Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
RIBOFLAV5 & RIBOFLAV5-DEXTRAN 0.146 &0.146-20 % OP SOSY
Maple Grove, MN
See all hospitals reporting HCPCS J2787 →Price type
Fairview Maple Grove Surgery Center’s median price of $2.2k is 47% below the median hospital's median price ($4.1k), higher than 11% of the 929 hospitals reporting HCPCS J2787. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 8 payers, 21 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | |||||||
|---|---|---|---|---|---|---|---|
| 1 | Blue Cross Blue Shield federal fee schedule · outpatient | $1.9k | $1.9k | — | — | — | $1.9k – $1.9k |
| 2 | Blue Cross Blue Shield commercial fee schedule · outpatient | $2.0k | $2.0k | — | — | — | $2.0k – $2.0k |
| 3 | Blue Cross Blue Shield medicaid fee schedule · outpatient | $2.0k | $2.0k | — | — | — | $2.0k – $2.0k |
| 4 | Cigna commercial fee schedule · both | $2.0k | $2.0k | $172 | 9% | — | $1.8k – $2.2k |
| 5 | Blue Cross Blue Shield federal fee schedule · both | $2.1k | $2.1k | — | — | — | $2.1k – $2.1k |
| 6 | Blue Cross Blue Shield commercial fee schedule · both | $2.2k | $2.2k | — | — | — | $2.2k – $2.2k |
| 7 | Ucare mhcp fee schedule · both | $2.2k | $2.2k | — | — | — | $2.2k – $2.2k |
| 8 | Medica ma non-snp fee schedule · both | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 9 | Medica ma snp fee schedule · both | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 10 | Medica prime solution fee schedule · both | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 11 | Medica vantage fee schedule · both | $2.3k | $2.3k | — | — | — | $2.3k – $2.3k |
| 12 | Ucare ifp percent of total billed charges · outpatientfrom % of charges | $2.3k | $2.3k | $2.3k | 100% | — | $0 – $4.6k |
| 13 | Ucare ifp with fairview percent of total billed charges · outpatientfrom % of charges | $2.3k | $2.3k | $2.3k | 100% | — | $0 – $4.6k |
| 14 | Medicaid medicaid fee schedule · both | $2.4k | $2.4k | — | — | — | $2.4k – $2.4k |
| 15 | Medica bold fee schedule · both | $3.7k | $3.7k | — | — | — | $3.7k – $3.7k |
| 16 | First Health commercial percent of total billed charges · outpatientfrom % of charges | $3.8k | $3.8k | $3.8k | 100% | — | $0 – $7.6k |
| 17 | UnitedHealthcare commercial fee schedule · both | $3.9k | $3.9k | — | — | — | $3.9k – $3.9k |
| 18 | MultiPlan commercial percent of total billed charges · outpatientfrom % of charges | $3.9k | $3.9k | $3.9k | 100% | — | $0 – $7.9k |
| 19 | Medica choice without / elect fee schedule · both | $4.1k | $4.1k | — | — | — | $4.1k – $4.1k |
| 20 | Medica city of st paul / essential uplan fee schedule · both | $4.1k | $4.1k | — | — | — | $4.1k – $4.1k |
| 21 | Medica choice with fee schedule · both | $4.2k | $4.2k | — | — | — | $4.2k – $4.2k |
Last updated: May 18, 2026
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