|
POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$215.65
|
|
|
Service Code
|
NDC 0904-7216-61
|
| Hospital Charge Code |
6436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.52 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: BCBS Trust/PPO |
$166.65
|
| Rate for Payer: BCN Commercial |
$166.65
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.52
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$161.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.30
|
| Rate for Payer: PHP Commercial |
$183.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$187.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$131.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$189.77
|
| Rate for Payer: UHC Core |
$180.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$161.74
|
|
|
POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$336.30
|
|
|
Service Code
|
NDC 66758-160-13
|
| Hospital Charge Code |
6436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.11 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: BCBS Trust/PPO |
$259.89
|
| Rate for Payer: BCN Commercial |
$259.89
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$292.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$205.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$295.94
|
| Rate for Payer: UHC Core |
$280.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$77.78
|
|
|
Service Code
|
NDC 63323-086-05
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.44 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna Commercial |
$66.11
|
| Rate for Payer: BCBS Trust/PPO |
$60.11
|
| Rate for Payer: BCN Commercial |
$60.11
|
| Rate for Payer: Cash Price |
$62.22
|
| Rate for Payer: Cofinity Commercial |
$66.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.22
|
| Rate for Payer: Healthscope Commercial |
$70.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.11
|
| Rate for Payer: PHP Commercial |
$66.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.45
|
| Rate for Payer: UHC Core |
$64.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.34
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$78.33
|
|
|
Service Code
|
NDC 65219-052-29
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.77 |
| Max. Negotiated Rate |
$70.50 |
| Rate for Payer: Aetna Commercial |
$66.58
|
| Rate for Payer: BCBS Trust/PPO |
$60.53
|
| Rate for Payer: BCN Commercial |
$60.53
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Cofinity Commercial |
$67.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.66
|
| Rate for Payer: Healthscope Commercial |
$70.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.58
|
| Rate for Payer: PHP Commercial |
$66.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$68.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.93
|
| Rate for Payer: UHC Core |
$65.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.75
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$183.79
|
|
|
Service Code
|
NDC 0409-7295-01
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$112.09 |
| Max. Negotiated Rate |
$165.41 |
| Rate for Payer: Aetna Commercial |
$156.22
|
| Rate for Payer: BCBS Trust/PPO |
$142.03
|
| Rate for Payer: BCN Commercial |
$142.03
|
| Rate for Payer: Cash Price |
$147.03
|
| Rate for Payer: Cofinity Commercial |
$158.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.03
|
| Rate for Payer: Healthscope Commercial |
$165.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$156.22
|
| Rate for Payer: PHP Commercial |
$156.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$159.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$112.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$161.74
|
| Rate for Payer: UHC Core |
$153.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.84
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$78.33
|
|
|
Service Code
|
NDC 65219-052-09
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.77 |
| Max. Negotiated Rate |
$70.50 |
| Rate for Payer: Aetna Commercial |
$66.58
|
| Rate for Payer: BCBS Trust/PPO |
$60.53
|
| Rate for Payer: BCN Commercial |
$60.53
|
| Rate for Payer: Cash Price |
$62.66
|
| Rate for Payer: Cofinity Commercial |
$67.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.66
|
| Rate for Payer: Healthscope Commercial |
$70.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.58
|
| Rate for Payer: PHP Commercial |
$66.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$68.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.93
|
| Rate for Payer: UHC Core |
$65.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.75
|
|
|
POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB
|
Facility
|
IP
|
$109.98
|
|
|
Service Code
|
NDC 1650004108
|
| Hospital Charge Code |
174294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.08 |
| Max. Negotiated Rate |
$98.98 |
| Rate for Payer: Aetna Commercial |
$93.48
|
| Rate for Payer: BCBS Trust/PPO |
$84.99
|
| Rate for Payer: BCN Commercial |
$84.99
|
| Rate for Payer: Cash Price |
$87.98
|
| Rate for Payer: Cofinity Commercial |
$94.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.98
|
| Rate for Payer: Healthscope Commercial |
$98.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.48
|
| Rate for Payer: PHP Commercial |
$93.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$95.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$96.78
|
| Rate for Payer: UHC Core |
$91.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.48
|
|
|
POVIDONE-IODINE 10 % TOPICAL OINTMENT
|
Facility
|
IP
|
$8.34
|
|
|
Service Code
|
NDC 0904-1102-31
|
| Hospital Charge Code |
6455
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.09 |
| Max. Negotiated Rate |
$7.51 |
| Rate for Payer: Aetna Commercial |
$7.09
|
| Rate for Payer: BCBS Trust/PPO |
$6.45
|
| Rate for Payer: BCN Commercial |
$6.45
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Cofinity Commercial |
$7.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.67
|
| Rate for Payer: Healthscope Commercial |
$7.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.09
|
| Rate for Payer: PHP Commercial |
$7.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.34
|
| Rate for Payer: UHC Core |
$6.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.26
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$14.94
|
|
|
Service Code
|
NDC 52380-1905-8
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: BCBS Trust/PPO |
$11.55
|
| Rate for Payer: BCN Commercial |
$11.55
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: Cofinity Commercial |
$12.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.95
|
| Rate for Payer: Healthscope Commercial |
$13.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.70
|
| Rate for Payer: PHP Commercial |
$12.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.15
|
| Rate for Payer: UHC Core |
$12.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.20
|
|
|
PR 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR
|
Professional
|
Both
|
$2,057.00
|
|
|
Service Code
|
HCPCS 54332
|
| Min. Negotiated Rate |
$640.92 |
| Max. Negotiated Rate |
$2,967.99 |
| Rate for Payer: Aetna Commercial |
$1,320.28
|
| Rate for Payer: Aetna Medicare |
$1,024.69
|
| Rate for Payer: BCBS Complete |
$672.97
|
| Rate for Payer: BCBS MAPPO |
$985.28
|
| Rate for Payer: BCBS Trust/PPO |
$2,967.99
|
| Rate for Payer: BCN Commercial |
$1,452.84
|
| Rate for Payer: BCN Medicare Advantage |
$985.28
|
| Rate for Payer: Cash Price |
$1,645.60
|
| Rate for Payer: Cash Price |
$1,645.60
|
| Rate for Payer: Cofinity Commercial |
$1,320.28
|
| Rate for Payer: Cofinity Commercial |
$1,418.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$985.28
|
| Rate for Payer: Mclaren Medicaid |
$640.92
|
| Rate for Payer: Meridian Medicaid |
$672.97
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,034.54
|
| Rate for Payer: PACE SWMI |
$985.28
|
| Rate for Payer: PHP Medicare Advantage |
$985.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$640.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,439.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,606.49
|
| Rate for Payer: Priority Health Medicare |
$985.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,606.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$985.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$985.28
|
| Rate for Payer: UHC Medicare Advantage |
$1,014.84
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS
|
Professional
|
Both
|
$1,739.00
|
|
|
Service Code
|
HCPCS 54326
|
| Min. Negotiated Rate |
$598.53 |
| Max. Negotiated Rate |
$2,714.41 |
| Rate for Payer: Aetna Commercial |
$1,232.28
|
| Rate for Payer: Aetna Medicare |
$956.39
|
| Rate for Payer: BCBS Complete |
$628.46
|
| Rate for Payer: BCBS MAPPO |
$919.61
|
| Rate for Payer: BCBS Trust/PPO |
$2,714.41
|
| Rate for Payer: BCN Commercial |
$1,356.57
|
| Rate for Payer: BCN Medicare Advantage |
$919.61
|
| Rate for Payer: Cash Price |
$1,391.20
|
| Rate for Payer: Cash Price |
$1,391.20
|
| Rate for Payer: Cofinity Commercial |
$1,324.24
|
| Rate for Payer: Cofinity Commercial |
$1,232.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$919.61
|
| Rate for Payer: Mclaren Medicaid |
$598.53
|
| Rate for Payer: Meridian Medicaid |
$628.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$965.59
|
| Rate for Payer: PACE SWMI |
$919.61
|
| Rate for Payer: PHP Medicare Advantage |
$919.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$598.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,217.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,500.04
|
| Rate for Payer: Priority Health Medicare |
$919.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,500.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$919.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$919.61
|
| Rate for Payer: UHC Medicare Advantage |
$947.20
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT
|
Professional
|
Both
|
$4,902.00
|
|
|
Service Code
|
HCPCS 54322
|
| Min. Negotiated Rate |
$362.41 |
| Max. Negotiated Rate |
$3,431.40 |
| Rate for Payer: Aetna Commercial |
$1,022.53
|
| Rate for Payer: Aetna Medicare |
$793.60
|
| Rate for Payer: BCBS Complete |
$521.56
|
| Rate for Payer: BCBS MAPPO |
$763.08
|
| Rate for Payer: BCBS Trust/PPO |
$362.41
|
| Rate for Payer: BCN Commercial |
$1,126.40
|
| Rate for Payer: BCN Medicare Advantage |
$763.08
|
| Rate for Payer: Cash Price |
$3,921.60
|
| Rate for Payer: Cash Price |
$3,921.60
|
| Rate for Payer: Cofinity Commercial |
$1,098.84
|
| Rate for Payer: Cofinity Commercial |
$1,022.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$763.08
|
| Rate for Payer: Mclaren Medicaid |
$496.72
|
| Rate for Payer: Meridian Medicaid |
$521.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$801.23
|
| Rate for Payer: PACE SWMI |
$763.08
|
| Rate for Payer: PHP Medicare Advantage |
$763.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$496.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,431.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,245.52
|
| Rate for Payer: Priority Health Medicare |
$763.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,245.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$763.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$763.08
|
| Rate for Payer: UHC Medicare Advantage |
$785.97
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS
|
Professional
|
Both
|
$1,972.94
|
|
|
Service Code
|
HCPCS 54324
|
| Min. Negotiated Rate |
$517.21 |
| Max. Negotiated Rate |
$1,540.55 |
| Rate for Payer: Aetna Commercial |
$1,265.90
|
| Rate for Payer: Aetna Medicare |
$982.49
|
| Rate for Payer: BCBS Complete |
$645.46
|
| Rate for Payer: BCBS MAPPO |
$944.70
|
| Rate for Payer: BCBS Trust/PPO |
$517.21
|
| Rate for Payer: BCN Commercial |
$1,393.22
|
| Rate for Payer: BCN Medicare Advantage |
$944.70
|
| Rate for Payer: Cash Price |
$1,578.35
|
| Rate for Payer: Cash Price |
$1,578.35
|
| Rate for Payer: Cofinity Commercial |
$1,360.37
|
| Rate for Payer: Cofinity Commercial |
$1,265.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$944.70
|
| Rate for Payer: Mclaren Medicaid |
$614.72
|
| Rate for Payer: Meridian Medicaid |
$645.46
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$991.94
|
| Rate for Payer: PACE SWMI |
$944.70
|
| Rate for Payer: PHP Medicare Advantage |
$944.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$614.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,381.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,540.55
|
| Rate for Payer: Priority Health Medicare |
$944.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,540.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$944.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$944.70
|
| Rate for Payer: UHC Medicare Advantage |
$973.04
|
|
|
PR 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB
|
Professional
|
Both
|
$155.00
|
|
|
Service Code
|
HCPCS 99460
|
| Min. Negotiated Rate |
$58.58 |
| Max. Negotiated Rate |
$190.72 |
| Rate for Payer: Aetna Commercial |
$122.01
|
| Rate for Payer: Aetna Medicare |
$94.69
|
| Rate for Payer: BCBS Complete |
$61.51
|
| Rate for Payer: BCBS MAPPO |
$91.05
|
| Rate for Payer: BCBS Trust/PPO |
$190.72
|
| Rate for Payer: BCN Commercial |
$133.89
|
| Rate for Payer: BCN Medicare Advantage |
$91.05
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cash Price |
$124.00
|
| Rate for Payer: Cofinity Commercial |
$122.01
|
| Rate for Payer: Cofinity Commercial |
$131.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.05
|
| Rate for Payer: Mclaren Medicaid |
$58.58
|
| Rate for Payer: Meridian Medicaid |
$61.51
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$95.60
|
| Rate for Payer: PACE SWMI |
$91.05
|
| Rate for Payer: PHP Medicare Advantage |
$91.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$58.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$117.36
|
| Rate for Payer: Priority Health Medicare |
$91.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$117.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$91.05
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.05
|
| Rate for Payer: UHC Medicare Advantage |
$93.78
|
|
|
PR 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT
|
Professional
|
Both
|
$169.00
|
|
|
Service Code
|
HCPCS 99463
|
| Min. Negotiated Rate |
$68.37 |
| Max. Negotiated Rate |
$1,537.35 |
| Rate for Payer: Aetna Commercial |
$143.09
|
| Rate for Payer: Aetna Medicare |
$111.05
|
| Rate for Payer: BCBS Complete |
$71.79
|
| Rate for Payer: BCBS MAPPO |
$106.78
|
| Rate for Payer: BCBS Trust/PPO |
$1,537.35
|
| Rate for Payer: BCN Commercial |
$157.35
|
| Rate for Payer: BCN Medicare Advantage |
$106.78
|
| Rate for Payer: Cash Price |
$135.20
|
| Rate for Payer: Cash Price |
$135.20
|
| Rate for Payer: Cofinity Commercial |
$143.09
|
| Rate for Payer: Cofinity Commercial |
$153.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$106.78
|
| Rate for Payer: Mclaren Medicaid |
$68.37
|
| Rate for Payer: Meridian Medicaid |
$71.79
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$112.12
|
| Rate for Payer: PACE SWMI |
$106.78
|
| Rate for Payer: PHP Medicare Advantage |
$106.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$68.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$137.92
|
| Rate for Payer: Priority Health Medicare |
$106.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$137.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$106.78
|
| Rate for Payer: UHC Medicare Advantage |
$109.98
|
|
|
PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES
|
Professional
|
Both
|
$346.00
|
|
|
Service Code
|
HCPCS 99223
|
| Min. Negotiated Rate |
$109.48 |
| Max. Negotiated Rate |
$1,363.01 |
| Rate for Payer: Aetna Commercial |
$228.31
|
| Rate for Payer: Aetna Medicare |
$177.20
|
| Rate for Payer: BCBS Complete |
$114.95
|
| Rate for Payer: BCBS MAPPO |
$170.38
|
| Rate for Payer: BCBS Trust/PPO |
$1,363.01
|
| Rate for Payer: BCN Commercial |
$183.78
|
| Rate for Payer: BCN Medicare Advantage |
$170.38
|
| Rate for Payer: Cash Price |
$276.80
|
| Rate for Payer: Cash Price |
$276.80
|
| Rate for Payer: Cofinity Commercial |
$228.31
|
| Rate for Payer: Cofinity Commercial |
$245.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$170.38
|
| Rate for Payer: Mclaren Medicaid |
$109.48
|
| Rate for Payer: Meridian Medicaid |
$114.95
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$178.90
|
| Rate for Payer: PACE SWMI |
$170.38
|
| Rate for Payer: PHP Medicare Advantage |
$170.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$109.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$219.73
|
| Rate for Payer: Priority Health Medicare |
$170.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$219.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$170.38
|
| Rate for Payer: UHC Medicare Advantage |
$175.49
|
|
|
PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES
|
Professional
|
Both
|
$236.00
|
|
|
Service Code
|
HCPCS 99222
|
| Min. Negotiated Rate |
$82.64 |
| Max. Negotiated Rate |
$2,113.20 |
| Rate for Payer: Aetna Commercial |
$171.43
|
| Rate for Payer: Aetna Medicare |
$133.05
|
| Rate for Payer: BCBS Complete |
$86.77
|
| Rate for Payer: BCBS MAPPO |
$127.93
|
| Rate for Payer: BCBS Trust/PPO |
$2,113.20
|
| Rate for Payer: BCN Commercial |
$137.93
|
| Rate for Payer: BCN Medicare Advantage |
$127.93
|
| Rate for Payer: Cash Price |
$188.80
|
| Rate for Payer: Cash Price |
$188.80
|
| Rate for Payer: Cofinity Commercial |
$184.22
|
| Rate for Payer: Cofinity Commercial |
$171.43
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$127.93
|
| Rate for Payer: Mclaren Medicaid |
$82.64
|
| Rate for Payer: Meridian Medicaid |
$86.77
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$134.33
|
| Rate for Payer: PACE SWMI |
$127.93
|
| Rate for Payer: PHP Medicare Advantage |
$127.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$82.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$164.91
|
| Rate for Payer: Priority Health Medicare |
$127.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$164.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$127.93
|
| Rate for Payer: UHC Dual Complete DSNP |
$127.93
|
| Rate for Payer: UHC Medicare Advantage |
$131.77
|
|
|
PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES
|
Professional
|
Both
|
$174.00
|
|
|
Service Code
|
HCPCS 99221
|
| Min. Negotiated Rate |
$52.40 |
| Max. Negotiated Rate |
$1,817.88 |
| Rate for Payer: Aetna Commercial |
$109.71
|
| Rate for Payer: Aetna Medicare |
$85.14
|
| Rate for Payer: BCBS Complete |
$55.02
|
| Rate for Payer: BCBS MAPPO |
$81.87
|
| Rate for Payer: BCBS Trust/PPO |
$1,817.88
|
| Rate for Payer: BCN Commercial |
$88.13
|
| Rate for Payer: BCN Medicare Advantage |
$81.87
|
| Rate for Payer: Cash Price |
$139.20
|
| Rate for Payer: Cash Price |
$139.20
|
| Rate for Payer: Cofinity Commercial |
$117.89
|
| Rate for Payer: Cofinity Commercial |
$109.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$81.87
|
| Rate for Payer: Mclaren Medicaid |
$52.40
|
| Rate for Payer: Meridian Medicaid |
$55.02
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$85.96
|
| Rate for Payer: PACE SWMI |
$81.87
|
| Rate for Payer: PHP Medicare Advantage |
$81.87
|
| Rate for Payer: Priority Health Choice Medicaid |
$52.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$105.36
|
| Rate for Payer: Priority Health Medicare |
$81.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$105.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$81.87
|
| Rate for Payer: UHC Dual Complete DSNP |
$81.87
|
| Rate for Payer: UHC Medicare Advantage |
$84.33
|
|
|
PR 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/<
|
Professional
|
Both
|
$1,642.00
|
|
|
Service Code
|
HCPCS 99468
|
| Min. Negotiated Rate |
$127.77 |
| Max. Negotiated Rate |
$1,290.60 |
| Rate for Payer: Aetna Commercial |
$1,176.41
|
| Rate for Payer: Aetna Medicare |
$913.04
|
| Rate for Payer: BCBS Complete |
$881.36
|
| Rate for Payer: BCBS MAPPO |
$877.92
|
| Rate for Payer: BCBS Trust/PPO |
$127.77
|
| Rate for Payer: BCN Commercial |
$1,290.60
|
| Rate for Payer: BCN Medicare Advantage |
$877.92
|
| Rate for Payer: Cash Price |
$1,313.60
|
| Rate for Payer: Cash Price |
$1,313.60
|
| Rate for Payer: Cofinity Commercial |
$1,264.20
|
| Rate for Payer: Cofinity Commercial |
$1,176.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$877.92
|
| Rate for Payer: Mclaren Medicaid |
$839.39
|
| Rate for Payer: Meridian Medicaid |
$881.36
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$921.82
|
| Rate for Payer: PACE SWMI |
$877.92
|
| Rate for Payer: PHP Medicare Advantage |
$877.92
|
| Rate for Payer: Priority Health Choice Medicaid |
$839.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,149.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,131.19
|
| Rate for Payer: Priority Health Medicare |
$877.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,131.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$877.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$877.92
|
| Rate for Payer: UHC Medicare Advantage |
$904.26
|
|
|
PR 1ST PSYCHIATRIC COLLAB CARE MGMT 1ST 70 MINS
|
Professional
|
Both
|
$309.00
|
|
|
Service Code
|
HCPCS 99492
|
| Min. Negotiated Rate |
$59.43 |
| Max. Negotiated Rate |
$1,323.39 |
| Rate for Payer: Aetna Commercial |
$121.85
|
| Rate for Payer: Aetna Medicare |
$94.57
|
| Rate for Payer: BCBS Complete |
$62.40
|
| Rate for Payer: BCBS MAPPO |
$90.93
|
| Rate for Payer: BCBS Trust/PPO |
$1,323.39
|
| Rate for Payer: BCN Commercial |
$193.46
|
| Rate for Payer: BCN Medicare Advantage |
$90.93
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cofinity Commercial |
$130.94
|
| Rate for Payer: Cofinity Commercial |
$121.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$90.93
|
| Rate for Payer: Mclaren Medicaid |
$59.43
|
| Rate for Payer: Meridian Medicaid |
$62.40
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$95.48
|
| Rate for Payer: PACE SWMI |
$90.93
|
| Rate for Payer: PHP Medicare Advantage |
$90.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$172.40
|
| Rate for Payer: Priority Health Medicare |
$90.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$172.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.93
|
| Rate for Payer: UHC Dual Complete DSNP |
$90.93
|
| Rate for Payer: UHC Medicare Advantage |
$93.66
|
|
|
PR 1ST/SBSQ PSYCH COLLAB CARE MGMT EA ADDL 30 MINS
|
Professional
|
Both
|
$126.00
|
|
|
Service Code
|
HCPCS 99494
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$984.75 |
| Rate for Payer: Aetna Commercial |
$53.40
|
| Rate for Payer: Aetna Medicare |
$41.44
|
| Rate for Payer: BCBS Complete |
$27.29
|
| Rate for Payer: BCBS MAPPO |
$39.85
|
| Rate for Payer: BCBS Trust/PPO |
$984.75
|
| Rate for Payer: BCN Commercial |
$79.98
|
| Rate for Payer: BCN Medicare Advantage |
$39.85
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cofinity Commercial |
$53.40
|
| Rate for Payer: Cofinity Commercial |
$57.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$39.85
|
| Rate for Payer: Mclaren Medicaid |
$25.99
|
| Rate for Payer: Meridian Medicaid |
$27.29
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$41.84
|
| Rate for Payer: PACE SWMI |
$39.85
|
| Rate for Payer: PHP Medicare Advantage |
$39.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$25.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$82.71
|
| Rate for Payer: Priority Health Medicare |
$39.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$82.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$39.85
|
| Rate for Payer: UHC Medicare Advantage |
$41.05
|
|
|
PR 2VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
Professional
|
Both
|
$274.00
|
|
|
Service Code
|
HCPCS 90650
|
| Min. Negotiated Rate |
$109.60 |
| Max. Negotiated Rate |
$191.80 |
| Rate for Payer: Aetna Commercial |
$141.25
|
| Rate for Payer: BCBS Complete |
$109.60
|
| Rate for Payer: BCBS Trust/PPO |
$133.16
|
| Rate for Payer: BCN Commercial |
$133.16
|
| Rate for Payer: Cash Price |
$219.20
|
| Rate for Payer: Cash Price |
$219.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.80
|
|
|
PR 4VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
Professional
|
Both
|
$258.00
|
|
|
Service Code
|
HCPCS 90649
|
| Min. Negotiated Rate |
$103.20 |
| Max. Negotiated Rate |
$180.60 |
| Rate for Payer: Aetna Commercial |
$163.24
|
| Rate for Payer: BCBS Complete |
$103.20
|
| Rate for Payer: BCBS Trust/PPO |
$160.17
|
| Rate for Payer: BCN Commercial |
$160.17
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Cash Price |
$206.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.60
|
|
|
PR 5% DEXTROSE IN LAC RINGERS
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS J7121
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna Commercial |
$7.42
|
| Rate for Payer: BCBS Complete |
$12.00
|
| Rate for Payer: BCBS Trust/PPO |
$1.86
|
| Rate for Payer: BCN Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.00
|
|
|
PR 9VHPV VACC 2/3 DOSE SCHED IM USE
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS 90651
|
| Min. Negotiated Rate |
$116.00 |
| Max. Negotiated Rate |
$293.16 |
| Rate for Payer: Aetna Commercial |
$293.16
|
| Rate for Payer: BCBS Complete |
$116.00
|
| Rate for Payer: BCBS Trust/PPO |
$277.00
|
| Rate for Payer: BCN Commercial |
$265.15
|
| Rate for Payer: Cash Price |
$232.00
|
| Rate for Payer: Cash Price |
$232.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.00
|
|
