|
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 |
$79.78 |
| Max. Negotiated Rate |
$199.45 |
| Rate for Payer: Aetna Commercial |
$179.50
|
| Rate for Payer: Aetna Medicare |
$99.72
|
| Rate for Payer: ASR ASR |
$193.47
|
| Rate for Payer: ASR Commercial |
$193.47
|
| Rate for Payer: BCBS Complete |
$79.78
|
| Rate for Payer: BCBS Trust/PPO |
$163.33
|
| Rate for Payer: BCN Commercial |
$154.63
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$187.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.56
|
| Rate for Payer: Healthscope Commercial |
$199.45
|
| Rate for Payer: Healthscope Whirlpool |
$193.47
|
| Rate for Payer: Mclaren Commercial |
$179.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.53
|
| Rate for Payer: Nomi Health Commercial |
$163.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$174.76
|
| Rate for Payer: Priority Health Narrow Network |
$139.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$175.52
|
|
|
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 |
$199.45 |
| Rate for Payer: Aetna Commercial |
$179.50
|
| Rate for Payer: ASR ASR |
$193.47
|
| Rate for Payer: ASR Commercial |
$193.47
|
| Rate for Payer: BCBS Trust/PPO |
$162.53
|
| Rate for Payer: BCN Commercial |
$154.63
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$187.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.56
|
| Rate for Payer: Healthscope Commercial |
$199.45
|
| Rate for Payer: Healthscope Whirlpool |
$193.47
|
| Rate for Payer: Mclaren Commercial |
$179.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.53
|
| Rate for Payer: Nomi Health Commercial |
$163.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$175.52
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$410.64
|
|
|
Service Code
|
NDC 63323008615
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.26 |
| Max. Negotiated Rate |
$410.64 |
| Rate for Payer: Aetna Commercial |
$369.58
|
| Rate for Payer: Aetna Medicare |
$205.32
|
| Rate for Payer: ASR ASR |
$398.32
|
| Rate for Payer: ASR Commercial |
$398.32
|
| Rate for Payer: BCBS Complete |
$164.26
|
| Rate for Payer: BCBS Trust/PPO |
$336.27
|
| Rate for Payer: BCN Commercial |
$318.37
|
| Rate for Payer: Cash Price |
$328.51
|
| Rate for Payer: Cofinity Commercial |
$386.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.51
|
| Rate for Payer: Healthscope Commercial |
$410.64
|
| Rate for Payer: Healthscope Whirlpool |
$398.32
|
| Rate for Payer: Mclaren Commercial |
$369.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.04
|
| Rate for Payer: Nomi Health Commercial |
$336.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$359.80
|
| Rate for Payer: Priority Health Narrow Network |
$287.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$361.36
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$199.45
|
|
|
Service Code
|
NDC 00409729511
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.78 |
| Max. Negotiated Rate |
$199.45 |
| Rate for Payer: Aetna Commercial |
$179.50
|
| Rate for Payer: Aetna Medicare |
$99.72
|
| Rate for Payer: ASR ASR |
$193.47
|
| Rate for Payer: ASR Commercial |
$193.47
|
| Rate for Payer: BCBS Complete |
$79.78
|
| Rate for Payer: BCBS Trust/PPO |
$163.33
|
| Rate for Payer: BCN Commercial |
$154.63
|
| Rate for Payer: Cash Price |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$187.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.56
|
| Rate for Payer: Healthscope Commercial |
$199.45
|
| Rate for Payer: Healthscope Whirlpool |
$193.47
|
| Rate for Payer: Mclaren Commercial |
$179.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.53
|
| Rate for Payer: Nomi Health Commercial |
$163.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$174.76
|
| Rate for Payer: Priority Health Narrow Network |
$139.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$175.52
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$410.64
|
|
|
Service Code
|
NDC 63323008615
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$266.92 |
| Max. Negotiated Rate |
$410.64 |
| Rate for Payer: Aetna Commercial |
$369.58
|
| Rate for Payer: ASR ASR |
$398.32
|
| Rate for Payer: ASR Commercial |
$398.32
|
| Rate for Payer: BCBS Trust/PPO |
$334.63
|
| Rate for Payer: BCN Commercial |
$318.37
|
| Rate for Payer: Cash Price |
$328.51
|
| Rate for Payer: Cofinity Commercial |
$386.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.51
|
| Rate for Payer: Healthscope Commercial |
$410.64
|
| Rate for Payer: Healthscope Whirlpool |
$398.32
|
| Rate for Payer: Mclaren Commercial |
$369.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.04
|
| Rate for Payer: Nomi Health Commercial |
$336.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$361.36
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$77.85
|
|
|
Service Code
|
NDC 63323008605
|
| Hospital Charge Code |
6451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.60 |
| Max. Negotiated Rate |
$77.85 |
| Rate for Payer: Aetna Commercial |
$70.06
|
| Rate for Payer: ASR ASR |
$75.51
|
| Rate for Payer: ASR Commercial |
$75.51
|
| Rate for Payer: BCBS Trust/PPO |
$63.44
|
| Rate for Payer: BCN Commercial |
$60.36
|
| Rate for Payer: Cash Price |
$62.28
|
| Rate for Payer: Cofinity Commercial |
$73.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.28
|
| Rate for Payer: Healthscope Commercial |
$77.85
|
| Rate for Payer: Healthscope Whirlpool |
$75.51
|
| Rate for Payer: Mclaren Commercial |
$70.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.17
|
| Rate for Payer: Nomi Health Commercial |
$63.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.51
|
|
|
PR 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR
|
Professional
|
Both
|
$2,098.00
|
|
|
Service Code
|
HCPCS 54332
|
| Min. Negotiated Rate |
$645.39 |
| Max. Negotiated Rate |
$2,967.99 |
| Rate for Payer: Aetna Commercial |
$1,298.52
|
| Rate for Payer: Aetna Medicare |
$1,049.00
|
| Rate for Payer: BCBS Complete |
$677.66
|
| Rate for Payer: BCBS Trust/PPO |
$2,967.99
|
| Rate for Payer: BCN Commercial |
$1,452.84
|
| Rate for Payer: Cash Price |
$1,678.40
|
| Rate for Payer: Cash Price |
$1,678.40
|
| Rate for Payer: Meridian Medicaid |
$677.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$645.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,363.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,602.59
|
| Rate for Payer: Priority Health Narrow Network |
$1,602.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,231.95
|
| Rate for Payer: UHC Exchange |
$1,231.95
|
| Rate for Payer: UHCCP Medicaid |
$645.39
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS
|
Professional
|
Both
|
$1,774.00
|
|
|
Service Code
|
HCPCS 54326
|
| Min. Negotiated Rate |
$602.36 |
| Max. Negotiated Rate |
$2,714.41 |
| Rate for Payer: Aetna Commercial |
$1,210.28
|
| Rate for Payer: Aetna Medicare |
$887.00
|
| Rate for Payer: BCBS Complete |
$632.48
|
| Rate for Payer: BCBS Trust/PPO |
$2,714.41
|
| Rate for Payer: BCN Commercial |
$1,356.57
|
| Rate for Payer: Cash Price |
$1,419.20
|
| Rate for Payer: Cash Price |
$1,419.20
|
| Rate for Payer: Meridian Medicaid |
$632.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$602.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,153.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,496.61
|
| Rate for Payer: Priority Health Narrow Network |
$1,496.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,120.76
|
| Rate for Payer: UHC Exchange |
$1,120.76
|
| Rate for Payer: UHCCP Medicaid |
$602.36
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT
|
Professional
|
Both
|
$5,000.00
|
|
|
Service Code
|
HCPCS 54322
|
| Min. Negotiated Rate |
$362.41 |
| Max. Negotiated Rate |
$3,250.00 |
| Rate for Payer: Aetna Commercial |
$1,003.62
|
| Rate for Payer: Aetna Medicare |
$2,500.00
|
| Rate for Payer: BCBS Complete |
$525.13
|
| Rate for Payer: BCBS Trust/PPO |
$362.41
|
| Rate for Payer: BCN Commercial |
$1,126.40
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Meridian Medicaid |
$525.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$500.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,250.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,242.02
|
| Rate for Payer: Priority Health Narrow Network |
$1,242.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$950.38
|
| Rate for Payer: UHC Exchange |
$950.38
|
| Rate for Payer: UHCCP Medicaid |
$500.12
|
|
|
PR 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS
|
Professional
|
Both
|
$2,012.00
|
|
|
Service Code
|
HCPCS 54324
|
| Min. Negotiated Rate |
$517.21 |
| Max. Negotiated Rate |
$1,537.09 |
| Rate for Payer: Aetna Commercial |
$1,242.77
|
| Rate for Payer: Aetna Medicare |
$1,006.00
|
| Rate for Payer: BCBS Complete |
$649.71
|
| Rate for Payer: BCBS Trust/PPO |
$517.21
|
| Rate for Payer: BCN Commercial |
$1,393.22
|
| Rate for Payer: Cash Price |
$1,609.60
|
| Rate for Payer: Cash Price |
$1,609.60
|
| Rate for Payer: Meridian Medicaid |
$649.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$618.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,307.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,537.09
|
| Rate for Payer: Priority Health Narrow Network |
$1,537.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,180.91
|
| Rate for Payer: UHC Exchange |
$1,180.91
|
| Rate for Payer: UHCCP Medicaid |
$618.77
|
|
|
PR 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
HCPCS 99460
|
| Min. Negotiated Rate |
$58.36 |
| Max. Negotiated Rate |
$190.72 |
| Rate for Payer: Aetna Commercial |
$94.30
|
| Rate for Payer: Aetna Medicare |
$79.00
|
| Rate for Payer: BCBS Complete |
$61.28
|
| Rate for Payer: BCBS Trust/PPO |
$190.72
|
| Rate for Payer: BCN Commercial |
$133.89
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Meridian Medicaid |
$61.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$58.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$123.40
|
| Rate for Payer: Priority Health Narrow Network |
$123.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$63.65
|
| Rate for Payer: UHC Exchange |
$63.65
|
| Rate for Payer: UHCCP Medicaid |
$58.36
|
|
|
PR 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT
|
Professional
|
Both
|
$172.00
|
|
|
Service Code
|
HCPCS 99463
|
| Min. Negotiated Rate |
$68.37 |
| Max. Negotiated Rate |
$1,537.35 |
| Rate for Payer: Aetna Commercial |
$108.47
|
| Rate for Payer: Aetna Medicare |
$86.00
|
| Rate for Payer: BCBS Complete |
$71.79
|
| Rate for Payer: BCBS Trust/PPO |
$1,537.35
|
| Rate for Payer: BCN Commercial |
$157.35
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Meridian Medicaid |
$71.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$68.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$144.03
|
| Rate for Payer: Priority Health Narrow Network |
$144.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$86.11
|
| Rate for Payer: UHC Exchange |
$86.11
|
| Rate for Payer: UHCCP Medicaid |
$68.37
|
|
|
PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES
|
Professional
|
Both
|
$353.00
|
|
|
Service Code
|
HCPCS 99223
|
| Min. Negotiated Rate |
$110.12 |
| Max. Negotiated Rate |
$1,363.01 |
| Rate for Payer: Aetna Commercial |
$197.06
|
| Rate for Payer: Aetna Medicare |
$176.50
|
| Rate for Payer: BCBS Complete |
$115.63
|
| Rate for Payer: BCBS Trust/PPO |
$1,363.01
|
| Rate for Payer: BCN Commercial |
$183.78
|
| Rate for Payer: Cash Price |
$282.40
|
| Rate for Payer: Cash Price |
$282.40
|
| Rate for Payer: Meridian Medicaid |
$115.63
|
| Rate for Payer: Priority Health Choice Medicaid |
$110.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$230.64
|
| Rate for Payer: Priority Health Narrow Network |
$230.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$212.61
|
| Rate for Payer: UHC Exchange |
$212.61
|
| Rate for Payer: UHCCP Medicaid |
$110.12
|
|
|
PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
HCPCS 99222
|
| Min. Negotiated Rate |
$82.64 |
| Max. Negotiated Rate |
$2,113.20 |
| Rate for Payer: Aetna Commercial |
$133.90
|
| Rate for Payer: Aetna Medicare |
$120.50
|
| Rate for Payer: BCBS Complete |
$86.77
|
| Rate for Payer: BCBS Trust/PPO |
$2,113.20
|
| Rate for Payer: BCN Commercial |
$137.93
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Meridian Medicaid |
$86.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$82.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$174.11
|
| Rate for Payer: Priority Health Narrow Network |
$174.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$144.50
|
| Rate for Payer: UHC Exchange |
$144.50
|
| Rate for Payer: UHCCP Medicaid |
$82.64
|
|
|
PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
HCPCS 99221
|
| Min. Negotiated Rate |
$52.40 |
| Max. Negotiated Rate |
$1,817.88 |
| Rate for Payer: Aetna Commercial |
$99.61
|
| Rate for Payer: Aetna Medicare |
$88.50
|
| Rate for Payer: BCBS Complete |
$55.02
|
| Rate for Payer: BCBS Trust/PPO |
$1,817.88
|
| Rate for Payer: BCN Commercial |
$88.13
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Meridian Medicaid |
$55.02
|
| Rate for Payer: Priority Health Choice Medicaid |
$52.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$110.39
|
| Rate for Payer: Priority Health Narrow Network |
$110.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$106.61
|
| Rate for Payer: UHC Exchange |
$106.61
|
| Rate for Payer: UHCCP Medicaid |
$52.40
|
|
|
PR 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/<
|
Professional
|
Both
|
$1,675.00
|
|
|
Service Code
|
HCPCS 99468
|
| Min. Negotiated Rate |
$127.77 |
| Max. Negotiated Rate |
$1,290.60 |
| Rate for Payer: Aetna Commercial |
$902.56
|
| Rate for Payer: Aetna Medicare |
$837.50
|
| Rate for Payer: BCBS Complete |
$882.92
|
| Rate for Payer: BCBS Trust/PPO |
$127.77
|
| Rate for Payer: BCN Commercial |
$1,290.60
|
| Rate for Payer: Cash Price |
$1,340.00
|
| Rate for Payer: Cash Price |
$1,340.00
|
| Rate for Payer: Meridian Medicaid |
$882.92
|
| Rate for Payer: Priority Health Choice Medicaid |
$840.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,088.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,188.19
|
| Rate for Payer: Priority Health Narrow Network |
$1,188.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,001.62
|
| Rate for Payer: UHC Exchange |
$1,001.62
|
| Rate for Payer: UHCCP Medicaid |
$840.88
|
|
|
PR 1ST PSYCHIATRIC COLLAB CARE MGMT 1ST 70 MINS
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
HCPCS 99492
|
| Min. Negotiated Rate |
$59.85 |
| Max. Negotiated Rate |
$1,323.39 |
| Rate for Payer: Aetna Commercial |
$92.57
|
| Rate for Payer: Aetna Medicare |
$157.50
|
| Rate for Payer: BCBS Complete |
$62.84
|
| Rate for Payer: BCBS Trust/PPO |
$1,323.39
|
| Rate for Payer: BCN Commercial |
$193.46
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Meridian Medicaid |
$62.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$59.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$204.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$172.40
|
| Rate for Payer: Priority Health Narrow Network |
$172.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$101.10
|
| Rate for Payer: UHC Exchange |
$101.10
|
| Rate for Payer: UHCCP Medicaid |
$59.85
|
|
|
PR 1ST/SBSQ PSYCH COLLAB CARE MGMT EA ADDL 30 MINS
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
HCPCS 99494
|
| Min. Negotiated Rate |
$25.56 |
| Max. Negotiated Rate |
$984.75 |
| Rate for Payer: Aetna Commercial |
$40.26
|
| Rate for Payer: Aetna Medicare |
$64.50
|
| Rate for Payer: BCBS Complete |
$26.84
|
| Rate for Payer: BCBS Trust/PPO |
$984.75
|
| Rate for Payer: BCN Commercial |
$79.98
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Meridian Medicaid |
$26.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$25.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$82.71
|
| Rate for Payer: Priority Health Narrow Network |
$82.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$48.72
|
| Rate for Payer: UHC Exchange |
$48.72
|
| Rate for Payer: UHCCP Medicaid |
$25.56
|
|
|
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 |
$190.75 |
| Rate for Payer: Aetna Commercial |
$141.25
|
| Rate for Payer: Aetna Medicare |
$139.50
|
| Rate for Payer: BCBS Complete |
$111.60
|
| Rate for Payer: BCBS Trust/PPO |
$133.16
|
| Rate for Payer: BCN Commercial |
$133.16
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$190.75
|
| Rate for Payer: UHC Exchange |
$190.75
|
|
|
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 |
$197.98 |
| Rate for Payer: Aetna Commercial |
$163.24
|
| Rate for Payer: Aetna Medicare |
$131.50
|
| Rate for Payer: BCBS Complete |
$105.20
|
| Rate for Payer: BCBS Trust/PPO |
$160.17
|
| Rate for Payer: BCN Commercial |
$160.17
|
| Rate for Payer: Cash Price |
$210.40
|
| Rate for Payer: Cash Price |
$210.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$197.98
|
| Rate for Payer: UHC Exchange |
$197.98
|
|
|
PR 5% DEXTROSE IN LAC RINGERS
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS J7121
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Commercial |
$7.42
|
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: BCBS Trust/PPO |
$1.86
|
| Rate for Payer: BCN Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.98
|
| Rate for Payer: UHC Exchange |
$7.98
|
|
|
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 |
$369.20 |
| Rate for Payer: Aetna Commercial |
$293.16
|
| Rate for Payer: Aetna Medicare |
$148.00
|
| Rate for Payer: BCBS Complete |
$118.40
|
| Rate for Payer: BCBS Trust/PPO |
$277.00
|
| Rate for Payer: BCN Commercial |
$265.15
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$369.20
|
| Rate for Payer: UHC Exchange |
$369.20
|
|
|
PR AAA REPAIR,AORTO-AORTIC TUBE PROSTH
|
Professional
|
Both
|
$3,937.00
|
|
|
Service Code
|
HCPCS 34800
|
| Min. Negotiated Rate |
$1,574.80 |
| Max. Negotiated Rate |
$2,559.05 |
| Rate for Payer: Aetna Medicare |
$1,968.50
|
| Rate for Payer: BCBS Complete |
$1,574.80
|
| Rate for Payer: Cash Price |
$3,149.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,559.05
|
|
|
PR AAA REPAIR,MODULR BIFURCATED PROSTH
|
Professional
|
Both
|
$2,555.00
|
|
|
Service Code
|
HCPCS 34802
|
| Min. Negotiated Rate |
$1,022.00 |
| Max. Negotiated Rate |
$1,660.75 |
| Rate for Payer: Aetna Medicare |
$1,277.50
|
| Rate for Payer: BCBS Complete |
$1,022.00
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,660.75
|
|
|
PR AAA REPAIR,MODULR BIFUR PROSTH,2-DOCK
|
Professional
|
Both
|
$2,622.00
|
|
|
Service Code
|
HCPCS 34803
|
| Min. Negotiated Rate |
$1,048.80 |
| Max. Negotiated Rate |
$1,704.30 |
| Rate for Payer: Aetna Medicare |
$1,311.00
|
| Rate for Payer: BCBS Complete |
$1,048.80
|
| Rate for Payer: Cash Price |
$2,097.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,704.30
|
|
