|
RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP
|
Facility
|
OP
|
$16,386.90
|
|
|
Service Code
|
CPT 30400
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,212.85 |
| Max. Negotiated Rate |
$16,386.90 |
| Rate for Payer: Aetna Medicare |
$5,413.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,506.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,506.78
|
| Rate for Payer: BCBS Complete |
$2,989.99
|
| Rate for Payer: BCBS MAPPO |
$5,205.42
|
| Rate for Payer: BCBS Trust/PPO |
$1,845.15
|
| Rate for Payer: BCN Medicare Advantage |
$5,205.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,205.42
|
| Rate for Payer: Mclaren Medicaid |
$2,847.36
|
| Rate for Payer: Mclaren Medicare |
$5,205.42
|
| Rate for Payer: Meridian Medicaid |
$2,989.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,465.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,986.23
|
| Rate for Payer: PACE Medicare |
$4,945.15
|
| Rate for Payer: PACE SWMI |
$5,205.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,205.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,847.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,386.90
|
| Rate for Payer: Priority Health Medicare |
$5,205.42
|
| Rate for Payer: Priority Health Narrow Network |
$13,109.52
|
| Rate for Payer: Railroad Medicare Medicare |
$5,205.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,334.14
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,205.42
|
| Rate for Payer: UHC Exchange |
$1,212.85
|
| Rate for Payer: UHC Medicare Advantage |
$5,361.58
|
| Rate for Payer: VA VA |
$5,205.42
|
|
|
RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES)
|
Facility
|
OP
|
$16,386.90
|
|
|
Service Code
|
CPT 30435
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,320.90 |
| Max. Negotiated Rate |
$16,386.90 |
| Rate for Payer: Aetna Medicare |
$5,413.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,506.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,506.78
|
| Rate for Payer: BCBS Complete |
$2,989.99
|
| Rate for Payer: BCBS MAPPO |
$5,205.42
|
| Rate for Payer: BCBS Trust/PPO |
$3,783.79
|
| Rate for Payer: BCN Medicare Advantage |
$5,205.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,205.42
|
| Rate for Payer: Mclaren Medicaid |
$2,847.36
|
| Rate for Payer: Mclaren Medicare |
$5,205.42
|
| Rate for Payer: Meridian Medicaid |
$2,989.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,465.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,986.23
|
| Rate for Payer: PACE Medicare |
$4,945.15
|
| Rate for Payer: PACE SWMI |
$5,205.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,205.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,847.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,386.90
|
| Rate for Payer: Priority Health Medicare |
$5,205.42
|
| Rate for Payer: Priority Health Narrow Network |
$13,109.52
|
| Rate for Payer: Railroad Medicare Medicare |
$5,205.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,452.99
|
| Rate for Payer: UHC Core |
$6,395.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,205.42
|
| Rate for Payer: UHC Exchange |
$1,320.90
|
| Rate for Payer: UHC Medicare Advantage |
$5,361.58
|
| Rate for Payer: VA VA |
$5,205.42
|
|
|
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 |
$114.83 |
| Max. Negotiated Rate |
$234.88 |
| Rate for Payer: Aetna American Axle |
$169.64
|
| Rate for Payer: Aetna American Axle |
$169.63
|
| Rate for Payer: Aetna Commercial |
$221.83
|
| Rate for Payer: Aetna Commercial |
$221.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.63
|
| Rate for Payer: Cash Price |
$208.78
|
| Rate for Payer: Cash Price |
$208.78
|
| Rate for Payer: Cofinity Commercial |
$224.43
|
| Rate for Payer: Cofinity Commercial |
$182.68
|
| Rate for Payer: Cofinity Commercial |
$182.69
|
| Rate for Payer: Cofinity Commercial |
$224.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.78
|
| Rate for Payer: Healthscope Commercial |
$234.88
|
| Rate for Payer: Healthscope Commercial |
$234.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.83
|
| Rate for Payer: PHP Commercial |
$221.82
|
| Rate for Payer: PHP Commercial |
$221.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.69
|
| Rate for Payer: Priority Health SBD |
$164.41
|
| Rate for Payer: Priority Health SBD |
$164.42
|
| Rate for Payer: UMR Bronson Commercial |
$114.83
|
| Rate for Payer: UMR Bronson Commercial |
$114.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.74
|
|
|
RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$260.97
|
|
|
Service Code
|
HCPCS J2790
|
| Hospital Charge Code |
11283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.56 |
| Max. Negotiated Rate |
$291.42 |
| Rate for Payer: Aetna American Axle |
$169.63
|
| Rate for Payer: Aetna Commercial |
$221.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.63
|
| Rate for Payer: BCBS Complete |
$104.39
|
| Rate for Payer: BCBS Trust/PPO |
$291.42
|
| Rate for Payer: Cash Price |
$208.78
|
| Rate for Payer: Cash Price |
$208.78
|
| Rate for Payer: Cofinity Commercial |
$182.68
|
| Rate for Payer: Cofinity Commercial |
$224.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.78
|
| Rate for Payer: Healthscope Commercial |
$234.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.82
|
| Rate for Payer: PHP Commercial |
$221.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.68
|
| Rate for Payer: Priority Health SBD |
$164.41
|
| Rate for Payer: UMR Bronson Commercial |
$96.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.73
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 1,500 UNIT (300 MCG)/1.3 ML INJECT.SOLN
|
Facility
|
IP
|
$1,326.12
|
|
|
Service Code
|
HCPCS J2792
|
| Hospital Charge Code |
70575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$583.49 |
| Max. Negotiated Rate |
$1,193.51 |
| Rate for Payer: Aetna American Axle |
$861.98
|
| Rate for Payer: Aetna Commercial |
$1,127.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$861.98
|
| Rate for Payer: Cash Price |
$1,060.90
|
| Rate for Payer: Cofinity Commercial |
$1,140.46
|
| Rate for Payer: Cofinity Commercial |
$928.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,060.90
|
| Rate for Payer: Healthscope Commercial |
$1,193.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$928.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$994.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,127.20
|
| Rate for Payer: PHP Commercial |
$1,127.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$928.28
|
| Rate for Payer: Priority Health SBD |
$835.46
|
| Rate for Payer: UMR Bronson Commercial |
$583.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$994.59
|
|
|
RHO(D) IMMUNE GLOBULIN-MALTOSE 5,000 UNIT (1,000 MCG)/4.4 ML INJ. SOLN
|
Facility
|
IP
|
$4,419.69
|
|
|
Service Code
|
HCPCS J2792
|
| Hospital Charge Code |
70574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,944.66 |
| Max. Negotiated Rate |
$3,977.72 |
| Rate for Payer: Aetna American Axle |
$2,872.80
|
| Rate for Payer: Aetna Commercial |
$3,756.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,872.80
|
| Rate for Payer: Cash Price |
$3,535.75
|
| Rate for Payer: Cofinity Commercial |
$3,093.78
|
| Rate for Payer: Cofinity Commercial |
$3,800.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,535.75
|
| Rate for Payer: Healthscope Commercial |
$3,977.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,093.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,314.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,756.74
|
| Rate for Payer: PHP Commercial |
$3,756.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,093.78
|
| Rate for Payer: Priority Health SBD |
$2,784.40
|
| Rate for Payer: UMR Bronson Commercial |
$1,944.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,314.77
|
|
|
RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP
|
Facility
|
OP
|
$10,039.01
|
|
|
Service Code
|
CPT 15829
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,744.36 |
| Max. Negotiated Rate |
$10,039.01 |
| Rate for Payer: Aetna Medicare |
$3,316.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,986.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,986.20
|
| Rate for Payer: BCBS Complete |
$1,831.74
|
| Rate for Payer: BCBS MAPPO |
$3,188.96
|
| Rate for Payer: BCBS Trust/PPO |
$2,009.98
|
| Rate for Payer: BCN Medicare Advantage |
$3,188.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,188.96
|
| Rate for Payer: Mclaren Medicaid |
$1,744.36
|
| Rate for Payer: Mclaren Medicare |
$3,188.96
|
| Rate for Payer: Meridian Medicaid |
$1,831.74
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,348.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,667.30
|
| Rate for Payer: PACE Medicare |
$3,029.51
|
| Rate for Payer: PACE SWMI |
$3,188.96
|
| Rate for Payer: PHP Medicare Advantage |
$3,188.96
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,744.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,039.01
|
| Rate for Payer: Priority Health Medicare |
$3,188.96
|
| Rate for Payer: Priority Health Narrow Network |
$8,031.21
|
| Rate for Payer: Railroad Medicare Medicare |
$3,188.96
|
| Rate for Payer: UHC Core |
$5,042.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,188.96
|
| Rate for Payer: UHC Medicare Advantage |
$3,284.63
|
| Rate for Payer: VA VA |
$3,188.96
|
|
|
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 |
$1,499.39 |
| Max. Negotiated Rate |
$3,066.93 |
| Rate for Payer: Aetna American Axle |
$2,215.00
|
| 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: Encore Health Key Benefits Commercial |
$2,726.16
|
| Rate for Payer: Healthscope Commercial |
$3,066.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,385.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,555.78
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$1,499.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,555.78
|
|
|
RIFABUTIN 150 MG CAPSULE
|
Facility
|
IP
|
$10,981.23
|
|
|
Service Code
|
NDC 0013-5301-17
|
| Hospital Charge Code |
11290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,831.74 |
| Max. Negotiated Rate |
$9,883.11 |
| Rate for Payer: Aetna American Axle |
$7,137.80
|
| Rate for Payer: Aetna Commercial |
$9,334.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,137.80
|
| Rate for Payer: Cash Price |
$8,784.98
|
| Rate for Payer: Cofinity Commercial |
$7,686.86
|
| Rate for Payer: Cofinity Commercial |
$9,443.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,784.98
|
| Rate for Payer: Healthscope Commercial |
$9,883.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,686.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,235.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9,334.05
|
| Rate for Payer: PHP Commercial |
$9,334.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,686.86
|
| Rate for Payer: Priority Health SBD |
$6,918.17
|
| Rate for Payer: UMR Bronson Commercial |
$4,831.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,235.92
|
|
|
RIFAMPIN 150 MG CAPSULE
|
Facility
|
IP
|
$91.59
|
|
|
Service Code
|
NDC 68180-658-06
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.30 |
| Max. Negotiated Rate |
$82.43 |
| Rate for Payer: Aetna American Axle |
$59.53
|
| Rate for Payer: Aetna Commercial |
$77.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.53
|
| Rate for Payer: Cash Price |
$73.27
|
| Rate for Payer: Cofinity Commercial |
$64.11
|
| Rate for Payer: Cofinity Commercial |
$78.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.27
|
| Rate for Payer: Healthscope Commercial |
$82.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$64.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.85
|
| Rate for Payer: PHP Commercial |
$77.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.11
|
| Rate for Payer: Priority Health SBD |
$57.70
|
| Rate for Payer: UMR Bronson Commercial |
$40.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.69
|
|
|
RIFAMPIN 150 MG CAPSULE
|
Facility
|
IP
|
$267.40
|
|
|
Service Code
|
NDC 0185-0801-30
|
| Hospital Charge Code |
11292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.66 |
| Max. Negotiated Rate |
$240.66 |
| Rate for Payer: Aetna American Axle |
$173.81
|
| Rate for Payer: Aetna Commercial |
$227.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.81
|
| Rate for Payer: Cash Price |
$213.92
|
| Rate for Payer: Cofinity Commercial |
$187.18
|
| Rate for Payer: Cofinity Commercial |
$229.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.92
|
| Rate for Payer: Healthscope Commercial |
$240.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.29
|
| Rate for Payer: PHP Commercial |
$227.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.18
|
| Rate for Payer: Priority Health SBD |
$168.46
|
| Rate for Payer: UMR Bronson Commercial |
$117.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.55
|
|
|
RIFAMPIN 300 MG CAPSULE
|
Facility
|
IP
|
$266.40
|
|
|
Service Code
|
NDC 0904-5282-61
|
| Hospital Charge Code |
11293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.22 |
| Max. Negotiated Rate |
$239.76 |
| Rate for Payer: Aetna American Axle |
$173.16
|
| Rate for Payer: Aetna Commercial |
$226.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.16
|
| Rate for Payer: Cash Price |
$213.12
|
| Rate for Payer: Cofinity Commercial |
$186.48
|
| Rate for Payer: Cofinity Commercial |
$229.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.12
|
| Rate for Payer: Healthscope Commercial |
$239.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$226.44
|
| Rate for Payer: PHP Commercial |
$226.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.48
|
| Rate for Payer: Priority Health SBD |
$167.83
|
| Rate for Payer: UMR Bronson Commercial |
$117.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.80
|
|
|
RIFAMPIN 300 MG CAPSULE
|
Facility
|
IP
|
$127.40
|
|
|
Service Code
|
NDC 68180-659-06
|
| Hospital Charge Code |
11293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.06 |
| Max. Negotiated Rate |
$114.66 |
| Rate for Payer: Aetna American Axle |
$82.81
|
| Rate for Payer: Aetna Commercial |
$108.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.81
|
| Rate for Payer: Cash Price |
$101.92
|
| Rate for Payer: Cofinity Commercial |
$109.56
|
| Rate for Payer: Cofinity Commercial |
$89.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.92
|
| Rate for Payer: Healthscope Commercial |
$114.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$89.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$108.29
|
| Rate for Payer: PHP Commercial |
$108.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$89.18
|
| Rate for Payer: Priority Health SBD |
$80.26
|
| Rate for Payer: UMR Bronson Commercial |
$56.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.55
|
|
|
RIFAMPIN 300 MG CAPSULE
|
Facility
|
IP
|
$443.52
|
|
|
Service Code
|
NDC 60687-586-01
|
| Hospital Charge Code |
11293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.15 |
| Max. Negotiated Rate |
$399.17 |
| Rate for Payer: Aetna American Axle |
$288.29
|
| Rate for Payer: Aetna Commercial |
$376.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.29
|
| Rate for Payer: Cash Price |
$354.82
|
| Rate for Payer: Cofinity Commercial |
$381.43
|
| Rate for Payer: Cofinity Commercial |
$310.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$354.82
|
| Rate for Payer: Healthscope Commercial |
$399.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$332.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$376.99
|
| Rate for Payer: PHP Commercial |
$376.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$310.46
|
| Rate for Payer: Priority Health SBD |
$279.42
|
| Rate for Payer: UMR Bronson Commercial |
$195.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$332.64
|
|
|
RIFAMPIN 300 MG CAPSULE
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 60687-586-11
|
| Hospital Charge Code |
11293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna American Axle |
$2.89
|
| Rate for Payer: Aetna Commercial |
$3.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.89
|
| Rate for Payer: Cash Price |
$3.55
|
| Rate for Payer: Cofinity Commercial |
$3.11
|
| Rate for Payer: Cofinity Commercial |
$3.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.55
|
| Rate for Payer: Healthscope Commercial |
$4.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.77
|
| Rate for Payer: PHP Commercial |
$3.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.11
|
| Rate for Payer: Priority Health SBD |
$2.80
|
| Rate for Payer: UMR Bronson Commercial |
$1.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.33
|
|
|
RIFAMPIN 300 MG CAPSULE
|
Facility
|
IP
|
$187.20
|
|
|
Service Code
|
NDC 68180-659-07
|
| Hospital Charge Code |
11293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.37 |
| Max. Negotiated Rate |
$168.48 |
| Rate for Payer: Aetna American Axle |
$121.68
|
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.68
|
| Rate for Payer: Cash Price |
$149.76
|
| Rate for Payer: Cofinity Commercial |
$131.04
|
| Rate for Payer: Cofinity Commercial |
$160.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$149.76
|
| Rate for Payer: Healthscope Commercial |
$168.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$140.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$159.12
|
| Rate for Payer: PHP Commercial |
$159.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.04
|
| Rate for Payer: Priority Health SBD |
$117.94
|
| Rate for Payer: UMR Bronson Commercial |
$82.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$140.40
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$424.83
|
|
|
Service Code
|
NDC 67457-445-60
|
| Hospital Charge Code |
11291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.93 |
| Max. Negotiated Rate |
$382.35 |
| Rate for Payer: Aetna American Axle |
$276.14
|
| Rate for Payer: Aetna Commercial |
$361.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.14
|
| Rate for Payer: Cash Price |
$339.86
|
| Rate for Payer: Cofinity Commercial |
$297.38
|
| Rate for Payer: Cofinity Commercial |
$365.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.86
|
| Rate for Payer: Healthscope Commercial |
$382.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$318.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$361.11
|
| Rate for Payer: PHP Commercial |
$361.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.38
|
| Rate for Payer: Priority Health SBD |
$267.64
|
| Rate for Payer: UMR Bronson Commercial |
$186.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$318.62
|
|
|
RIFAMPIN 600 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$505.10
|
|
|
Service Code
|
NDC 63323-351-20
|
| Hospital Charge Code |
11291
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$222.24 |
| Max. Negotiated Rate |
$454.59 |
| Rate for Payer: Aetna American Axle |
$328.32
|
| Rate for Payer: Aetna Commercial |
$429.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$328.32
|
| Rate for Payer: Cash Price |
$404.08
|
| Rate for Payer: Cofinity Commercial |
$353.57
|
| Rate for Payer: Cofinity Commercial |
$434.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$404.08
|
| Rate for Payer: Healthscope Commercial |
$454.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$353.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$378.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$429.34
|
| Rate for Payer: PHP Commercial |
$429.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$353.57
|
| Rate for Payer: Priority Health SBD |
$318.21
|
| Rate for Payer: UMR Bronson Commercial |
$222.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$378.82
|
|
|
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 |
$259.39 |
| Max. Negotiated Rate |
$530.57 |
| Rate for Payer: Aetna American Axle |
$383.19
|
| 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: Encore Health Key Benefits Commercial |
$471.62
|
| Rate for Payer: Healthscope Commercial |
$530.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$412.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$442.14
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$259.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$442.14
|
|
|
RIFAXIMIN 200 MG TABLET
|
Facility
|
IP
|
$1,057.28
|
|
|
Service Code
|
NDC 65649-301-03
|
| Hospital Charge Code |
39063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$465.20 |
| Max. Negotiated Rate |
$951.55 |
| Rate for Payer: Aetna American Axle |
$687.23
|
| Rate for Payer: Aetna Commercial |
$898.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$687.23
|
| Rate for Payer: Cash Price |
$845.82
|
| Rate for Payer: Cofinity Commercial |
$740.10
|
| Rate for Payer: Cofinity Commercial |
$909.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$845.82
|
| Rate for Payer: Healthscope Commercial |
$951.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$740.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$792.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$898.69
|
| Rate for Payer: PHP Commercial |
$898.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$740.10
|
| Rate for Payer: Priority Health SBD |
$666.09
|
| Rate for Payer: UMR Bronson Commercial |
$465.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$792.96
|
|
|
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 |
$4,784.08 |
| Max. Negotiated Rate |
$9,785.61 |
| Rate for Payer: Aetna American Axle |
$7,067.38
|
| 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: Encore Health Key Benefits Commercial |
$8,698.32
|
| Rate for Payer: Healthscope Commercial |
$9,785.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,611.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,154.68
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$4,784.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,154.68
|
|
|
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 |
$4,784.08 |
| Max. Negotiated Rate |
$9,785.61 |
| Rate for Payer: Aetna American Axle |
$7,067.38
|
| 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: Encore Health Key Benefits Commercial |
$8,698.32
|
| Rate for Payer: Healthscope Commercial |
$9,785.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,611.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,154.68
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$4,784.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,154.68
|
|
|
RILPIVIRINE HCL 25 MG TABLET
|
Facility
|
IP
|
$4,870.91
|
|
|
Service Code
|
NDC 59676-278-01
|
| Hospital Charge Code |
152774
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,143.20 |
| Max. Negotiated Rate |
$4,383.82 |
| Rate for Payer: Aetna American Axle |
$3,166.09
|
| Rate for Payer: Aetna Commercial |
$4,140.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,166.09
|
| Rate for Payer: Cash Price |
$3,896.73
|
| Rate for Payer: Cofinity Commercial |
$3,409.64
|
| Rate for Payer: Cofinity Commercial |
$4,188.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,896.73
|
| Rate for Payer: Healthscope Commercial |
$4,383.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,409.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,653.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,140.27
|
| Rate for Payer: PHP Commercial |
$4,140.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,409.64
|
| Rate for Payer: Priority Health SBD |
$3,068.67
|
| Rate for Payer: UMR Bronson Commercial |
$2,143.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,653.18
|
|
|
RIMANTADINE 100 MG TABLET
|
Facility
|
IP
|
$782.55
|
|
|
Service Code
|
NDC 0115-1911-01
|
| Hospital Charge Code |
15440
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$344.32 |
| Max. Negotiated Rate |
$704.30 |
| Rate for Payer: Aetna American Axle |
$508.66
|
| Rate for Payer: Aetna Commercial |
$665.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$508.66
|
| Rate for Payer: Cash Price |
$626.04
|
| Rate for Payer: Cofinity Commercial |
$547.78
|
| Rate for Payer: Cofinity Commercial |
$672.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$626.04
|
| Rate for Payer: Healthscope Commercial |
$704.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$547.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$586.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$665.17
|
| Rate for Payer: PHP Commercial |
$665.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$547.78
|
| Rate for Payer: Priority Health SBD |
$493.01
|
| Rate for Payer: UMR Bronson Commercial |
$344.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$586.91
|
|
|
RINGERS LACTATE INFUSION, UP TO 1000 CC
|
Facility
|
OP
|
$8.34
|
|
|
Service Code
|
CPT J7120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: BCBS Trust/PPO |
$8.34
|
|
