|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$166.32
|
|
|
Service Code
|
NDC 10006073038
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.78 |
| Max. Negotiated Rate |
$149.69 |
| Rate for Payer: Aetna Commercial |
$141.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.11
|
| Rate for Payer: Cash Price |
$133.06
|
| Rate for Payer: Cofinity Commercial |
$116.42
|
| Rate for Payer: Cofinity Commercial |
$143.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.06
|
| Rate for Payer: Healthscope Commercial |
$149.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.37
|
| Rate for Payer: PHP Commercial |
$141.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.11
|
| Rate for Payer: Priority Health SBD |
$104.78
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
NDC 37864078599
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna Commercial |
$149.60
|
| Rate for Payer: Aetna Medicare |
$88.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.40
|
| Rate for Payer: BCBS Complete |
$70.40
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Cofinity Commercial |
$123.20
|
| Rate for Payer: Cofinity Commercial |
$151.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.80
|
| Rate for Payer: Healthscope Commercial |
$158.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.60
|
| Rate for Payer: PHP Commercial |
$149.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.40
|
| Rate for Payer: Priority Health SBD |
$110.88
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
NDC 51645078599
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.92 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Aetna Commercial |
$156.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.60
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cofinity Commercial |
$128.80
|
| Rate for Payer: Cofinity Commercial |
$158.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.20
|
| Rate for Payer: Healthscope Commercial |
$165.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$156.40
|
| Rate for Payer: PHP Commercial |
$156.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.60
|
| Rate for Payer: Priority Health SBD |
$115.92
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
NDC 51645078599
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.60 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Aetna Commercial |
$156.40
|
| Rate for Payer: Aetna Medicare |
$92.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.60
|
| Rate for Payer: BCBS Complete |
$73.60
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cofinity Commercial |
$128.80
|
| Rate for Payer: Cofinity Commercial |
$158.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.20
|
| Rate for Payer: Healthscope Commercial |
$165.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$156.40
|
| Rate for Payer: PHP Commercial |
$156.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.60
|
| Rate for Payer: Priority Health SBD |
$115.92
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$393.60
|
|
|
Service Code
|
NDC 60258017101
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.97 |
| Max. Negotiated Rate |
$354.24 |
| Rate for Payer: Aetna Commercial |
$334.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$255.84
|
| Rate for Payer: Cash Price |
$314.88
|
| Rate for Payer: Cofinity Commercial |
$275.52
|
| Rate for Payer: Cofinity Commercial |
$338.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$275.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$314.88
|
| Rate for Payer: Healthscope Commercial |
$354.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$334.56
|
| Rate for Payer: PHP Commercial |
$334.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.84
|
| Rate for Payer: Priority Health SBD |
$247.97
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 64980033990
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Aetna Commercial |
$0.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.70
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cofinity Commercial |
$0.76
|
| Rate for Payer: Cofinity Commercial |
$0.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.86
|
| Rate for Payer: Healthscope Commercial |
$0.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.92
|
| Rate for Payer: PHP Commercial |
$0.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.70
|
| Rate for Payer: Priority Health SBD |
$0.68
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$256.00
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.40 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna Commercial |
$217.60
|
| Rate for Payer: Aetna Medicare |
$128.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.40
|
| Rate for Payer: BCBS Complete |
$102.40
|
| Rate for Payer: Cash Price |
$204.80
|
| Rate for Payer: Cofinity Commercial |
$179.20
|
| Rate for Payer: Cofinity Commercial |
$220.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.80
|
| Rate for Payer: Healthscope Commercial |
$230.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.60
|
| Rate for Payer: PHP Commercial |
$217.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.40
|
| Rate for Payer: Priority Health SBD |
$161.28
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
NDC 37864078599
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.88 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna Commercial |
$149.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.40
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Cofinity Commercial |
$123.20
|
| Rate for Payer: Cofinity Commercial |
$151.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.80
|
| Rate for Payer: Healthscope Commercial |
$158.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.60
|
| Rate for Payer: PHP Commercial |
$149.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.40
|
| Rate for Payer: Priority Health SBD |
$110.88
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$166.32
|
|
|
Service Code
|
NDC 10006073038
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.53 |
| Max. Negotiated Rate |
$149.69 |
| Rate for Payer: Aetna Commercial |
$141.37
|
| Rate for Payer: Aetna Medicare |
$83.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.11
|
| Rate for Payer: BCBS Complete |
$66.53
|
| Rate for Payer: Cash Price |
$133.06
|
| Rate for Payer: Cofinity Commercial |
$116.42
|
| Rate for Payer: Cofinity Commercial |
$143.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.06
|
| Rate for Payer: Healthscope Commercial |
$149.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.37
|
| Rate for Payer: PHP Commercial |
$141.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.11
|
| Rate for Payer: Priority Health SBD |
$104.78
|
|
|
MAGNESIUM OXIDE 420 MG TABLET
|
Facility
|
OP
|
$138.65
|
|
|
Service Code
|
NDC 00603021321
|
| Hospital Charge Code |
13643
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.46 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna Medicare |
$69.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: BCBS Complete |
$55.46
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Cofinity Commercial |
$97.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health SBD |
$87.35
|
|
|
MAGNESIUM OXIDE 420 MG TABLET
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 00603021321
|
| Hospital Charge Code |
13643
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.35 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Cofinity Commercial |
$97.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health SBD |
$87.35
|
|
|
MAGNESIUM SULFATE 0.5 GRAM/ML (50 %) INJECTION (CODE)
|
Facility
|
OP
|
$26.50
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
163706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$23.85 |
| Rate for Payer: Aetna Commercial |
$22.52
|
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Medicare |
$10.72
|
| Rate for Payer: Aetna Medicare |
$13.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.23
|
| Rate for Payer: BCBS Complete |
$10.60
|
| Rate for Payer: BCBS Complete |
$8.58
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$21.20
|
| Rate for Payer: Cofinity Commercial |
$15.01
|
| Rate for Payer: Cofinity Commercial |
$18.55
|
| Rate for Payer: Cofinity Commercial |
$22.79
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.20
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Commercial |
$23.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.52
|
| Rate for Payer: PHP Commercial |
$22.52
|
| Rate for Payer: PHP Commercial |
$18.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.23
|
| Rate for Payer: Priority Health SBD |
$16.70
|
| Rate for Payer: Priority Health SBD |
$13.51
|
|
|
MAGNESIUM SULFATE 0.5 GRAM/ML (50 %) INJECTION (CODE)
|
Facility
|
IP
|
$26.50
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
163706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.70 |
| Max. Negotiated Rate |
$23.85 |
| Rate for Payer: Aetna Commercial |
$22.52
|
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.23
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$21.20
|
| Rate for Payer: Cofinity Commercial |
$15.01
|
| Rate for Payer: Cofinity Commercial |
$18.55
|
| Rate for Payer: Cofinity Commercial |
$22.79
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.20
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Commercial |
$23.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.52
|
| Rate for Payer: PHP Commercial |
$18.22
|
| Rate for Payer: PHP Commercial |
$22.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.94
|
| Rate for Payer: Priority Health SBD |
$16.70
|
| Rate for Payer: Priority Health SBD |
$13.51
|
|
|
MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$55.83
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
117958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.33 |
| Max. Negotiated Rate |
$50.25 |
| Rate for Payer: Aetna Commercial |
$47.46
|
| Rate for Payer: Aetna Commercial |
$74.57
|
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna Medicare |
$43.87
|
| Rate for Payer: Aetna Medicare |
$27.91
|
| Rate for Payer: Aetna Medicare |
$39.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.84
|
| Rate for Payer: BCBS Complete |
$31.90
|
| Rate for Payer: BCBS Complete |
$22.33
|
| Rate for Payer: BCBS Complete |
$35.09
|
| Rate for Payer: Cash Price |
$70.18
|
| Rate for Payer: Cash Price |
$44.66
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Commercial |
$75.45
|
| Rate for Payer: Cofinity Commercial |
$48.01
|
| Rate for Payer: Cofinity Commercial |
$39.08
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Cofinity Commercial |
$55.83
|
| Rate for Payer: Cofinity Commercial |
$61.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.66
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Healthscope Commercial |
$50.25
|
| Rate for Payer: Healthscope Commercial |
$78.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.46
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: PHP Commercial |
$47.46
|
| Rate for Payer: PHP Commercial |
$74.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.84
|
| Rate for Payer: Priority Health SBD |
$55.27
|
| Rate for Payer: Priority Health SBD |
$50.24
|
| Rate for Payer: Priority Health SBD |
$35.17
|
|
|
MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$55.83
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
117958
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.17 |
| Max. Negotiated Rate |
$50.25 |
| Rate for Payer: Aetna Commercial |
$47.46
|
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna Commercial |
$74.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.02
|
| Rate for Payer: Cash Price |
$44.66
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cash Price |
$70.18
|
| Rate for Payer: Cofinity Commercial |
$61.41
|
| Rate for Payer: Cofinity Commercial |
$39.08
|
| Rate for Payer: Cofinity Commercial |
$48.01
|
| Rate for Payer: Cofinity Commercial |
$75.45
|
| Rate for Payer: Cofinity Commercial |
$55.83
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.18
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Healthscope Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$50.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.57
|
| Rate for Payer: PHP Commercial |
$74.57
|
| Rate for Payer: PHP Commercial |
$47.46
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.84
|
| Rate for Payer: Priority Health SBD |
$55.27
|
| Rate for Payer: Priority Health SBD |
$35.17
|
| Rate for Payer: Priority Health SBD |
$50.24
|
|
|
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$52.07
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
117869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.80 |
| Max. Negotiated Rate |
$46.86 |
| Rate for Payer: Aetna Commercial |
$44.26
|
| Rate for Payer: Aetna Commercial |
$20.13
|
| Rate for Payer: Aetna Commercial |
$16.67
|
| Rate for Payer: Aetna Commercial |
$52.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.85
|
| Rate for Payer: Cash Price |
$41.66
|
| Rate for Payer: Cash Price |
$15.69
|
| Rate for Payer: Cash Price |
$48.95
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cofinity Commercial |
$42.83
|
| Rate for Payer: Cofinity Commercial |
$52.62
|
| Rate for Payer: Cofinity Commercial |
$13.73
|
| Rate for Payer: Cofinity Commercial |
$16.58
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$16.86
|
| Rate for Payer: Cofinity Commercial |
$36.45
|
| Rate for Payer: Cofinity Commercial |
$44.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Healthscope Commercial |
$17.65
|
| Rate for Payer: Healthscope Commercial |
$55.07
|
| Rate for Payer: Healthscope Commercial |
$46.86
|
| Rate for Payer: Healthscope Commercial |
$21.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.67
|
| Rate for Payer: PHP Commercial |
$20.13
|
| Rate for Payer: PHP Commercial |
$44.26
|
| Rate for Payer: PHP Commercial |
$52.01
|
| Rate for Payer: PHP Commercial |
$16.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.39
|
| Rate for Payer: Priority Health SBD |
$32.80
|
| Rate for Payer: Priority Health SBD |
$12.35
|
| Rate for Payer: Priority Health SBD |
$14.92
|
| Rate for Payer: Priority Health SBD |
$38.55
|
|
|
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$52.07
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
117869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.83 |
| Max. Negotiated Rate |
$46.86 |
| Rate for Payer: Aetna Commercial |
$44.26
|
| Rate for Payer: Aetna Commercial |
$20.13
|
| Rate for Payer: Aetna Commercial |
$52.01
|
| Rate for Payer: Aetna Commercial |
$16.67
|
| Rate for Payer: Aetna Medicare |
$30.59
|
| Rate for Payer: Aetna Medicare |
$26.04
|
| Rate for Payer: Aetna Medicare |
$11.84
|
| Rate for Payer: Aetna Medicare |
$9.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.77
|
| Rate for Payer: BCBS Complete |
$7.84
|
| Rate for Payer: BCBS Complete |
$24.48
|
| Rate for Payer: BCBS Complete |
$9.47
|
| Rate for Payer: BCBS Complete |
$20.83
|
| Rate for Payer: Cash Price |
$48.95
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cash Price |
$41.66
|
| Rate for Payer: Cash Price |
$15.69
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$52.62
|
| Rate for Payer: Cofinity Commercial |
$36.45
|
| Rate for Payer: Cofinity Commercial |
$42.83
|
| Rate for Payer: Cofinity Commercial |
$44.78
|
| Rate for Payer: Cofinity Commercial |
$13.73
|
| Rate for Payer: Cofinity Commercial |
$16.86
|
| Rate for Payer: Cofinity Commercial |
$16.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$42.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Healthscope Commercial |
$17.65
|
| Rate for Payer: Healthscope Commercial |
$55.07
|
| Rate for Payer: Healthscope Commercial |
$21.31
|
| Rate for Payer: Healthscope Commercial |
$46.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$52.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.67
|
| Rate for Payer: PHP Commercial |
$20.13
|
| Rate for Payer: PHP Commercial |
$52.01
|
| Rate for Payer: PHP Commercial |
$44.26
|
| Rate for Payer: PHP Commercial |
$16.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.77
|
| Rate for Payer: Priority Health SBD |
$12.35
|
| Rate for Payer: Priority Health SBD |
$32.80
|
| Rate for Payer: Priority Health SBD |
$14.92
|
| Rate for Payer: Priority Health SBD |
$38.55
|
|
|
MAGNESIUM SULFATE 4.06 MEQ/ML (50 %) INJECTION (TPN COMPONENT)
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
180902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.56 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$95.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.80
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cofinity Commercial |
$78.40
|
| Rate for Payer: Cofinity Commercial |
$96.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.60
|
| Rate for Payer: Healthscope Commercial |
$100.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$95.20
|
| Rate for Payer: PHP Commercial |
$95.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.80
|
| Rate for Payer: Priority Health SBD |
$70.56
|
|
|
MAGNESIUM SULFATE 4.06 MEQ/ML (50 %) INJECTION (TPN COMPONENT)
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
180902
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.80 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna Commercial |
$95.20
|
| Rate for Payer: Aetna Medicare |
$56.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.80
|
| Rate for Payer: BCBS Complete |
$44.80
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cofinity Commercial |
$78.40
|
| Rate for Payer: Cofinity Commercial |
$96.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.60
|
| Rate for Payer: Healthscope Commercial |
$100.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$95.20
|
| Rate for Payer: PHP Commercial |
$95.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.80
|
| Rate for Payer: Priority Health SBD |
$70.56
|
|
|
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$152.02
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.77 |
| Max. Negotiated Rate |
$136.82 |
| Rate for Payer: Aetna Commercial |
$129.22
|
| Rate for Payer: Aetna Commercial |
$146.84
|
| Rate for Payer: Aetna Commercial |
$193.83
|
| Rate for Payer: Aetna Commercial |
$340.66
|
| Rate for Payer: Aetna Commercial |
$399.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.29
|
| Rate for Payer: Cash Price |
$375.90
|
| Rate for Payer: Cash Price |
$138.20
|
| Rate for Payer: Cash Price |
$320.62
|
| Rate for Payer: Cash Price |
$182.42
|
| Rate for Payer: Cash Price |
$121.62
|
| Rate for Payer: Cofinity Commercial |
$120.92
|
| Rate for Payer: Cofinity Commercial |
$106.41
|
| Rate for Payer: Cofinity Commercial |
$130.74
|
| Rate for Payer: Cofinity Commercial |
$404.10
|
| Rate for Payer: Cofinity Commercial |
$328.92
|
| Rate for Payer: Cofinity Commercial |
$148.56
|
| Rate for Payer: Cofinity Commercial |
$344.67
|
| Rate for Payer: Cofinity Commercial |
$280.55
|
| Rate for Payer: Cofinity Commercial |
$159.62
|
| Rate for Payer: Cofinity Commercial |
$196.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$328.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$106.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$159.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$280.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$120.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.90
|
| Rate for Payer: Healthscope Commercial |
$205.23
|
| Rate for Payer: Healthscope Commercial |
$155.47
|
| Rate for Payer: Healthscope Commercial |
$136.82
|
| Rate for Payer: Healthscope Commercial |
$360.70
|
| Rate for Payer: Healthscope Commercial |
$422.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$193.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.22
|
| Rate for Payer: PHP Commercial |
$340.66
|
| Rate for Payer: PHP Commercial |
$399.40
|
| Rate for Payer: PHP Commercial |
$193.83
|
| Rate for Payer: PHP Commercial |
$146.84
|
| Rate for Payer: PHP Commercial |
$129.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.51
|
| Rate for Payer: Priority Health SBD |
$252.49
|
| Rate for Payer: Priority Health SBD |
$108.83
|
| Rate for Payer: Priority Health SBD |
$143.66
|
| Rate for Payer: Priority Health SBD |
$95.77
|
| Rate for Payer: Priority Health SBD |
$296.02
|
|
|
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$400.78
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4719
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$160.31 |
| Max. Negotiated Rate |
$360.70 |
| Rate for Payer: Aetna Commercial |
$340.66
|
| Rate for Payer: Aetna Commercial |
$193.83
|
| Rate for Payer: Aetna Commercial |
$399.40
|
| Rate for Payer: Aetna Commercial |
$129.22
|
| Rate for Payer: Aetna Commercial |
$146.84
|
| Rate for Payer: Aetna Medicare |
$114.02
|
| Rate for Payer: Aetna Medicare |
$234.94
|
| Rate for Payer: Aetna Medicare |
$200.39
|
| Rate for Payer: Aetna Medicare |
$86.38
|
| Rate for Payer: Aetna Medicare |
$76.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$112.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.81
|
| Rate for Payer: BCBS Complete |
$69.10
|
| Rate for Payer: BCBS Complete |
$160.31
|
| Rate for Payer: BCBS Complete |
$91.21
|
| Rate for Payer: BCBS Complete |
$60.81
|
| Rate for Payer: BCBS Complete |
$187.95
|
| Rate for Payer: Cash Price |
$121.62
|
| Rate for Payer: Cash Price |
$182.42
|
| Rate for Payer: Cash Price |
$375.90
|
| Rate for Payer: Cash Price |
$138.20
|
| Rate for Payer: Cash Price |
$320.62
|
| Rate for Payer: Cofinity Commercial |
$344.67
|
| Rate for Payer: Cofinity Commercial |
$106.41
|
| Rate for Payer: Cofinity Commercial |
$130.74
|
| Rate for Payer: Cofinity Commercial |
$120.92
|
| Rate for Payer: Cofinity Commercial |
$148.56
|
| Rate for Payer: Cofinity Commercial |
$159.62
|
| Rate for Payer: Cofinity Commercial |
$196.11
|
| Rate for Payer: Cofinity Commercial |
$280.55
|
| Rate for Payer: Cofinity Commercial |
$328.92
|
| Rate for Payer: Cofinity Commercial |
$404.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$159.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$120.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$280.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$106.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$328.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.20
|
| Rate for Payer: Healthscope Commercial |
$155.47
|
| Rate for Payer: Healthscope Commercial |
$136.82
|
| Rate for Payer: Healthscope Commercial |
$360.70
|
| Rate for Payer: Healthscope Commercial |
$422.89
|
| Rate for Payer: Healthscope Commercial |
$205.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$193.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.40
|
| Rate for Payer: PHP Commercial |
$340.66
|
| Rate for Payer: PHP Commercial |
$193.83
|
| Rate for Payer: PHP Commercial |
$146.84
|
| Rate for Payer: PHP Commercial |
$129.22
|
| Rate for Payer: PHP Commercial |
$399.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.22
|
| Rate for Payer: Priority Health SBD |
$296.02
|
| Rate for Payer: Priority Health SBD |
$95.77
|
| Rate for Payer: Priority Health SBD |
$108.83
|
| Rate for Payer: Priority Health SBD |
$252.49
|
| Rate for Payer: Priority Health SBD |
$143.66
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION
|
Facility
|
OP
|
$27.70
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$24.93 |
| Rate for Payer: Aetna Commercial |
$23.55
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$47.47
|
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Aetna Medicare |
$27.93
|
| Rate for Payer: Aetna Medicare |
$13.85
|
| Rate for Payer: Aetna Medicare |
$10.72
|
| Rate for Payer: Aetna Medicare |
$7.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.99
|
| Rate for Payer: BCBS Complete |
$8.58
|
| Rate for Payer: BCBS Complete |
$11.08
|
| Rate for Payer: BCBS Complete |
$8.90
|
| Rate for Payer: BCBS Complete |
$6.15
|
| Rate for Payer: BCBS Complete |
$22.34
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$44.68
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$22.16
|
| Rate for Payer: Cofinity Commercial |
$23.82
|
| Rate for Payer: Cofinity Commercial |
$10.76
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$15.01
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$15.57
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Commercial |
$19.39
|
| Rate for Payer: Cofinity Commercial |
$39.09
|
| Rate for Payer: Cofinity Commercial |
$48.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.15
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Commercial |
$13.83
|
| Rate for Payer: Healthscope Commercial |
$24.93
|
| Rate for Payer: Healthscope Commercial |
$50.27
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.47
|
| Rate for Payer: PHP Commercial |
$23.55
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$18.22
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: PHP Commercial |
$47.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health SBD |
$35.19
|
| Rate for Payer: Priority Health SBD |
$9.68
|
| Rate for Payer: Priority Health SBD |
$13.51
|
| Rate for Payer: Priority Health SBD |
$17.45
|
| Rate for Payer: Priority Health SBD |
$14.02
|
|
|
MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION
|
Facility
|
IP
|
$15.37
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
4720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$23.55
|
| Rate for Payer: Aetna Commercial |
$47.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.94
|
| Rate for Payer: Cash Price |
$44.68
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$22.16
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cofinity Commercial |
$15.01
|
| Rate for Payer: Cofinity Commercial |
$10.76
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$48.03
|
| Rate for Payer: Cofinity Commercial |
$39.09
|
| Rate for Payer: Cofinity Commercial |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$23.82
|
| Rate for Payer: Cofinity Commercial |
$19.39
|
| Rate for Payer: Cofinity Commercial |
$15.57
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.68
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Commercial |
$13.83
|
| Rate for Payer: Healthscope Commercial |
$24.93
|
| Rate for Payer: Healthscope Commercial |
$50.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: PHP Commercial |
$23.55
|
| Rate for Payer: PHP Commercial |
$47.47
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$18.22
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.00
|
| Rate for Payer: Priority Health SBD |
$17.45
|
| Rate for Payer: Priority Health SBD |
$13.51
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: Priority Health SBD |
$9.68
|
| Rate for Payer: Priority Health SBD |
$35.19
|
|
|
MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES)
|
Facility
|
OP
|
$4,393.64
|
|
|
Service Code
|
CPT 27570
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.62 |
| Max. Negotiated Rate |
$4,393.64 |
| Rate for Payer: Aetna Medicare |
$1,623.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,951.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,951.06
|
| Rate for Payer: BCBS Complete |
$878.45
|
| Rate for Payer: BCBS MAPPO |
$1,560.85
|
| Rate for Payer: BCN Medicare Advantage |
$1,560.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,560.85
|
| Rate for Payer: Mclaren Medicaid |
$836.62
|
| Rate for Payer: Mclaren Medicare |
$1,560.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,638.89
|
| Rate for Payer: Meridian Medicaid |
$878.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,794.98
|
| Rate for Payer: PACE Medicare |
$1,482.81
|
| Rate for Payer: PACE SWMI |
$1,560.85
|
| Rate for Payer: PHP Medicare Advantage |
$1,560.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$836.62
|
| Rate for Payer: Priority Health Medicare |
$1,560.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,560.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,393.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,560.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,560.85
|
| Rate for Payer: UHCCP Medicaid |
$878.76
|
| Rate for Payer: VA VA |
$1,560.85
|
|
|
MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED)
|
Facility
|
OP
|
$4,393.64
|
|
|
Service Code
|
CPT 23700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$836.62 |
| Max. Negotiated Rate |
$4,393.64 |
| Rate for Payer: Aetna Medicare |
$1,623.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,951.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,951.06
|
| Rate for Payer: BCBS Complete |
$878.45
|
| Rate for Payer: BCBS MAPPO |
$1,560.85
|
| Rate for Payer: BCN Medicare Advantage |
$1,560.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,560.85
|
| Rate for Payer: Mclaren Medicaid |
$836.62
|
| Rate for Payer: Mclaren Medicare |
$1,560.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,638.89
|
| Rate for Payer: Meridian Medicaid |
$878.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,794.98
|
| Rate for Payer: PACE Medicare |
$1,482.81
|
| Rate for Payer: PACE SWMI |
$1,560.85
|
| Rate for Payer: PHP Medicare Advantage |
$1,560.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$836.62
|
| Rate for Payer: Priority Health Medicare |
$1,560.85
|
| Rate for Payer: Railroad Medicare Medicare |
$1,560.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,393.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,560.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,560.85
|
| Rate for Payer: UHCCP Medicaid |
$878.76
|
| Rate for Payer: VA VA |
$1,560.85
|
|
