi Health Commercial |
$16,633.44
|
| Rate for Payer: PACE Medicare |
$5,267.26
|
| Rate for Payer: PACE SWMI |
$5,544.48
|
| Rate for Payer: PHP Medicare Advantage |
$5,544.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,899.76
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$17,930.33
|
| Rate for Payer: Priority Health Medicare |
$5,544.48
|
| Rate for Payer: Priority Health Tiered Network |
$14,344.26
|
| Rate for Payer: Railroad Medicare Medicare |
$5,544.48
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5,544.48
|
| Rate for Payer: UHC Medicaid |
$2,899.76
|
| Rate for Payer: UHCCP Medicaid |
$2,899.76
|
| Rate for Payer: VA VA |
$5,544.48
|
|
|
REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY
|
Facility
|
OP
|
$11,265.44
|
|
|
Service Code
|
CPT 64595
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,821.89 |
| Max. Negotiated Rate |
$11,265.44 |
| Rate for Payer: Aetna Medicare |
$3,622.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,354.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,354.41
|
| Rate for Payer: BCBS Complete |
$1,913.15
|
| Rate for Payer: BCBS MAPPO |
$3,483.53
|
| Rate for Payer: BCBS Trust/PPO |
$1,942.05
|
| Rate for Payer: BCN Commercial |
$1,942.05
|
| Rate for Payer: BCN Medicare Advantage |
$3,483.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,483.53
|
| Rate for Payer: Mclaren Medicaid |
$1,821.89
|
| Rate for Payer: Mclaren Medicare |
$3,483.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,657.71
|
| Rate for Payer: Meridian Medicaid |
$3,657.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,006.06
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,831.88
|
| Rate for Payer: Nomi Health Commercial |
$10,450.59
|
| Rate for Payer: PACE Medicare |
$3,309.35
|
| Rate for Payer: PACE SWMI |
$3,483.53
|
| Rate for Payer: PHP Medicare Advantage |
$3,483.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,821.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$11,265.44
|
| Rate for Payer: Priority Health Medicare |
$3,483.53
|
| Rate for Payer: Priority Health Tiered Network |
$9,012.35
|
| Rate for Payer: Railroad Medicare Medicare |
$3,483.53
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,483.53
|
| Rate for Payer: UHC Medicaid |
$1,821.89
|
| Rate for Payer: UHCCP Medicaid |
$1,821.89
|
| Rate for Payer: VA VA |
$3,483.53
|
|
|
REZAFUNGIN 200 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$5,326.47
|
|
|
Service Code
|
HCPCS J0349
|
| Hospital Charge Code |
204281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,355.68 |
| Max. Negotiated Rate |
$4,793.82 |
| Rate for Payer: Aetna Commercial |
$4,527.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,462.21
|
| Rate for Payer: Cash Price |
$4,261.18
|
| Rate for Payer: Cofinity Advantage |
$3,728.53
|
| Rate for Payer: Cofinity Commercial |
$4,580.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,261.18
|
| Rate for Payer: Healthscope Commercial |
$4,793.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,527.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,994.85
|
| Rate for Payer: PHP Commercial |
$4,527.50
|
| Rate for Payer: Priority Health SBD |
$3,355.68
|
|
|
REZAFUNGIN 200 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,326.47
|
|
|
Service Code
|
HCPCS J0349
|
| Hospital Charge Code |
204281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.64 |
| Max. Negotiated Rate |
$4,793.82 |
| Rate for Payer: Aetna Commercial |
$4,527.50
|
| Rate for Payer: Aetna Medicare |
$11.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,462.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13.49
|
| Rate for Payer: BCBS Complete |
$5.93
|
| Rate for Payer: BCBS MAPPO |
$10.79
|
| Rate for Payer: BCBS Trust/PPO |
$27.11
|
| Rate for Payer: BCN Commercial |
$27.11
|
| Rate for Payer: BCN Medicare Advantage |
$10.79
|
| Rate for Payer: Cash Price |
$4,261.18
|
| Rate for Payer: Cash Price |
$4,261.18
|
| Rate for Payer: Cofinity Advantage |
$3,728.53
|
| Rate for Payer: Cofinity Commercial |
$4,580.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,261.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.79
|
| Rate for Payer: Healthscope Commercial |
$4,793.82
|
| Rate for Payer: Mclaren Medicaid |
$5.64
|
| Rate for Payer: Mclaren Medicare |
$10.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11.33
|
| Rate for Payer: Meridian Medicaid |
$11.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.41
|
| Rate for Payer: Molina Medicare/Medicaid |
$11.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,527.50
|
| Rate for Payer: Nomi Health Commercial |
$32.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,994.85
|
| Rate for Payer: PACE Medicare |
$10.25
|
| Rate for Payer: PACE SWMI |
$10.79
|
| Rate for Payer: PHP Commercial |
$4,527.50
|
| Rate for Payer: PHP Medicare Advantage |
$10.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$5.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$33.50
|
| Rate for Payer: Priority Health Medicare |
$10.79
|
| Rate for Payer: Priority Health SBD |
$3,355.68
|
| Rate for Payer: Priority Health Tiered Network |
$26.80
|
| Rate for Payer: Railroad Medicare Medicare |
$10.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.85
|
| Rate for Payer: UHC Core |
$17.85
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$10.79
|
| Rate for Payer: UHC Exchange |
$17.85
|
| Rate for Payer: UHC Medicaid |
$5.64
|
| Rate for Payer: UHCCP Medicaid |
$5.64
|
| Rate for Payer: VA VA |
$10.79
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$287.29
|
|
|
Service Code
|
HCPCS J2790
|
| Hospital Charge Code |
11283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$114.92 |
| Max. Negotiated Rate |
$258.56 |
| Rate for Payer: Aetna Commercial |
$244.20
|
| Rate for Payer: Aetna Medicare |
$143.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.74
|
| Rate for Payer: BCBS Complete |
$114.92
|
| Rate for Payer: BCBS Trust/PPO |
$210.07
|
| Rate for Payer: BCN Commercial |
$210.07
|
| Rate for Payer: Cash Price |
$229.83
|
| Rate for Payer: Cash Price |
$229.83
|
| Rate for Payer: Cofinity Advantage |
$201.10
|
| Rate for Payer: Cofinity Commercial |
$247.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.83
|
| Rate for Payer: Healthscope Commercial |
$258.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$229.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$244.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$215.47
|
| Rate for Payer: PHP Commercial |
$244.20
|
| Rate for Payer: Priority Health SBD |
$180.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$132.87
|
| Rate for Payer: UHC Core |
$132.87
|
| Rate for Payer: UHC Exchange |
$132.87
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$287.29
|
|
|
Service Code
|
HCPCS J2790
|
| Hospital Charge Code |
11283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.99 |
| Max. Negotiated Rate |
$258.56 |
| Rate for Payer: Aetna Commercial |
$244.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.74
|
| Rate for Payer: Cash Price |
$229.83
|
| Rate for Payer: Cofinity Advantage |
$201.10
|
| Rate for Payer: Cofinity Commercial |
$247.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.83
|
| Rate for Payer: Healthscope Commercial |
$258.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$244.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$215.47
|
| Rate for Payer: PHP Commercial |
$244.20
|
| Rate for Payer: Priority Health SBD |
$180.99
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 07610003220
|
| Hospital Charge Code |
11288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.15 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Advantage |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$121.61
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health SBD |
$102.15
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET
|
Facility
|
OP
|
$162.15
|
|
|
Service Code
|
NDC 07610003220
|
| Hospital Charge Code |
11288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.72 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna Medicare |
$81.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: BCBS Complete |
$64.86
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Advantage |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$129.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$121.61
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health SBD |
$102.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.40
|
| Rate for Payer: UHC Core |
$84.48
|
| Rate for Payer: UHC Exchange |
$63.72
|
|
|
RIFABUTIN 150 MG CAPSULE
|
Facility
|
OP
|
$4,334.18
|
|
|
Service Code
|
NDC 70954004110
|
| Hospital Charge Code |
11290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,703.33 |
| Max. Negotiated Rate |
$3,900.76 |
| Rate for Payer: Aetna Commercial |
$3,684.05
|
| Rate for Payer: Aetna Medicare |
$2,167.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,817.22
|
| Rate for Payer: BCBS Complete |
$1,733.67
|
| Rate for Payer: Cash Price |
$3,467.34
|
| Rate for Payer: Cofinity Advantage |
$3,033.93
|
| Rate for Payer: Cofinity Commercial |
$3,727.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,467.34
|
| Rate for Payer: Healthscope Commercial |
$3,900.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,467.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,684.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,250.64
|
| Rate for Payer: PHP Commercial |
$3,684.05
|
| Rate for Payer: Priority Health SBD |
$2,730.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,817.22
|
| Rate for Payer: UHC Core |
$2,258.11
|
| Rate for Payer: UHC Exchange |
$1,703.33
|
|
|
RIFABUTIN 150 MG CAPSULE
|
Facility
|
IP
|
$3,869.09
|
|
|
Service Code
|
NDC 59762135001
|
| Hospital Charge Code |
11290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,437.53 |
| Max. Negotiated Rate |
$3,482.18 |
| Rate for Payer: Aetna Commercial |
$3,288.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,514.91
|
| Rate for Payer: Cash Price |
$3,095.27
|
| Rate for Payer: Cofinity Advantage |
$2,708.36
|
| Rate for Payer: Cofinity Commercial |
$3,327.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,095.27
|
| Rate for Payer: Healthscope Commercial |
$3,482.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,288.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,901.82
|
| Rate for Payer: PHP Commercial |
$3,288.73
|
| Rate for Payer: Priority Health SBD |
$2,437.53
|
|
|
RIFABUTIN 150 MG CAPSULE
|
Facility
|
IP
|
$4,334.18
|
|
|
Service Code
|
NDC 70954004110
|
| Hospital Charge Code |
11290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,730.53 |
| Max. Negotiated Rate |
$3,900.76 |
| Rate for Payer: Aetna Commercial |
$3,684.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,817.22
|
| Rate for Payer: Cash Price |
$3,467.34
|
| Rate for Payer: Cofinity Advantage |
$3,033.93
|
| Rate for Payer: Cofinity Commercial |
$3,727.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,467.34
|
| Rate for Payer: Healthscope Commercial |
$3,900.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,684.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,250.64
|
| Rate for Payer: PHP Commercial |
$3,684.05
|
| Rate for Payer: Priority Health SBD |
$2,730.53
|
|
|
RIFABUTIN 150 MG CAPSULE
|
Facility
|
OP
|
$3,869.09
|
|
|
Service Code
|
NDC 59762135001
|
| Hospital Charge Code |
11290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,520.55 |
| Max. Negotiated Rate |
$3,482.18 |
| Rate for Payer: Aetna Commercial |
$3,288.73
|
| Rate for Payer: Aetna Medicare |
$1,934.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,514.91
|
| Rate for Payer: BCBS Complete |
$1,547.64
|
| Rate for Payer: Cash Price |
$3,095.27
|
| Rate for Payer: Cofinity Advantage |
$2,708.36
|
| Rate for Payer: Cofinity Commercial |
$3,327.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,095.27
|
| Rate for Payer: Healthscope Commercial |
$3,482.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,095.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,288.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,901.82
|
| Rate for Payer: PHP Commercial |
$3,288.73
|
| Rate for Payer: Priority Health SBD |
$2,437.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,514.91
|
| Rate for Payer: UHC Core |
$2,015.80
|
| Rate for Payer: UHC Exchange |
$1,520.55
|
|
|
RIFAMPIN 150 MG CAPSULE
|
Facility
|
IP
|
$361.09
|
|
|
Service Code
|
NDC 60687057521
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$227.49 |
| Max. Negotiated Rate |
$324.98 |
| Rate for Payer: Aetna Commercial |
$306.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.71
|
| Rate for Payer: Cash Price |
$288.87
|
| Rate for Payer: Cofinity Advantage |
$252.76
|
| Rate for Payer: Cofinity Commercial |
$310.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$288.87
|
| Rate for Payer: Healthscope Commercial |
$324.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$270.82
|
| Rate for Payer: PHP Commercial |
$306.93
|
| Rate for Payer: Priority Health SBD |
$227.49
|
|
|
RIFAMPIN 150 MG CAPSULE
|
Facility
|
OP
|
$361.09
|
|
|
Service Code
|
NDC 60687057521
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.91 |
| Max. Negotiated Rate |
$324.98 |
| Rate for Payer: Aetna Commercial |
$306.93
|
| Rate for Payer: Aetna Medicare |
$180.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.71
|
| Rate for Payer: BCBS Complete |
$144.44
|
| Rate for Payer: Cash Price |
$288.87
|
| Rate for Payer: Cofinity Advantage |
$252.76
|
| Rate for Payer: Cofinity Commercial |
$310.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$288.87
|
| Rate for Payer: Healthscope Commercial |
$324.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$288.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$270.82
|
| Rate for Payer: PHP Commercial |
$306.93
|
| Rate for Payer: Priority Health SBD |
$227.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$234.71
|
| Rate for Payer: UHC Core |
$188.13
|
| Rate for Payer: UHC Exchange |
$141.91
|
|
|
RIFAMPIN 150 MG CAPSULE
|
Facility
|
IP
|
$12.04
|
|
|
Service Code
|
NDC 60687057511
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$10.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.83
|
| Rate for Payer: Cash Price |
$9.63
|
| Rate for Payer: Cofinity Advantage |
$8.43
|
| Rate for Payer: Cofinity Commercial |
$10.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.63
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.03
|
| Rate for Payer: PHP Commercial |
$10.23
|
| Rate for Payer: Priority Health SBD |
$7.59
|
|
|
RIFAMPIN 150 MG CAPSULE
|
Facility
|
OP
|
$12.04
|
|
|
Service Code
|
NDC 60687057511
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$10.23
|
| Rate for Payer: Aetna Medicare |
$6.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.83
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: Cash Price |
$9.63
|
| Rate for Payer: Cofinity Advantage |
$8.43
|
| Rate for Payer: Cofinity Commercial |
$10.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.63
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.03
|
| Rate for Payer: PHP Commercial |
$10.23
|
| Rate for Payer: Priority Health SBD |
$7.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.83
|
| Rate for Payer: UHC Core |
$6.27
|
| Rate for Payer: UHC Exchange |
$4.73
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$589.52
|
|
|
Service Code
|
HCPCS J2804
|
| Hospital Charge Code |
11291
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$530.57 |
| Rate for Payer: Aetna Commercial |
$501.09
|
| Rate for Payer: Aetna Medicare |
$294.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$383.19
|
| Rate for Payer: BCBS Complete |
$235.81
|
| Rate for Payer: BCBS Trust/PPO |
$0.37
|
| Rate for Payer: BCN Commercial |
$0.37
|
| Rate for Payer: Cash Price |
$471.62
|
| Rate for Payer: Cash Price |
$471.62
|
| Rate for Payer: Cofinity Advantage |
$412.66
|
| Rate for Payer: Cofinity Commercial |
$506.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$471.62
|
| Rate for Payer: Healthscope Commercial |
$530.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$471.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$501.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$442.14
|
| Rate for Payer: PHP Commercial |
$501.09
|
| Rate for Payer: Priority Health SBD |
$371.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.25
|
| Rate for Payer: UHC Core |
$0.25
|
| Rate for Payer: UHC Exchange |
$0.25
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$589.52
|
|
|
Service Code
|
HCPCS J2804
|
| Hospital Charge Code |
11291
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$371.40 |
| Max. Negotiated Rate |
$530.57 |
| Rate for Payer: Aetna Commercial |
$501.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$383.19
|
| Rate for Payer: Cash Price |
$471.62
|
| Rate for Payer: Cofinity Advantage |
$412.66
|
| Rate for Payer: Cofinity Commercial |
$506.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$471.62
|
| Rate for Payer: Healthscope Commercial |
$530.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$501.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$442.14
|
| Rate for Payer: PHP Commercial |
$501.09
|
| Rate for Payer: Priority Health SBD |
$371.40
|
|
|
RIFAXIMIN 550 MG TABLET
|
Facility
|
IP
|
$11,916.96
|
|
|
Service Code
|
NDC 65649030302
|
| Hospital Charge Code |
104604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,507.68 |
| Max. Negotiated Rate |
$10,725.26 |
| Rate for Payer: Aetna Commercial |
$10,129.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,746.02
|
| Rate for Payer: Cash Price |
$9,533.57
|
| Rate for Payer: Cofinity Advantage |
$8,341.87
|
| Rate for Payer: Cofinity Commercial |
$10,248.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,533.57
|
| Rate for Payer: Healthscope Commercial |
$10,725.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,129.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8,937.72
|
| Rate for Payer: PHP Commercial |
$10,129.42
|
| Rate for Payer: Priority Health SBD |
$7,507.68
|
|
|
RIFAXIMIN 550 MG TABLET
|
Facility
|
IP
|
$11,916.96
|
|
|
Service Code
|
NDC 65649030303
|
| Hospital Charge Code |
104604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,507.68 |
| Max. Negotiated Rate |
$10,725.26 |
| Rate for Payer: Aetna Commercial |
$10,129.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,746.02
|
| Rate for Payer: Cash Price |
$9,533.57
|
| Rate for Payer: Cofinity Advantage |
$8,341.87
|
| Rate for Payer: Cofinity Commercial |
$10,248.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,533.57
|
| Rate for Payer: Healthscope Commercial |
$10,725.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,129.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8,937.72
|
| Rate for Payer: PHP Commercial |
$10,129.42
|
| Rate for Payer: Priority Health SBD |
$7,507.68
|
|
