|
REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY
|
Facility
|
OP
|
$17,557.45
|
|
|
Service Code
|
CPT 37220
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$423.69 |
| Max. Negotiated Rate |
$17,557.45 |
| Rate for Payer: Aetna Medicare |
$5,809.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,982.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,982.80
|
| Rate for Payer: BCBS Complete |
$3,143.94
|
| Rate for Payer: BCBS MAPPO |
$5,586.24
|
| Rate for Payer: BCBS Trust/PPO |
$2,043.66
|
| Rate for Payer: BCN Commercial |
$2,043.66
|
| Rate for Payer: BCN Medicare Advantage |
$5,586.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,586.24
|
| Rate for Payer: Mclaren Medicaid |
$2,994.22
|
| Rate for Payer: Mclaren Medicare |
$5,586.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,865.55
|
| Rate for Payer: Meridian Medicaid |
$3,143.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,424.18
|
| Rate for Payer: Nomi Health Commercial |
$11,731.10
|
| Rate for Payer: PACE Medicare |
$5,306.93
|
| Rate for Payer: PACE SWMI |
$5,586.24
|
| Rate for Payer: PHP Medicare Advantage |
$5,586.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,994.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,557.45
|
| Rate for Payer: Priority Health Medicare |
$5,586.24
|
| Rate for Payer: Priority Health Narrow Network |
$14,045.96
|
| Rate for Payer: Railroad Medicare Medicare |
$5,586.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$423.69
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,586.24
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,586.24
|
| Rate for Payer: UHCCP Medicaid |
$3,145.05
|
| Rate for Payer: VA VA |
$5,586.24
|
|
|
REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, ILIAC ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S), INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED
|
Facility
|
OP
|
$34,922.52
|
|
|
Service Code
|
CPT 37221
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$522.65 |
| Max. Negotiated Rate |
$34,922.52 |
| Rate for Payer: Aetna Medicare |
$11,555.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,889.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,889.08
|
| Rate for Payer: BCBS Complete |
$6,253.42
|
| Rate for Payer: BCBS MAPPO |
$11,111.26
|
| Rate for Payer: BCBS Trust/PPO |
$4,909.45
|
| Rate for Payer: BCN Commercial |
$4,909.45
|
| Rate for Payer: BCN Medicare Advantage |
$11,111.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,111.26
|
| Rate for Payer: Mclaren Medicaid |
$5,955.64
|
| Rate for Payer: Mclaren Medicare |
$11,111.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11,666.82
|
| Rate for Payer: Meridian Medicaid |
$6,253.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,777.95
|
| Rate for Payer: Nomi Health Commercial |
$23,333.65
|
| Rate for Payer: PACE Medicare |
$10,555.70
|
| Rate for Payer: PACE SWMI |
$11,111.26
|
| Rate for Payer: PHP Medicare Advantage |
$11,111.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,955.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34,922.52
|
| Rate for Payer: Priority Health Medicare |
$11,111.26
|
| Rate for Payer: Priority Health Narrow Network |
$27,938.02
|
| Rate for Payer: Railroad Medicare Medicare |
$11,111.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$522.65
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,111.26
|
| Rate for Payer: UHC Exchange |
$9,445.00
|
| Rate for Payer: UHC Medicare Advantage |
$11,111.26
|
| Rate for Payer: UHCCP Medicaid |
$6,255.64
|
| Rate for Payer: VA VA |
$11,111.26
|
|
|
REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL ANGIOPLASTY
|
Facility
|
OP
|
$34,922.52
|
|
|
Service Code
|
CPT 37228
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$573.07 |
| Max. Negotiated Rate |
$34,922.52 |
| Rate for Payer: Aetna Medicare |
$11,555.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13,889.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13,889.08
|
| Rate for Payer: BCBS Complete |
$6,253.42
|
| Rate for Payer: BCBS MAPPO |
$11,111.26
|
| Rate for Payer: BCBS Trust/PPO |
$3,959.41
|
| Rate for Payer: BCN Commercial |
$3,959.41
|
| Rate for Payer: BCN Medicare Advantage |
$11,111.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,111.26
|
| Rate for Payer: Mclaren Medicaid |
$5,955.64
|
| Rate for Payer: Mclaren Medicare |
$11,111.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11,666.82
|
| Rate for Payer: Meridian Medicaid |
$6,253.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,777.95
|
| Rate for Payer: Nomi Health Commercial |
$23,333.65
|
| Rate for Payer: PACE Medicare |
$10,555.70
|
| Rate for Payer: PACE SWMI |
$11,111.26
|
| Rate for Payer: PHP Medicare Advantage |
$11,111.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,955.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34,922.52
|
| Rate for Payer: Priority Health Medicare |
$11,111.26
|
| Rate for Payer: Priority Health Narrow Network |
$27,938.02
|
| Rate for Payer: Railroad Medicare Medicare |
$11,111.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$573.07
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,111.26
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
| Rate for Payer: UHC Medicare Advantage |
$11,111.26
|
| Rate for Payer: UHCCP Medicaid |
$6,255.64
|
| Rate for Payer: VA VA |
$11,111.26
|
|
|
REVASCULARIZATION, ENDOVASCULAR, OPEN OR PERCUTANEOUS, TIBIAL, PERONEAL ARTERY, UNILATERAL, INITIAL VESSEL; WITH TRANSLUMINAL STENT PLACEMENT(S) AND ATHERECTOMY, INCLUDES ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED
|
Facility
|
OP
|
$55,296.52
|
|
|
Service Code
|
CPT 37231
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$773.14 |
| Max. Negotiated Rate |
$55,296.52 |
| Rate for Payer: Aetna Medicare |
$18,297.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,992.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,992.05
|
| Rate for Payer: BCBS Complete |
$9,901.70
|
| Rate for Payer: BCBS MAPPO |
$17,593.64
|
| Rate for Payer: BCBS Trust/PPO |
$10,129.87
|
| Rate for Payer: BCN Commercial |
$10,129.87
|
| Rate for Payer: BCN Medicare Advantage |
$17,593.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,593.64
|
| Rate for Payer: Mclaren Medicaid |
$9,430.19
|
| Rate for Payer: Mclaren Medicare |
$17,593.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18,473.32
|
| Rate for Payer: Meridian Medicaid |
$9,901.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20,232.69
|
| Rate for Payer: Nomi Health Commercial |
$36,946.64
|
| Rate for Payer: PACE Medicare |
$16,713.96
|
| Rate for Payer: PACE SWMI |
$17,593.64
|
| Rate for Payer: PHP Medicare Advantage |
$17,593.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,430.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55,296.52
|
| Rate for Payer: Priority Health Medicare |
$17,593.64
|
| Rate for Payer: Priority Health Narrow Network |
$44,237.22
|
| Rate for Payer: Railroad Medicare Medicare |
$17,593.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$773.14
|
| Rate for Payer: UHC Core |
$11,194.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$17,593.64
|
| Rate for Payer: UHC Exchange |
$11,989.00
|
| Rate for Payer: UHC Medicare Advantage |
$17,593.64
|
| Rate for Payer: UHCCP Medicaid |
$9,905.22
|
| Rate for Payer: VA VA |
$17,593.64
|
|
|
REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH
|
Facility
|
OP
|
$9,791.14
|
|
|
Service Code
|
CPT 57295
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$534.03 |
| Max. Negotiated Rate |
$9,791.14 |
| Rate for Payer: Aetna Medicare |
$3,239.85
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,894.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,894.05
|
| Rate for Payer: BCBS Complete |
$1,753.26
|
| Rate for Payer: BCBS MAPPO |
$3,115.24
|
| Rate for Payer: BCBS Trust/PPO |
$1,111.97
|
| Rate for Payer: BCN Commercial |
$1,111.97
|
| Rate for Payer: BCN Medicare Advantage |
$3,115.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,115.24
|
| Rate for Payer: Mclaren Medicaid |
$1,669.77
|
| Rate for Payer: Mclaren Medicare |
$3,115.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,271.00
|
| Rate for Payer: Meridian Medicaid |
$1,753.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,582.53
|
| Rate for Payer: Nomi Health Commercial |
$6,542.00
|
| Rate for Payer: PACE Medicare |
$2,959.48
|
| Rate for Payer: PACE SWMI |
$3,115.24
|
| Rate for Payer: PHP Medicare Advantage |
$3,115.24
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,669.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,791.14
|
| Rate for Payer: Priority Health Medicare |
$3,115.24
|
| Rate for Payer: Priority Health Narrow Network |
$7,832.91
|
| Rate for Payer: Railroad Medicare Medicare |
$3,115.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$534.03
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,115.24
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,115.24
|
| Rate for Payer: UHCCP Medicaid |
$1,753.88
|
| Rate for Payer: VA VA |
$3,115.24
|
|
|
REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL CAPSULECTOMY
|
Facility
|
OP
|
$11,792.02
|
|
|
Service Code
|
CPT 19370
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$710.00 |
| Max. Negotiated Rate |
$11,792.02 |
| Rate for Payer: Aetna Medicare |
$3,901.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,689.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,689.81
|
| Rate for Payer: BCBS Complete |
$2,111.54
|
| Rate for Payer: BCBS MAPPO |
$3,751.85
|
| Rate for Payer: BCBS Trust/PPO |
$1,366.44
|
| Rate for Payer: BCN Commercial |
$1,366.44
|
| Rate for Payer: BCN Medicare Advantage |
$3,751.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,751.85
|
| Rate for Payer: Mclaren Medicaid |
$2,010.99
|
| Rate for Payer: Mclaren Medicare |
$3,751.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,939.44
|
| Rate for Payer: Meridian Medicaid |
$2,111.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,314.63
|
| Rate for Payer: Nomi Health Commercial |
$7,878.88
|
| Rate for Payer: PACE Medicare |
$3,564.26
|
| Rate for Payer: PACE SWMI |
$3,751.85
|
| Rate for Payer: PHP Medicare Advantage |
$3,751.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,010.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11,792.02
|
| Rate for Payer: Priority Health Medicare |
$3,751.85
|
| Rate for Payer: Priority Health Narrow Network |
$9,433.62
|
| Rate for Payer: Railroad Medicare Medicare |
$3,751.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$710.00
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,751.85
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,751.85
|
| Rate for Payer: UHCCP Medicaid |
$2,112.29
|
| Rate for Payer: VA VA |
$3,751.85
|
|
|
REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)
|
Facility
|
OP
|
$20,082.39
|
|
|
Service Code
|
CPT 19380
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$853.12 |
| Max. Negotiated Rate |
$20,082.39 |
| Rate for Payer: Aetna Medicare |
$6,645.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,987.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,987.00
|
| Rate for Payer: BCBS Complete |
$3,596.07
|
| Rate for Payer: BCBS MAPPO |
$6,389.60
|
| Rate for Payer: BCBS Trust/PPO |
$2,983.93
|
| Rate for Payer: BCN Commercial |
$2,983.93
|
| Rate for Payer: BCN Medicare Advantage |
$6,389.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,389.60
|
| Rate for Payer: Mclaren Medicaid |
$3,424.83
|
| Rate for Payer: Mclaren Medicare |
$6,389.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,709.08
|
| Rate for Payer: Meridian Medicaid |
$3,596.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7,348.04
|
| Rate for Payer: Nomi Health Commercial |
$13,418.16
|
| Rate for Payer: PACE Medicare |
$6,070.12
|
| Rate for Payer: PACE SWMI |
$6,389.60
|
| Rate for Payer: PHP Medicare Advantage |
$6,389.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,424.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20,082.39
|
| Rate for Payer: Priority Health Medicare |
$6,389.60
|
| Rate for Payer: Priority Health Narrow Network |
$16,065.91
|
| Rate for Payer: Railroad Medicare Medicare |
$6,389.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$853.12
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$6,389.60
|
| Rate for Payer: UHC Exchange |
$7,322.00
|
| Rate for Payer: UHC Medicare Advantage |
$6,389.60
|
| Rate for Payer: UHCCP Medicaid |
$3,597.34
|
| Rate for Payer: VA VA |
$6,389.60
|
|
|
REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT
|
Facility
|
OP
|
$9,445.00
|
|
|
Service Code
|
CPT 27134
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,027.61 |
| Max. Negotiated Rate |
$9,445.00 |
| Rate for Payer: BCBS Trust/PPO |
$6,587.48
|
| Rate for Payer: BCN Commercial |
$6,587.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,027.61
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Exchange |
$9,445.00
|
|
|
REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; 1 COMPONENT
|
Facility
|
OP
|
$9,445.00
|
|
|
Service Code
|
CPT 27486
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,494.58 |
| Max. Negotiated Rate |
$9,445.00 |
| Rate for Payer: BCBS Trust/PPO |
$4,270.33
|
| Rate for Payer: BCN Commercial |
$4,270.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,494.58
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Exchange |
$9,445.00
|
|
|
REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT
|
Facility
|
OP
|
$9,445.00
|
|
|
Service Code
|
CPT 27487
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,865.85 |
| Max. Negotiated Rate |
$9,445.00 |
| Rate for Payer: BCBS Trust/PPO |
$7,847.24
|
| Rate for Payer: BCN Commercial |
$7,847.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,865.85
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Exchange |
$9,445.00
|
|
|
REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT
|
Facility
|
OP
|
$10,994.25
|
|
|
Service Code
|
CPT 23474
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,848.21 |
| Max. Negotiated Rate |
$10,994.25 |
| Rate for Payer: BCBS Trust/PPO |
$10,994.25
|
| Rate for Payer: BCN Commercial |
$10,994.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,848.21
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
|
|
REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT
|
Facility
|
OP
|
$39,622.51
|
|
|
Service Code
|
CPT 23473
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,711.10 |
| Max. Negotiated Rate |
$39,622.51 |
| Rate for Payer: Aetna Medicare |
$13,110.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,758.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,758.31
|
| Rate for Payer: BCBS Complete |
$7,095.02
|
| Rate for Payer: BCBS MAPPO |
$12,606.65
|
| Rate for Payer: BCBS Trust/PPO |
$4,102.07
|
| Rate for Payer: BCN Commercial |
$4,102.07
|
| Rate for Payer: BCN Medicare Advantage |
$12,606.65
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,606.65
|
| Rate for Payer: Mclaren Medicaid |
$6,757.16
|
| Rate for Payer: Mclaren Medicare |
$12,606.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13,236.98
|
| Rate for Payer: Meridian Medicaid |
$7,095.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,497.65
|
| Rate for Payer: Nomi Health Commercial |
$26,473.96
|
| Rate for Payer: PACE Medicare |
$11,976.32
|
| Rate for Payer: PACE SWMI |
$12,606.65
|
| Rate for Payer: PHP Medicare Advantage |
$12,606.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,757.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39,622.51
|
| Rate for Payer: Priority Health Medicare |
$12,606.65
|
| Rate for Payer: Priority Health Narrow Network |
$31,698.01
|
| Rate for Payer: Railroad Medicare Medicare |
$12,606.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,711.10
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,606.65
|
| Rate for Payer: UHC Exchange |
$7,322.00
|
| Rate for Payer: UHC Medicare Advantage |
$12,606.65
|
| Rate for Payer: UHCCP Medicaid |
$7,097.54
|
| Rate for Payer: VA VA |
$12,606.65
|
|
|
REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$16,646.50
|
|
|
Service Code
|
CPT 36832
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$804.23 |
| Max. Negotiated Rate |
$16,646.50 |
| Rate for Payer: Aetna Medicare |
$5,508.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,620.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,620.50
|
| Rate for Payer: BCBS Complete |
$2,980.81
|
| Rate for Payer: BCBS MAPPO |
$5,296.40
|
| Rate for Payer: BCBS Trust/PPO |
$3,326.61
|
| Rate for Payer: BCN Commercial |
$3,326.61
|
| Rate for Payer: BCN Medicare Advantage |
$5,296.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,296.40
|
| Rate for Payer: Mclaren Medicaid |
$2,838.87
|
| Rate for Payer: Mclaren Medicare |
$5,296.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,561.22
|
| Rate for Payer: Meridian Medicaid |
$2,980.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,090.86
|
| Rate for Payer: Nomi Health Commercial |
$11,122.44
|
| Rate for Payer: PACE Medicare |
$5,031.58
|
| Rate for Payer: PACE SWMI |
$5,296.40
|
| Rate for Payer: PHP Medicare Advantage |
$5,296.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,838.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,646.50
|
| Rate for Payer: Priority Health Medicare |
$5,296.40
|
| Rate for Payer: Priority Health Narrow Network |
$13,317.20
|
| Rate for Payer: Railroad Medicare Medicare |
$5,296.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$804.23
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,296.40
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,296.40
|
| Rate for Payer: UHCCP Medicaid |
$2,981.87
|
| Rate for Payer: VA VA |
$5,296.40
|
|
|
REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$16,646.50
|
|
|
Service Code
|
CPT 36833
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$858.45 |
| Max. Negotiated Rate |
$16,646.50 |
| Rate for Payer: Aetna Medicare |
$5,508.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,620.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,620.50
|
| Rate for Payer: BCBS Complete |
$2,980.81
|
| Rate for Payer: BCBS MAPPO |
$5,296.40
|
| Rate for Payer: BCBS Trust/PPO |
$2,211.50
|
| Rate for Payer: BCN Commercial |
$2,211.50
|
| Rate for Payer: BCN Medicare Advantage |
$5,296.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,296.40
|
| Rate for Payer: Mclaren Medicaid |
$2,838.87
|
| Rate for Payer: Mclaren Medicare |
$5,296.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,561.22
|
| Rate for Payer: Meridian Medicaid |
$2,980.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,090.86
|
| Rate for Payer: Nomi Health Commercial |
$11,122.44
|
| Rate for Payer: PACE Medicare |
$5,031.58
|
| Rate for Payer: PACE SWMI |
$5,296.40
|
| Rate for Payer: PHP Medicare Advantage |
$5,296.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,838.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,646.50
|
| Rate for Payer: Priority Health Medicare |
$5,296.40
|
| Rate for Payer: Priority Health Narrow Network |
$13,317.20
|
| Rate for Payer: Railroad Medicare Medicare |
$5,296.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$858.45
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,296.40
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,296.40
|
| Rate for Payer: UHCCP Medicaid |
$2,981.87
|
| Rate for Payer: VA VA |
$5,296.40
|
|
|
REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY
|
Facility
|
OP
|
$10,590.19
|
|
|
Service Code
|
CPT 63688
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$321.75 |
| Max. Negotiated Rate |
$10,590.19 |
| Rate for Payer: Aetna Medicare |
$3,504.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,211.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,211.84
|
| Rate for Payer: BCBS Complete |
$1,896.34
|
| Rate for Payer: BCBS MAPPO |
$3,369.47
|
| Rate for Payer: BCBS Trust/PPO |
$1,299.59
|
| Rate for Payer: BCN Commercial |
$1,299.59
|
| Rate for Payer: BCN Medicare Advantage |
$3,369.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,369.47
|
| Rate for Payer: Mclaren Medicaid |
$1,806.04
|
| Rate for Payer: Mclaren Medicare |
$3,369.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,537.94
|
| Rate for Payer: Meridian Medicaid |
$1,896.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,874.89
|
| Rate for Payer: Nomi Health Commercial |
$7,075.89
|
| Rate for Payer: PACE Medicare |
$3,201.00
|
| Rate for Payer: PACE SWMI |
$3,369.47
|
| Rate for Payer: PHP Medicare Advantage |
$3,369.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,806.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,590.19
|
| Rate for Payer: Priority Health Medicare |
$3,369.47
|
| Rate for Payer: Priority Health Narrow Network |
$8,472.15
|
| Rate for Payer: Railroad Medicare Medicare |
$3,369.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$321.75
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,369.47
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,369.47
|
| Rate for Payer: UHCCP Medicaid |
$1,897.01
|
| Rate for Payer: VA VA |
$3,369.47
|
|
|
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY
|
Facility
|
OP
|
$10,590.19
|
|
|
Service Code
|
CPT 64585
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$151.68 |
| Max. Negotiated Rate |
$10,590.19 |
| Rate for Payer: Aetna Medicare |
$3,504.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,211.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,211.84
|
| Rate for Payer: BCBS Complete |
$1,896.34
|
| Rate for Payer: BCBS MAPPO |
$3,369.47
|
| Rate for Payer: BCBS Trust/PPO |
$1,299.59
|
| Rate for Payer: BCN Commercial |
$1,299.59
|
| Rate for Payer: BCN Medicare Advantage |
$3,369.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,369.47
|
| Rate for Payer: Mclaren Medicaid |
$1,806.04
|
| Rate for Payer: Mclaren Medicare |
$3,369.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,537.94
|
| Rate for Payer: Meridian Medicaid |
$1,896.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,874.89
|
| Rate for Payer: Nomi Health Commercial |
$7,075.89
|
| Rate for Payer: PACE Medicare |
$3,201.00
|
| Rate for Payer: PACE SWMI |
$3,369.47
|
| Rate for Payer: PHP Medicare Advantage |
$3,369.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,806.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,590.19
|
| Rate for Payer: Priority Health Medicare |
$3,369.47
|
| Rate for Payer: Priority Health Narrow Network |
$8,472.15
|
| Rate for Payer: Railroad Medicare Medicare |
$3,369.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$151.68
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,369.47
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,369.47
|
| Rate for Payer: UHCCP Medicaid |
$1,897.01
|
| Rate for Payer: VA VA |
$3,369.47
|
|
|
REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY
|
Facility
|
OP
|
$10,590.19
|
|
|
Service Code
|
CPT 64595
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$243.52 |
| Max. Negotiated Rate |
$10,590.19 |
| Rate for Payer: Aetna Medicare |
$3,504.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,211.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,211.84
|
| Rate for Payer: BCBS Complete |
$1,896.34
|
| Rate for Payer: BCBS MAPPO |
$3,369.47
|
| Rate for Payer: BCBS Trust/PPO |
$1,516.19
|
| Rate for Payer: BCN Commercial |
$1,516.19
|
| Rate for Payer: BCN Medicare Advantage |
$3,369.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,369.47
|
| Rate for Payer: Mclaren Medicaid |
$1,806.04
|
| Rate for Payer: Mclaren Medicare |
$3,369.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,537.94
|
| Rate for Payer: Meridian Medicaid |
$1,896.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,874.89
|
| Rate for Payer: Nomi Health Commercial |
$7,075.89
|
| Rate for Payer: PACE Medicare |
$3,201.00
|
| Rate for Payer: PACE SWMI |
$3,369.47
|
| Rate for Payer: PHP Medicare Advantage |
$3,369.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,806.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,590.19
|
| Rate for Payer: Priority Health Medicare |
$3,369.47
|
| Rate for Payer: Priority Health Narrow Network |
$8,472.15
|
| Rate for Payer: Railroad Medicare Medicare |
$3,369.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$243.52
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,369.47
|
| Rate for Payer: UHC Exchange |
$5,811.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,369.47
|
| Rate for Payer: UHCCP Medicaid |
$1,897.01
|
| Rate for Payer: VA VA |
$3,369.47
|
|
|
REVISION OR REPLACEMENT OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY, INCLUDING CONNECTION TO EXISTING PULSE GENERATOR
|
Facility
|
OP
|
$38,401.49
|
|
|
Service Code
|
CPT 64583
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$917.65 |
| Max. Negotiated Rate |
$38,401.49 |
| Rate for Payer: Aetna Medicare |
$12,706.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,272.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,272.70
|
| Rate for Payer: BCBS Complete |
$6,876.38
|
| Rate for Payer: BCBS MAPPO |
$12,218.16
|
| Rate for Payer: BCBS Trust/PPO |
$7,660.22
|
| Rate for Payer: BCN Commercial |
$7,660.22
|
| Rate for Payer: BCN Medicare Advantage |
$12,218.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,218.16
|
| Rate for Payer: Mclaren Medicaid |
$6,548.93
|
| Rate for Payer: Mclaren Medicare |
$12,218.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,829.07
|
| Rate for Payer: Meridian Medicaid |
$6,876.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,050.88
|
| Rate for Payer: Nomi Health Commercial |
$25,658.14
|
| Rate for Payer: PACE Medicare |
$11,607.25
|
| Rate for Payer: PACE SWMI |
$12,218.16
|
| Rate for Payer: PHP Medicare Advantage |
$12,218.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,548.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38,401.49
|
| Rate for Payer: Priority Health Medicare |
$12,218.16
|
| Rate for Payer: Priority Health Narrow Network |
$30,721.19
|
| Rate for Payer: Railroad Medicare Medicare |
$12,218.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$917.65
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,218.16
|
| Rate for Payer: UHC Exchange |
$9,445.00
|
| Rate for Payer: UHC Medicare Advantage |
$12,218.16
|
| Rate for Payer: UHCCP Medicaid |
$6,878.82
|
| Rate for Payer: VA VA |
$12,218.16
|
|
|
REZAFUNGIN 200 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$6,224.00
|
|
|
Service Code
|
HCPCS J0349
|
| Hospital Charge Code |
204281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,921.12 |
| Max. Negotiated Rate |
$5,601.60 |
| Rate for Payer: Aetna Commercial |
$5,290.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,045.60
|
| Rate for Payer: Cash Price |
$4,979.20
|
| Rate for Payer: Cofinity Commercial |
$4,356.80
|
| Rate for Payer: Cofinity Commercial |
$5,352.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,356.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,979.20
|
| Rate for Payer: Healthscope Commercial |
$5,601.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,290.40
|
| Rate for Payer: PHP Commercial |
$5,290.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,045.60
|
| Rate for Payer: Priority Health SBD |
$3,921.12
|
|
|
REZAFUNGIN 200 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$6,224.00
|
|
|
Service Code
|
HCPCS J0349
|
| Hospital Charge Code |
204281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.59 |
| Max. Negotiated Rate |
$5,601.60 |
| Rate for Payer: Aetna Commercial |
$5,290.40
|
| Rate for Payer: Aetna Medicare |
$10.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,045.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13.02
|
| Rate for Payer: BCBS Complete |
$5.86
|
| Rate for Payer: BCBS MAPPO |
$10.42
|
| Rate for Payer: BCBS Trust/PPO |
$29.44
|
| Rate for Payer: BCN Commercial |
$29.44
|
| Rate for Payer: BCN Medicare Advantage |
$10.42
|
| Rate for Payer: Cash Price |
$4,979.20
|
| Rate for Payer: Cash Price |
$4,979.20
|
| Rate for Payer: Cofinity Commercial |
$5,352.64
|
| Rate for Payer: Cofinity Commercial |
$4,356.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,356.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,979.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.42
|
| Rate for Payer: Healthscope Commercial |
$5,601.60
|
| Rate for Payer: Mclaren Medicaid |
$5.59
|
| Rate for Payer: Mclaren Medicare |
$10.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.94
|
| Rate for Payer: Meridian Medicaid |
$5.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,290.40
|
| Rate for Payer: Nomi Health Commercial |
$31.26
|
| Rate for Payer: PACE Medicare |
$9.90
|
| Rate for Payer: PACE SWMI |
$10.42
|
| Rate for Payer: PHP Commercial |
$5,290.40
|
| Rate for Payer: PHP Medicare Advantage |
$10.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$5.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,045.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$29.13
|
| Rate for Payer: Priority Health Medicare |
$10.42
|
| Rate for Payer: Priority Health Narrow Network |
$23.30
|
| Rate for Payer: Priority Health SBD |
$3,921.12
|
| Rate for Payer: Railroad Medicare Medicare |
$10.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.33
|
| Rate for Payer: UHC Dual Complete DSNP |
$10.42
|
| Rate for Payer: UHC Medicare Advantage |
$10.42
|
| Rate for Payer: UHCCP Medicaid |
$5.87
|
| Rate for Payer: VA VA |
$10.42
|
|
|
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 Commercial |
$201.10
|
| Rate for Payer: Cofinity Commercial |
$247.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$201.10
|
| 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: PHP Commercial |
$244.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.74
|
| Rate for Payer: Priority Health SBD |
$180.99
|
|
|
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 |
$693.12 |
| Rate for Payer: Aetna Commercial |
$244.20
|
| Rate for Payer: Aetna Medicare |
$143.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.74
|
| Rate for Payer: BCBS Complete |
$114.92
|
| Rate for Payer: BCBS Trust/PPO |
$693.12
|
| Rate for Payer: BCN Commercial |
$693.12
|
| Rate for Payer: Cash Price |
$229.83
|
| Rate for Payer: Cash Price |
$229.83
|
| Rate for Payer: Cofinity Commercial |
$201.10
|
| Rate for Payer: Cofinity Commercial |
$247.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$201.10
|
| 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: PHP Commercial |
$244.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.74
|
| Rate for Payer: Priority Health SBD |
$180.99
|
|
|
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 |
$64.86 |
| 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 Commercial |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.50
|
| 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: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: Priority Health SBD |
$102.15
|
|
|
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 Commercial |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.50
|
| 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: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: Priority Health SBD |
$102.15
|
|
|
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 Commercial |
$3,033.93
|
| Rate for Payer: Cofinity Commercial |
$3,727.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,033.93
|
| 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: PHP Commercial |
$3,684.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,817.22
|
| Rate for Payer: Priority Health SBD |
$2,730.53
|
|
