|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
NDC 121115430
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Aetna Commercial |
$6.35
|
| Rate for Payer: Aetna Medicare |
$2.61
|
| Rate for Payer: ASR ASR |
$6.84
|
| Rate for Payer: BCBS Complete |
$2.82
|
| Rate for Payer: BCBS Trust/PPO |
$5.82
|
| Rate for Payer: BCN Commercial |
$5.82
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cofinity Commercial |
$6.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.64
|
| Rate for Payer: Healthscope Commercial |
$6.84
|
| Rate for Payer: Healthscope Whirlpool |
$7.06
|
| Rate for Payer: Mclaren Commercial |
$6.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: Nomi Health Commercial |
$5.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.29
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$6.18
|
| Rate for Payer: Priority Health Narrow Network |
$4.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.21
|
|
|
LACTULOSE 20 GRAM/30 ML ORAL SOLUTION
|
Facility
|
IP
|
$6.05
|
|
|
Service Code
|
NDC 116400511
|
| Hospital Charge Code |
150919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.54 |
| Max. Negotiated Rate |
$6.05 |
| Rate for Payer: Aetna Commercial |
$5.44
|
| Rate for Payer: ASR ASR |
$5.87
|
| Rate for Payer: BCBS Trust/PPO |
$4.97
|
| Rate for Payer: BCN Commercial |
$4.97
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cofinity Commercial |
$5.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.84
|
| Rate for Payer: Healthscope Commercial |
$5.87
|
| Rate for Payer: Healthscope Whirlpool |
$6.05
|
| Rate for Payer: Mclaren Commercial |
$5.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.14
|
| Rate for Payer: Nomi Health Commercial |
$4.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.32
|
|
|
LAMOTRIGINE 200 MG TABLET
|
Facility
|
OP
|
$122.67
|
|
|
Service Code
|
NDC 65862023060
|
| Hospital Charge Code |
13983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.39 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$110.40
|
| Rate for Payer: Aetna Medicare |
$45.39
|
| Rate for Payer: ASR ASR |
$118.99
|
| Rate for Payer: BCBS Complete |
$49.07
|
| Rate for Payer: BCBS Trust/PPO |
$101.14
|
| Rate for Payer: BCN Commercial |
$101.14
|
| Rate for Payer: Cash Price |
$98.14
|
| Rate for Payer: Cofinity Commercial |
$115.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.14
|
| Rate for Payer: Healthscope Commercial |
$118.99
|
| Rate for Payer: Healthscope Whirlpool |
$122.67
|
| Rate for Payer: Mclaren Commercial |
$110.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$98.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.27
|
| Rate for Payer: Nomi Health Commercial |
$100.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$92.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$107.48
|
| Rate for Payer: Priority Health Narrow Network |
$85.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$107.95
|
|
|
LAMOTRIGINE 200 MG TABLET
|
Facility
|
IP
|
$122.67
|
|
|
Service Code
|
NDC 65862023060
|
| Hospital Charge Code |
13983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.00 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$110.40
|
| Rate for Payer: ASR ASR |
$118.99
|
| Rate for Payer: BCBS Trust/PPO |
$100.74
|
| Rate for Payer: BCN Commercial |
$100.74
|
| Rate for Payer: Cash Price |
$98.14
|
| Rate for Payer: Cofinity Commercial |
$115.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.14
|
| Rate for Payer: Healthscope Commercial |
$118.99
|
| Rate for Payer: Healthscope Whirlpool |
$122.67
|
| Rate for Payer: Mclaren Commercial |
$110.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$104.27
|
| Rate for Payer: Nomi Health Commercial |
$100.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$92.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$107.95
|
|
|
LAMOTRIGINE 200 MG TABLET
|
Facility
|
IP
|
$183.30
|
|
|
Service Code
|
NDC 51672413304
|
| Hospital Charge Code |
13983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.47 |
| Max. Negotiated Rate |
$183.30 |
| Rate for Payer: Aetna Commercial |
$164.97
|
| Rate for Payer: ASR ASR |
$177.80
|
| Rate for Payer: BCBS Trust/PPO |
$150.53
|
| Rate for Payer: BCN Commercial |
$150.53
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$172.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$177.80
|
| Rate for Payer: Healthscope Whirlpool |
$183.30
|
| Rate for Payer: Mclaren Commercial |
$164.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.81
|
| Rate for Payer: Nomi Health Commercial |
$150.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$137.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$161.30
|
|
|
LAMOTRIGINE 200 MG TABLET
|
Facility
|
OP
|
$183.30
|
|
|
Service Code
|
NDC 51672413304
|
| Hospital Charge Code |
13983
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.82 |
| Max. Negotiated Rate |
$183.30 |
| Rate for Payer: Aetna Commercial |
$164.97
|
| Rate for Payer: Aetna Medicare |
$67.82
|
| Rate for Payer: ASR ASR |
$177.80
|
| Rate for Payer: BCBS Complete |
$73.32
|
| Rate for Payer: BCBS Trust/PPO |
$151.13
|
| Rate for Payer: BCN Commercial |
$151.13
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$172.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$177.80
|
| Rate for Payer: Healthscope Whirlpool |
$183.30
|
| Rate for Payer: Mclaren Commercial |
$164.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$146.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.81
|
| Rate for Payer: Nomi Health Commercial |
$150.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$137.47
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$160.61
|
| Rate for Payer: Priority Health Narrow Network |
$128.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$161.30
|
|
|
LAMOTRIGINE 25 MG TABLET
|
Facility
|
OP
|
$321.95
|
|
|
Service Code
|
NDC 904700761
|
| Hospital Charge Code |
13981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.12 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Medicare |
$119.12
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: BCBS Trust/PPO |
$265.45
|
| Rate for Payer: BCN Commercial |
$265.45
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$302.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$312.29
|
| Rate for Payer: Healthscope Whirlpool |
$321.95
|
| Rate for Payer: Mclaren Commercial |
$289.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$257.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: Nomi Health Commercial |
$264.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$282.09
|
| Rate for Payer: Priority Health Narrow Network |
$225.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.32
|
|
|
LAMOTRIGINE 25 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 904700761
|
| Hospital Charge Code |
13981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.46 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: BCBS Trust/PPO |
$264.39
|
| Rate for Payer: BCN Commercial |
$264.39
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$302.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$312.29
|
| Rate for Payer: Healthscope Whirlpool |
$321.95
|
| Rate for Payer: Mclaren Commercial |
$289.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: Nomi Health Commercial |
$264.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.32
|
|
|
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC
|
Facility
|
IP
|
$23,240.55
|
|
|
Service Code
|
MSDRG 418
|
| Min. Negotiated Rate |
$13,239.28 |
| Max. Negotiated Rate |
$23,240.55 |
| Rate for Payer: Aetna Medicare |
$13,936.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17,420.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17,420.10
|
| Rate for Payer: BCBS MAPPO |
$13,936.08
|
| Rate for Payer: BCN Medicare Advantage |
$13,936.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13,936.08
|
| Rate for Payer: Humana Choice PPO Medicare |
$13,936.08
|
| Rate for Payer: Mclaren Medicare |
$13,936.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14,632.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16,026.49
|
| Rate for Payer: Molina Medicare/Medicaid |
$15,329.69
|
| Rate for Payer: PACE Medicare |
$13,239.28
|
| Rate for Payer: PACE SWMI |
$13,936.08
|
| Rate for Payer: PHP Commercial |
$15,329.69
|
| Rate for Payer: PHP Medicare Advantage |
$13,936.08
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23,240.55
|
| Rate for Payer: Priority Health Medicare |
$13,936.08
|
| Rate for Payer: Priority Health Narrow Network |
$18,592.44
|
| Rate for Payer: Railroad Medicare Medicare |
$13,936.08
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$13,936.08
|
| Rate for Payer: UHC Exchange |
$21,600.92
|
| Rate for Payer: UHCCP DNSP |
$13,936.08
|
| Rate for Payer: VA VA |
$13,936.08
|
|
|
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC
|
Facility
|
IP
|
$32,786.27
|
|
|
Service Code
|
MSDRG 417
|
| Min. Negotiated Rate |
$17,992.53 |
| Max. Negotiated Rate |
$32,786.27 |
| Rate for Payer: Aetna Medicare |
$18,939.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23,674.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23,674.39
|
| Rate for Payer: BCBS MAPPO |
$18,939.51
|
| Rate for Payer: BCN Medicare Advantage |
$18,939.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18,939.51
|
| Rate for Payer: Humana Choice PPO Medicare |
$18,939.51
|
| Rate for Payer: Mclaren Medicare |
$18,939.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19,886.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21,780.44
|
| Rate for Payer: Molina Medicare/Medicaid |
$20,833.46
|
| Rate for Payer: PACE Medicare |
$17,992.53
|
| Rate for Payer: PACE SWMI |
$18,939.51
|
| Rate for Payer: PHP Commercial |
$20,833.46
|
| Rate for Payer: PHP Medicare Advantage |
$18,939.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$32,786.27
|
| Rate for Payer: Priority Health Medicare |
$18,939.51
|
| Rate for Payer: Priority Health Narrow Network |
$26,229.02
|
| Rate for Payer: Railroad Medicare Medicare |
$18,939.51
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$18,939.51
|
| Rate for Payer: UHC Exchange |
$29,356.24
|
| Rate for Payer: UHCCP DNSP |
$18,939.51
|
| Rate for Payer: VA VA |
$18,939.51
|
|
|
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC
|
Facility
|
IP
|
$18,764.45
|
|
|
Service Code
|
MSDRG 419
|
| Min. Negotiated Rate |
$11,010.42 |
| Max. Negotiated Rate |
$18,764.45 |
| Rate for Payer: Aetna Medicare |
$11,589.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14,487.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14,487.40
|
| Rate for Payer: BCBS MAPPO |
$11,589.92
|
| Rate for Payer: BCN Medicare Advantage |
$11,589.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11,589.92
|
| Rate for Payer: Humana Choice PPO Medicare |
$11,589.92
|
| Rate for Payer: Mclaren Medicare |
$11,589.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12,169.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13,328.41
|
| Rate for Payer: Molina Medicare/Medicaid |
$12,748.91
|
| Rate for Payer: PACE Medicare |
$11,010.42
|
| Rate for Payer: PACE SWMI |
$11,589.92
|
| Rate for Payer: PHP Commercial |
$12,748.91
|
| Rate for Payer: PHP Medicare Advantage |
$11,589.92
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18,764.45
|
| Rate for Payer: Priority Health Medicare |
$11,589.92
|
| Rate for Payer: Priority Health Narrow Network |
$15,011.56
|
| Rate for Payer: Railroad Medicare Medicare |
$11,589.92
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$11,589.92
|
| Rate for Payer: UHC Exchange |
$17,964.38
|
| Rate for Payer: UHCCP DNSP |
$11,589.92
|
| Rate for Payer: VA VA |
$11,589.92
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$50.75
|
|
|
Service Code
|
NDC 17478062512
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.67
|
| Rate for Payer: Aetna Medicare |
$18.78
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: BCBS Complete |
$20.30
|
| Rate for Payer: BCBS Trust/PPO |
$41.84
|
| Rate for Payer: BCN Commercial |
$41.84
|
| Rate for Payer: Cash Price |
$40.60
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.60
|
| Rate for Payer: Healthscope Commercial |
$49.23
|
| Rate for Payer: Healthscope Whirlpool |
$50.75
|
| Rate for Payer: Mclaren Commercial |
$45.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.14
|
| Rate for Payer: Nomi Health Commercial |
$41.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$44.47
|
| Rate for Payer: Priority Health Narrow Network |
$35.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.66
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$26.28
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.71 |
| Max. Negotiated Rate |
$26.28 |
| Rate for Payer: Aetna Commercial |
$23.65
|
| Rate for Payer: ASR ASR |
$25.49
|
| Rate for Payer: BCBS Trust/PPO |
$21.58
|
| Rate for Payer: BCN Commercial |
$21.58
|
| Rate for Payer: Cash Price |
$21.02
|
| Rate for Payer: Cofinity Commercial |
$24.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.02
|
| Rate for Payer: Healthscope Commercial |
$25.49
|
| Rate for Payer: Healthscope Whirlpool |
$26.28
|
| Rate for Payer: Mclaren Commercial |
$23.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.34
|
| Rate for Payer: Nomi Health Commercial |
$21.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.13
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$52.12
|
|
|
Service Code
|
NDC 61314054703
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$52.12 |
| Rate for Payer: Aetna Commercial |
$46.91
|
| Rate for Payer: Aetna Medicare |
$19.29
|
| Rate for Payer: ASR ASR |
$50.56
|
| Rate for Payer: BCBS Complete |
$20.85
|
| Rate for Payer: BCBS Trust/PPO |
$42.98
|
| Rate for Payer: BCN Commercial |
$42.98
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.70
|
| Rate for Payer: Healthscope Commercial |
$50.56
|
| Rate for Payer: Healthscope Whirlpool |
$52.12
|
| Rate for Payer: Mclaren Commercial |
$46.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.31
|
| Rate for Payer: Nomi Health Commercial |
$42.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$45.67
|
| Rate for Payer: Priority Health Narrow Network |
$36.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.87
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$50.75
|
|
|
Service Code
|
NDC 17478062512
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.06 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.67
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: BCBS Trust/PPO |
$41.68
|
| Rate for Payer: BCN Commercial |
$41.68
|
| Rate for Payer: Cash Price |
$40.60
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.60
|
| Rate for Payer: Healthscope Commercial |
$49.23
|
| Rate for Payer: Healthscope Whirlpool |
$50.75
|
| Rate for Payer: Mclaren Commercial |
$45.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.14
|
| Rate for Payer: Nomi Health Commercial |
$41.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.66
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$26.28
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.72 |
| Max. Negotiated Rate |
$26.28 |
| Rate for Payer: Aetna Commercial |
$23.65
|
| Rate for Payer: Aetna Medicare |
$9.72
|
| Rate for Payer: ASR ASR |
$25.49
|
| Rate for Payer: BCBS Complete |
$10.51
|
| Rate for Payer: BCBS Trust/PPO |
$21.67
|
| Rate for Payer: BCN Commercial |
$21.67
|
| Rate for Payer: Cash Price |
$21.02
|
| Rate for Payer: Cofinity Commercial |
$24.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.02
|
| Rate for Payer: Healthscope Commercial |
$25.49
|
| Rate for Payer: Healthscope Whirlpool |
$26.28
|
| Rate for Payer: Mclaren Commercial |
$23.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.34
|
| Rate for Payer: Nomi Health Commercial |
$21.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23.03
|
| Rate for Payer: Priority Health Narrow Network |
$18.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.13
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$52.12
|
|
|
Service Code
|
NDC 61314054703
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.09 |
| Max. Negotiated Rate |
$52.12 |
| Rate for Payer: Aetna Commercial |
$46.91
|
| Rate for Payer: ASR ASR |
$50.56
|
| Rate for Payer: BCBS Trust/PPO |
$42.80
|
| Rate for Payer: BCN Commercial |
$42.80
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.70
|
| Rate for Payer: Healthscope Commercial |
$50.56
|
| Rate for Payer: Healthscope Whirlpool |
$52.12
|
| Rate for Payer: Mclaren Commercial |
$46.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.31
|
| Rate for Payer: Nomi Health Commercial |
$42.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$39.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.87
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$19.22
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.11 |
| Max. Negotiated Rate |
$19.21 |
| Rate for Payer: Aetna Commercial |
$17.29
|
| Rate for Payer: Aetna Medicare |
$7.11
|
| Rate for Payer: ASR ASR |
$18.64
|
| Rate for Payer: BCBS Complete |
$7.69
|
| Rate for Payer: BCBS Trust/PPO |
$15.84
|
| Rate for Payer: BCN Commercial |
$15.84
|
| Rate for Payer: Cash Price |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.37
|
| Rate for Payer: Healthscope Commercial |
$18.64
|
| Rate for Payer: Healthscope Whirlpool |
$19.21
|
| Rate for Payer: Mclaren Commercial |
$17.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.33
|
| Rate for Payer: Nomi Health Commercial |
$15.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.41
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.84
|
| Rate for Payer: Priority Health Narrow Network |
$13.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.91
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$19.22
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.41 |
| Max. Negotiated Rate |
$19.21 |
| Rate for Payer: Aetna Commercial |
$17.29
|
| Rate for Payer: ASR ASR |
$18.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.78
|
| Rate for Payer: BCN Commercial |
$15.78
|
| Rate for Payer: Cash Price |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.37
|
| Rate for Payer: Healthscope Commercial |
$18.64
|
| Rate for Payer: Healthscope Whirlpool |
$19.21
|
| Rate for Payer: Mclaren Commercial |
$17.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.33
|
| Rate for Payer: Nomi Health Commercial |
$15.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.91
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$22,606.73
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16,955.05 |
| Max. Negotiated Rate |
$22,606.73 |
| Rate for Payer: Aetna Commercial |
$20,346.06
|
| Rate for Payer: ASR ASR |
$21,928.53
|
| Rate for Payer: BCBS Trust/PPO |
$18,564.65
|
| Rate for Payer: BCN Commercial |
$18,564.65
|
| Rate for Payer: Cash Price |
$18,085.38
|
| Rate for Payer: Cofinity Commercial |
$21,250.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,085.38
|
| Rate for Payer: Healthscope Commercial |
$21,928.53
|
| Rate for Payer: Healthscope Whirlpool |
$22,606.73
|
| Rate for Payer: Mclaren Commercial |
$20,346.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,215.72
|
| Rate for Payer: Nomi Health Commercial |
$18,537.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16,955.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19,893.92
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$22,606.73
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$923.39 |
| Max. Negotiated Rate |
$22,606.73 |
| Rate for Payer: Aetna Commercial |
$20,346.06
|
| Rate for Payer: Aetna Medicare |
$1,765.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,206.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,206.96
|
| Rate for Payer: ASR ASR |
$21,928.53
|
| Rate for Payer: BCBS Complete |
$969.65
|
| Rate for Payer: BCBS MAPPO |
$1,765.57
|
| Rate for Payer: BCBS Trust/PPO |
$18,639.25
|
| Rate for Payer: BCN Commercial |
$18,639.25
|
| Rate for Payer: BCN Medicare Advantage |
$1,765.57
|
| Rate for Payer: Cash Price |
$18,085.38
|
| Rate for Payer: Cash Price |
$18,085.38
|
| Rate for Payer: Cofinity Commercial |
$21,250.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,085.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,765.57
|
| Rate for Payer: Healthscope Commercial |
$21,928.53
|
| Rate for Payer: Healthscope Whirlpool |
$22,606.73
|
| Rate for Payer: Humana Choice PPO Medicare |
$1,765.57
|
| Rate for Payer: Mclaren Commercial |
$20,346.06
|
| Rate for Payer: Mclaren Medicaid |
$1,765.57
|
| Rate for Payer: Mclaren Medicare |
$1,765.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,853.85
|
| Rate for Payer: Meridian Medicaid |
$969.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,030.41
|
| Rate for Payer: Molina Medicare/Medicaid |
$1,942.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,215.72
|
| Rate for Payer: Nomi Health Commercial |
$18,537.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16,955.05
|
| Rate for Payer: PACE Medicare |
$1,677.29
|
| Rate for Payer: PACE SWMI |
$1,765.57
|
| Rate for Payer: PHP Commercial |
$1,942.13
|
| Rate for Payer: PHP Medicaid |
$946.35
|
| Rate for Payer: PHP Medicare Advantage |
$1,765.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$923.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1,830.43
|
| Rate for Payer: Priority Health Medicare |
$1,765.57
|
| Rate for Payer: Priority Health Narrow Network |
$1,464.34
|
| Rate for Payer: Railroad Medicare Medicare |
$1,765.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19,893.92
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1,765.57
|
| Rate for Payer: UHC Exchange |
$2,736.63
|
| Rate for Payer: UHC Medicaid |
$923.39
|
| Rate for Payer: UHCCP DNSP |
$1,765.57
|
| Rate for Payer: UHCCP Medicaid |
$923.39
|
| Rate for Payer: VA VA |
$1,765.57
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$17,138.68
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,854.01 |
| Max. Negotiated Rate |
$17,138.68 |
| Rate for Payer: Aetna Commercial |
$15,424.81
|
| Rate for Payer: ASR ASR |
$16,624.52
|
| Rate for Payer: BCBS Trust/PPO |
$14,074.28
|
| Rate for Payer: BCN Commercial |
$14,074.28
|
| Rate for Payer: Cash Price |
$13,710.94
|
| Rate for Payer: Cofinity Commercial |
$16,110.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,710.94
|
| Rate for Payer: Healthscope Commercial |
$16,624.52
|
| Rate for Payer: Healthscope Whirlpool |
$17,138.68
|
| Rate for Payer: Mclaren Commercial |
$15,424.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,567.88
|
| Rate for Payer: Nomi Health Commercial |
$14,053.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12,854.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15,082.04
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$17,138.68
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.15 |
| Max. Negotiated Rate |
$17,138.68 |
| Rate for Payer: Aetna Commercial |
$15,424.81
|
| Rate for Payer: Aetna Medicare |
$176.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.25
|
| Rate for Payer: ASR ASR |
$16,624.52
|
| Rate for Payer: BCBS Complete |
$96.77
|
| Rate for Payer: BCBS MAPPO |
$176.20
|
| Rate for Payer: BCBS Trust/PPO |
$14,130.84
|
| Rate for Payer: BCN Commercial |
$14,130.84
|
| Rate for Payer: BCN Medicare Advantage |
$176.20
|
| Rate for Payer: Cash Price |
$13,710.94
|
| Rate for Payer: Cash Price |
$13,710.94
|
| Rate for Payer: Cofinity Commercial |
$16,110.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,710.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.20
|
| Rate for Payer: Healthscope Commercial |
$16,624.52
|
| Rate for Payer: Healthscope Whirlpool |
$17,138.68
|
| Rate for Payer: Humana Choice PPO Medicare |
$176.20
|
| Rate for Payer: Mclaren Commercial |
$15,424.81
|
| Rate for Payer: Mclaren Medicaid |
$176.20
|
| Rate for Payer: Mclaren Medicare |
$176.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.01
|
| Rate for Payer: Meridian Medicaid |
$96.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$193.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,567.88
|
| Rate for Payer: Nomi Health Commercial |
$14,053.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12,854.01
|
| Rate for Payer: PACE Medicare |
$167.39
|
| Rate for Payer: PACE SWMI |
$176.20
|
| Rate for Payer: PHP Commercial |
$193.82
|
| Rate for Payer: PHP Medicaid |
$94.44
|
| Rate for Payer: PHP Medicare Advantage |
$176.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$177.22
|
| Rate for Payer: Priority Health Medicare |
$176.20
|
| Rate for Payer: Priority Health Narrow Network |
$141.78
|
| Rate for Payer: Railroad Medicare Medicare |
$176.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15,082.04
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$176.20
|
| Rate for Payer: UHC Exchange |
$273.11
|
| Rate for Payer: UHC Medicaid |
$92.15
|
| Rate for Payer: UHCCP DNSP |
$176.20
|
| Rate for Payer: UHCCP Medicaid |
$92.15
|
| Rate for Payer: VA VA |
$176.20
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$2,188.80
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
40801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,641.60 |
| Max. Negotiated Rate |
$2,188.80 |
| Rate for Payer: Aetna Commercial |
$1,969.92
|
| Rate for Payer: ASR ASR |
$2,123.14
|
| Rate for Payer: BCBS Trust/PPO |
$1,797.44
|
| Rate for Payer: BCN Commercial |
$1,797.44
|
| Rate for Payer: Cash Price |
$1,751.04
|
| Rate for Payer: Cofinity Commercial |
$2,057.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,751.04
|
| Rate for Payer: Healthscope Commercial |
$2,123.14
|
| Rate for Payer: Healthscope Whirlpool |
$2,188.80
|
| Rate for Payer: Mclaren Commercial |
$1,969.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,860.48
|
| Rate for Payer: Nomi Health Commercial |
$1,794.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,641.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,926.14
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$2,188.80
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
40801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.15 |
| Max. Negotiated Rate |
$2,188.80 |
| Rate for Payer: Aetna Commercial |
$1,969.92
|
| Rate for Payer: Aetna Medicare |
$176.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.25
|
| Rate for Payer: ASR ASR |
$2,123.14
|
| Rate for Payer: BCBS Complete |
$96.77
|
| Rate for Payer: BCBS MAPPO |
$176.20
|
| Rate for Payer: BCBS Trust/PPO |
$1,804.67
|
| Rate for Payer: BCN Commercial |
$1,804.67
|
| Rate for Payer: BCN Medicare Advantage |
$176.20
|
| Rate for Payer: Cash Price |
$1,751.04
|
| Rate for Payer: Cash Price |
$1,751.04
|
| Rate for Payer: Cofinity Commercial |
$2,057.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,751.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.20
|
| Rate for Payer: Healthscope Commercial |
$2,123.14
|
| Rate for Payer: Healthscope Whirlpool |
$2,188.80
|
| Rate for Payer: Humana Choice PPO Medicare |
$176.20
|
| Rate for Payer: Mclaren Commercial |
$1,969.92
|
| Rate for Payer: Mclaren Medicaid |
$176.20
|
| Rate for Payer: Mclaren Medicare |
$176.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.01
|
| Rate for Payer: Meridian Medicaid |
$96.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$193.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,860.48
|
| Rate for Payer: Nomi Health Commercial |
$1,794.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,641.60
|
| Rate for Payer: PACE Medicare |
$167.39
|
| Rate for Payer: PACE SWMI |
$176.20
|
| Rate for Payer: PHP Commercial |
$193.82
|
| Rate for Payer: PHP Medicaid |
$94.44
|
| Rate for Payer: PHP Medicare Advantage |
$176.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$177.22
|
| Rate for Payer: Priority Health Medicare |
$176.20
|
| Rate for Payer: Priority Health Narrow Network |
$141.78
|
| Rate for Payer: Railroad Medicare Medicare |
$176.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,926.14
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$176.20
|
| Rate for Payer: UHC Exchange |
$273.11
|
| Rate for Payer: UHC Medicaid |
$92.15
|
| Rate for Payer: UHCCP DNSP |
$176.20
|
| Rate for Payer: UHCCP Medicaid |
$92.15
|
| Rate for Payer: VA VA |
$176.20
|
|
