|
LAMOTRIGINE 25 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 00904700761
|
| Hospital Charge Code |
13981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$209.27 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: ASR Commercial |
$312.29
|
| Rate for Payer: BCBS Trust/PPO |
$262.36
|
| Rate for Payer: BCN Commercial |
$249.61
|
| 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 |
$321.95
|
| Rate for Payer: Healthscope Whirlpool |
$312.29
|
| 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: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.32
|
|
|
LAMOTRIGINE 25 MG TABLET
|
Facility
|
OP
|
$321.95
|
|
|
Service Code
|
NDC 00904700761
|
| Hospital Charge Code |
13981
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.78 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Medicare |
$160.97
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: ASR Commercial |
$312.29
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: BCBS Trust/PPO |
$263.64
|
| Rate for Payer: BCN Commercial |
$249.61
|
| 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 |
$321.95
|
| Rate for Payer: Healthscope Whirlpool |
$312.29
|
| 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: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: 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
|
|
|
LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL;
|
Facility
|
OP
|
$2,606.85
|
|
|
Service Code
|
CPT 31530
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$901.47 |
| Max. Negotiated Rate |
$2,606.85 |
| Rate for Payer: Aetna Medicare |
$1,681.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,102.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,102.30
|
| Rate for Payer: BCBS Complete |
$946.54
|
| Rate for Payer: BCBS MAPPO |
$1,681.84
|
| Rate for Payer: BCN Medicare Advantage |
$1,681.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,681.84
|
| Rate for Payer: Humana Choice PPO Medicare |
$1,681.84
|
| Rate for Payer: Mclaren Medicaid |
$901.47
|
| Rate for Payer: Mclaren Medicare |
$1,681.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,765.93
|
| Rate for Payer: Meridian Medicaid |
$946.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,934.12
|
| Rate for Payer: PACE Medicare |
$1,597.75
|
| Rate for Payer: PACE SWMI |
$1,681.84
|
| Rate for Payer: PHP Commercial |
$1,850.02
|
| Rate for Payer: PHP Medicaid |
$901.47
|
| Rate for Payer: PHP Medicare Advantage |
$1,681.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$901.47
|
| Rate for Payer: Priority Health Medicare |
$1,681.84
|
| Rate for Payer: Railroad Medicare Medicare |
$1,681.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,681.84
|
| Rate for Payer: UHC Exchange |
$2,606.85
|
| Rate for Payer: UHC Medicare Advantage |
$1,681.84
|
| Rate for Payer: UHCCP DNSP |
$1,681.84
|
| Rate for Payer: UHCCP Medicaid |
$901.47
|
| Rate for Payer: VA VA |
$1,681.84
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$50.75
|
|
|
Service Code
|
NDC 00517083001
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.99 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.67
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: ASR Commercial |
$49.23
|
| Rate for Payer: BCBS Trust/PPO |
$41.36
|
| Rate for Payer: BCN Commercial |
$39.35
|
| 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 |
$50.75
|
| Rate for Payer: Healthscope Whirlpool |
$49.23
|
| 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: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.66
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$19.22
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$19.22 |
| Rate for Payer: Aetna Commercial |
$17.30
|
| Rate for Payer: Aetna Medicare |
$9.61
|
| Rate for Payer: ASR ASR |
$18.64
|
| Rate for Payer: ASR Commercial |
$18.64
|
| Rate for Payer: BCBS Complete |
$7.69
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Healthscope Commercial |
$19.22
|
| Rate for Payer: Healthscope Whirlpool |
$18.64
|
| Rate for Payer: Mclaren Commercial |
$17.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.34
|
| Rate for Payer: Nomi Health Commercial |
$15.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.49
|
| Rate for Payer: 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
|
$50.75
|
|
|
Service Code
|
NDC 17478062512
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.99 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.67
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: ASR Commercial |
$49.23
|
| Rate for Payer: BCBS Trust/PPO |
$41.36
|
| Rate for Payer: BCN Commercial |
$39.35
|
| 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 |
$50.75
|
| Rate for Payer: Healthscope Whirlpool |
$49.23
|
| 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: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$44.66
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$50.75
|
|
|
Service Code
|
NDC 17478062512
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.67
|
| Rate for Payer: Aetna Medicare |
$25.38
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: ASR Commercial |
$49.23
|
| Rate for Payer: BCBS Complete |
$20.30
|
| Rate for Payer: BCBS Trust/PPO |
$41.56
|
| Rate for Payer: BCN Commercial |
$39.35
|
| 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 |
$50.75
|
| Rate for Payer: Healthscope Whirlpool |
$49.23
|
| 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: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: 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
|
$46.38
|
|
|
Service Code
|
NDC 61314054703
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.15 |
| Max. Negotiated Rate |
$46.38 |
| Rate for Payer: Aetna Commercial |
$41.74
|
| Rate for Payer: ASR ASR |
$44.99
|
| Rate for Payer: ASR Commercial |
$44.99
|
| Rate for Payer: BCBS Trust/PPO |
$37.80
|
| Rate for Payer: BCN Commercial |
$35.96
|
| Rate for Payer: Cash Price |
$37.11
|
| Rate for Payer: Cofinity Commercial |
$43.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.10
|
| Rate for Payer: Healthscope Commercial |
$46.38
|
| Rate for Payer: Healthscope Whirlpool |
$44.99
|
| Rate for Payer: Mclaren Commercial |
$41.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.42
|
| Rate for Payer: Nomi Health Commercial |
$38.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.81
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$26.46
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Aetna Commercial |
$23.81
|
| Rate for Payer: ASR ASR |
$25.67
|
| Rate for Payer: ASR Commercial |
$25.67
|
| Rate for Payer: BCBS Trust/PPO |
$21.56
|
| Rate for Payer: BCN Commercial |
$20.51
|
| Rate for Payer: Cash Price |
$21.17
|
| Rate for Payer: Cofinity Commercial |
$24.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.17
|
| Rate for Payer: Healthscope Commercial |
$26.46
|
| Rate for Payer: Healthscope Whirlpool |
$25.67
|
| Rate for Payer: Mclaren Commercial |
$23.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.49
|
| Rate for Payer: Nomi Health Commercial |
$21.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.28
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$19.22
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.49 |
| Max. Negotiated Rate |
$19.22 |
| Rate for Payer: Aetna Commercial |
$17.30
|
| Rate for Payer: ASR ASR |
$18.64
|
| Rate for Payer: ASR Commercial |
$18.64
|
| Rate for Payer: BCBS Trust/PPO |
$15.66
|
| Rate for Payer: BCN Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Healthscope Commercial |
$19.22
|
| Rate for Payer: Healthscope Whirlpool |
$18.64
|
| Rate for Payer: Mclaren Commercial |
$17.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.34
|
| Rate for Payer: Nomi Health Commercial |
$15.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.91
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$26.46
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$26.46 |
| Rate for Payer: Aetna Commercial |
$23.81
|
| Rate for Payer: Aetna Medicare |
$13.23
|
| Rate for Payer: ASR ASR |
$25.67
|
| Rate for Payer: ASR Commercial |
$25.67
|
| Rate for Payer: BCBS Complete |
$10.58
|
| Rate for Payer: BCBS Trust/PPO |
$21.67
|
| Rate for Payer: BCN Commercial |
$20.51
|
| Rate for Payer: Cash Price |
$21.17
|
| Rate for Payer: Cofinity Commercial |
$24.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.17
|
| Rate for Payer: Healthscope Commercial |
$26.46
|
| Rate for Payer: Healthscope Whirlpool |
$25.67
|
| Rate for Payer: Mclaren Commercial |
$23.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.49
|
| Rate for Payer: Nomi Health Commercial |
$21.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.18
|
| Rate for Payer: Priority Health Narrow Network |
$18.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.28
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$50.75
|
|
|
Service Code
|
NDC 00517083001
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$50.75 |
| Rate for Payer: Aetna Commercial |
$45.67
|
| Rate for Payer: Aetna Medicare |
$25.38
|
| Rate for Payer: ASR ASR |
$49.23
|
| Rate for Payer: ASR Commercial |
$49.23
|
| Rate for Payer: BCBS Complete |
$20.30
|
| Rate for Payer: BCBS Trust/PPO |
$41.56
|
| Rate for Payer: BCN Commercial |
$39.35
|
| 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 |
$50.75
|
| Rate for Payer: Healthscope Whirlpool |
$49.23
|
| 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: Priority Health Cigna Priority Health |
$32.99
|
| Rate for Payer: 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
|
OP
|
$46.38
|
|
|
Service Code
|
NDC 61314054703
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.55 |
| Max. Negotiated Rate |
$46.38 |
| Rate for Payer: Aetna Commercial |
$41.74
|
| Rate for Payer: Aetna Medicare |
$23.19
|
| Rate for Payer: ASR ASR |
$44.99
|
| Rate for Payer: ASR Commercial |
$44.99
|
| Rate for Payer: BCBS Complete |
$18.55
|
| Rate for Payer: BCBS Trust/PPO |
$37.98
|
| Rate for Payer: BCN Commercial |
$35.96
|
| Rate for Payer: Cash Price |
$37.11
|
| Rate for Payer: Cofinity Commercial |
$43.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.10
|
| Rate for Payer: Healthscope Commercial |
$46.38
|
| Rate for Payer: Healthscope Whirlpool |
$44.99
|
| Rate for Payer: Mclaren Commercial |
$41.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.42
|
| Rate for Payer: Nomi Health Commercial |
$38.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.64
|
| Rate for Payer: Priority Health Narrow Network |
$32.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.81
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$19,492.67
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$927.45 |
| Max. Negotiated Rate |
$19,492.67 |
| Rate for Payer: Aetna Commercial |
$17,543.40
|
| Rate for Payer: Aetna Medicare |
$1,730.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,162.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,162.90
|
| Rate for Payer: ASR ASR |
$18,907.89
|
| Rate for Payer: ASR Commercial |
$18,907.89
|
| Rate for Payer: BCBS Complete |
$973.82
|
| Rate for Payer: BCBS MAPPO |
$1,730.32
|
| Rate for Payer: BCBS Trust/PPO |
$15,962.55
|
| Rate for Payer: BCN Commercial |
$15,112.67
|
| Rate for Payer: BCN Medicare Advantage |
$1,730.32
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cofinity Commercial |
$18,323.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,594.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,730.32
|
| Rate for Payer: Healthscope Commercial |
$19,492.67
|
| Rate for Payer: Healthscope Whirlpool |
$18,907.89
|
| Rate for Payer: Humana Choice PPO Medicare |
$1,730.32
|
| Rate for Payer: Mclaren Commercial |
$17,543.40
|
| Rate for Payer: Mclaren Medicaid |
$927.45
|
| Rate for Payer: Mclaren Medicare |
$1,730.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,816.84
|
| Rate for Payer: Meridian Medicaid |
$973.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,989.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,568.77
|
| Rate for Payer: Nomi Health Commercial |
$15,983.99
|
| Rate for Payer: PACE Medicare |
$1,643.80
|
| Rate for Payer: PACE SWMI |
$1,730.32
|
| Rate for Payer: PHP Commercial |
$1,903.35
|
| Rate for Payer: PHP Medicaid |
$927.45
|
| Rate for Payer: PHP Medicare Advantage |
$1,730.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$927.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,670.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,079.48
|
| Rate for Payer: Priority Health Medicare |
$1,730.32
|
| Rate for Payer: Priority Health Narrow Network |
$13,664.36
|
| Rate for Payer: Railroad Medicare Medicare |
$1,730.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17,153.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,730.32
|
| Rate for Payer: UHC Exchange |
$2,682.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,730.32
|
| Rate for Payer: UHCCP DNSP |
$1,730.32
|
| Rate for Payer: UHCCP Medicaid |
$927.45
|
| Rate for Payer: VA VA |
$1,730.32
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$19,492.67
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,670.24 |
| Max. Negotiated Rate |
$19,492.67 |
| Rate for Payer: Aetna Commercial |
$17,543.40
|
| Rate for Payer: ASR ASR |
$18,907.89
|
| Rate for Payer: ASR Commercial |
$18,907.89
|
| Rate for Payer: BCBS Trust/PPO |
$15,884.58
|
| Rate for Payer: BCN Commercial |
$15,112.67
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cofinity Commercial |
$18,323.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,594.14
|
| Rate for Payer: Healthscope Commercial |
$19,492.67
|
| Rate for Payer: Healthscope Whirlpool |
$18,907.89
|
| Rate for Payer: Mclaren Commercial |
$17,543.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,568.77
|
| Rate for Payer: Nomi Health Commercial |
$15,983.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,670.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17,153.55
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$16,322.57
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,609.67 |
| Max. Negotiated Rate |
$16,322.57 |
| Rate for Payer: Aetna Commercial |
$14,690.31
|
| Rate for Payer: ASR ASR |
$15,832.89
|
| Rate for Payer: ASR Commercial |
$15,832.89
|
| Rate for Payer: BCBS Trust/PPO |
$13,301.26
|
| Rate for Payer: BCN Commercial |
$12,654.89
|
| Rate for Payer: Cash Price |
$13,058.05
|
| Rate for Payer: Cofinity Commercial |
$15,343.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,058.06
|
| Rate for Payer: Healthscope Commercial |
$16,322.57
|
| Rate for Payer: Healthscope Whirlpool |
$15,832.89
|
| Rate for Payer: Mclaren Commercial |
$14,690.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,874.18
|
| Rate for Payer: Nomi Health Commercial |
$13,384.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,609.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14,363.86
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$16,322.57
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.58 |
| Max. Negotiated Rate |
$16,322.57 |
| Rate for Payer: Aetna Commercial |
$14,690.31
|
| Rate for Payer: Aetna Medicare |
$176.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.56
|
| Rate for Payer: ASR ASR |
$15,832.89
|
| Rate for Payer: ASR Commercial |
$15,832.89
|
| Rate for Payer: BCBS Complete |
$99.31
|
| Rate for Payer: BCBS MAPPO |
$176.45
|
| Rate for Payer: BCBS Trust/PPO |
$13,366.55
|
| Rate for Payer: BCN Commercial |
$12,654.89
|
| Rate for Payer: BCN Medicare Advantage |
$176.45
|
| Rate for Payer: Cash Price |
$13,058.05
|
| Rate for Payer: Cash Price |
$13,058.05
|
| Rate for Payer: Cofinity Commercial |
$15,343.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,058.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.45
|
| Rate for Payer: Healthscope Commercial |
$16,322.57
|
| Rate for Payer: Healthscope Whirlpool |
$15,832.89
|
| Rate for Payer: Humana Choice PPO Medicare |
$176.45
|
| Rate for Payer: Mclaren Commercial |
$14,690.31
|
| Rate for Payer: Mclaren Medicaid |
$94.58
|
| Rate for Payer: Mclaren Medicare |
$176.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.27
|
| Rate for Payer: Meridian Medicaid |
$99.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,874.18
|
| Rate for Payer: Nomi Health Commercial |
$13,384.51
|
| Rate for Payer: PACE Medicare |
$167.63
|
| Rate for Payer: PACE SWMI |
$176.45
|
| Rate for Payer: PHP Commercial |
$194.09
|
| Rate for Payer: PHP Medicaid |
$94.58
|
| Rate for Payer: PHP Medicare Advantage |
$176.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$94.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,609.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14,301.84
|
| Rate for Payer: Priority Health Medicare |
$176.45
|
| Rate for Payer: Priority Health Narrow Network |
$11,442.12
|
| Rate for Payer: Railroad Medicare Medicare |
$176.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14,363.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$176.45
|
| Rate for Payer: UHC Exchange |
$273.50
|
| Rate for Payer: UHC Medicare Advantage |
$176.45
|
| Rate for Payer: UHCCP DNSP |
$176.45
|
| Rate for Payer: UHCCP Medicaid |
$94.58
|
| Rate for Payer: VA VA |
$176.45
|
|
|
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 |
$94.58 |
| Max. Negotiated Rate |
$2,188.80 |
| Rate for Payer: Aetna Commercial |
$1,969.92
|
| Rate for Payer: Aetna Medicare |
$176.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.56
|
| Rate for Payer: ASR ASR |
$2,123.14
|
| Rate for Payer: ASR Commercial |
$2,123.14
|
| Rate for Payer: BCBS Complete |
$99.31
|
| Rate for Payer: BCBS MAPPO |
$176.45
|
| Rate for Payer: BCBS Trust/PPO |
$1,792.41
|
| Rate for Payer: BCN Commercial |
$1,696.98
|
| Rate for Payer: BCN Medicare Advantage |
$176.45
|
| 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 |
$176.45
|
| Rate for Payer: Healthscope Commercial |
$2,188.80
|
| Rate for Payer: Healthscope Whirlpool |
$2,123.14
|
| Rate for Payer: Humana Choice PPO Medicare |
$176.45
|
| Rate for Payer: Mclaren Commercial |
$1,969.92
|
| Rate for Payer: Mclaren Medicaid |
$94.58
|
| Rate for Payer: Mclaren Medicare |
$176.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.27
|
| Rate for Payer: Meridian Medicaid |
$99.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,860.48
|
| Rate for Payer: Nomi Health Commercial |
$1,794.82
|
| Rate for Payer: PACE Medicare |
$167.63
|
| Rate for Payer: PACE SWMI |
$176.45
|
| Rate for Payer: PHP Commercial |
$194.09
|
| Rate for Payer: PHP Medicaid |
$94.58
|
| Rate for Payer: PHP Medicare Advantage |
$176.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$94.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,422.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,917.83
|
| Rate for Payer: Priority Health Medicare |
$176.45
|
| Rate for Payer: Priority Health Narrow Network |
$1,534.35
|
| Rate for Payer: Railroad Medicare Medicare |
$176.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,926.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$176.45
|
| Rate for Payer: UHC Exchange |
$273.50
|
| Rate for Payer: UHC Medicare Advantage |
$176.45
|
| Rate for Payer: UHCCP DNSP |
$176.45
|
| Rate for Payer: UHCCP Medicaid |
$94.58
|
| Rate for Payer: VA VA |
$176.45
|
|
|
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 |
$1,422.72 |
| 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: ASR Commercial |
$2,123.14
|
| Rate for Payer: BCBS Trust/PPO |
$1,783.65
|
| Rate for Payer: BCN Commercial |
$1,696.98
|
| 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 |
$2,188.80
|
| Rate for Payer: Healthscope Whirlpool |
$2,123.14
|
| 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: Priority Health Cigna Priority Health |
$1,422.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,926.14
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$32,645.70
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21,219.71 |
| Max. Negotiated Rate |
$32,645.70 |
| Rate for Payer: Aetna Commercial |
$29,381.13
|
| Rate for Payer: ASR ASR |
$31,666.33
|
| Rate for Payer: ASR Commercial |
$31,666.33
|
| Rate for Payer: BCBS Trust/PPO |
$26,602.98
|
| Rate for Payer: BCN Commercial |
$25,310.21
|
| Rate for Payer: Cash Price |
$26,116.56
|
| Rate for Payer: Cofinity Commercial |
$30,686.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26,116.56
|
| Rate for Payer: Healthscope Commercial |
$32,645.70
|
| Rate for Payer: Healthscope Whirlpool |
$31,666.33
|
| Rate for Payer: Mclaren Commercial |
$29,381.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27,748.85
|
| Rate for Payer: Nomi Health Commercial |
$26,769.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21,219.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28,728.22
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$32,645.70
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.58 |
| Max. Negotiated Rate |
$32,645.70 |
| Rate for Payer: Aetna Commercial |
$29,381.13
|
| Rate for Payer: Aetna Medicare |
$176.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.56
|
| Rate for Payer: ASR ASR |
$31,666.33
|
| Rate for Payer: ASR Commercial |
$31,666.33
|
| Rate for Payer: BCBS Complete |
$99.31
|
| Rate for Payer: BCBS MAPPO |
$176.45
|
| Rate for Payer: BCBS Trust/PPO |
$26,733.56
|
| Rate for Payer: BCN Commercial |
$25,310.21
|
| Rate for Payer: BCN Medicare Advantage |
$176.45
|
| Rate for Payer: Cash Price |
$26,116.56
|
| Rate for Payer: Cash Price |
$26,116.56
|
| Rate for Payer: Cofinity Commercial |
$30,686.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26,116.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.45
|
| Rate for Payer: Healthscope Commercial |
$32,645.70
|
| Rate for Payer: Healthscope Whirlpool |
$31,666.33
|
| Rate for Payer: Humana Choice PPO Medicare |
$176.45
|
| Rate for Payer: Mclaren Commercial |
$29,381.13
|
| Rate for Payer: Mclaren Medicaid |
$94.58
|
| Rate for Payer: Mclaren Medicare |
$176.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.27
|
| Rate for Payer: Meridian Medicaid |
$99.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27,748.85
|
| Rate for Payer: Nomi Health Commercial |
$26,769.47
|
| Rate for Payer: PACE Medicare |
$167.63
|
| Rate for Payer: PACE SWMI |
$176.45
|
| Rate for Payer: PHP Commercial |
$194.09
|
| Rate for Payer: PHP Medicaid |
$94.58
|
| Rate for Payer: PHP Medicare Advantage |
$176.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$94.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21,219.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28,604.16
|
| Rate for Payer: Priority Health Medicare |
$176.45
|
| Rate for Payer: Priority Health Narrow Network |
$22,884.64
|
| Rate for Payer: Railroad Medicare Medicare |
$176.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28,728.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$176.45
|
| Rate for Payer: UHC Exchange |
$273.50
|
| Rate for Payer: UHC Medicare Advantage |
$176.45
|
| Rate for Payer: UHCCP DNSP |
$176.45
|
| Rate for Payer: UHCCP Medicaid |
$94.58
|
| Rate for Payer: VA VA |
$176.45
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.41 |
| Max. Negotiated Rate |
$291.40 |
| Rate for Payer: Aetna Commercial |
$262.26
|
| Rate for Payer: ASR ASR |
$282.66
|
| Rate for Payer: ASR Commercial |
$282.66
|
| Rate for Payer: BCBS Trust/PPO |
$237.46
|
| Rate for Payer: BCN Commercial |
$225.92
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$273.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$291.40
|
| Rate for Payer: Healthscope Whirlpool |
$282.66
|
| Rate for Payer: Mclaren Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$256.43
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$3.46
|
|
|
Service Code
|
NDC 68084085911
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna Commercial |
$3.11
|
| Rate for Payer: Aetna Medicare |
$1.73
|
| Rate for Payer: ASR ASR |
$3.36
|
| Rate for Payer: ASR Commercial |
$3.36
|
| Rate for Payer: BCBS Complete |
$1.38
|
| Rate for Payer: BCBS Trust/PPO |
$2.83
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$3.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.77
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.36
|
| Rate for Payer: Mclaren Commercial |
$3.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.94
|
| Rate for Payer: Nomi Health Commercial |
$2.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.03
|
| Rate for Payer: Priority Health Narrow Network |
$2.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.04
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 68084085911
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna Commercial |
$3.11
|
| Rate for Payer: ASR ASR |
$3.36
|
| Rate for Payer: ASR Commercial |
$3.36
|
| Rate for Payer: BCBS Trust/PPO |
$2.82
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$3.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.77
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.36
|
| Rate for Payer: Mclaren Commercial |
$3.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.94
|
| Rate for Payer: Nomi Health Commercial |
$2.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.04
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 68084085901
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.54 |
| Max. Negotiated Rate |
$345.45 |
| Rate for Payer: Aetna Commercial |
$310.90
|
| Rate for Payer: ASR ASR |
$335.09
|
| Rate for Payer: ASR Commercial |
$335.09
|
| Rate for Payer: BCBS Trust/PPO |
$281.51
|
| Rate for Payer: BCN Commercial |
$267.83
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$324.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$345.45
|
| Rate for Payer: Healthscope Whirlpool |
$335.09
|
| Rate for Payer: Mclaren Commercial |
$310.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.63
|
| Rate for Payer: Nomi Health Commercial |
$283.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$304.00
|
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