|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION
|
Facility
|
IP
|
$426.98
|
|
|
Service Code
|
HCPCS J1611
|
| Hospital Charge Code |
168350
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$269.00 |
| Max. Negotiated Rate |
$384.28 |
| Rate for Payer: Aetna Commercial |
$362.93
|
| Rate for Payer: Aetna Commercial |
$362.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.55
|
| Rate for Payer: Cash Price |
$341.58
|
| Rate for Payer: Cash Price |
$341.60
|
| Rate for Payer: Cofinity Advantage |
$298.89
|
| Rate for Payer: Cofinity Advantage |
$298.90
|
| Rate for Payer: Cofinity Commercial |
$367.20
|
| Rate for Payer: Cofinity Commercial |
$367.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.58
|
| Rate for Payer: Healthscope Commercial |
$384.30
|
| Rate for Payer: Healthscope Commercial |
$384.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$320.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$320.25
|
| Rate for Payer: PHP Commercial |
$362.93
|
| Rate for Payer: PHP Commercial |
$362.95
|
| Rate for Payer: Priority Health SBD |
$269.00
|
| Rate for Payer: Priority Health SBD |
$269.01
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
NDC 21292000434
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Aetna Commercial |
$2.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.62
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cofinity Advantage |
$1.75
|
| Rate for Payer: Cofinity Commercial |
$2.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.00
|
| Rate for Payer: Healthscope Commercial |
$2.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.88
|
| Rate for Payer: PHP Commercial |
$2.12
|
| Rate for Payer: Priority Health SBD |
$1.57
|
|
|
GLUCOSE 4 GRAM CHEWABLE TABLET
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
NDC 21292000434
|
| Hospital Charge Code |
16050
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$2.25 |
| Rate for Payer: Aetna Commercial |
$2.12
|
| Rate for Payer: Aetna Medicare |
$1.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.62
|
| Rate for Payer: BCBS Complete |
$1.00
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cofinity Advantage |
$1.75
|
| Rate for Payer: Cofinity Commercial |
$2.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.00
|
| Rate for Payer: Healthscope Commercial |
$2.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.88
|
| Rate for Payer: PHP Commercial |
$2.12
|
| Rate for Payer: Priority Health SBD |
$1.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.62
|
| Rate for Payer: UHC Core |
$1.30
|
| Rate for Payer: UHC Exchange |
$0.98
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
IP
|
$220.90
|
|
|
Service Code
|
NDC 00093943301
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.17 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.59
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Advantage |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.72
|
| Rate for Payer: Healthscope Commercial |
$198.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.68
|
| Rate for Payer: PHP Commercial |
$187.76
|
| Rate for Payer: Priority Health SBD |
$139.17
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
OP
|
$220.90
|
|
|
Service Code
|
NDC 00093943301
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.81 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna Medicare |
$110.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.59
|
| Rate for Payer: BCBS Complete |
$88.36
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Advantage |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.72
|
| Rate for Payer: Healthscope Commercial |
$198.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$176.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.68
|
| Rate for Payer: PHP Commercial |
$187.76
|
| Rate for Payer: Priority Health SBD |
$139.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$143.59
|
| Rate for Payer: UHC Core |
$115.09
|
| Rate for Payer: UHC Exchange |
$86.81
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
OP
|
$89.30
|
|
|
Service Code
|
NDC 00132007950
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$75.91
|
| Rate for Payer: Aetna Medicare |
$44.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.05
|
| Rate for Payer: BCBS Complete |
$35.72
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Advantage |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.97
|
| Rate for Payer: PHP Commercial |
$75.91
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.05
|
| Rate for Payer: UHC Core |
$46.53
|
| Rate for Payer: UHC Exchange |
$35.09
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
IP
|
$60.35
|
|
|
Service Code
|
NDC 00132007924
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.02 |
| Max. Negotiated Rate |
$54.31 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.23
|
| Rate for Payer: Cash Price |
$48.28
|
| Rate for Payer: Cofinity Advantage |
$42.24
|
| Rate for Payer: Cofinity Commercial |
$51.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.28
|
| Rate for Payer: Healthscope Commercial |
$54.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.26
|
| Rate for Payer: PHP Commercial |
$51.30
|
| Rate for Payer: Priority Health SBD |
$38.02
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
IP
|
$89.30
|
|
|
Service Code
|
NDC 00132007950
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.26 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$75.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.05
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Advantage |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.97
|
| Rate for Payer: PHP Commercial |
$75.91
|
| Rate for Payer: Priority Health SBD |
$56.26
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
OP
|
$60.35
|
|
|
Service Code
|
NDC 00132007924
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.72 |
| Max. Negotiated Rate |
$54.31 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Medicare |
$30.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.23
|
| Rate for Payer: BCBS Complete |
$24.14
|
| Rate for Payer: Cash Price |
$48.28
|
| Rate for Payer: Cofinity Advantage |
$42.24
|
| Rate for Payer: Cofinity Commercial |
$51.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.28
|
| Rate for Payer: Healthscope Commercial |
$54.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.26
|
| Rate for Payer: PHP Commercial |
$51.30
|
| Rate for Payer: Priority Health SBD |
$38.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.23
|
| Rate for Payer: UHC Core |
$31.44
|
| Rate for Payer: UHC Exchange |
$23.72
|
|
|
GLYCERIN (CHILD) RECTAL SUPPOSITORY
|
Facility
|
IP
|
$49.35
|
|
|
Service Code
|
NDC 70000042901
|
| Hospital Charge Code |
3492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.09 |
| Max. Negotiated Rate |
$44.41 |
| Rate for Payer: Aetna Commercial |
$41.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.08
|
| Rate for Payer: Cash Price |
$39.48
|
| Rate for Payer: Cofinity Advantage |
$34.55
|
| Rate for Payer: Cofinity Commercial |
$42.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.48
|
| Rate for Payer: Healthscope Commercial |
$44.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.01
|
| Rate for Payer: PHP Commercial |
$41.95
|
| Rate for Payer: Priority Health SBD |
$31.09
|
|
|
GLYCERIN (CHILD) RECTAL SUPPOSITORY
|
Facility
|
OP
|
$49.35
|
|
|
Service Code
|
NDC 70000042901
|
| Hospital Charge Code |
3492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$44.41 |
| Rate for Payer: Aetna Commercial |
$41.95
|
| Rate for Payer: Aetna Medicare |
$24.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.08
|
| Rate for Payer: BCBS Complete |
$19.74
|
| Rate for Payer: Cash Price |
$39.48
|
| Rate for Payer: Cofinity Advantage |
$34.55
|
| Rate for Payer: Cofinity Commercial |
$42.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.48
|
| Rate for Payer: Healthscope Commercial |
$44.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.01
|
| Rate for Payer: PHP Commercial |
$41.95
|
| Rate for Payer: Priority Health SBD |
$31.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.08
|
| Rate for Payer: UHC Core |
$25.71
|
| Rate for Payer: UHC Exchange |
$19.39
|
|
|
GLYCERIN-DIMETHICONE-WHITE PETROLATUM TOPICAL CREAM
|
Facility
|
IP
|
$23.72
|
|
|
Service Code
|
NDC 00299391753
|
| Hospital Charge Code |
100949
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.94 |
| Max. Negotiated Rate |
$21.35 |
| Rate for Payer: Aetna Commercial |
$20.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.42
|
| Rate for Payer: Cash Price |
$18.98
|
| Rate for Payer: Cofinity Advantage |
$16.60
|
| Rate for Payer: Cofinity Commercial |
$20.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.98
|
| Rate for Payer: Healthscope Commercial |
$21.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.79
|
| Rate for Payer: PHP Commercial |
$20.16
|
| Rate for Payer: Priority Health SBD |
$14.94
|
|
|
GLYCERIN-DIMETHICONE-WHITE PETROLATUM TOPICAL CREAM
|
Facility
|
OP
|
$23.72
|
|
|
Service Code
|
NDC 00299391753
|
| Hospital Charge Code |
100949
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$21.35 |
| Rate for Payer: Aetna Commercial |
$20.16
|
| Rate for Payer: Aetna Medicare |
$11.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.42
|
| Rate for Payer: BCBS Complete |
$9.49
|
| Rate for Payer: Cash Price |
$18.98
|
| Rate for Payer: Cofinity Advantage |
$16.60
|
| Rate for Payer: Cofinity Commercial |
$20.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.98
|
| Rate for Payer: Healthscope Commercial |
$21.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.79
|
| Rate for Payer: PHP Commercial |
$20.16
|
| Rate for Payer: Priority Health SBD |
$14.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.42
|
| Rate for Payer: UHC Core |
$12.36
|
| Rate for Payer: UHC Exchange |
$9.32
|
|
|
GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS
|
Facility
|
IP
|
$12.24
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
116088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$11.02 |
| Rate for Payer: Aetna Commercial |
$10.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.96
|
| Rate for Payer: Cash Price |
$9.79
|
| Rate for Payer: Cofinity Advantage |
$8.57
|
| Rate for Payer: Cofinity Commercial |
$10.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.79
|
| Rate for Payer: Healthscope Commercial |
$11.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.18
|
| Rate for Payer: PHP Commercial |
$10.40
|
| Rate for Payer: Priority Health SBD |
$7.71
|
|
|
GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS
|
Facility
|
OP
|
$12.24
|
|
|
Service Code
|
NDC 50289325001
|
| Hospital Charge Code |
116088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$11.02 |
| Rate for Payer: Aetna Commercial |
$10.40
|
| Rate for Payer: Aetna Medicare |
$6.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.96
|
| Rate for Payer: BCBS Complete |
$4.90
|
| Rate for Payer: Cash Price |
$9.79
|
| Rate for Payer: Cofinity Advantage |
$8.57
|
| Rate for Payer: Cofinity Commercial |
$10.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.79
|
| Rate for Payer: Healthscope Commercial |
$11.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.18
|
| Rate for Payer: PHP Commercial |
$10.40
|
| Rate for Payer: Priority Health SBD |
$7.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.96
|
| Rate for Payer: UHC Core |
$6.38
|
| Rate for Payer: UHC Exchange |
$4.81
|
|
|
GLYCINE 1.5 % UROLOGIC SOLUTION FOR IRRIGATION
|
Facility
|
IP
|
$162.72
|
|
|
Service Code
|
NDC 00264739060
|
| Hospital Charge Code |
3493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.51 |
| Max. Negotiated Rate |
$146.45 |
| Rate for Payer: Aetna Commercial |
$138.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.77
|
| Rate for Payer: Cash Price |
$130.18
|
| Rate for Payer: Cofinity Advantage |
$113.90
|
| Rate for Payer: Cofinity Commercial |
$139.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.18
|
| Rate for Payer: Healthscope Commercial |
$146.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$122.04
|
| Rate for Payer: PHP Commercial |
$138.31
|
| Rate for Payer: Priority Health SBD |
$102.51
|
|
|
GLYCINE 1.5 % UROLOGIC SOLUTION FOR IRRIGATION
|
Facility
|
OP
|
$162.72
|
|
|
Service Code
|
NDC 00264739060
|
| Hospital Charge Code |
3493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.95 |
| Max. Negotiated Rate |
$146.45 |
| Rate for Payer: Aetna Commercial |
$138.31
|
| Rate for Payer: Aetna Medicare |
$81.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.77
|
| Rate for Payer: BCBS Complete |
$65.09
|
| Rate for Payer: Cash Price |
$130.18
|
| Rate for Payer: Cofinity Advantage |
$113.90
|
| Rate for Payer: Cofinity Commercial |
$139.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.18
|
| Rate for Payer: Healthscope Commercial |
$146.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$130.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$122.04
|
| Rate for Payer: PHP Commercial |
$138.31
|
| Rate for Payer: Priority Health SBD |
$102.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.77
|
| Rate for Payer: UHC Core |
$84.78
|
| Rate for Payer: UHC Exchange |
$63.95
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$15.11
|
|
|
Service Code
|
HCPCS J1596
|
| Hospital Charge Code |
3497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$13.60 |
| Rate for Payer: Aetna Commercial |
$12.84
|
| Rate for Payer: Aetna Commercial |
$15.58
|
| Rate for Payer: Aetna Commercial |
$18.47
|
| Rate for Payer: Aetna Medicare |
$7.55
|
| Rate for Payer: Aetna Medicare |
$9.16
|
| Rate for Payer: Aetna Medicare |
$10.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.12
|
| Rate for Payer: BCBS Complete |
$8.69
|
| Rate for Payer: BCBS Complete |
$6.04
|
| Rate for Payer: BCBS Complete |
$7.33
|
| Rate for Payer: BCBS Trust/PPO |
$0.94
|
| Rate for Payer: BCBS Trust/PPO |
$0.94
|
| Rate for Payer: BCBS Trust/PPO |
$0.94
|
| Rate for Payer: BCN Commercial |
$0.94
|
| Rate for Payer: BCN Commercial |
$0.94
|
| Rate for Payer: BCN Commercial |
$0.94
|
| Rate for Payer: Cash Price |
$17.38
|
| Rate for Payer: Cash Price |
$12.09
|
| Rate for Payer: Cash Price |
$12.09
|
| Rate for Payer: Cash Price |
$14.66
|
| Rate for Payer: Cash Price |
$17.38
|
| Rate for Payer: Cash Price |
$14.66
|
| Rate for Payer: Cofinity Advantage |
$12.83
|
| Rate for Payer: Cofinity Advantage |
$10.58
|
| Rate for Payer: Cofinity Advantage |
$15.21
|
| Rate for Payer: Cofinity Commercial |
$12.99
|
| Rate for Payer: Cofinity Commercial |
$15.76
|
| Rate for Payer: Cofinity Commercial |
$18.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.09
|
| Rate for Payer: Healthscope Commercial |
$19.56
|
| Rate for Payer: Healthscope Commercial |
$16.50
|
| Rate for Payer: Healthscope Commercial |
$13.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.30
|
| Rate for Payer: PHP Commercial |
$12.84
|
| Rate for Payer: PHP Commercial |
$15.58
|
| Rate for Payer: PHP Commercial |
$18.47
|
| Rate for Payer: Priority Health SBD |
$9.52
|
| Rate for Payer: Priority Health SBD |
$13.69
|
| Rate for Payer: Priority Health SBD |
$11.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.63
|
| Rate for Payer: UHC Core |
$0.63
|
| Rate for Payer: UHC Core |
$0.63
|
| Rate for Payer: UHC Core |
$0.63
|
| Rate for Payer: UHC Exchange |
$0.63
|
| Rate for Payer: UHC Exchange |
$0.63
|
| Rate for Payer: UHC Exchange |
$0.63
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$18.33
|
|
|
Service Code
|
HCPCS J1596
|
| Hospital Charge Code |
3497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.55 |
| Max. Negotiated Rate |
$16.50 |
| Rate for Payer: Aetna Commercial |
$15.58
|
| Rate for Payer: Aetna Commercial |
$12.84
|
| Rate for Payer: Aetna Commercial |
$18.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.82
|
| Rate for Payer: Cash Price |
$12.09
|
| Rate for Payer: Cash Price |
$14.66
|
| Rate for Payer: Cash Price |
$17.38
|
| Rate for Payer: Cofinity Advantage |
$15.21
|
| Rate for Payer: Cofinity Advantage |
$10.58
|
| Rate for Payer: Cofinity Advantage |
$12.83
|
| Rate for Payer: Cofinity Commercial |
$15.76
|
| Rate for Payer: Cofinity Commercial |
$12.99
|
| Rate for Payer: Cofinity Commercial |
$18.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.66
|
| Rate for Payer: Healthscope Commercial |
$19.56
|
| Rate for Payer: Healthscope Commercial |
$13.60
|
| Rate for Payer: Healthscope Commercial |
$16.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.75
|
| Rate for Payer: PHP Commercial |
$12.84
|
| Rate for Payer: PHP Commercial |
$18.47
|
| Rate for Payer: PHP Commercial |
$15.58
|
| Rate for Payer: Priority Health SBD |
$13.69
|
| Rate for Payer: Priority Health SBD |
$11.55
|
| Rate for Payer: Priority Health SBD |
$9.52
|
|
|
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLN (CUSTOM)
|
Facility
|
IP
|
$442.67
|
|
|
Service Code
|
NDC 00900000230
|
| Hospital Charge Code |
158482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$278.88 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.74
|
| Rate for Payer: Cash Price |
$354.14
|
| Rate for Payer: Cofinity Advantage |
$309.87
|
| Rate for Payer: Cofinity Commercial |
$380.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$354.14
|
| Rate for Payer: Healthscope Commercial |
$398.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$376.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$332.00
|
| Rate for Payer: PHP Commercial |
$376.27
|
| Rate for Payer: Priority Health SBD |
$278.88
|
|
|
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLN (CUSTOM)
|
Facility
|
OP
|
$442.67
|
|
|
Service Code
|
NDC 00900000230
|
| Hospital Charge Code |
158482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$173.97 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: Aetna Medicare |
$221.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.74
|
| Rate for Payer: BCBS Complete |
$177.07
|
| Rate for Payer: Cash Price |
$354.14
|
| Rate for Payer: Cofinity Advantage |
$309.87
|
| Rate for Payer: Cofinity Commercial |
$380.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$354.14
|
| Rate for Payer: Healthscope Commercial |
$398.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$354.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$376.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$332.00
|
| Rate for Payer: PHP Commercial |
$376.27
|
| Rate for Payer: Priority Health SBD |
$278.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$287.74
|
| Rate for Payer: UHC Core |
$230.63
|
| Rate for Payer: UHC Exchange |
$173.97
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
IP
|
$375.36
|
|
|
Service Code
|
NDC 00904670961
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$236.48 |
| Max. Negotiated Rate |
$337.82 |
| Rate for Payer: Aetna Commercial |
$319.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.98
|
| Rate for Payer: Cash Price |
$300.29
|
| Rate for Payer: Cofinity Advantage |
$262.75
|
| Rate for Payer: Cofinity Commercial |
$322.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$300.29
|
| Rate for Payer: Healthscope Commercial |
$337.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$319.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$281.52
|
| Rate for Payer: PHP Commercial |
$319.06
|
| Rate for Payer: Priority Health SBD |
$236.48
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
IP
|
$385.70
|
|
|
Service Code
|
NDC 69076047501
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.99 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna Commercial |
$327.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.71
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Advantage |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.27
|
| Rate for Payer: PHP Commercial |
$327.85
|
| Rate for Payer: Priority Health SBD |
$242.99
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
OP
|
$260.85
|
|
|
Service Code
|
NDC 23155060601
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.51 |
| Max. Negotiated Rate |
$234.76 |
| Rate for Payer: Aetna Commercial |
$221.72
|
| Rate for Payer: Aetna Medicare |
$130.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.55
|
| Rate for Payer: BCBS Complete |
$104.34
|
| Rate for Payer: Cash Price |
$208.68
|
| Rate for Payer: Cofinity Advantage |
$182.59
|
| Rate for Payer: Cofinity Commercial |
$224.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.68
|
| Rate for Payer: Healthscope Commercial |
$234.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.64
|
| Rate for Payer: PHP Commercial |
$221.72
|
| Rate for Payer: Priority Health SBD |
$164.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.55
|
| Rate for Payer: UHC Core |
$135.90
|
| Rate for Payer: UHC Exchange |
$102.51
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
OP
|
$375.36
|
|
|
Service Code
|
NDC 00904670961
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.52 |
| Max. Negotiated Rate |
$337.82 |
| Rate for Payer: Aetna Commercial |
$319.06
|
| Rate for Payer: Aetna Medicare |
$187.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.98
|
| Rate for Payer: BCBS Complete |
$150.14
|
| Rate for Payer: Cash Price |
$300.29
|
| Rate for Payer: Cofinity Advantage |
$262.75
|
| Rate for Payer: Cofinity Commercial |
$322.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$300.29
|
| Rate for Payer: Healthscope Commercial |
$337.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$300.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$319.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$281.52
|
| Rate for Payer: PHP Commercial |
$319.06
|
| Rate for Payer: Priority Health SBD |
$236.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$243.98
|
| Rate for Payer: UHC Core |
$195.56
|
| Rate for Payer: UHC Exchange |
$147.52
|
|
