|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$78.33
|
|
|
Service Code
|
NDC 65219005209
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$70.50 |
| Rate for Payer: Aetna Commercial |
$66.58
|
| Rate for Payer: Aetna Medicare |
$20.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.48
|
| Rate for Payer: BCBS Complete |
$31.33
|
| Rate for Payer: BCBS MAPPO |
$19.58
|
| Rate for Payer: BCBS Trust/PPO |
$64.40
|
| Rate for Payer: BCN Commercial |
$60.90
|
| Rate for Payer: BCN Medicare Advantage |
$19.58
|
| 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: Health Alliance Plan Medicare Advantage |
$19.58
|
| Rate for Payer: Healthscope Commercial |
$70.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.58
|
| Rate for Payer: Nomi Health Commercial |
$64.23
|
| Rate for Payer: PACE Senior Care Partners |
$18.60
|
| Rate for Payer: PACE SWMI |
$19.58
|
| Rate for Payer: PHP Commercial |
$66.58
|
| Rate for Payer: PHP Medicare Advantage |
$19.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.91
|
| Rate for Payer: Priority Health HMO/PPO |
$68.15
|
| Rate for Payer: Priority Health Medicare |
$19.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.48
|
| Rate for Payer: Railroad Medicare Medicare |
$19.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.93
|
| Rate for Payer: UHC Core |
$65.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.58
|
| Rate for Payer: UHC Exchange |
$19.58
|
| Rate for Payer: UHC Medicare Advantage |
$19.58
|
| Rate for Payer: VA VA |
$19.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.75
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$77.78
|
|
|
Service Code
|
NDC 63323008605
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.56 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna Commercial |
$66.11
|
| Rate for Payer: BCBS Trust/PPO |
$63.49
|
| 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 Commercial |
$66.11
|
| Rate for Payer: Nomi Health Commercial |
$63.78
|
| Rate for Payer: PHP Commercial |
$66.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.56
|
| Rate for Payer: Priority Health HMO/PPO |
$67.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.11
|
| 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
|
OP
|
$77.78
|
|
|
Service Code
|
NDC 63323008605
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.47 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna Commercial |
$66.11
|
| Rate for Payer: Aetna Medicare |
$20.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.31
|
| Rate for Payer: BCBS Complete |
$31.11
|
| Rate for Payer: BCBS MAPPO |
$19.45
|
| Rate for Payer: BCBS Trust/PPO |
$63.94
|
| Rate for Payer: BCN Commercial |
$60.47
|
| Rate for Payer: BCN Medicare Advantage |
$19.45
|
| 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: Health Alliance Plan Medicare Advantage |
$19.45
|
| Rate for Payer: Healthscope Commercial |
$70.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.11
|
| Rate for Payer: Nomi Health Commercial |
$63.78
|
| Rate for Payer: PACE Senior Care Partners |
$18.47
|
| Rate for Payer: PACE SWMI |
$19.45
|
| Rate for Payer: PHP Commercial |
$66.11
|
| Rate for Payer: PHP Medicare Advantage |
$19.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.56
|
| Rate for Payer: Priority Health HMO/PPO |
$67.67
|
| Rate for Payer: Priority Health Medicare |
$19.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.11
|
| Rate for Payer: Railroad Medicare Medicare |
$19.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.45
|
| Rate for Payer: UHC Core |
$64.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.45
|
| Rate for Payer: UHC Exchange |
$19.45
|
| Rate for Payer: UHC Medicare Advantage |
$19.45
|
| Rate for Payer: VA VA |
$19.45
|
| 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 65219005229
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.91 |
| Max. Negotiated Rate |
$70.50 |
| Rate for Payer: Aetna Commercial |
$66.58
|
| Rate for Payer: BCBS Trust/PPO |
$63.94
|
| 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 Commercial |
$66.58
|
| Rate for Payer: Nomi Health Commercial |
$64.23
|
| Rate for Payer: PHP Commercial |
$66.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.91
|
| Rate for Payer: Priority Health HMO/PPO |
$68.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.48
|
| 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
|
$199.45
|
|
|
Service Code
|
NDC 00409729501
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$129.64 |
| Max. Negotiated Rate |
$179.50 |
| Rate for Payer: Aetna Commercial |
$169.53
|
| Rate for Payer: BCBS Trust/PPO |
$162.81
|
| Rate for Payer: BCN Commercial |
$154.13
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$171.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.56
|
| Rate for Payer: Healthscope Commercial |
$179.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.53
|
| Rate for Payer: Nomi Health Commercial |
$163.55
|
| Rate for Payer: PHP Commercial |
$169.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.64
|
| Rate for Payer: Priority Health HMO/PPO |
$173.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$133.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.52
|
| Rate for Payer: UHC Core |
$166.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.59
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$78.33
|
|
|
Service Code
|
NDC 65219005229
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$70.50 |
| Rate for Payer: Aetna Commercial |
$66.58
|
| Rate for Payer: Aetna Medicare |
$20.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.48
|
| Rate for Payer: BCBS Complete |
$31.33
|
| Rate for Payer: BCBS MAPPO |
$19.58
|
| Rate for Payer: BCBS Trust/PPO |
$64.40
|
| Rate for Payer: BCN Commercial |
$60.90
|
| Rate for Payer: BCN Medicare Advantage |
$19.58
|
| 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: Health Alliance Plan Medicare Advantage |
$19.58
|
| Rate for Payer: Healthscope Commercial |
$70.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.58
|
| Rate for Payer: Nomi Health Commercial |
$64.23
|
| Rate for Payer: PACE Senior Care Partners |
$18.60
|
| Rate for Payer: PACE SWMI |
$19.58
|
| Rate for Payer: PHP Commercial |
$66.58
|
| Rate for Payer: PHP Medicare Advantage |
$19.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.91
|
| Rate for Payer: Priority Health HMO/PPO |
$68.15
|
| Rate for Payer: Priority Health Medicare |
$19.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.48
|
| Rate for Payer: Railroad Medicare Medicare |
$19.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.93
|
| Rate for Payer: UHC Core |
$65.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.58
|
| Rate for Payer: UHC Exchange |
$19.58
|
| Rate for Payer: UHC Medicare Advantage |
$19.58
|
| Rate for Payer: VA VA |
$19.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.75
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$199.45
|
|
|
Service Code
|
NDC 00409729501
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.37 |
| Max. Negotiated Rate |
$179.50 |
| Rate for Payer: Aetna Commercial |
$169.53
|
| Rate for Payer: Aetna Medicare |
$51.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.33
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.33
|
| Rate for Payer: BCBS Complete |
$79.78
|
| Rate for Payer: BCBS MAPPO |
$49.86
|
| Rate for Payer: BCBS Trust/PPO |
$163.97
|
| Rate for Payer: BCN Commercial |
$155.07
|
| Rate for Payer: BCN Medicare Advantage |
$49.86
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$171.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49.86
|
| Rate for Payer: Healthscope Commercial |
$179.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.53
|
| Rate for Payer: Nomi Health Commercial |
$163.55
|
| Rate for Payer: PACE Senior Care Partners |
$47.37
|
| Rate for Payer: PACE SWMI |
$49.86
|
| Rate for Payer: PHP Commercial |
$169.53
|
| Rate for Payer: PHP Medicare Advantage |
$49.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.64
|
| Rate for Payer: Priority Health HMO/PPO |
$173.52
|
| Rate for Payer: Priority Health Medicare |
$50.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$133.63
|
| Rate for Payer: Railroad Medicare Medicare |
$49.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.52
|
| Rate for Payer: UHC Core |
$166.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$49.86
|
| Rate for Payer: UHC Exchange |
$49.86
|
| Rate for Payer: UHC Medicare Advantage |
$49.86
|
| Rate for Payer: VA VA |
$49.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.59
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
OP
|
$14.94
|
|
|
Service Code
|
NDC 52380190508
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: Aetna Medicare |
$3.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.67
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.67
|
| Rate for Payer: BCBS Complete |
$5.98
|
| Rate for Payer: BCBS MAPPO |
$3.73
|
| Rate for Payer: BCBS Trust/PPO |
$12.28
|
| Rate for Payer: BCN Commercial |
$11.62
|
| Rate for Payer: BCN Medicare Advantage |
$3.73
|
| 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: Health Alliance Plan Medicare Advantage |
$3.73
|
| Rate for Payer: Healthscope Commercial |
$13.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.70
|
| Rate for Payer: Nomi Health Commercial |
$12.25
|
| Rate for Payer: PACE Senior Care Partners |
$3.55
|
| Rate for Payer: PACE SWMI |
$3.73
|
| Rate for Payer: PHP Commercial |
$12.70
|
| Rate for Payer: PHP Medicare Advantage |
$3.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.71
|
| Rate for Payer: Priority Health HMO/PPO |
$13.00
|
| Rate for Payer: Priority Health Medicare |
$3.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.01
|
| Rate for Payer: Railroad Medicare Medicare |
$3.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.15
|
| Rate for Payer: UHC Core |
$12.47
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.73
|
| Rate for Payer: UHC Exchange |
$3.73
|
| Rate for Payer: UHC Medicare Advantage |
$3.73
|
| Rate for Payer: VA VA |
$3.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.21
|
|
|
POVIDONE-IODINE 10 % TOPICAL SOLUTION
|
Facility
|
IP
|
$14.94
|
|
|
Service Code
|
NDC 52380190508
|
| Hospital Charge Code |
6458
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.71 |
| Max. Negotiated Rate |
$13.45 |
| Rate for Payer: Aetna Commercial |
$12.70
|
| Rate for Payer: BCBS Trust/PPO |
$12.20
|
| 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 |
$11.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.70
|
| Rate for Payer: Nomi Health Commercial |
$12.25
|
| Rate for Payer: PHP Commercial |
$12.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.71
|
| Rate for Payer: Priority Health HMO/PPO |
$13.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.01
|
| 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 |
$11.21
|
|
|
PR 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR
|
Professional
|
Both
|
$2,098.00
|
|
|
Service Code
|
HCPCS 54332
|
| Min. Negotiated Rate |
$839.20 |
| Max. Negotiated Rate |
$1,389.10 |
| Rate for Payer: Aetna Commercial |
$1,292.63
|
| Rate for Payer: Aetna Medicare |
$1,003.24
|
| Rate for Payer: BCBS Complete |
$839.20
|
| Rate for Payer: BCBS MAPPO |
$964.65
|
| Rate for Payer: BCN Medicare Advantage |
$964.65
|
| Rate for Payer: Cash Price |
$1,678.40
|
| Rate for Payer: Cash Price |
$1,678.40
|
| Rate for Payer: Cofinity Commercial |
$1,389.10
|
| Rate for Payer: Cofinity Commercial |
$1,292.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$964.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,012.88
|
| Rate for Payer: Nomi Health Commercial |
$1,157.58
|
| Rate for Payer: PACE SWMI |
$964.65
|
| Rate for Payer: PHP Medicare Advantage |
$964.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,363.70
|
| Rate for Payer: Priority Health Medicare |
$974.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$964.65
|
| Rate for Payer: UHC Dual Complete DSNP |
$964.65
|
| Rate for Payer: UHC Exchange |
$964.65
|
| Rate for Payer: UHC Medicare Advantage |
$964.65
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS
|
Professional
|
Both
|
$1,774.00
|
|
|
Service Code
|
HCPCS 54326
|
| Min. Negotiated Rate |
$709.60 |
| Max. Negotiated Rate |
$1,295.71 |
| Rate for Payer: Aetna Commercial |
$1,205.73
|
| Rate for Payer: Aetna Medicare |
$935.79
|
| Rate for Payer: BCBS Complete |
$709.60
|
| Rate for Payer: BCBS MAPPO |
$899.80
|
| Rate for Payer: BCN Medicare Advantage |
$899.80
|
| Rate for Payer: Cash Price |
$1,419.20
|
| Rate for Payer: Cash Price |
$1,419.20
|
| Rate for Payer: Cofinity Commercial |
$1,295.71
|
| Rate for Payer: Cofinity Commercial |
$1,205.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$899.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$944.79
|
| Rate for Payer: Nomi Health Commercial |
$1,079.76
|
| Rate for Payer: PACE SWMI |
$899.80
|
| Rate for Payer: PHP Medicare Advantage |
$899.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,153.10
|
| Rate for Payer: Priority Health Medicare |
$908.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$899.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$899.80
|
| Rate for Payer: UHC Exchange |
$899.80
|
| Rate for Payer: UHC Medicare Advantage |
$899.80
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT
|
Professional
|
Both
|
$5,000.00
|
|
|
Service Code
|
HCPCS 54322
|
| Min. Negotiated Rate |
$746.55 |
| Max. Negotiated Rate |
$3,250.00 |
| Rate for Payer: Aetna Commercial |
$1,000.38
|
| Rate for Payer: Aetna Medicare |
$776.41
|
| Rate for Payer: BCBS Complete |
$2,000.00
|
| Rate for Payer: BCBS MAPPO |
$746.55
|
| Rate for Payer: BCN Medicare Advantage |
$746.55
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cofinity Commercial |
$1,075.03
|
| Rate for Payer: Cofinity Commercial |
$1,000.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$746.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$783.88
|
| Rate for Payer: Nomi Health Commercial |
$895.86
|
| Rate for Payer: PACE SWMI |
$746.55
|
| Rate for Payer: PHP Medicare Advantage |
$746.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,250.00
|
| Rate for Payer: Priority Health Medicare |
$754.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$746.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$746.55
|
| Rate for Payer: UHC Exchange |
$746.55
|
| Rate for Payer: UHC Medicare Advantage |
$746.55
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS
|
Professional
|
Both
|
$2,012.00
|
|
|
Service Code
|
HCPCS 54324
|
| Min. Negotiated Rate |
$804.80 |
| Max. Negotiated Rate |
$1,331.44 |
| Rate for Payer: Aetna Commercial |
$1,238.98
|
| Rate for Payer: Aetna Medicare |
$961.59
|
| Rate for Payer: BCBS Complete |
$804.80
|
| Rate for Payer: BCBS MAPPO |
$924.61
|
| Rate for Payer: BCN Medicare Advantage |
$924.61
|
| Rate for Payer: Cash Price |
$1,609.60
|
| Rate for Payer: Cash Price |
$1,609.60
|
| Rate for Payer: Cofinity Commercial |
$1,331.44
|
| Rate for Payer: Cofinity Commercial |
$1,238.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$924.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$970.84
|
| Rate for Payer: Nomi Health Commercial |
$1,109.53
|
| Rate for Payer: PACE SWMI |
$924.61
|
| Rate for Payer: PHP Medicare Advantage |
$924.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,307.80
|
| Rate for Payer: Priority Health Medicare |
$933.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$924.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$924.61
|
| Rate for Payer: UHC Exchange |
$924.61
|
| Rate for Payer: UHC Medicare Advantage |
$924.61
|
|
|
PR 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
HCPCS 99460
|
| Min. Negotiated Rate |
$63.20 |
| Max. Negotiated Rate |
$125.81 |
| Rate for Payer: Aetna Commercial |
$117.08
|
| Rate for Payer: Aetna Medicare |
$90.86
|
| Rate for Payer: BCBS Complete |
$63.20
|
| Rate for Payer: BCBS MAPPO |
$87.37
|
| Rate for Payer: BCN Medicare Advantage |
$87.37
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cofinity Commercial |
$125.81
|
| Rate for Payer: Cofinity Commercial |
$117.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$87.37
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$91.74
|
| Rate for Payer: Nomi Health Commercial |
$104.84
|
| Rate for Payer: PACE SWMI |
$87.37
|
| Rate for Payer: PHP Medicare Advantage |
$87.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.70
|
| Rate for Payer: Priority Health Medicare |
$88.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$87.37
|
| Rate for Payer: UHC Exchange |
$87.37
|
| Rate for Payer: UHC Medicare Advantage |
$87.37
|
|
|
PR 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS 99463
|
| Min. Negotiated Rate |
$68.80 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: Aetna Commercial |
$136.79
|
| Rate for Payer: Aetna Medicare |
$106.16
|
| Rate for Payer: BCBS Complete |
$68.80
|
| Rate for Payer: BCBS MAPPO |
$102.08
|
| Rate for Payer: BCN Medicare Advantage |
$102.08
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cofinity Commercial |
$147.00
|
| Rate for Payer: Cofinity Commercial |
$136.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$102.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$107.18
|
| Rate for Payer: Nomi Health Commercial |
$122.50
|
| Rate for Payer: PACE SWMI |
$102.08
|
| Rate for Payer: PHP Medicare Advantage |
$102.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.80
|
| Rate for Payer: Priority Health Medicare |
$103.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$102.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$102.08
|
| Rate for Payer: UHC Exchange |
$102.08
|
| Rate for Payer: UHC Medicare Advantage |
$102.08
|
|
|
PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES
|
Professional
|
Both
|
$353.00
|
|
|
Service Code
|
HCPCS 99223
|
| Min. Negotiated Rate |
$141.20 |
| Max. Negotiated Rate |
$237.31 |
| Rate for Payer: Aetna Commercial |
$220.83
|
| Rate for Payer: Aetna Medicare |
$171.39
|
| Rate for Payer: BCBS Complete |
$141.20
|
| Rate for Payer: BCBS MAPPO |
$164.80
|
| Rate for Payer: BCN Medicare Advantage |
$164.80
|
| Rate for Payer: Cash Price |
$282.40
|
| Rate for Payer: Cash Price |
$282.40
|
| Rate for Payer: Cofinity Commercial |
$237.31
|
| Rate for Payer: Cofinity Commercial |
$220.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$164.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$173.04
|
| Rate for Payer: Nomi Health Commercial |
$197.76
|
| Rate for Payer: PACE SWMI |
$164.80
|
| Rate for Payer: PHP Medicare Advantage |
$164.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.45
|
| Rate for Payer: Priority Health Medicare |
$166.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$164.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$164.80
|
| Rate for Payer: UHC Exchange |
$164.80
|
| Rate for Payer: UHC Medicare Advantage |
$164.80
|
|
|
PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
HCPCS 99222
|
| Min. Negotiated Rate |
$96.40 |
| Max. Negotiated Rate |
$178.10 |
| Rate for Payer: Aetna Commercial |
$165.73
|
| Rate for Payer: Aetna Medicare |
$128.63
|
| Rate for Payer: BCBS Complete |
$96.40
|
| Rate for Payer: BCBS MAPPO |
$123.68
|
| Rate for Payer: BCN Medicare Advantage |
$123.68
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Cofinity Commercial |
$178.10
|
| Rate for Payer: Cofinity Commercial |
$165.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$123.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$129.86
|
| Rate for Payer: Nomi Health Commercial |
$148.42
|
| Rate for Payer: PACE SWMI |
$123.68
|
| Rate for Payer: PHP Medicare Advantage |
$123.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.65
|
| Rate for Payer: Priority Health Medicare |
$124.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$123.68
|
| Rate for Payer: UHC Exchange |
$123.68
|
| Rate for Payer: UHC Medicare Advantage |
$123.68
|
|
|
PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
HCPCS 99221
|
| Min. Negotiated Rate |
$70.80 |
| Max. Negotiated Rate |
$115.05 |
| Rate for Payer: Aetna Commercial |
$105.35
|
| Rate for Payer: Aetna Medicare |
$81.76
|
| Rate for Payer: BCBS Complete |
$70.80
|
| Rate for Payer: BCBS MAPPO |
$78.62
|
| Rate for Payer: BCN Medicare Advantage |
$78.62
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cofinity Commercial |
$113.21
|
| Rate for Payer: Cofinity Commercial |
$105.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.55
|
| Rate for Payer: Nomi Health Commercial |
$94.34
|
| Rate for Payer: PACE SWMI |
$78.62
|
| Rate for Payer: PHP Medicare Advantage |
$78.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.05
|
| Rate for Payer: Priority Health Medicare |
$79.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$78.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.62
|
| Rate for Payer: UHC Exchange |
$78.62
|
| Rate for Payer: UHC Medicare Advantage |
$78.62
|
|
|
PR 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/<
|
Professional
|
Both
|
$1,675.00
|
|
|
Service Code
|
HCPCS 99468
|
| Min. Negotiated Rate |
$670.00 |
| Max. Negotiated Rate |
$1,210.87 |
| Rate for Payer: Aetna Commercial |
$1,126.78
|
| Rate for Payer: Aetna Medicare |
$874.52
|
| Rate for Payer: BCBS Complete |
$670.00
|
| Rate for Payer: BCBS MAPPO |
$840.88
|
| Rate for Payer: BCN Medicare Advantage |
$840.88
|
| Rate for Payer: Cash Price |
$1,340.00
|
| Rate for Payer: Cash Price |
$1,340.00
|
| Rate for Payer: Cofinity Commercial |
$1,210.87
|
| Rate for Payer: Cofinity Commercial |
$1,126.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$840.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$882.92
|
| Rate for Payer: Nomi Health Commercial |
$1,009.06
|
| Rate for Payer: PACE SWMI |
$840.88
|
| Rate for Payer: PHP Medicare Advantage |
$840.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,088.75
|
| Rate for Payer: Priority Health Medicare |
$849.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$840.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$840.88
|
| Rate for Payer: UHC Exchange |
$840.88
|
| Rate for Payer: UHC Medicare Advantage |
$840.88
|
|
|
PR 1ST PSYCHIATRIC COLLAB CARE MGMT 1ST 70 MINS
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
HCPCS 99492
|
| Min. Negotiated Rate |
$89.32 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Aetna Commercial |
$119.69
|
| Rate for Payer: Aetna Medicare |
$92.89
|
| Rate for Payer: BCBS Complete |
$126.00
|
| Rate for Payer: BCBS MAPPO |
$89.32
|
| Rate for Payer: BCN Medicare Advantage |
$89.32
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cofinity Commercial |
$128.62
|
| Rate for Payer: Cofinity Commercial |
$119.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$89.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$93.79
|
| Rate for Payer: Nomi Health Commercial |
$107.18
|
| Rate for Payer: PACE SWMI |
$89.32
|
| Rate for Payer: PHP Medicare Advantage |
$89.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.75
|
| Rate for Payer: Priority Health Medicare |
$90.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$89.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$89.32
|
| Rate for Payer: UHC Exchange |
$89.32
|
| Rate for Payer: UHC Medicare Advantage |
$89.32
|
|
|
PR 1ST/SBSQ PSYCH COLLAB CARE MGMT EA ADDL 30 MINS
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
HCPCS 99494
|
| Min. Negotiated Rate |
$38.06 |
| Max. Negotiated Rate |
$83.85 |
| Rate for Payer: Aetna Commercial |
$51.00
|
| Rate for Payer: Aetna Medicare |
$39.58
|
| Rate for Payer: BCBS Complete |
$51.60
|
| Rate for Payer: BCBS MAPPO |
$38.06
|
| Rate for Payer: BCN Medicare Advantage |
$38.06
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cofinity Commercial |
$51.00
|
| Rate for Payer: Cofinity Commercial |
$54.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$38.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.96
|
| Rate for Payer: Nomi Health Commercial |
$45.67
|
| Rate for Payer: PACE SWMI |
$38.06
|
| Rate for Payer: PHP Medicare Advantage |
$38.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.85
|
| Rate for Payer: Priority Health Medicare |
$38.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$38.06
|
| Rate for Payer: UHC Exchange |
$38.06
|
| Rate for Payer: UHC Medicare Advantage |
$38.06
|
|
|
PR 2VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
Professional
|
Both
|
$279.00
|
|
|
Service Code
|
HCPCS 90650
|
| Min. Negotiated Rate |
$111.60 |
| Max. Negotiated Rate |
$181.35 |
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS Complete |
$111.60
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.35
|
|
|
PR 4VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE
|
Professional
|
Both
|
$263.00
|
|
|
Service Code
|
HCPCS 90649
|
| Min. Negotiated Rate |
$105.20 |
| Max. Negotiated Rate |
$170.95 |
| Rate for Payer: Aetna Medicare |
$131.50
|
| Rate for Payer: BCBS Complete |
$105.20
|
| Rate for Payer: Cash Price |
$210.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.95
|
|
|
PR 5% DEXTROSE IN LAC RINGERS
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS J7121
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
|
|
PR 9VHPV VACC 2/3 DOSE SCHED IM USE
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS 90651
|
| Min. Negotiated Rate |
$118.40 |
| Max. Negotiated Rate |
$192.40 |
| Rate for Payer: Aetna Medicare |
$148.00
|
| Rate for Payer: BCBS Complete |
$118.40
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.40
|
|
