|
REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL AND GLENOID COMPONENT
|
Facility
|
OP
|
$10,676.57
|
|
|
Service Code
|
CPT 23474
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,706.63 |
| Max. Negotiated Rate |
$10,676.57 |
| Rate for Payer: BCBS Trust/PPO |
$10,676.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,877.29
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Exchange |
$1,706.63
|
|
|
REVISION OF TOTAL SHOULDER ARTHROPLASTY, INCLUDING ALLOGRAFT WHEN PERFORMED; HUMERAL OR GLENOID COMPONENT
|
Facility
|
OP
|
$14,638.36
|
|
|
Service Code
|
CPT 23473
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,581.22 |
| Max. Negotiated Rate |
$14,638.36 |
| Rate for Payer: Aetna Medicare |
$12,179.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,638.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,638.36
|
| Rate for Payer: BCBS Complete |
$6,726.62
|
| Rate for Payer: BCBS MAPPO |
$11,710.69
|
| Rate for Payer: BCBS Trust/PPO |
$3,983.54
|
| Rate for Payer: BCN Medicare Advantage |
$11,710.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,710.69
|
| Rate for Payer: Mclaren Medicaid |
$6,405.75
|
| Rate for Payer: Mclaren Medicare |
$11,710.69
|
| Rate for Payer: Meridian Medicaid |
$6,726.62
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,296.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,467.29
|
| Rate for Payer: PACE Medicare |
$11,125.16
|
| Rate for Payer: PACE SWMI |
$11,710.69
|
| Rate for Payer: PHP Medicare Advantage |
$11,710.69
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,405.75
|
| Rate for Payer: Priority Health Medicare |
$11,710.69
|
| Rate for Payer: Railroad Medicare Medicare |
$11,710.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,739.34
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$11,710.69
|
| Rate for Payer: UHC Exchange |
$1,581.22
|
| Rate for Payer: UHC Medicare Advantage |
$12,062.01
|
| Rate for Payer: VA VA |
$11,710.69
|
|
|
REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$15,411.76
|
|
|
Service Code
|
CPT 36832
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$727.90 |
| Max. Negotiated Rate |
$15,411.76 |
| Rate for Payer: Aetna Medicare |
$5,085.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,112.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,112.15
|
| Rate for Payer: BCBS Complete |
$2,808.66
|
| Rate for Payer: BCBS MAPPO |
$4,889.72
|
| Rate for Payer: BCBS Trust/PPO |
$3,230.49
|
| Rate for Payer: BCN Medicare Advantage |
$4,889.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,889.72
|
| Rate for Payer: Mclaren Medicaid |
$2,674.68
|
| Rate for Payer: Mclaren Medicare |
$4,889.72
|
| Rate for Payer: Meridian Medicaid |
$2,808.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,134.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,623.18
|
| Rate for Payer: PACE Medicare |
$4,645.23
|
| Rate for Payer: PACE SWMI |
$4,889.72
|
| Rate for Payer: PHP Medicare Advantage |
$4,889.72
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,674.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,411.76
|
| Rate for Payer: Priority Health Medicare |
$4,889.72
|
| Rate for Payer: Priority Health Narrow Network |
$12,329.41
|
| Rate for Payer: Railroad Medicare Medicare |
$4,889.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$800.69
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,889.72
|
| Rate for Payer: UHC Exchange |
$727.90
|
| Rate for Payer: UHC Medicare Advantage |
$5,036.41
|
| Rate for Payer: VA VA |
$4,889.72
|
|
|
REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$15,411.76
|
|
|
Service Code
|
CPT 36833
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$776.36 |
| Max. Negotiated Rate |
$15,411.76 |
| Rate for Payer: Aetna Medicare |
$5,085.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,112.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,112.15
|
| Rate for Payer: BCBS Complete |
$2,808.66
|
| Rate for Payer: BCBS MAPPO |
$4,889.72
|
| Rate for Payer: BCBS Trust/PPO |
$2,147.59
|
| Rate for Payer: BCN Medicare Advantage |
$4,889.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,889.72
|
| Rate for Payer: Mclaren Medicaid |
$2,674.68
|
| Rate for Payer: Mclaren Medicare |
$4,889.72
|
| Rate for Payer: Meridian Medicaid |
$2,808.66
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,134.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,623.18
|
| Rate for Payer: PACE Medicare |
$4,645.23
|
| Rate for Payer: PACE SWMI |
$4,889.72
|
| Rate for Payer: PHP Medicare Advantage |
$4,889.72
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,674.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,411.76
|
| Rate for Payer: Priority Health Medicare |
$4,889.72
|
| Rate for Payer: Priority Health Narrow Network |
$12,329.41
|
| Rate for Payer: Railroad Medicare Medicare |
$4,889.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$854.00
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,889.72
|
| Rate for Payer: UHC Exchange |
$776.36
|
| Rate for Payer: UHC Medicare Advantage |
$5,036.41
|
| Rate for Payer: VA VA |
$4,889.72
|
|
|
REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY
|
Facility
|
OP
|
$5,427.00
|
|
|
Service Code
|
CPT 63688
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$297.64 |
| Max. Negotiated Rate |
$5,427.00 |
| Rate for Payer: Aetna Medicare |
$3,148.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,784.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,784.44
|
| Rate for Payer: BCBS Complete |
$1,739.02
|
| Rate for Payer: BCBS MAPPO |
$3,027.55
|
| Rate for Payer: BCBS Trust/PPO |
$1,262.04
|
| Rate for Payer: BCN Medicare Advantage |
$3,027.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,027.55
|
| Rate for Payer: Mclaren Medicaid |
$1,656.07
|
| Rate for Payer: Mclaren Medicare |
$3,027.55
|
| Rate for Payer: Meridian Medicaid |
$1,739.02
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,178.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,481.68
|
| Rate for Payer: PACE Medicare |
$2,876.17
|
| Rate for Payer: PACE SWMI |
$3,027.55
|
| Rate for Payer: PHP Medicare Advantage |
$3,027.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,656.07
|
| Rate for Payer: Priority Health Medicare |
$3,027.55
|
| Rate for Payer: Railroad Medicare Medicare |
$3,027.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$327.40
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,027.55
|
| Rate for Payer: UHC Exchange |
$297.64
|
| Rate for Payer: UHC Medicare Advantage |
$3,118.38
|
| Rate for Payer: VA VA |
$3,027.55
|
|
|
REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODE ARRAY
|
Facility
|
OP
|
$10,200.12
|
|
|
Service Code
|
CPT 64585
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$141.78 |
| Max. Negotiated Rate |
$10,200.12 |
| Rate for Payer: Aetna Medicare |
$3,148.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,784.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,784.44
|
| Rate for Payer: BCBS Complete |
$1,739.02
|
| Rate for Payer: BCBS MAPPO |
$3,027.55
|
| Rate for Payer: BCBS Trust/PPO |
$1,262.04
|
| Rate for Payer: BCN Medicare Advantage |
$3,027.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,027.55
|
| Rate for Payer: Mclaren Medicaid |
$1,656.07
|
| Rate for Payer: Mclaren Medicare |
$3,027.55
|
| Rate for Payer: Meridian Medicaid |
$1,739.02
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,178.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,481.68
|
| Rate for Payer: PACE Medicare |
$2,876.17
|
| Rate for Payer: PACE SWMI |
$3,027.55
|
| Rate for Payer: PHP Medicare Advantage |
$3,027.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,656.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,200.12
|
| Rate for Payer: Priority Health Medicare |
$3,027.55
|
| Rate for Payer: Priority Health Narrow Network |
$8,160.10
|
| Rate for Payer: Railroad Medicare Medicare |
$3,027.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$155.96
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,027.55
|
| Rate for Payer: UHC Exchange |
$141.78
|
| Rate for Payer: UHC Medicare Advantage |
$3,118.38
|
| Rate for Payer: VA VA |
$3,027.55
|
|
|
REVISION OR REMOVAL OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, WITH DETACHABLE CONNECTION TO ELECTRODE ARRAY
|
Facility
|
OP
|
$10,200.12
|
|
|
Service Code
|
CPT 64595
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$225.61 |
| Max. Negotiated Rate |
$10,200.12 |
| Rate for Payer: Aetna Medicare |
$3,148.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,784.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,784.44
|
| Rate for Payer: BCBS Complete |
$1,739.02
|
| Rate for Payer: BCBS MAPPO |
$3,027.55
|
| Rate for Payer: BCBS Trust/PPO |
$1,472.38
|
| Rate for Payer: BCN Medicare Advantage |
$3,027.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,027.55
|
| Rate for Payer: Mclaren Medicaid |
$1,656.07
|
| Rate for Payer: Mclaren Medicare |
$3,027.55
|
| Rate for Payer: Meridian Medicaid |
$1,739.02
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,178.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,481.68
|
| Rate for Payer: PACE Medicare |
$2,876.17
|
| Rate for Payer: PACE SWMI |
$3,027.55
|
| Rate for Payer: PHP Medicare Advantage |
$3,027.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,656.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,200.12
|
| Rate for Payer: Priority Health Medicare |
$3,027.55
|
| Rate for Payer: Priority Health Narrow Network |
$8,160.10
|
| Rate for Payer: Railroad Medicare Medicare |
$3,027.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.17
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,027.55
|
| Rate for Payer: UHC Exchange |
$225.61
|
| Rate for Payer: UHC Medicare Advantage |
$3,118.38
|
| Rate for Payer: VA VA |
$3,027.55
|
|
|
REVISION OR REPLACEMENT OF HYPOGLOSSAL NERVE NEUROSTIMULATOR ARRAY AND DISTAL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY, INCLUDING CONNECTION TO EXISTING PULSE GENERATOR
|
Facility
|
OP
|
$15,150.98
|
|
|
Service Code
|
CPT 64583
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$849.38 |
| Max. Negotiated Rate |
$15,150.98 |
| Rate for Payer: Aetna Medicare |
$12,605.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,150.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,150.98
|
| Rate for Payer: BCBS Complete |
$6,962.18
|
| Rate for Payer: BCBS MAPPO |
$12,120.78
|
| Rate for Payer: BCBS Trust/PPO |
$7,438.87
|
| Rate for Payer: BCN Medicare Advantage |
$12,120.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,120.78
|
| Rate for Payer: Mclaren Medicaid |
$6,630.07
|
| Rate for Payer: Mclaren Medicare |
$12,120.78
|
| Rate for Payer: Meridian Medicaid |
$6,962.18
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$12,726.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,938.90
|
| Rate for Payer: PACE Medicare |
$11,514.74
|
| Rate for Payer: PACE SWMI |
$12,120.78
|
| Rate for Payer: PHP Medicare Advantage |
$12,120.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,630.07
|
| Rate for Payer: Priority Health Medicare |
$12,120.78
|
| Rate for Payer: Railroad Medicare Medicare |
$12,120.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$934.32
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$12,120.78
|
| Rate for Payer: UHC Exchange |
$849.38
|
| Rate for Payer: UHC Medicare Advantage |
$12,484.40
|
| Rate for Payer: VA VA |
$12,120.78
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$260.98
|
|
|
Service Code
|
HCPCS J2790
|
| Hospital Charge Code |
11283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$164.42 |
| Max. Negotiated Rate |
$234.88 |
| Rate for Payer: Aetna Commercial |
$221.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.64
|
| Rate for Payer: Cash Price |
$208.78
|
| Rate for Payer: Cofinity Commercial |
$182.69
|
| Rate for Payer: Cofinity Commercial |
$224.44
|
| Rate for Payer: Healthscope Commercial |
$234.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.83
|
| Rate for Payer: PHP Commercial |
$221.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.69
|
| Rate for Payer: Priority Health SBD |
$164.42
|
|
|
RIBOFLAVIN (VITAMIN B2) 100 MG TABLET
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 761003220
|
| 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: Healthscope Commercial |
$145.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.83
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.50
|
| Rate for Payer: Priority Health SBD |
$102.15
|
|
|
RIFABUTIN 150 MG CAPSULE
|
Facility
|
IP
|
$3,407.70
|
|
|
Service Code
|
NDC 59762-1350-1
|
| Hospital Charge Code |
11290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,146.85 |
| Max. Negotiated Rate |
$3,066.93 |
| Rate for Payer: Aetna Commercial |
$2,896.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,215.00
|
| Rate for Payer: Cash Price |
$2,726.16
|
| Rate for Payer: Cofinity Commercial |
$2,385.39
|
| Rate for Payer: Cofinity Commercial |
$2,930.62
|
| Rate for Payer: Healthscope Commercial |
$3,066.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,896.54
|
| Rate for Payer: PHP Commercial |
$2,896.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,385.39
|
| Rate for Payer: Priority Health SBD |
$2,146.85
|
|
|
RIFAMPIN 150 MG CAPSULE
|
Facility
|
IP
|
$201.75
|
|
|
Service Code
|
NDC 60687-575-21
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.10 |
| Max. Negotiated Rate |
$181.58 |
| Rate for Payer: Aetna Commercial |
$171.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.14
|
| Rate for Payer: Cash Price |
$161.40
|
| Rate for Payer: Cofinity Commercial |
$141.22
|
| Rate for Payer: Cofinity Commercial |
$173.50
|
| Rate for Payer: Healthscope Commercial |
$181.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.49
|
| Rate for Payer: PHP Commercial |
$171.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.22
|
| Rate for Payer: Priority Health SBD |
$127.10
|
|
|
RIFAMPIN 150 MG CAPSULE
|
Facility
|
IP
|
$6.73
|
|
|
Service Code
|
NDC 60687-575-11
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$6.06 |
| Rate for Payer: Aetna Commercial |
$5.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.37
|
| Rate for Payer: Cash Price |
$5.38
|
| Rate for Payer: Cofinity Commercial |
$4.71
|
| Rate for Payer: Cofinity Commercial |
$5.79
|
| Rate for Payer: Healthscope Commercial |
$6.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.72
|
| Rate for Payer: PHP Commercial |
$5.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.71
|
| Rate for Payer: Priority Health SBD |
$4.24
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$589.52
|
|
|
Service Code
|
NDC 0068-0597-01
|
| Hospital Charge Code |
11291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$371.40 |
| Max. Negotiated Rate |
$530.57 |
| Rate for Payer: Aetna Commercial |
$501.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$383.19
|
| Rate for Payer: Cash Price |
$471.62
|
| Rate for Payer: Cofinity Commercial |
$412.66
|
| Rate for Payer: Cofinity Commercial |
$506.99
|
| Rate for Payer: Healthscope Commercial |
$530.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$501.09
|
| Rate for Payer: PHP Commercial |
$501.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$412.66
|
| Rate for Payer: Priority Health SBD |
$371.40
|
|
|
RIFAXIMIN 550 MG TABLET
|
Facility
|
IP
|
$10,872.90
|
|
|
Service Code
|
NDC 65649-303-02
|
| Hospital Charge Code |
104604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,849.93 |
| Max. Negotiated Rate |
$9,785.61 |
| Rate for Payer: Aetna Commercial |
$9,241.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,067.38
|
| Rate for Payer: Cash Price |
$8,698.32
|
| Rate for Payer: Cofinity Commercial |
$7,611.03
|
| Rate for Payer: Cofinity Commercial |
$9,350.69
|
| Rate for Payer: Healthscope Commercial |
$9,785.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,241.96
|
| Rate for Payer: PHP Commercial |
$9,241.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,611.03
|
| Rate for Payer: Priority Health SBD |
$6,849.93
|
|
|
RIFAXIMIN 550 MG TABLET
|
Facility
|
IP
|
$10,872.90
|
|
|
Service Code
|
NDC 65649-303-03
|
| Hospital Charge Code |
104604
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,849.93 |
| Max. Negotiated Rate |
$9,785.61 |
| Rate for Payer: Aetna Commercial |
$9,241.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,067.38
|
| Rate for Payer: Cash Price |
$8,698.32
|
| Rate for Payer: Cofinity Commercial |
$7,611.03
|
| Rate for Payer: Cofinity Commercial |
$9,350.69
|
| Rate for Payer: Healthscope Commercial |
$9,785.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,241.96
|
| Rate for Payer: PHP Commercial |
$9,241.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,611.03
|
| Rate for Payer: Priority Health SBD |
$6,849.93
|
|
|
RINGERS LACTATE INFUSION, UP TO 1000 CC
|
Facility
|
OP
|
$7.64
|
|
|
Service Code
|
CPT J7120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$7.64 |
| Rate for Payer: BCBS Trust/PPO |
$7.64
|
|
|
RISPERIDONE 0.25 MG TABLET
|
Facility
|
IP
|
$249.85
|
|
|
Service Code
|
NDC 51079-460-20
|
| Hospital Charge Code |
25519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.41 |
| Max. Negotiated Rate |
$224.86 |
| Rate for Payer: Aetna Commercial |
$212.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.40
|
| Rate for Payer: Cash Price |
$199.88
|
| Rate for Payer: Cofinity Commercial |
$174.90
|
| Rate for Payer: Cofinity Commercial |
$214.87
|
| Rate for Payer: Healthscope Commercial |
$224.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.37
|
| Rate for Payer: PHP Commercial |
$212.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.90
|
| Rate for Payer: Priority Health SBD |
$157.41
|
|
|
RISPERIDONE 0.25 MG TABLET
|
Facility
|
IP
|
$310.20
|
|
|
Service Code
|
NDC 0904-6357-61
|
| Hospital Charge Code |
25519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.43 |
| Max. Negotiated Rate |
$279.18 |
| Rate for Payer: Aetna Commercial |
$263.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.63
|
| Rate for Payer: Cash Price |
$248.16
|
| Rate for Payer: Cofinity Commercial |
$217.14
|
| Rate for Payer: Cofinity Commercial |
$266.77
|
| Rate for Payer: Healthscope Commercial |
$279.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$263.67
|
| Rate for Payer: PHP Commercial |
$263.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.14
|
| Rate for Payer: Priority Health SBD |
$195.43
|
|
|
RISPERIDONE 0.25 MG TABLET
|
Facility
|
IP
|
$399.50
|
|
|
Service Code
|
NDC 68084-270-11
|
| Hospital Charge Code |
25519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.68 |
| Max. Negotiated Rate |
$359.55 |
| Rate for Payer: Aetna Commercial |
$339.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.68
|
| Rate for Payer: Cash Price |
$319.60
|
| Rate for Payer: Cofinity Commercial |
$279.65
|
| Rate for Payer: Cofinity Commercial |
$343.57
|
| Rate for Payer: Healthscope Commercial |
$359.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$339.58
|
| Rate for Payer: PHP Commercial |
$339.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.65
|
| Rate for Payer: Priority Health SBD |
$251.68
|
|
|
RISPERIDONE 0.25 MG TABLET
|
Facility
|
IP
|
$399.50
|
|
|
Service Code
|
NDC 68084-270-01
|
| Hospital Charge Code |
25519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.68 |
| Max. Negotiated Rate |
$359.55 |
| Rate for Payer: Aetna Commercial |
$339.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.68
|
| Rate for Payer: Cash Price |
$319.60
|
| Rate for Payer: Cofinity Commercial |
$279.65
|
| Rate for Payer: Cofinity Commercial |
$343.57
|
| Rate for Payer: Healthscope Commercial |
$359.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$339.58
|
| Rate for Payer: PHP Commercial |
$339.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.65
|
| Rate for Payer: Priority Health SBD |
$251.68
|
|
|
RISPERIDONE 0.5 MG TABLET
|
Facility
|
IP
|
$453.55
|
|
|
Service Code
|
NDC 68084-271-01
|
| Hospital Charge Code |
25520
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.74 |
| Max. Negotiated Rate |
$408.20 |
| Rate for Payer: Aetna Commercial |
$385.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$294.81
|
| Rate for Payer: Cash Price |
$362.84
|
| Rate for Payer: Cofinity Commercial |
$317.48
|
| Rate for Payer: Cofinity Commercial |
$390.05
|
| Rate for Payer: Healthscope Commercial |
$408.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$385.52
|
| Rate for Payer: PHP Commercial |
$385.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.48
|
| Rate for Payer: Priority Health SBD |
$285.74
|
|
|
RISPERIDONE 0.5 MG TABLET
|
Facility
|
IP
|
$453.55
|
|
|
Service Code
|
NDC 68084-271-11
|
| Hospital Charge Code |
25520
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.74 |
| Max. Negotiated Rate |
$408.20 |
| Rate for Payer: Aetna Commercial |
$385.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$294.81
|
| Rate for Payer: Cash Price |
$362.84
|
| Rate for Payer: Cofinity Commercial |
$317.48
|
| Rate for Payer: Cofinity Commercial |
$390.05
|
| Rate for Payer: Healthscope Commercial |
$408.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$385.52
|
| Rate for Payer: PHP Commercial |
$385.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$317.48
|
| Rate for Payer: Priority Health SBD |
$285.74
|
|
|
RISPERIDONE 0.5 MG TABLET
|
Facility
|
IP
|
$399.50
|
|
|
Service Code
|
NDC 0904-6358-61
|
| Hospital Charge Code |
25520
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.68 |
| Max. Negotiated Rate |
$359.55 |
| Rate for Payer: Aetna Commercial |
$339.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.68
|
| Rate for Payer: Cash Price |
$319.60
|
| Rate for Payer: Cofinity Commercial |
$279.65
|
| Rate for Payer: Cofinity Commercial |
$343.57
|
| Rate for Payer: Healthscope Commercial |
$359.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$339.58
|
| Rate for Payer: PHP Commercial |
$339.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.65
|
| Rate for Payer: Priority Health SBD |
$251.68
|
|
|
RISPERIDONE 1 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$389.33
|
|
|
Service Code
|
NDC 49884-315-91
|
| Hospital Charge Code |
35687
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.28 |
| Max. Negotiated Rate |
$350.40 |
| Rate for Payer: Aetna Commercial |
$330.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.06
|
| Rate for Payer: Cash Price |
$311.46
|
| Rate for Payer: Cofinity Commercial |
$272.53
|
| Rate for Payer: Cofinity Commercial |
$334.82
|
| Rate for Payer: Healthscope Commercial |
$350.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$330.93
|
| Rate for Payer: PHP Commercial |
$330.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$272.53
|
| Rate for Payer: Priority Health SBD |
$245.28
|
|
