|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
IP
|
$23.07
|
|
|
Service Code
|
NDC 0591-2070-26
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$20.76 |
| Rate for Payer: Aetna Commercial |
$19.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.00
|
| Rate for Payer: Cash Price |
$18.46
|
| Rate for Payer: Cofinity Commercial |
$16.15
|
| Rate for Payer: Cofinity Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$20.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.61
|
| Rate for Payer: PHP Commercial |
$19.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.15
|
| Rate for Payer: Priority Health SBD |
$14.53
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
IP
|
$26.90
|
|
|
Service Code
|
NDC 0168-0357-55
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.95 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$22.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.48
|
| Rate for Payer: Cash Price |
$21.52
|
| Rate for Payer: Cofinity Commercial |
$18.83
|
| Rate for Payer: Cofinity Commercial |
$23.13
|
| Rate for Payer: Healthscope Commercial |
$24.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.86
|
| Rate for Payer: PHP Commercial |
$22.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.83
|
| Rate for Payer: Priority Health SBD |
$16.95
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$14.18
|
|
|
Service Code
|
NDC 0496-0882-07
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.93 |
| Max. Negotiated Rate |
$12.76 |
| Rate for Payer: Aetna Commercial |
$12.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.22
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$12.19
|
| Rate for Payer: Cofinity Commercial |
$9.93
|
| Rate for Payer: Healthscope Commercial |
$12.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.05
|
| Rate for Payer: PHP Commercial |
$12.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.93
|
| Rate for Payer: Priority Health SBD |
$8.93
|
|
|
LIDOCAINE WITH EPINEPHRINE IN NS 50 ML
|
Facility
|
IP
|
$3.75
|
|
|
Service Code
|
NDC 9900-0002-02
|
| Hospital Charge Code |
158459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.44
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$3.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.19
|
| Rate for Payer: PHP Commercial |
$3.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.62
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS
|
Facility
|
OP
|
$8,913.25
|
|
|
Service Code
|
CPT 37700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$237.72 |
| Max. Negotiated Rate |
$8,913.25 |
| Rate for Payer: Aetna Medicare |
$2,949.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,545.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,545.25
|
| Rate for Payer: BCBS Complete |
$1,629.11
|
| Rate for Payer: BCBS MAPPO |
$2,836.20
|
| Rate for Payer: BCBS Trust/PPO |
$1,107.31
|
| Rate for Payer: BCN Medicare Advantage |
$2,836.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,836.20
|
| Rate for Payer: Mclaren Medicaid |
$1,551.40
|
| Rate for Payer: Mclaren Medicare |
$2,836.20
|
| Rate for Payer: Meridian Medicaid |
$1,629.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,978.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,261.63
|
| Rate for Payer: PACE Medicare |
$2,694.39
|
| Rate for Payer: PACE SWMI |
$2,836.20
|
| Rate for Payer: PHP Medicare Advantage |
$2,836.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,551.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,913.25
|
| Rate for Payer: Priority Health Medicare |
$2,836.20
|
| Rate for Payer: Priority Health Narrow Network |
$7,130.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,836.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.49
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,836.20
|
| Rate for Payer: UHC Exchange |
$237.72
|
| Rate for Payer: UHC Medicare Advantage |
$2,921.29
|
| Rate for Payer: VA VA |
$2,836.20
|
|
|
LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA
|
Facility
|
OP
|
$8,913.25
|
|
|
Service Code
|
CPT 37607
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$362.48 |
| Max. Negotiated Rate |
$8,913.25 |
| Rate for Payer: Aetna Medicare |
$2,949.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,545.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,545.25
|
| Rate for Payer: BCBS Complete |
$1,629.11
|
| Rate for Payer: BCBS MAPPO |
$2,836.20
|
| Rate for Payer: BCBS Trust/PPO |
$1,107.31
|
| Rate for Payer: BCN Medicare Advantage |
$2,836.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,836.20
|
| Rate for Payer: Mclaren Medicaid |
$1,551.40
|
| Rate for Payer: Mclaren Medicare |
$2,836.20
|
| Rate for Payer: Meridian Medicaid |
$1,629.11
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,978.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,261.63
|
| Rate for Payer: PACE Medicare |
$2,694.39
|
| Rate for Payer: PACE SWMI |
$2,836.20
|
| Rate for Payer: PHP Medicare Advantage |
$2,836.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,551.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,913.25
|
| Rate for Payer: Priority Health Medicare |
$2,836.20
|
| Rate for Payer: Priority Health Narrow Network |
$7,130.60
|
| Rate for Payer: Railroad Medicare Medicare |
$2,836.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$398.73
|
| Rate for Payer: UHC Core |
$5,427.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,836.20
|
| Rate for Payer: UHC Exchange |
$362.48
|
| Rate for Payer: UHC Medicare Advantage |
$2,921.29
|
| Rate for Payer: VA VA |
$2,836.20
|
|
|
LIGATION OR BIOPSY, TEMPORAL ARTERY
|
Facility
|
OP
|
$4,536.73
|
|
|
Service Code
|
CPT 37609
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$200.07 |
| Max. Negotiated Rate |
$4,536.73 |
| Rate for Payer: Aetna Medicare |
$1,500.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,803.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,803.26
|
| Rate for Payer: BCBS Complete |
$828.64
|
| Rate for Payer: BCBS MAPPO |
$1,442.61
|
| Rate for Payer: BCBS Trust/PPO |
$1,578.82
|
| Rate for Payer: BCN Medicare Advantage |
$1,442.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,442.61
|
| Rate for Payer: Mclaren Medicaid |
$789.11
|
| Rate for Payer: Mclaren Medicare |
$1,442.61
|
| Rate for Payer: Meridian Medicaid |
$828.64
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,514.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,659.00
|
| Rate for Payer: PACE Medicare |
$1,370.48
|
| Rate for Payer: PACE SWMI |
$1,442.61
|
| Rate for Payer: PHP Medicare Advantage |
$1,442.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$789.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,536.73
|
| Rate for Payer: Priority Health Medicare |
$1,442.61
|
| Rate for Payer: Priority Health Narrow Network |
$3,629.38
|
| Rate for Payer: Railroad Medicare Medicare |
$1,442.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$220.08
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,442.61
|
| Rate for Payer: UHC Exchange |
$200.07
|
| Rate for Payer: UHC Medicare Advantage |
$1,485.89
|
| Rate for Payer: VA VA |
$1,442.61
|
|
|
LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$102,381.64
|
|
|
Service Code
|
MS-DRG 956
|
| Min. Negotiated Rate |
$27,001.58 |
| Max. Negotiated Rate |
$102,381.64 |
| Rate for Payer: Aetna Medicare |
$29,559.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$35,528.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$35,528.40
|
| Rate for Payer: BCBS MAPPO |
$28,422.72
|
| Rate for Payer: BCBS Trust/PPO |
$102,381.64
|
| Rate for Payer: BCN Medicare Advantage |
$28,422.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$28,422.72
|
| Rate for Payer: Mclaren Medicare |
$28,422.72
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$29,843.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$32,686.13
|
| Rate for Payer: PACE Medicare |
$27,001.58
|
| Rate for Payer: PACE SWMI |
$28,422.72
|
| Rate for Payer: PHP Medicare Advantage |
$28,422.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55,651.86
|
| Rate for Payer: Priority Health Medicare |
$28,422.72
|
| Rate for Payer: Priority Health Narrow Network |
$44,521.49
|
| Rate for Payer: Railroad Medicare Medicare |
$28,422.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59,158.06
|
| Rate for Payer: UHC Core |
$36,299.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$28,422.72
|
| Rate for Payer: UHC Exchange |
$38,878.96
|
| Rate for Payer: UHC Medicare Advantage |
$29,275.40
|
| Rate for Payer: VA VA |
$28,422.72
|
|
|
LINACLOTIDE 145 MCG CAPSULE
|
Facility
|
IP
|
$1,771.79
|
|
|
Service Code
|
NDC 0456-1201-30
|
| Hospital Charge Code |
163662
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,116.23 |
| Max. Negotiated Rate |
$1,594.61 |
| Rate for Payer: Aetna Commercial |
$1,506.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,151.66
|
| Rate for Payer: Cash Price |
$1,417.43
|
| Rate for Payer: Cofinity Commercial |
$1,523.74
|
| Rate for Payer: Cofinity Commercial |
$1,240.25
|
| Rate for Payer: Healthscope Commercial |
$1,594.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,506.02
|
| Rate for Payer: PHP Commercial |
$1,506.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,240.25
|
| Rate for Payer: Priority Health SBD |
$1,116.23
|
|
|
LINACLOTIDE 145 MCG CAPSULE
|
Facility
|
IP
|
$226.27
|
|
|
Service Code
|
NDC 0456-1201-04
|
| Hospital Charge Code |
163662
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.55 |
| Max. Negotiated Rate |
$203.64 |
| Rate for Payer: Aetna Commercial |
$192.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.08
|
| Rate for Payer: Cash Price |
$181.02
|
| Rate for Payer: Cofinity Commercial |
$158.39
|
| Rate for Payer: Cofinity Commercial |
$194.59
|
| Rate for Payer: Healthscope Commercial |
$203.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$192.33
|
| Rate for Payer: PHP Commercial |
$192.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.39
|
| Rate for Payer: Priority Health SBD |
$142.55
|
|
|
LINAGLIPTIN 5 MG TABLET
|
Facility
|
IP
|
$4,697.89
|
|
|
Service Code
|
NDC 0597-0140-61
|
| Hospital Charge Code |
152649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,959.67 |
| Max. Negotiated Rate |
$4,228.10 |
| Rate for Payer: Aetna Commercial |
$3,993.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,053.63
|
| Rate for Payer: Cash Price |
$3,758.31
|
| Rate for Payer: Cofinity Commercial |
$3,288.52
|
| Rate for Payer: Cofinity Commercial |
$4,040.19
|
| Rate for Payer: Healthscope Commercial |
$4,228.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,993.21
|
| Rate for Payer: PHP Commercial |
$3,993.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,288.52
|
| Rate for Payer: Priority Health SBD |
$2,959.67
|
|
|
LINEZOLID 600 MG TABLET
|
Facility
|
IP
|
$118.03
|
|
|
Service Code
|
NDC 72606-001-11
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.36 |
| Max. Negotiated Rate |
$106.23 |
| Rate for Payer: Aetna Commercial |
$100.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.72
|
| Rate for Payer: Cash Price |
$94.42
|
| Rate for Payer: Cofinity Commercial |
$101.51
|
| Rate for Payer: Cofinity Commercial |
$82.62
|
| Rate for Payer: Healthscope Commercial |
$106.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$100.33
|
| Rate for Payer: PHP Commercial |
$100.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.62
|
| Rate for Payer: Priority Health SBD |
$74.36
|
|
|
LINEZOLID 600 MG TABLET
|
Facility
|
IP
|
$228.78
|
|
|
Service Code
|
NDC 0904-6553-04
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.13 |
| Max. Negotiated Rate |
$205.90 |
| Rate for Payer: Aetna Commercial |
$194.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.71
|
| Rate for Payer: Cash Price |
$183.02
|
| Rate for Payer: Cofinity Commercial |
$160.15
|
| Rate for Payer: Cofinity Commercial |
$196.75
|
| Rate for Payer: Healthscope Commercial |
$205.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$194.46
|
| Rate for Payer: PHP Commercial |
$194.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.15
|
| Rate for Payer: Priority Health SBD |
$144.13
|
|
|
LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$138.32
|
|
|
Service Code
|
HCPCS J2020
|
| Hospital Charge Code |
112020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$87.14 |
| Max. Negotiated Rate |
$124.49 |
| Rate for Payer: Aetna Commercial |
$117.57
|
| Rate for Payer: Aetna Commercial |
$65.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.13
|
| Rate for Payer: Cash Price |
$61.70
|
| Rate for Payer: Cash Price |
$110.66
|
| Rate for Payer: Cofinity Commercial |
$66.32
|
| Rate for Payer: Cofinity Commercial |
$96.82
|
| Rate for Payer: Cofinity Commercial |
$118.96
|
| Rate for Payer: Cofinity Commercial |
$53.98
|
| Rate for Payer: Healthscope Commercial |
$69.41
|
| Rate for Payer: Healthscope Commercial |
$124.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$117.57
|
| Rate for Payer: PHP Commercial |
$117.57
|
| Rate for Payer: PHP Commercial |
$65.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.98
|
| Rate for Payer: Priority Health SBD |
$87.14
|
| Rate for Payer: Priority Health SBD |
$48.59
|
|
|
LIOTHYRONINE 25 MCG TABLET
|
Facility
|
IP
|
$620.64
|
|
|
Service Code
|
NDC 51862-321-01
|
| Hospital Charge Code |
4504
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$391.00 |
| Max. Negotiated Rate |
$558.58 |
| Rate for Payer: Aetna Commercial |
$527.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$403.42
|
| Rate for Payer: Cash Price |
$496.51
|
| Rate for Payer: Cofinity Commercial |
$434.45
|
| Rate for Payer: Cofinity Commercial |
$533.75
|
| Rate for Payer: Healthscope Commercial |
$558.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$527.54
|
| Rate for Payer: PHP Commercial |
$527.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$434.45
|
| Rate for Payer: Priority Health SBD |
$391.00
|
|
|
LIOTHYRONINE 5 MCG TABLET
|
Facility
|
IP
|
$340.10
|
|
|
Service Code
|
NDC 60793-115-01
|
| Hospital Charge Code |
10443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.26 |
| Max. Negotiated Rate |
$306.09 |
| Rate for Payer: Aetna Commercial |
$289.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.06
|
| Rate for Payer: Cash Price |
$272.08
|
| Rate for Payer: Cofinity Commercial |
$238.07
|
| Rate for Payer: Cofinity Commercial |
$292.49
|
| Rate for Payer: Healthscope Commercial |
$306.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$289.08
|
| Rate for Payer: PHP Commercial |
$289.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.07
|
| Rate for Payer: Priority Health SBD |
$214.26
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$2,832.72
|
|
|
Service Code
|
NDC 0032-1224-01
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,784.61 |
| Max. Negotiated Rate |
$2,549.45 |
| Rate for Payer: Aetna Commercial |
$2,407.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,841.27
|
| Rate for Payer: Cash Price |
$2,266.18
|
| Rate for Payer: Cofinity Commercial |
$1,982.90
|
| Rate for Payer: Cofinity Commercial |
$2,436.14
|
| Rate for Payer: Healthscope Commercial |
$2,549.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,407.81
|
| Rate for Payer: PHP Commercial |
$2,407.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,982.90
|
| Rate for Payer: Priority Health SBD |
$1,784.61
|
|
|
LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL
|
Facility
|
IP
|
$4,301.25
|
|
|
Service Code
|
NDC 0032-3016-13
|
| Hospital Charge Code |
166135
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,709.79 |
| Max. Negotiated Rate |
$3,871.12 |
| Rate for Payer: Aetna Commercial |
$3,656.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,795.81
|
| Rate for Payer: Cash Price |
$3,441.00
|
| Rate for Payer: Cofinity Commercial |
$3,010.88
|
| Rate for Payer: Cofinity Commercial |
$3,699.08
|
| Rate for Payer: Healthscope Commercial |
$3,871.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,656.06
|
| Rate for Payer: PHP Commercial |
$3,656.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,010.88
|
| Rate for Payer: Priority Health SBD |
$2,709.79
|
|
|
LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$927.36
|
|
|
Service Code
|
NDC 0032-1206-01
|
| Hospital Charge Code |
98034
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$584.24 |
| Max. Negotiated Rate |
$834.62 |
| Rate for Payer: Aetna Commercial |
$788.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$602.78
|
| Rate for Payer: Cash Price |
$741.89
|
| Rate for Payer: Cofinity Commercial |
$649.15
|
| Rate for Payer: Cofinity Commercial |
$797.53
|
| Rate for Payer: Healthscope Commercial |
$834.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$788.26
|
| Rate for Payer: PHP Commercial |
$788.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$649.15
|
| Rate for Payer: Priority Health SBD |
$584.24
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 60687-325-11
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Aetna Commercial |
$1.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.51
|
| Rate for Payer: Cash Price |
$1.86
|
| Rate for Payer: Cofinity Commercial |
$1.63
|
| Rate for Payer: Cofinity Commercial |
$2.00
|
| Rate for Payer: Healthscope Commercial |
$2.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.98
|
| Rate for Payer: PHP Commercial |
$1.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.63
|
| Rate for Payer: Priority Health SBD |
$1.47
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$232.65
|
|
|
Service Code
|
NDC 60687-325-01
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.57 |
| Max. Negotiated Rate |
$209.38 |
| Rate for Payer: Aetna Commercial |
$197.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.22
|
| Rate for Payer: Cash Price |
$186.12
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Cofinity Commercial |
$200.08
|
| Rate for Payer: Healthscope Commercial |
$209.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.75
|
| Rate for Payer: PHP Commercial |
$197.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.86
|
| Rate for Payer: Priority Health SBD |
$146.57
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
NDC 63739-349-10
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.43 |
| Max. Negotiated Rate |
$116.32 |
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.01
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Cofinity Commercial |
$90.48
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.86
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.48
|
| Rate for Payer: Priority Health SBD |
$81.43
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 0904-6798-61
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.10 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna Commercial |
$91.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.26
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.88
|
| Rate for Payer: PHP Commercial |
$91.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.67
|
| Rate for Payer: Priority Health SBD |
$68.10
|
|
|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$44.65
|
|
|
Service Code
|
NDC 68180-980-01
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.13 |
| Max. Negotiated Rate |
$40.18 |
| Rate for Payer: Aetna Commercial |
$37.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.02
|
| Rate for Payer: Cash Price |
$35.72
|
| Rate for Payer: Cofinity Commercial |
$31.26
|
| Rate for Payer: Cofinity Commercial |
$38.40
|
| Rate for Payer: Healthscope Commercial |
$40.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.95
|
| Rate for Payer: PHP Commercial |
$37.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.26
|
| Rate for Payer: Priority Health SBD |
$28.13
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 68180-981-01
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.01 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.12
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
