|
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
|
|
|
LITHIUM CARBONATE 300 MG CAPSULE
|
Facility
|
IP
|
$25.93
|
|
|
Service Code
|
NDC 0054-8527-25
|
| Hospital Charge Code |
4529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.15 |
| Max. Negotiated Rate |
$25.93 |
| Rate for Payer: Aetna Commercial |
$23.34
|
| Rate for Payer: ASR ASR |
$25.15
|
| Rate for Payer: BCBS Trust/PPO |
$20.10
|
| Rate for Payer: BCN Commercial |
$20.10
|
| Rate for Payer: Cash Price |
$20.75
|
| Rate for Payer: Cofinity Commercial |
$24.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.74
|
| Rate for Payer: Healthscope Commercial |
$25.93
|
| Rate for Payer: Healthscope Whirlpool |
$25.15
|
| Rate for Payer: Mclaren Commercial |
$23.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.82
|
|
|
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT
|
Facility
|
IP
|
$132,894.00
|
|
|
Service Code
|
MS-DRG 005
|
| Min. Negotiated Rate |
$84,842.74 |
| Max. Negotiated Rate |
$132,894.00 |
| Rate for Payer: Aetna Medicare |
$89,308.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$111,635.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$111,635.19
|
| Rate for Payer: BCBS MAPPO |
$89,308.15
|
| Rate for Payer: BCN Medicare Advantage |
$89,308.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$89,308.15
|
| Rate for Payer: Humana Choice PPO Medicare |
$89,308.15
|
| Rate for Payer: Mclaren Medicare |
$89,308.15
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$93,773.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102,704.37
|
| Rate for Payer: PACE Medicare |
$84,842.74
|
| Rate for Payer: PACE SWMI |
$89,308.15
|
| Rate for Payer: PHP Commercial |
$98,238.96
|
| Rate for Payer: PHP Medicare Advantage |
$89,308.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$132,894.00
|
| Rate for Payer: Priority Health Medicare |
$89,308.15
|
| Rate for Payer: Priority Health Narrow Network |
$106,315.20
|
| Rate for Payer: Railroad Medicare Medicare |
$89,308.15
|
| Rate for Payer: UHC Medicare Advantage |
$91,987.39
|
| Rate for Payer: VA VA |
$89,308.15
|
|
|
LIVER TRANSPLANT WITHOUT MCC
|
Facility
|
IP
|
$62,105.80
|
|
|
Service Code
|
MS-DRG 006
|
| Min. Negotiated Rate |
$40,500.45 |
| Max. Negotiated Rate |
$62,105.80 |
| Rate for Payer: Aetna Medicare |
$42,632.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$53,290.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$53,290.06
|
| Rate for Payer: BCBS MAPPO |
$42,632.05
|
| Rate for Payer: BCN Medicare Advantage |
$42,632.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$42,632.05
|
| Rate for Payer: Humana Choice PPO Medicare |
$42,632.05
|
| Rate for Payer: Mclaren Medicare |
$42,632.05
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$44,763.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$49,026.86
|
| Rate for Payer: PACE Medicare |
$40,500.45
|
| Rate for Payer: PACE SWMI |
$42,632.05
|
| Rate for Payer: PHP Commercial |
$46,895.26
|
| Rate for Payer: PHP Medicare Advantage |
$42,632.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$62,105.80
|
| Rate for Payer: Priority Health Medicare |
$42,632.05
|
| Rate for Payer: Priority Health Narrow Network |
$49,684.64
|
| Rate for Payer: Railroad Medicare Medicare |
$42,632.05
|
| Rate for Payer: UHC Medicare Advantage |
$43,911.01
|
| Rate for Payer: VA VA |
$42,632.05
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC
|
Facility
|
IP
|
$25,519.50
|
|
|
Service Code
|
MS-DRG 496
|
| Min. Negotiated Rate |
$17,582.50 |
| Max. Negotiated Rate |
$25,519.50 |
| Rate for Payer: Aetna Medicare |
$18,507.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23,134.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23,134.88
|
| Rate for Payer: BCBS MAPPO |
$18,507.90
|
| Rate for Payer: BCN Medicare Advantage |
$18,507.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18,507.90
|
| Rate for Payer: Humana Choice PPO Medicare |
$18,507.90
|
| Rate for Payer: Mclaren Medicare |
$18,507.90
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19,433.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21,284.08
|
| Rate for Payer: PACE Medicare |
$17,582.50
|
| Rate for Payer: PACE SWMI |
$18,507.90
|
| Rate for Payer: PHP Commercial |
$20,358.69
|
| Rate for Payer: PHP Medicare Advantage |
$18,507.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25,519.50
|
| Rate for Payer: Priority Health Medicare |
$18,507.90
|
| Rate for Payer: Priority Health Narrow Network |
$20,415.60
|
| Rate for Payer: Railroad Medicare Medicare |
$18,507.90
|
| Rate for Payer: UHC Medicare Advantage |
$19,063.14
|
| Rate for Payer: VA VA |
$18,507.90
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC
|
Facility
|
IP
|
$45,982.61
|
|
|
Service Code
|
MS-DRG 495
|
| Min. Negotiated Rate |
$30,400.77 |
| Max. Negotiated Rate |
$45,982.61 |
| Rate for Payer: Aetna Medicare |
$32,000.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$40,001.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$40,001.01
|
| Rate for Payer: BCBS MAPPO |
$32,000.81
|
| Rate for Payer: BCN Medicare Advantage |
$32,000.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$32,000.81
|
| Rate for Payer: Humana Choice PPO Medicare |
$32,000.81
|
| Rate for Payer: Mclaren Medicare |
$32,000.81
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$33,600.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$36,800.93
|
| Rate for Payer: PACE Medicare |
$30,400.77
|
| Rate for Payer: PACE SWMI |
$32,000.81
|
| Rate for Payer: PHP Commercial |
$35,200.89
|
| Rate for Payer: PHP Medicare Advantage |
$32,000.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$45,982.61
|
| Rate for Payer: Priority Health Medicare |
$32,000.81
|
| Rate for Payer: Priority Health Narrow Network |
$36,786.09
|
| Rate for Payer: Railroad Medicare Medicare |
$32,000.81
|
| Rate for Payer: UHC Medicare Advantage |
$32,960.83
|
| Rate for Payer: VA VA |
$32,000.81
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$18,327.82
|
|
|
Service Code
|
MS-DRG 497
|
| Min. Negotiated Rate |
$13,077.57 |
| Max. Negotiated Rate |
$18,327.82 |
| Rate for Payer: Aetna Medicare |
$13,765.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,207.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,207.32
|
| Rate for Payer: BCBS MAPPO |
$13,765.86
|
| Rate for Payer: BCN Medicare Advantage |
$13,765.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,765.86
|
| Rate for Payer: Humana Choice PPO Medicare |
$13,765.86
|
| Rate for Payer: Mclaren Medicare |
$13,765.86
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$14,454.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15,830.74
|
| Rate for Payer: PACE Medicare |
$13,077.57
|
| Rate for Payer: PACE SWMI |
$13,765.86
|
| Rate for Payer: PHP Commercial |
$15,142.45
|
| Rate for Payer: PHP Medicare Advantage |
$13,765.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,327.82
|
| Rate for Payer: Priority Health Medicare |
$13,765.86
|
| Rate for Payer: Priority Health Narrow Network |
$14,662.26
|
| Rate for Payer: Railroad Medicare Medicare |
$13,765.86
|
| Rate for Payer: UHC Medicare Advantage |
$14,178.84
|
| Rate for Payer: VA VA |
$13,765.86
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC
|
Facility
|
IP
|
$33,525.24
|
|
|
Service Code
|
MS-DRG 498
|
| Min. Negotiated Rate |
$22,597.37 |
| Max. Negotiated Rate |
$33,525.24 |
| Rate for Payer: Aetna Medicare |
$23,786.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29,733.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29,733.39
|
| Rate for Payer: BCBS MAPPO |
$23,786.71
|
| Rate for Payer: BCN Medicare Advantage |
$23,786.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23,786.71
|
| Rate for Payer: Humana Choice PPO Medicare |
$23,786.71
|
| Rate for Payer: Mclaren Medicare |
$23,786.71
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$24,976.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27,354.72
|
| Rate for Payer: PACE Medicare |
$22,597.37
|
| Rate for Payer: PACE SWMI |
$23,786.71
|
| Rate for Payer: PHP Commercial |
$26,165.38
|
| Rate for Payer: PHP Medicare Advantage |
$23,786.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33,525.24
|
| Rate for Payer: Priority Health Medicare |
$23,786.71
|
| Rate for Payer: Priority Health Narrow Network |
$26,820.19
|
| Rate for Payer: Railroad Medicare Medicare |
$23,786.71
|
| Rate for Payer: UHC Medicare Advantage |
$24,500.31
|
| Rate for Payer: VA VA |
$23,786.71
|
|
|
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$16,561.03
|
|
|
Service Code
|
MS-DRG 499
|
| Min. Negotiated Rate |
$11,970.86 |
| Max. Negotiated Rate |
$16,561.03 |
| Rate for Payer: Aetna Medicare |
$12,600.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15,751.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15,751.12
|
| Rate for Payer: BCBS MAPPO |
$12,600.90
|
| Rate for Payer: BCN Medicare Advantage |
$12,600.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12,600.90
|
| Rate for Payer: Humana Choice PPO Medicare |
$12,600.90
|
| Rate for Payer: Mclaren Medicare |
$12,600.90
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$13,230.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14,491.04
|
| Rate for Payer: PACE Medicare |
$11,970.86
|
| Rate for Payer: PACE SWMI |
$12,600.90
|
| Rate for Payer: PHP Commercial |
$13,860.99
|
| Rate for Payer: PHP Medicare Advantage |
$12,600.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,561.03
|
| Rate for Payer: Priority Health Medicare |
$12,600.90
|
| Rate for Payer: Priority Health Narrow Network |
$13,248.82
|
| Rate for Payer: Railroad Medicare Medicare |
$12,600.90
|
| Rate for Payer: UHC Medicare Advantage |
$12,978.93
|
| Rate for Payer: VA VA |
$12,600.90
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$98.14
|
|
|
Service Code
|
NDC 70000-0461-1
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.70 |
| Max. Negotiated Rate |
$98.14 |
| Rate for Payer: Aetna Commercial |
$88.33
|
| Rate for Payer: ASR ASR |
$95.20
|
| Rate for Payer: BCBS Trust/PPO |
$76.09
|
| Rate for Payer: BCN Commercial |
$76.09
|
| Rate for Payer: Cash Price |
$78.51
|
| Rate for Payer: Cofinity Commercial |
$92.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.51
|
| Rate for Payer: Healthscope Commercial |
$98.14
|
| Rate for Payer: Healthscope Whirlpool |
$95.20
|
| Rate for Payer: Mclaren Commercial |
$88.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$86.36
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$2.43
|
|
|
Service Code
|
NDC 60687-229-11
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$2.43 |
| Rate for Payer: Aetna Commercial |
$2.19
|
| Rate for Payer: ASR ASR |
$2.36
|
| Rate for Payer: BCBS Trust/PPO |
$1.88
|
| Rate for Payer: BCN Commercial |
$1.88
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$2.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.94
|
| Rate for Payer: Healthscope Commercial |
$2.43
|
| Rate for Payer: Healthscope Whirlpool |
$2.36
|
| Rate for Payer: Mclaren Commercial |
$2.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.14
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$3.25
|
|
|
Service Code
|
NDC 51079-690-01
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Aetna Commercial |
$2.92
|
| Rate for Payer: ASR ASR |
$3.15
|
| Rate for Payer: BCBS Trust/PPO |
$2.52
|
| Rate for Payer: BCN Commercial |
$2.52
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cofinity Commercial |
$3.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.60
|
| Rate for Payer: Healthscope Commercial |
$3.25
|
| Rate for Payer: Healthscope Whirlpool |
$3.15
|
| Rate for Payer: Mclaren Commercial |
$2.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.86
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$242.88
|
|
|
Service Code
|
NDC 60687-229-01
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.02 |
| Max. Negotiated Rate |
$242.88 |
| Rate for Payer: Aetna Commercial |
$218.59
|
| Rate for Payer: ASR ASR |
$235.59
|
| Rate for Payer: BCBS Trust/PPO |
$188.30
|
| Rate for Payer: BCN Commercial |
$188.30
|
| Rate for Payer: Cash Price |
$194.30
|
| Rate for Payer: Cofinity Commercial |
$228.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.30
|
| Rate for Payer: Healthscope Commercial |
$242.88
|
| Rate for Payer: Healthscope Whirlpool |
$235.59
|
| Rate for Payer: Mclaren Commercial |
$218.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$213.73
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
NDC 51079-246-01
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna Commercial |
$2.16
|
| Rate for Payer: ASR ASR |
$2.33
|
| Rate for Payer: BCBS Trust/PPO |
$1.86
|
| Rate for Payer: BCN Commercial |
$1.86
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Cofinity Commercial |
$2.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.92
|
| Rate for Payer: Healthscope Commercial |
$2.40
|
| Rate for Payer: Healthscope Whirlpool |
$2.33
|
| Rate for Payer: Mclaren Commercial |
$2.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.11
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$211.85
|
|
|
Service Code
|
NDC 0904-6852-61
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.30 |
| Max. Negotiated Rate |
$211.85 |
| Rate for Payer: Aetna Commercial |
$190.66
|
| Rate for Payer: ASR ASR |
$205.49
|
| Rate for Payer: BCBS Trust/PPO |
$164.25
|
| Rate for Payer: BCN Commercial |
$164.25
|
| Rate for Payer: Cash Price |
$169.48
|
| Rate for Payer: Cofinity Commercial |
$199.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.48
|
| Rate for Payer: Healthscope Commercial |
$211.85
|
| Rate for Payer: Healthscope Whirlpool |
$205.49
|
| Rate for Payer: Mclaren Commercial |
$190.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$180.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$186.43
|
|
|
LORATADINE 10 MG TABLET
|
Facility
|
IP
|
$240.35
|
|
|
Service Code
|
NDC 51079-246-20
|
| Hospital Charge Code |
10466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.24 |
| Max. Negotiated Rate |
$240.35 |
| Rate for Payer: Aetna Commercial |
$216.32
|
| Rate for Payer: ASR ASR |
$233.14
|
| Rate for Payer: BCBS Trust/PPO |
$186.34
|
| Rate for Payer: BCN Commercial |
$186.34
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$225.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$240.35
|
| Rate for Payer: Healthscope Whirlpool |
$233.14
|
| Rate for Payer: Mclaren Commercial |
$216.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$211.51
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$197.75
|
|
|
Service Code
|
NDC 60687-401-01
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.42 |
| Max. Negotiated Rate |
$197.75 |
| Rate for Payer: Aetna Commercial |
$177.98
|
| Rate for Payer: ASR ASR |
$191.82
|
| Rate for Payer: BCBS Trust/PPO |
$153.32
|
| Rate for Payer: BCN Commercial |
$153.32
|
| Rate for Payer: Cash Price |
$158.20
|
| Rate for Payer: Cofinity Commercial |
$185.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.20
|
| Rate for Payer: Healthscope Commercial |
$197.75
|
| Rate for Payer: Healthscope Whirlpool |
$191.82
|
| Rate for Payer: Mclaren Commercial |
$177.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$168.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$174.02
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$227.50
|
|
|
Service Code
|
NDC 69315-904-05
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.25 |
| Max. Negotiated Rate |
$227.50 |
| Rate for Payer: Aetna Commercial |
$204.75
|
| Rate for Payer: ASR ASR |
$220.68
|
| Rate for Payer: BCBS Trust/PPO |
$176.38
|
| Rate for Payer: BCN Commercial |
$176.38
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cofinity Commercial |
$213.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.00
|
| Rate for Payer: Healthscope Commercial |
$227.50
|
| Rate for Payer: Healthscope Whirlpool |
$220.68
|
| Rate for Payer: Mclaren Commercial |
$204.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$200.20
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 60687-401-11
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Aetna Commercial |
$1.78
|
| Rate for Payer: ASR ASR |
$1.92
|
| Rate for Payer: BCBS Trust/PPO |
$1.54
|
| Rate for Payer: BCN Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cofinity Commercial |
$1.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.58
|
| Rate for Payer: Healthscope Commercial |
$1.98
|
| Rate for Payer: Healthscope Whirlpool |
$1.92
|
| Rate for Payer: Mclaren Commercial |
$1.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.74
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$129.50
|
|
|
Service Code
|
NDC 0904-6007-61
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.65 |
| Max. Negotiated Rate |
$129.50 |
| Rate for Payer: Aetna Commercial |
$116.55
|
| Rate for Payer: ASR ASR |
$125.62
|
| Rate for Payer: BCBS Trust/PPO |
$100.40
|
| Rate for Payer: BCN Commercial |
$100.40
|
| Rate for Payer: Cash Price |
$103.60
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.60
|
| Rate for Payer: Healthscope Commercial |
$129.50
|
| Rate for Payer: Healthscope Whirlpool |
$125.62
|
| Rate for Payer: Mclaren Commercial |
$116.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$110.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$113.96
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$150.50
|
|
|
Service Code
|
NDC 0904-6008-61
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.35 |
| Max. Negotiated Rate |
$150.50 |
| Rate for Payer: Aetna Commercial |
$135.45
|
| Rate for Payer: ASR ASR |
$145.98
|
| Rate for Payer: BCBS Trust/PPO |
$116.68
|
| Rate for Payer: BCN Commercial |
$116.68
|
| Rate for Payer: Cash Price |
$120.40
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.40
|
| Rate for Payer: Healthscope Commercial |
$150.50
|
| Rate for Payer: Healthscope Whirlpool |
$145.98
|
| Rate for Payer: Mclaren Commercial |
$135.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$132.44
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 60687-638-11
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.17 |
| Rate for Payer: Aetna Commercial |
$1.95
|
| Rate for Payer: ASR ASR |
$2.10
|
| Rate for Payer: BCBS Trust/PPO |
$1.68
|
| Rate for Payer: BCN Commercial |
$1.68
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cofinity Commercial |
$2.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.74
|
| Rate for Payer: Healthscope Commercial |
$2.17
|
| Rate for Payer: Healthscope Whirlpool |
$2.10
|
| Rate for Payer: Mclaren Commercial |
$1.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.91
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
NDC 60687-638-01
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.90 |
| Max. Negotiated Rate |
$217.00 |
| Rate for Payer: Aetna Commercial |
$195.30
|
| Rate for Payer: ASR ASR |
$210.49
|
| Rate for Payer: BCBS Trust/PPO |
$168.24
|
| Rate for Payer: BCN Commercial |
$168.24
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.60
|
| Rate for Payer: Healthscope Commercial |
$217.00
|
| Rate for Payer: Healthscope Whirlpool |
$210.49
|
| Rate for Payer: Mclaren Commercial |
$195.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$184.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$190.96
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$68.25
|
|
|
Service Code
|
NDC 69315-905-01
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.78 |
| Max. Negotiated Rate |
$68.25 |
| Rate for Payer: Aetna Commercial |
$61.42
|
| Rate for Payer: ASR ASR |
$66.20
|
| Rate for Payer: BCBS Trust/PPO |
$52.91
|
| Rate for Payer: BCN Commercial |
$52.91
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cofinity Commercial |
$64.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.60
|
| Rate for Payer: Healthscope Commercial |
$68.25
|
| Rate for Payer: Healthscope Whirlpool |
$66.20
|
| Rate for Payer: Mclaren Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$60.06
|
|
