|
LACTATED RINGERS IV -DKA
|
Facility
|
IP
|
$67.19
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
301462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Advantage |
$47.03
|
| Rate for Payer: Cofinity Advantage |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
LACTATED RINGERS IV INFUSION/BOLUS (CODE)
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
163717
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Medicare |
$33.59
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$5.96
|
| Rate for Payer: BCBS Trust/PPO |
$5.96
|
| Rate for Payer: BCN Commercial |
$5.96
|
| Rate for Payer: BCN Commercial |
$5.96
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Advantage |
$48.94
|
| Rate for Payer: Cofinity Advantage |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$53.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.93
|
| Rate for Payer: UHC Core |
$3.93
|
| Rate for Payer: UHC Core |
$3.93
|
| Rate for Payer: UHC Exchange |
$3.93
|
| Rate for Payer: UHC Exchange |
$3.93
|
|
|
LACTATED RINGERS IV INFUSION/BOLUS (CODE)
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
163717
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Advantage |
$47.03
|
| Rate for Payer: Cofinity Advantage |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$50.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.44
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: Priority Health SBD |
$42.33
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE
|
Facility
|
OP
|
$390.24
|
|
|
Service Code
|
NDC 49100040007
|
| Hospital Charge Code |
27974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.36 |
| Max. Negotiated Rate |
$351.22 |
| Rate for Payer: Aetna Commercial |
$331.70
|
| Rate for Payer: Aetna Medicare |
$195.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.66
|
| Rate for Payer: BCBS Complete |
$156.10
|
| Rate for Payer: Cash Price |
$312.19
|
| Rate for Payer: Cofinity Advantage |
$273.17
|
| Rate for Payer: Cofinity Commercial |
$335.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.19
|
| Rate for Payer: Healthscope Commercial |
$351.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$312.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.68
|
| Rate for Payer: PHP Commercial |
$331.70
|
| Rate for Payer: Priority Health SBD |
$245.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$253.66
|
| Rate for Payer: UHC Core |
$203.32
|
| Rate for Payer: UHC Exchange |
$153.36
|
|
|
LACTOBACILLUS RHAMNOSUS GG 10 BILLION CELL CAPSULE
|
Facility
|
IP
|
$390.24
|
|
|
Service Code
|
NDC 49100040007
|
| Hospital Charge Code |
27974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.85 |
| Max. Negotiated Rate |
$351.22 |
| Rate for Payer: Aetna Commercial |
$331.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.66
|
| Rate for Payer: Cash Price |
$312.19
|
| Rate for Payer: Cofinity Advantage |
$273.17
|
| Rate for Payer: Cofinity Commercial |
$335.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.19
|
| Rate for Payer: Healthscope Commercial |
$351.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.68
|
| Rate for Payer: PHP Commercial |
$331.70
|
| Rate for Payer: Priority Health SBD |
$245.85
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
IP
|
$43.76
|
|
|
Service Code
|
NDC 00121087316
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.57 |
| Max. Negotiated Rate |
$39.38 |
| Rate for Payer: Aetna Commercial |
$37.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.44
|
| Rate for Payer: Cash Price |
$35.01
|
| Rate for Payer: Cofinity Advantage |
$30.63
|
| Rate for Payer: Cofinity Commercial |
$37.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.01
|
| Rate for Payer: Healthscope Commercial |
$39.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.82
|
| Rate for Payer: PHP Commercial |
$37.20
|
| Rate for Payer: Priority Health SBD |
$27.57
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
IP
|
$29.76
|
|
|
Service Code
|
NDC 45963043864
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$26.78 |
| Rate for Payer: Aetna Commercial |
$25.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.34
|
| Rate for Payer: Cash Price |
$23.81
|
| Rate for Payer: Cofinity Advantage |
$20.83
|
| Rate for Payer: Cofinity Commercial |
$25.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.81
|
| Rate for Payer: Healthscope Commercial |
$26.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.32
|
| Rate for Payer: PHP Commercial |
$25.30
|
| Rate for Payer: Priority Health SBD |
$18.75
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
OP
|
$29.76
|
|
|
Service Code
|
NDC 45963043864
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$26.78 |
| Rate for Payer: Aetna Commercial |
$25.30
|
| Rate for Payer: Aetna Medicare |
$14.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.34
|
| Rate for Payer: BCBS Complete |
$11.90
|
| Rate for Payer: Cash Price |
$23.81
|
| Rate for Payer: Cofinity Advantage |
$20.83
|
| Rate for Payer: Cofinity Commercial |
$25.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.81
|
| Rate for Payer: Healthscope Commercial |
$26.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.32
|
| Rate for Payer: PHP Commercial |
$25.30
|
| Rate for Payer: Priority Health SBD |
$18.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.34
|
| Rate for Payer: UHC Core |
$15.50
|
| Rate for Payer: UHC Exchange |
$11.70
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
IP
|
$5.91
|
|
|
Service Code
|
NDC 81033024151
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna Commercial |
$5.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.84
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cofinity Advantage |
$4.14
|
| Rate for Payer: Cofinity Commercial |
$5.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.73
|
| Rate for Payer: Healthscope Commercial |
$5.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.43
|
| Rate for Payer: PHP Commercial |
$5.02
|
| Rate for Payer: Priority Health SBD |
$3.72
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
IP
|
$38.51
|
|
|
Service Code
|
NDC 50383077932
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.26 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna Commercial |
$32.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.03
|
| Rate for Payer: Cash Price |
$30.81
|
| Rate for Payer: Cofinity Advantage |
$26.96
|
| Rate for Payer: Cofinity Commercial |
$33.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.81
|
| Rate for Payer: Healthscope Commercial |
$34.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.88
|
| Rate for Payer: PHP Commercial |
$32.73
|
| Rate for Payer: Priority Health SBD |
$24.26
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
IP
|
$5.91
|
|
|
Service Code
|
NDC 81033024130
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna Commercial |
$5.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.84
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cofinity Advantage |
$4.14
|
| Rate for Payer: Cofinity Commercial |
$5.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.73
|
| Rate for Payer: Healthscope Commercial |
$5.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.43
|
| Rate for Payer: PHP Commercial |
$5.02
|
| Rate for Payer: Priority Health SBD |
$3.72
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
OP
|
$38.51
|
|
|
Service Code
|
NDC 50383077932
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.13 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna Commercial |
$32.73
|
| Rate for Payer: Aetna Medicare |
$19.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.03
|
| Rate for Payer: BCBS Complete |
$15.40
|
| Rate for Payer: Cash Price |
$30.81
|
| Rate for Payer: Cofinity Advantage |
$26.96
|
| Rate for Payer: Cofinity Commercial |
$33.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.81
|
| Rate for Payer: Healthscope Commercial |
$34.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.88
|
| Rate for Payer: PHP Commercial |
$32.73
|
| Rate for Payer: Priority Health SBD |
$24.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.03
|
| Rate for Payer: UHC Core |
$20.06
|
| Rate for Payer: UHC Exchange |
$15.13
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
OP
|
$43.76
|
|
|
Service Code
|
NDC 00121087316
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$39.38 |
| Rate for Payer: Aetna Commercial |
$37.20
|
| Rate for Payer: Aetna Medicare |
$21.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.44
|
| Rate for Payer: BCBS Complete |
$17.50
|
| Rate for Payer: Cash Price |
$35.01
|
| Rate for Payer: Cofinity Advantage |
$30.63
|
| Rate for Payer: Cofinity Commercial |
$37.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.01
|
| Rate for Payer: Healthscope Commercial |
$39.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.82
|
| Rate for Payer: PHP Commercial |
$37.20
|
| Rate for Payer: Priority Health SBD |
$27.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.44
|
| Rate for Payer: UHC Core |
$22.80
|
| Rate for Payer: UHC Exchange |
$17.20
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
OP
|
$5.91
|
|
|
Service Code
|
NDC 81033024130
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna Commercial |
$5.02
|
| Rate for Payer: Aetna Medicare |
$2.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.84
|
| Rate for Payer: BCBS Complete |
$2.36
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cofinity Advantage |
$4.14
|
| Rate for Payer: Cofinity Commercial |
$5.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.73
|
| Rate for Payer: Healthscope Commercial |
$5.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.43
|
| Rate for Payer: PHP Commercial |
$5.02
|
| Rate for Payer: Priority Health SBD |
$3.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.84
|
| Rate for Payer: UHC Core |
$3.08
|
| Rate for Payer: UHC Exchange |
$2.32
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION
|
Facility
|
OP
|
$5.91
|
|
|
Service Code
|
NDC 81033024151
|
| Hospital Charge Code |
38245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna Commercial |
$5.02
|
| Rate for Payer: Aetna Medicare |
$2.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.84
|
| Rate for Payer: BCBS Complete |
$2.36
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cofinity Advantage |
$4.14
|
| Rate for Payer: Cofinity Commercial |
$5.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.73
|
| Rate for Payer: Healthscope Commercial |
$5.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.43
|
| Rate for Payer: PHP Commercial |
$5.02
|
| Rate for Payer: Priority Health SBD |
$3.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.84
|
| Rate for Payer: UHC Core |
$3.08
|
| Rate for Payer: UHC Exchange |
$2.32
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
OP
|
$7.78
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna Commercial |
$6.61
|
| Rate for Payer: Aetna Medicare |
$3.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.06
|
| Rate for Payer: BCBS Complete |
$3.11
|
| Rate for Payer: Cash Price |
$6.22
|
| Rate for Payer: Cofinity Advantage |
$5.45
|
| Rate for Payer: Cofinity Commercial |
$6.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.22
|
| Rate for Payer: Healthscope Commercial |
$7.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.83
|
| Rate for Payer: PHP Commercial |
$6.61
|
| Rate for Payer: Priority Health SBD |
$4.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.06
|
| Rate for Payer: UHC Core |
$4.05
|
| Rate for Payer: UHC Exchange |
$3.06
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
IP
|
$7.06
|
|
|
Service Code
|
NDC 00121115430
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Advantage |
$4.94
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.29
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health SBD |
$4.45
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
NDC 00121115430
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna Medicare |
$3.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: BCBS Complete |
$2.82
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Advantage |
$4.94
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.29
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health SBD |
$4.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.59
|
| Rate for Payer: UHC Core |
$3.68
|
| Rate for Payer: UHC Exchange |
$2.77
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
IP
|
$7.78
|
|
|
Service Code
|
NDC 00121115440
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna Commercial |
$6.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.06
|
| Rate for Payer: Cash Price |
$6.22
|
| Rate for Payer: Cofinity Advantage |
$5.45
|
| Rate for Payer: Cofinity Commercial |
$6.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.22
|
| Rate for Payer: Healthscope Commercial |
$7.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.83
|
| Rate for Payer: PHP Commercial |
$6.61
|
| Rate for Payer: Priority Health SBD |
$4.90
|
|
|
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR
|
Facility
|
OP
|
$23,381.57
|
|
|
Service Code
|
CPT 63047
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,781.35 |
| Max. Negotiated Rate |
$23,381.57 |
| Rate for Payer: Aetna Medicare |
$7,519.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,037.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,037.65
|
| Rate for Payer: BCBS Complete |
$3,970.78
|
| Rate for Payer: BCBS MAPPO |
$7,230.12
|
| Rate for Payer: BCBS Trust/PPO |
$6,512.10
|
| Rate for Payer: BCN Commercial |
$6,512.10
|
| Rate for Payer: BCN Medicare Advantage |
$7,230.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,230.12
|
| Rate for Payer: Mclaren Medicaid |
$3,781.35
|
| Rate for Payer: Mclaren Medicare |
$7,230.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,591.63
|
| Rate for Payer: Meridian Medicaid |
$7,591.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,314.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,953.13
|
| Rate for Payer: Nomi Health Commercial |
$21,690.36
|
| Rate for Payer: PACE Medicare |
$6,868.61
|
| Rate for Payer: PACE SWMI |
$7,230.12
|
| Rate for Payer: PHP Medicare Advantage |
$7,230.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,781.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,381.57
|
| Rate for Payer: Priority Health Medicare |
$7,230.12
|
| Rate for Payer: Priority Health Tiered Network |
$18,705.26
|
| Rate for Payer: Railroad Medicare Medicare |
$7,230.12
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,230.12
|
| Rate for Payer: UHC Medicaid |
$3,781.35
|
| Rate for Payer: UHCCP Medicaid |
$3,781.35
|
| Rate for Payer: VA VA |
$7,230.12
|
|
|
LAMINECTOMY, FACETECTOMY, OR FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S] [EG, SPINAL OR LATERAL RECESS STENOSIS]), DURING POSTERIOR INTERBODY ARTHRODESIS, LUMBAR; SINGLE VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$640.01
|
|
|
Service Code
|
CPT 63052
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$640.01 |
| Max. Negotiated Rate |
$640.01 |
| Rate for Payer: BCBS Trust/PPO |
$640.01
|
| Rate for Payer: BCN Commercial |
$640.01
|
|
|
LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL
|
Facility
|
OP
|
$62,512.62
|
|
|
Service Code
|
CPT 63655
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$10,109.77 |
| Max. Negotiated Rate |
$62,512.62 |
| Rate for Payer: Aetna Medicare |
$20,103.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24,162.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24,162.94
|
| Rate for Payer: BCBS Complete |
$10,616.23
|
| Rate for Payer: BCBS MAPPO |
$19,330.35
|
| Rate for Payer: BCBS Trust/PPO |
$16,633.77
|
| Rate for Payer: BCN Commercial |
$16,633.77
|
| Rate for Payer: BCN Medicare Advantage |
$19,330.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19,330.35
|
| Rate for Payer: Mclaren Medicaid |
$10,109.77
|
| Rate for Payer: Mclaren Medicare |
$19,330.35
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20,296.87
|
| Rate for Payer: Meridian Medicaid |
$20,296.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22,229.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$21,263.38
|
| Rate for Payer: Nomi Health Commercial |
$57,991.05
|
| Rate for Payer: PACE Medicare |
$18,363.83
|
| Rate for Payer: PACE SWMI |
$19,330.35
|
| Rate for Payer: PHP Medicare Advantage |
$19,330.35
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,109.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$62,512.62
|
| Rate for Payer: Priority Health Medicare |
$19,330.35
|
| Rate for Payer: Priority Health Tiered Network |
$50,010.10
|
| Rate for Payer: Railroad Medicare Medicare |
$19,330.35
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$19,330.35
|
| Rate for Payer: UHC Medicaid |
$10,109.77
|
| Rate for Payer: UHCCP Medicaid |
$10,109.77
|
| Rate for Payer: VA VA |
$19,330.35
|
|
|
LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR
|
Facility
|
OP
|
$23,381.57
|
|
|
Service Code
|
CPT 63030
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,781.35 |
| Max. Negotiated Rate |
$23,381.57 |
| Rate for Payer: Aetna Medicare |
$7,519.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,037.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,037.65
|
| Rate for Payer: BCBS Complete |
$3,970.78
|
| Rate for Payer: BCBS MAPPO |
$7,230.12
|
| Rate for Payer: BCBS Trust/PPO |
$5,464.72
|
| Rate for Payer: BCN Commercial |
$5,464.72
|
| Rate for Payer: BCN Medicare Advantage |
$7,230.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,230.12
|
| Rate for Payer: Mclaren Medicaid |
$3,781.35
|
| Rate for Payer: Mclaren Medicare |
$7,230.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7,591.63
|
| Rate for Payer: Meridian Medicaid |
$7,591.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,314.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$7,953.13
|
| Rate for Payer: Nomi Health Commercial |
$21,690.36
|
| Rate for Payer: PACE Medicare |
$6,868.61
|
| Rate for Payer: PACE SWMI |
$7,230.12
|
| Rate for Payer: PHP Medicare Advantage |
$7,230.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,781.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23,381.57
|
| Rate for Payer: Priority Health Medicare |
$7,230.12
|
| Rate for Payer: Priority Health Tiered Network |
$18,705.26
|
| Rate for Payer: Railroad Medicare Medicare |
$7,230.12
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,230.12
|
| Rate for Payer: UHC Medicaid |
$3,781.35
|
| Rate for Payer: UHCCP Medicaid |
$3,781.35
|
| Rate for Payer: VA VA |
$7,230.12
|
|
|
LAMOTRIGINE 100 MG TABLET
|
Facility
|
IP
|
$2.47
|
|
|
Service Code
|
NDC 51079049901
|
| Hospital Charge Code |
13982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Advantage |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.85
|
| Rate for Payer: PHP Commercial |
$2.10
|
| Rate for Payer: Priority Health SBD |
$1.56
|
|
|
LAMOTRIGINE 100 MG TABLET
|
Facility
|
OP
|
$2.47
|
|
|
Service Code
|
NDC 51079049901
|
| Hospital Charge Code |
13982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: BCBS Complete |
$0.99
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Advantage |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.85
|
| Rate for Payer: PHP Commercial |
$2.10
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.61
|
| Rate for Payer: UHC Core |
$1.29
|
| Rate for Payer: UHC Exchange |
$0.97
|
|
