|
LABETALOL 200 MG TABLET
|
Facility
|
IP
|
$346.75
|
|
|
Service Code
|
NDC 60687-450-01
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$218.45 |
| Max. Negotiated Rate |
$312.08 |
| Rate for Payer: Aetna Commercial |
$294.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$225.39
|
| Rate for Payer: Cash Price |
$277.40
|
| Rate for Payer: Cofinity Commercial |
$242.72
|
| Rate for Payer: Cofinity Commercial |
$298.20
|
| Rate for Payer: Healthscope Commercial |
$312.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$294.74
|
| Rate for Payer: PHP Commercial |
$294.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.72
|
| Rate for Payer: Priority Health SBD |
$218.45
|
|
|
LABETALOL 200 MG TABLET
|
Facility
|
IP
|
$290.70
|
|
|
Service Code
|
NDC 0904-7110-61
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.14 |
| Max. Negotiated Rate |
$261.63 |
| Rate for Payer: Aetna Commercial |
$247.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.96
|
| Rate for Payer: Cash Price |
$232.56
|
| Rate for Payer: Cofinity Commercial |
$203.49
|
| Rate for Payer: Cofinity Commercial |
$250.00
|
| Rate for Payer: Healthscope Commercial |
$261.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$247.10
|
| Rate for Payer: PHP Commercial |
$247.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.49
|
| Rate for Payer: Priority Health SBD |
$183.14
|
|
|
LABETALOL 200 MG TABLET
|
Facility
|
IP
|
$3.47
|
|
|
Service Code
|
NDC 60687-450-11
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$3.12 |
| Rate for Payer: Aetna Commercial |
$2.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.26
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Cofinity Commercial |
$2.98
|
| Rate for Payer: Healthscope Commercial |
$3.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.95
|
| Rate for Payer: PHP Commercial |
$2.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.19
|
|
|
LABETALOL 200 MG TABLET
|
Facility
|
IP
|
$233.70
|
|
|
Service Code
|
NDC 0904-5929-61
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.23 |
| Max. Negotiated Rate |
$210.33 |
| Rate for Payer: Aetna Commercial |
$198.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.90
|
| Rate for Payer: Cash Price |
$186.96
|
| Rate for Payer: Cofinity Commercial |
$163.59
|
| Rate for Payer: Cofinity Commercial |
$200.98
|
| Rate for Payer: Healthscope Commercial |
$210.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$198.64
|
| Rate for Payer: PHP Commercial |
$198.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.59
|
| Rate for Payer: Priority Health SBD |
$147.23
|
|
|
LABETALOL 200 MG TABLET
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
NDC 51079-929-01
|
| Hospital Charge Code |
10374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.50
|
| Rate for Payer: Cash Price |
$3.08
|
| Rate for Payer: Cofinity Commercial |
$2.70
|
| Rate for Payer: Cofinity Commercial |
$3.31
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.27
|
| Rate for Payer: PHP Commercial |
$3.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.70
|
| Rate for Payer: Priority Health SBD |
$2.43
|
|
|
LABETALOL 20 MG/4 ML (5 MG/ML) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$16.90
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
155884
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.65 |
| Max. Negotiated Rate |
$15.21 |
| Rate for Payer: Aetna Commercial |
$14.36
|
| Rate for Payer: Aetna Commercial |
$13.86
|
| Rate for Payer: Aetna Commercial |
$22.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.60
|
| Rate for Payer: Cash Price |
$13.04
|
| Rate for Payer: Cash Price |
$13.52
|
| Rate for Payer: Cash Price |
$21.32
|
| Rate for Payer: Cofinity Commercial |
$11.41
|
| Rate for Payer: Cofinity Commercial |
$18.66
|
| Rate for Payer: Cofinity Commercial |
$11.83
|
| Rate for Payer: Cofinity Commercial |
$14.53
|
| Rate for Payer: Cofinity Commercial |
$22.92
|
| Rate for Payer: Cofinity Commercial |
$14.02
|
| Rate for Payer: Healthscope Commercial |
$15.21
|
| Rate for Payer: Healthscope Commercial |
$14.67
|
| Rate for Payer: Healthscope Commercial |
$23.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.86
|
| Rate for Payer: PHP Commercial |
$22.65
|
| Rate for Payer: PHP Commercial |
$13.86
|
| Rate for Payer: PHP Commercial |
$14.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.41
|
| Rate for Payer: Priority Health SBD |
$10.65
|
| Rate for Payer: Priority Health SBD |
$10.27
|
| Rate for Payer: Priority Health SBD |
$16.79
|
|
|
LABETALOL 5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
HCPCS J1920
|
| Hospital Charge Code |
10372
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.98 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna Commercial |
$39.10
|
| Rate for Payer: Aetna Commercial |
$36.12
|
| Rate for Payer: Aetna Commercial |
$272.00
|
| Rate for Payer: Aetna Commercial |
$260.55
|
| Rate for Payer: Aetna Commercial |
$92.65
|
| Rate for Payer: Aetna Commercial |
$133.45
|
| Rate for Payer: Aetna Commercial |
$71.82
|
| Rate for Payer: Aetna Commercial |
$59.50
|
| Rate for Payer: Aetna Commercial |
$196.35
|
| Rate for Payer: Aetna Commercial |
$114.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.24
|
| Rate for Payer: Cash Price |
$36.80
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$125.60
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cash Price |
$245.22
|
| Rate for Payer: Cash Price |
$256.00
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cash Price |
$67.60
|
| Rate for Payer: Cofinity Commercial |
$94.50
|
| Rate for Payer: Cofinity Commercial |
$161.70
|
| Rate for Payer: Cofinity Commercial |
$275.20
|
| Rate for Payer: Cofinity Commercial |
$224.00
|
| Rate for Payer: Cofinity Commercial |
$198.66
|
| Rate for Payer: Cofinity Commercial |
$72.67
|
| Rate for Payer: Cofinity Commercial |
$135.02
|
| Rate for Payer: Cofinity Commercial |
$76.30
|
| Rate for Payer: Cofinity Commercial |
$93.74
|
| Rate for Payer: Cofinity Commercial |
$60.20
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Cofinity Commercial |
$109.90
|
| Rate for Payer: Cofinity Commercial |
$39.56
|
| Rate for Payer: Cofinity Commercial |
$214.57
|
| Rate for Payer: Cofinity Commercial |
$263.62
|
| Rate for Payer: Cofinity Commercial |
$59.15
|
| Rate for Payer: Cofinity Commercial |
$32.20
|
| Rate for Payer: Cofinity Commercial |
$36.55
|
| Rate for Payer: Cofinity Commercial |
$29.75
|
| Rate for Payer: Cofinity Commercial |
$116.10
|
| Rate for Payer: Healthscope Commercial |
$98.10
|
| Rate for Payer: Healthscope Commercial |
$207.90
|
| Rate for Payer: Healthscope Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$121.50
|
| Rate for Payer: Healthscope Commercial |
$288.00
|
| Rate for Payer: Healthscope Commercial |
$38.25
|
| Rate for Payer: Healthscope Commercial |
$41.40
|
| Rate for Payer: Healthscope Commercial |
$141.30
|
| Rate for Payer: Healthscope Commercial |
$63.00
|
| Rate for Payer: Healthscope Commercial |
$76.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$92.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$272.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$36.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$260.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$114.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$196.35
|
| Rate for Payer: PHP Commercial |
$71.82
|
| Rate for Payer: PHP Commercial |
$114.75
|
| Rate for Payer: PHP Commercial |
$196.35
|
| Rate for Payer: PHP Commercial |
$272.00
|
| Rate for Payer: PHP Commercial |
$59.50
|
| Rate for Payer: PHP Commercial |
$92.65
|
| Rate for Payer: PHP Commercial |
$39.10
|
| Rate for Payer: PHP Commercial |
$36.12
|
| Rate for Payer: PHP Commercial |
$260.55
|
| Rate for Payer: PHP Commercial |
$133.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.00
|
| Rate for Payer: Priority Health SBD |
$193.11
|
| Rate for Payer: Priority Health SBD |
$44.10
|
| Rate for Payer: Priority Health SBD |
$28.98
|
| Rate for Payer: Priority Health SBD |
$98.91
|
| Rate for Payer: Priority Health SBD |
$85.05
|
| Rate for Payer: Priority Health SBD |
$145.53
|
| Rate for Payer: Priority Health SBD |
$26.78
|
| Rate for Payer: Priority Health SBD |
$68.67
|
| Rate for Payer: Priority Health SBD |
$201.60
|
| Rate for Payer: Priority Health SBD |
$53.24
|
|
|
LACOSAMIDE 100 MG TABLET
|
Facility
|
IP
|
$634.04
|
|
|
Service Code
|
NDC 60687-687-57
|
| Hospital Charge Code |
96969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$399.45 |
| Max. Negotiated Rate |
$570.64 |
| Rate for Payer: Aetna Commercial |
$538.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$412.13
|
| Rate for Payer: Cash Price |
$507.23
|
| Rate for Payer: Cofinity Commercial |
$443.83
|
| Rate for Payer: Cofinity Commercial |
$545.27
|
| Rate for Payer: Healthscope Commercial |
$570.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$538.93
|
| Rate for Payer: PHP Commercial |
$538.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.83
|
| Rate for Payer: Priority Health SBD |
$399.45
|
|
|
LACOSAMIDE 100 MG TABLET
|
Facility
|
IP
|
$10.57
|
|
|
Service Code
|
NDC 60687-687-11
|
| Hospital Charge Code |
96969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.66 |
| Max. Negotiated Rate |
$9.51 |
| Rate for Payer: Aetna Commercial |
$8.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.87
|
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Cofinity Commercial |
$7.40
|
| Rate for Payer: Cofinity Commercial |
$9.09
|
| Rate for Payer: Healthscope Commercial |
$9.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.98
|
| Rate for Payer: PHP Commercial |
$8.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.40
|
| Rate for Payer: Priority Health SBD |
$6.66
|
|
|
LACOSAMIDE 100 MG TABLET
|
Facility
|
IP
|
$4,182.04
|
|
|
Service Code
|
NDC 0131-2478-60
|
| Hospital Charge Code |
96969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,634.69 |
| Max. Negotiated Rate |
$3,763.84 |
| Rate for Payer: Aetna Commercial |
$3,554.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,718.33
|
| Rate for Payer: Cash Price |
$3,345.63
|
| Rate for Payer: Cofinity Commercial |
$2,927.43
|
| Rate for Payer: Cofinity Commercial |
$3,596.55
|
| Rate for Payer: Healthscope Commercial |
$3,763.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,554.73
|
| Rate for Payer: PHP Commercial |
$3,554.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,927.43
|
| Rate for Payer: Priority Health SBD |
$2,634.69
|
|
|
LACOSAMIDE 10 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$1,572.50
|
|
|
Service Code
|
NDC 0131-5410-72
|
| Hospital Charge Code |
105482
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$990.68 |
| Max. Negotiated Rate |
$1,415.25 |
| Rate for Payer: Aetna Commercial |
$1,336.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.12
|
| Rate for Payer: Cash Price |
$1,258.00
|
| Rate for Payer: Cofinity Commercial |
$1,100.75
|
| Rate for Payer: Cofinity Commercial |
$1,352.35
|
| Rate for Payer: Healthscope Commercial |
$1,415.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,336.62
|
| Rate for Payer: PHP Commercial |
$1,336.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,100.75
|
| Rate for Payer: Priority Health SBD |
$990.68
|
|
|
LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$100.49
|
|
|
Service Code
|
HCPCS C9254
|
| Hospital Charge Code |
96972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.31 |
| Max. Negotiated Rate |
$90.44 |
| Rate for Payer: Aetna Commercial |
$85.42
|
| Rate for Payer: Aetna Commercial |
$271.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.32
|
| Rate for Payer: Cash Price |
$80.39
|
| Rate for Payer: Cash Price |
$255.32
|
| Rate for Payer: Cofinity Commercial |
$70.34
|
| Rate for Payer: Cofinity Commercial |
$86.42
|
| Rate for Payer: Cofinity Commercial |
$223.40
|
| Rate for Payer: Cofinity Commercial |
$274.47
|
| Rate for Payer: Healthscope Commercial |
$287.24
|
| Rate for Payer: Healthscope Commercial |
$90.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$271.28
|
| Rate for Payer: PHP Commercial |
$85.42
|
| Rate for Payer: PHP Commercial |
$271.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.34
|
| Rate for Payer: Priority Health SBD |
$63.31
|
| Rate for Payer: Priority Health SBD |
$201.06
|
|
|
LACOSAMIDE 200 MG TABLET
|
Facility
|
IP
|
$262.20
|
|
|
Service Code
|
NDC 62332-174-60
|
| Hospital Charge Code |
96971
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.19 |
| Max. Negotiated Rate |
$235.98 |
| Rate for Payer: Aetna Commercial |
$222.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.43
|
| Rate for Payer: Cash Price |
$209.76
|
| Rate for Payer: Cofinity Commercial |
$183.54
|
| Rate for Payer: Cofinity Commercial |
$225.49
|
| Rate for Payer: Healthscope Commercial |
$235.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$222.87
|
| Rate for Payer: PHP Commercial |
$222.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.54
|
| Rate for Payer: Priority Health SBD |
$165.19
|
|
|
LACOSAMIDE 200 MG TABLET
|
Facility
|
IP
|
$4,027.31
|
|
|
Service Code
|
NDC 0131-2480-35
|
| Hospital Charge Code |
96971
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,537.21 |
| Max. Negotiated Rate |
$3,624.58 |
| Rate for Payer: Aetna Commercial |
$3,423.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,617.75
|
| Rate for Payer: Cash Price |
$3,221.85
|
| Rate for Payer: Cofinity Commercial |
$2,819.12
|
| Rate for Payer: Cofinity Commercial |
$3,463.49
|
| Rate for Payer: Healthscope Commercial |
$3,624.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,423.21
|
| Rate for Payer: PHP Commercial |
$3,423.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,819.12
|
| Rate for Payer: Priority Health SBD |
$2,537.21
|
|
|
LACOSAMIDE 200 MG TABLET
|
Facility
|
IP
|
$4,430.46
|
|
|
Service Code
|
NDC 0131-2480-60
|
| Hospital Charge Code |
96971
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,791.19 |
| Max. Negotiated Rate |
$3,987.41 |
| Rate for Payer: Aetna Commercial |
$3,765.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,879.80
|
| Rate for Payer: Cash Price |
$3,544.37
|
| Rate for Payer: Cofinity Commercial |
$3,101.32
|
| Rate for Payer: Cofinity Commercial |
$3,810.20
|
| Rate for Payer: Healthscope Commercial |
$3,987.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,765.89
|
| Rate for Payer: PHP Commercial |
$3,765.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,101.32
|
| Rate for Payer: Priority Health SBD |
$2,791.19
|
|
|
LACOSAMIDE 50 MG TABLET
|
Facility
|
IP
|
$2,675.10
|
|
|
Service Code
|
NDC 0131-2477-60
|
| Hospital Charge Code |
96968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,685.31 |
| Max. Negotiated Rate |
$2,407.59 |
| Rate for Payer: Aetna Commercial |
$2,273.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,738.82
|
| Rate for Payer: Cash Price |
$2,140.08
|
| Rate for Payer: Cofinity Commercial |
$1,872.57
|
| Rate for Payer: Cofinity Commercial |
$2,300.59
|
| Rate for Payer: Healthscope Commercial |
$2,407.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,273.84
|
| Rate for Payer: PHP Commercial |
$2,273.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,872.57
|
| Rate for Payer: Priority Health SBD |
$1,685.31
|
|
|
LACOSAMIDE 50 MG TABLET
|
Facility
|
IP
|
$2,431.57
|
|
|
Service Code
|
NDC 0131-2477-35
|
| Hospital Charge Code |
96968
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,531.89 |
| Max. Negotiated Rate |
$2,188.41 |
| Rate for Payer: Aetna Commercial |
$2,066.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,580.52
|
| Rate for Payer: Cash Price |
$1,945.26
|
| Rate for Payer: Cofinity Commercial |
$1,702.10
|
| Rate for Payer: Cofinity Commercial |
$2,091.15
|
| Rate for Payer: Healthscope Commercial |
$2,188.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,066.83
|
| Rate for Payer: PHP Commercial |
$2,066.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,702.10
|
| Rate for Payer: Priority Health SBD |
$1,531.89
|
|
|
LACTASE 9,000 UNIT TABLET
|
Facility
|
IP
|
$114.24
|
|
|
Service Code
|
NDC 45091060
|
| Hospital Charge Code |
109044
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.97 |
| Max. Negotiated Rate |
$102.82 |
| Rate for Payer: Aetna Commercial |
$97.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.26
|
| Rate for Payer: Cash Price |
$91.39
|
| Rate for Payer: Cofinity Commercial |
$79.97
|
| Rate for Payer: Cofinity Commercial |
$98.25
|
| Rate for Payer: Healthscope Commercial |
$102.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$97.10
|
| Rate for Payer: PHP Commercial |
$97.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.97
|
| Rate for Payer: Priority Health SBD |
$71.97
|
|
|
LACTASE 9,000 UNIT TABLET
|
Facility
|
IP
|
$45.76
|
|
|
Service Code
|
NDC 904590887
|
| Hospital Charge Code |
109044
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.83 |
| Max. Negotiated Rate |
$41.18 |
| Rate for Payer: Aetna Commercial |
$38.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.74
|
| Rate for Payer: Cash Price |
$36.61
|
| Rate for Payer: Cofinity Commercial |
$32.03
|
| Rate for Payer: Cofinity Commercial |
$39.35
|
| Rate for Payer: Healthscope Commercial |
$41.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.90
|
| Rate for Payer: PHP Commercial |
$38.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.03
|
| Rate for Payer: Priority Health SBD |
$28.83
|
|
|
LACTATED RINGERS EYE BOLUS
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
300324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
LACTATED RINGERS INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
4318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
LACTATED RINGERS INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$87.40
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
4318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$78.66 |
| Rate for Payer: Aetna Commercial |
$74.29
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$34.96
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS Trust/PPO |
$7.64
|
| Rate for Payer: BCBS Trust/PPO |
$7.64
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cash Price |
$69.92
|
| Rate for Payer: Cash Price |
$69.92
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$61.18
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Commercial |
$75.16
|
| Rate for Payer: Healthscope Commercial |
$78.66
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$74.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.18
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: Priority Health SBD |
$55.06
|
|
|
LACTATED RINGERS IV BOLUS
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
400296
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
LACTATED RINGERS IV -DKA
|
Facility
|
IP
|
$67.19
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
301462
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
LACTATED RINGERS IV INFUSION/BOLUS (CODE)
|
Facility
|
IP
|
$67.19
|
|
|
Service Code
|
HCPCS J7120
|
| Hospital Charge Code |
163717
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health SBD |
$44.05
|
| Rate for Payer: Priority Health SBD |
$42.33
|
|
