|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$46.33
|
|
|
Service Code
|
NDC 63323-492-07
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.43 |
| Max. Negotiated Rate |
$46.33 |
| Rate for Payer: Aetna Commercial |
$41.70
|
| Rate for Payer: ASR ASR |
$44.94
|
| Rate for Payer: BCBS Trust/PPO |
$35.92
|
| Rate for Payer: BCN Commercial |
$35.92
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Cofinity Commercial |
$43.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.06
|
| Rate for Payer: Healthscope Commercial |
$46.33
|
| Rate for Payer: Healthscope Whirlpool |
$44.94
|
| Rate for Payer: Mclaren Commercial |
$41.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.77
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$16.79
|
|
|
Service Code
|
NDC 55150-158-72
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.75 |
| Max. Negotiated Rate |
$16.79 |
| Rate for Payer: Aetna Commercial |
$15.11
|
| Rate for Payer: ASR ASR |
$16.29
|
| Rate for Payer: BCBS Trust/PPO |
$13.02
|
| Rate for Payer: BCN Commercial |
$13.02
|
| Rate for Payer: Cash Price |
$13.43
|
| Rate for Payer: Cofinity Commercial |
$15.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.43
|
| Rate for Payer: Healthscope Commercial |
$16.79
|
| Rate for Payer: Healthscope Whirlpool |
$16.29
|
| Rate for Payer: Mclaren Commercial |
$15.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.78
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$15.59
|
|
|
Service Code
|
NDC 63323-492-89
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.91 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna Commercial |
$14.03
|
| Rate for Payer: ASR ASR |
$15.12
|
| Rate for Payer: BCBS Trust/PPO |
$12.09
|
| Rate for Payer: BCN Commercial |
$12.09
|
| Rate for Payer: Cash Price |
$12.47
|
| Rate for Payer: Cofinity Commercial |
$14.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.47
|
| Rate for Payer: Healthscope Commercial |
$15.59
|
| Rate for Payer: Healthscope Whirlpool |
$15.12
|
| Rate for Payer: Mclaren Commercial |
$14.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.72
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$46.33
|
|
|
Service Code
|
NDC 63323-492-37
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.43 |
| Max. Negotiated Rate |
$46.33 |
| Rate for Payer: Aetna Commercial |
$41.70
|
| Rate for Payer: ASR ASR |
$44.94
|
| Rate for Payer: BCBS Trust/PPO |
$35.92
|
| Rate for Payer: BCN Commercial |
$35.92
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Cofinity Commercial |
$43.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.06
|
| Rate for Payer: Healthscope Commercial |
$46.33
|
| Rate for Payer: Healthscope Whirlpool |
$44.94
|
| Rate for Payer: Mclaren Commercial |
$41.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.77
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$25.64
|
|
|
Service Code
|
NDC 63323-492-04
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.95 |
| Max. Negotiated Rate |
$25.64 |
| Rate for Payer: Aetna Commercial |
$23.08
|
| Rate for Payer: ASR ASR |
$24.87
|
| Rate for Payer: BCBS Trust/PPO |
$19.88
|
| Rate for Payer: BCN Commercial |
$19.88
|
| Rate for Payer: Cash Price |
$20.51
|
| Rate for Payer: Cofinity Commercial |
$24.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.51
|
| Rate for Payer: Healthscope Commercial |
$25.64
|
| Rate for Payer: Healthscope Whirlpool |
$24.87
|
| Rate for Payer: Mclaren Commercial |
$23.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.56
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$27.05
|
|
|
Service Code
|
NDC 63323-492-57
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.94 |
| Max. Negotiated Rate |
$27.05 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: ASR ASR |
$26.24
|
| Rate for Payer: BCBS Trust/PPO |
$20.97
|
| Rate for Payer: BCN Commercial |
$20.97
|
| Rate for Payer: Cash Price |
$21.64
|
| Rate for Payer: Cofinity Commercial |
$25.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.64
|
| Rate for Payer: Healthscope Commercial |
$27.05
|
| Rate for Payer: Healthscope Whirlpool |
$26.24
|
| Rate for Payer: Mclaren Commercial |
$24.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.80
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$28.86
|
|
|
Service Code
|
NDC 63323-495-07
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.20 |
| Max. Negotiated Rate |
$28.86 |
| Rate for Payer: Aetna Commercial |
$25.97
|
| Rate for Payer: ASR ASR |
$27.99
|
| Rate for Payer: BCBS Trust/PPO |
$22.38
|
| Rate for Payer: BCN Commercial |
$22.38
|
| Rate for Payer: Cash Price |
$23.08
|
| Rate for Payer: Cofinity Commercial |
$27.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.09
|
| Rate for Payer: Healthscope Commercial |
$28.86
|
| Rate for Payer: Healthscope Whirlpool |
$27.99
|
| Rate for Payer: Mclaren Commercial |
$25.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$25.40
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$13.56
|
|
|
Service Code
|
NDC 55150-165-05
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.49 |
| Max. Negotiated Rate |
$13.56 |
| Rate for Payer: Aetna Commercial |
$12.20
|
| Rate for Payer: ASR ASR |
$13.15
|
| Rate for Payer: BCBS Trust/PPO |
$10.51
|
| Rate for Payer: BCN Commercial |
$10.51
|
| Rate for Payer: Cash Price |
$10.85
|
| Rate for Payer: Cofinity Commercial |
$12.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.85
|
| Rate for Payer: Healthscope Commercial |
$13.56
|
| Rate for Payer: Healthscope Whirlpool |
$13.15
|
| Rate for Payer: Mclaren Commercial |
$12.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.93
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$15.88
|
|
|
Service Code
|
NDC 0409-2066-05
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna Commercial |
$14.29
|
| Rate for Payer: ASR ASR |
$15.40
|
| Rate for Payer: BCBS Trust/PPO |
$12.31
|
| Rate for Payer: BCN Commercial |
$12.31
|
| Rate for Payer: Cash Price |
$12.70
|
| Rate for Payer: Cofinity Commercial |
$14.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.70
|
| Rate for Payer: Healthscope Commercial |
$15.88
|
| Rate for Payer: Healthscope Whirlpool |
$15.40
|
| Rate for Payer: Mclaren Commercial |
$14.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.97
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$19.14
|
|
|
Service Code
|
NDC 63323-495-27
|
| Hospital Charge Code |
103889
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.40 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Aetna Commercial |
$17.23
|
| Rate for Payer: ASR ASR |
$18.57
|
| Rate for Payer: BCBS Trust/PPO |
$14.84
|
| Rate for Payer: BCN Commercial |
$14.84
|
| Rate for Payer: Cash Price |
$15.31
|
| Rate for Payer: Cofinity Commercial |
$17.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.31
|
| Rate for Payer: Healthscope Commercial |
$19.14
|
| Rate for Payer: Healthscope Whirlpool |
$18.57
|
| Rate for Payer: Mclaren Commercial |
$17.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.84
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.61
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
116451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.53 |
| Max. Negotiated Rate |
$23.61 |
| Rate for Payer: Aetna Commercial |
$21.25
|
| Rate for Payer: ASR ASR |
$22.90
|
| Rate for Payer: BCBS Trust/PPO |
$18.30
|
| Rate for Payer: BCN Commercial |
$18.30
|
| Rate for Payer: Cash Price |
$18.88
|
| Rate for Payer: Cofinity Commercial |
$22.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.89
|
| Rate for Payer: Healthscope Commercial |
$23.61
|
| Rate for Payer: Healthscope Whirlpool |
$22.90
|
| Rate for Payer: Mclaren Commercial |
$21.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.78
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION
|
Facility
|
IP
|
$21.24
|
|
|
Service Code
|
NDC 0409-4283-11
|
| Hospital Charge Code |
4455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$21.24 |
| Rate for Payer: Aetna Commercial |
$19.12
|
| Rate for Payer: ASR ASR |
$20.60
|
| Rate for Payer: BCBS Trust/PPO |
$16.47
|
| Rate for Payer: BCN Commercial |
$16.47
|
| Rate for Payer: Cash Price |
$16.99
|
| Rate for Payer: Cofinity Commercial |
$19.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.99
|
| Rate for Payer: Healthscope Commercial |
$21.24
|
| Rate for Payer: Healthscope Whirlpool |
$20.60
|
| Rate for Payer: Mclaren Commercial |
$19.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.69
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION
|
Facility
|
IP
|
$21.24
|
|
|
Service Code
|
NDC 0409-4283-25
|
| Hospital Charge Code |
4455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$21.24 |
| Rate for Payer: Aetna Commercial |
$19.12
|
| Rate for Payer: ASR ASR |
$20.60
|
| Rate for Payer: BCBS Trust/PPO |
$16.47
|
| Rate for Payer: BCN Commercial |
$16.47
|
| Rate for Payer: Cash Price |
$16.99
|
| Rate for Payer: Cofinity Commercial |
$19.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.99
|
| Rate for Payer: Healthscope Commercial |
$21.24
|
| Rate for Payer: Healthscope Whirlpool |
$20.60
|
| Rate for Payer: Mclaren Commercial |
$19.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.69
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) NEBULIZED SOLUTION
|
Facility
|
IP
|
$21.24
|
|
|
Service Code
|
NDC 0409-4283-01
|
| Hospital Charge Code |
168979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$21.24 |
| Rate for Payer: Aetna Commercial |
$19.12
|
| Rate for Payer: ASR ASR |
$20.60
|
| Rate for Payer: BCBS Trust/PPO |
$16.47
|
| Rate for Payer: BCN Commercial |
$16.47
|
| Rate for Payer: Cash Price |
$16.99
|
| Rate for Payer: Cofinity Commercial |
$19.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.99
|
| Rate for Payer: Healthscope Commercial |
$21.24
|
| Rate for Payer: Healthscope Whirlpool |
$20.60
|
| Rate for Payer: Mclaren Commercial |
$19.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.69
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$22.20
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$22.20 |
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: Aetna Commercial |
$32.04
|
| Rate for Payer: Aetna Commercial |
$27.04
|
| Rate for Payer: ASR ASR |
$21.53
|
| Rate for Payer: ASR ASR |
$29.14
|
| Rate for Payer: ASR ASR |
$34.53
|
| Rate for Payer: BCBS Trust/PPO |
$23.29
|
| Rate for Payer: BCBS Trust/PPO |
$17.21
|
| Rate for Payer: BCBS Trust/PPO |
$27.60
|
| Rate for Payer: BCN Commercial |
$23.29
|
| Rate for Payer: BCN Commercial |
$27.60
|
| Rate for Payer: BCN Commercial |
$17.21
|
| Rate for Payer: Cash Price |
$24.03
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cofinity Commercial |
$20.87
|
| Rate for Payer: Cofinity Commercial |
$33.46
|
| Rate for Payer: Cofinity Commercial |
$28.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.03
|
| Rate for Payer: Healthscope Commercial |
$30.04
|
| Rate for Payer: Healthscope Commercial |
$22.20
|
| Rate for Payer: Healthscope Commercial |
$35.60
|
| Rate for Payer: Healthscope Whirlpool |
$21.53
|
| Rate for Payer: Healthscope Whirlpool |
$29.14
|
| Rate for Payer: Healthscope Whirlpool |
$34.53
|
| Rate for Payer: Mclaren Commercial |
$32.04
|
| Rate for Payer: Mclaren Commercial |
$27.04
|
| Rate for Payer: Mclaren Commercial |
$19.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.44
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION
|
Facility
|
IP
|
$15.91
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
105635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.14 |
| Max. Negotiated Rate |
$15.91 |
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Commercial |
$51.26
|
| Rate for Payer: ASR ASR |
$15.43
|
| Rate for Payer: ASR ASR |
$55.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.34
|
| Rate for Payer: BCBS Trust/PPO |
$44.16
|
| Rate for Payer: BCN Commercial |
$12.34
|
| Rate for Payer: BCN Commercial |
$44.16
|
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cofinity Commercial |
$53.54
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.57
|
| Rate for Payer: Healthscope Commercial |
$15.91
|
| Rate for Payer: Healthscope Commercial |
$56.96
|
| Rate for Payer: Healthscope Whirlpool |
$15.43
|
| Rate for Payer: Healthscope Whirlpool |
$55.25
|
| Rate for Payer: Mclaren Commercial |
$51.26
|
| Rate for Payer: Mclaren Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$50.12
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$10.49
|
|
|
Service Code
|
NDC 0496-0882-05
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.34 |
| Max. Negotiated Rate |
$10.49 |
| Rate for Payer: Aetna Commercial |
$9.44
|
| Rate for Payer: ASR ASR |
$10.18
|
| Rate for Payer: BCBS Trust/PPO |
$8.13
|
| Rate for Payer: BCN Commercial |
$8.13
|
| Rate for Payer: Cash Price |
$8.39
|
| Rate for Payer: Cofinity Commercial |
$9.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.39
|
| Rate for Payer: Healthscope Commercial |
$10.49
|
| Rate for Payer: Healthscope Whirlpool |
$10.18
|
| Rate for Payer: Mclaren Commercial |
$9.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.23
|
|
|
LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$49,796.09
|
|
|
Service Code
|
MS-DRG 956
|
| Min. Negotiated Rate |
$32,789.54 |
| Max. Negotiated Rate |
$49,796.09 |
| Rate for Payer: Aetna Medicare |
$34,515.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$43,144.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$43,144.14
|
| Rate for Payer: BCBS MAPPO |
$34,515.31
|
| Rate for Payer: BCN Medicare Advantage |
$34,515.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$34,515.31
|
| Rate for Payer: Humana Choice PPO Medicare |
$34,515.31
|
| Rate for Payer: Mclaren Medicare |
$34,515.31
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$36,241.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39,692.61
|
| Rate for Payer: PACE Medicare |
$32,789.54
|
| Rate for Payer: PACE SWMI |
$34,515.31
|
| Rate for Payer: PHP Commercial |
$37,966.84
|
| Rate for Payer: PHP Medicare Advantage |
$34,515.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49,796.09
|
| Rate for Payer: Priority Health Medicare |
$34,515.31
|
| Rate for Payer: Priority Health Narrow Network |
$39,836.87
|
| Rate for Payer: Railroad Medicare Medicare |
$34,515.31
|
| Rate for Payer: UHC Medicare Advantage |
$35,550.77
|
| Rate for Payer: VA VA |
$34,515.31
|
|
|
LINEZOLID 600 MG TABLET
|
Facility
|
IP
|
$228.77
|
|
|
Service Code
|
NDC 0904-6553-04
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.14 |
| Max. Negotiated Rate |
$228.77 |
| Rate for Payer: Aetna Commercial |
$205.89
|
| Rate for Payer: ASR ASR |
$221.91
|
| Rate for Payer: BCBS Trust/PPO |
$177.37
|
| Rate for Payer: BCN Commercial |
$177.37
|
| Rate for Payer: Cash Price |
$183.02
|
| Rate for Payer: Cofinity Commercial |
$215.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.02
|
| Rate for Payer: Healthscope Commercial |
$228.77
|
| Rate for Payer: Healthscope Whirlpool |
$221.91
|
| Rate for Payer: Mclaren Commercial |
$205.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$194.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.32
|
|
|
LIOTHYRONINE 5 MCG TABLET
|
Facility
|
IP
|
$323.00
|
|
|
Service Code
|
NDC 62756-589-88
|
| Hospital Charge Code |
10443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$226.10 |
| Max. Negotiated Rate |
$323.00 |
| Rate for Payer: Aetna Commercial |
$290.70
|
| Rate for Payer: ASR ASR |
$313.31
|
| Rate for Payer: BCBS Trust/PPO |
$250.42
|
| Rate for Payer: BCN Commercial |
$250.42
|
| Rate for Payer: Cash Price |
$258.40
|
| Rate for Payer: Cofinity Commercial |
$303.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$258.40
|
| Rate for Payer: Healthscope Commercial |
$323.00
|
| Rate for Payer: Healthscope Whirlpool |
$313.31
|
| Rate for Payer: Mclaren Commercial |
$290.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$274.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$226.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$284.24
|
|
|
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 |
$1,982.90 |
| Max. Negotiated Rate |
$2,832.72 |
| Rate for Payer: Aetna Commercial |
$2,549.45
|
| Rate for Payer: ASR ASR |
$2,747.74
|
| Rate for Payer: BCBS Trust/PPO |
$2,196.21
|
| Rate for Payer: BCN Commercial |
$2,196.21
|
| Rate for Payer: Cash Price |
$2,266.18
|
| Rate for Payer: Cofinity Commercial |
$2,662.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,266.18
|
| Rate for Payer: Healthscope Commercial |
$2,832.72
|
| Rate for Payer: Healthscope Whirlpool |
$2,747.74
|
| Rate for Payer: Mclaren Commercial |
$2,549.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,407.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,982.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,492.79
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$143.35
|
|
|
Service Code
|
NDC 0904-6799-61
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.34 |
| Max. Negotiated Rate |
$143.35 |
| Rate for Payer: Aetna Commercial |
$129.02
|
| Rate for Payer: ASR ASR |
$139.05
|
| Rate for Payer: BCBS Trust/PPO |
$111.14
|
| Rate for Payer: BCN Commercial |
$111.14
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$134.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$143.35
|
| Rate for Payer: Healthscope Whirlpool |
$139.05
|
| Rate for Payer: Mclaren Commercial |
$129.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$126.15
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$159.80
|
|
|
Service Code
|
NDC 63739-350-10
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.86 |
| Max. Negotiated Rate |
$159.80 |
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: ASR ASR |
$155.01
|
| Rate for Payer: BCBS Trust/PPO |
$123.89
|
| Rate for Payer: BCN Commercial |
$123.89
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$150.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$159.80
|
| Rate for Payer: Healthscope Whirlpool |
$155.01
|
| Rate for Payer: Mclaren Commercial |
$143.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$140.62
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 68084-196-11
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: ASR ASR |
$3.60
|
| Rate for Payer: BCBS Trust/PPO |
$2.88
|
| Rate for Payer: BCN Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cofinity Commercial |
$3.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.97
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Healthscope Whirlpool |
$3.60
|
| Rate for Payer: Mclaren Commercial |
$3.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.26
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
IP
|
$37.60
|
|
|
Service Code
|
NDC 68180-513-01
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.32 |
| Max. Negotiated Rate |
$37.60 |
| Rate for Payer: Aetna Commercial |
$33.84
|
| Rate for Payer: ASR ASR |
$36.47
|
| Rate for Payer: BCBS Trust/PPO |
$29.15
|
| Rate for Payer: BCN Commercial |
$29.15
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cofinity Commercial |
$35.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.08
|
| Rate for Payer: Healthscope Commercial |
$37.60
|
| Rate for Payer: Healthscope Whirlpool |
$36.47
|
| Rate for Payer: Mclaren Commercial |
$33.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.09
|
|
