|
LIDOCAINE (PF) 40 MG/ML (4 %) NEBULIZED SOLUTION
|
Facility
|
OP
|
$21.24
|
|
|
Service Code
|
NDC 409428301
|
| Hospital Charge Code |
168979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$21.24 |
| Rate for Payer: Aetna Commercial |
$19.11
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$20.60
|
| Rate for Payer: BCBS Complete |
$8.50
|
| Rate for Payer: BCBS Trust/PPO |
$17.51
|
| Rate for Payer: BCN Commercial |
$17.51
|
| Rate for Payer: Cash Price |
$16.99
|
| Rate for Payer: Cofinity Commercial |
$19.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.99
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Healthscope Whirlpool |
$21.24
|
| Rate for Payer: Mclaren Commercial |
$19.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.05
|
| Rate for Payer: Nomi Health Commercial |
$17.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18.61
|
| Rate for Payer: Priority Health Narrow Network |
$14.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.69
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) NEBULIZED SOLUTION
|
Facility
|
IP
|
$21.24
|
|
|
Service Code
|
NDC 409428301
|
| Hospital Charge Code |
168979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.93 |
| Max. Negotiated Rate |
$21.24 |
| Rate for Payer: Aetna Commercial |
$19.11
|
| Rate for Payer: ASR ASR |
$20.60
|
| Rate for Payer: BCBS Trust/PPO |
$17.44
|
| Rate for Payer: BCN Commercial |
$17.44
|
| Rate for Payer: Cash Price |
$16.99
|
| Rate for Payer: Cofinity Commercial |
$19.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.99
|
| Rate for Payer: Healthscope Commercial |
$20.60
|
| Rate for Payer: Healthscope Whirlpool |
$21.24
|
| Rate for Payer: Mclaren Commercial |
$19.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.05
|
| Rate for Payer: Nomi Health Commercial |
$17.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.69
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$22.20
|
|
|
Service Code
|
HCPCS J2002
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$22.20 |
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: Aetna Commercial |
$34.04
|
| Rate for Payer: Aetna Commercial |
$30.04
|
| Rate for Payer: ASR ASR |
$36.69
|
| Rate for Payer: ASR ASR |
$21.53
|
| Rate for Payer: ASR ASR |
$32.37
|
| Rate for Payer: BCBS Trust/PPO |
$31.06
|
| Rate for Payer: BCBS Trust/PPO |
$18.23
|
| Rate for Payer: BCBS Trust/PPO |
$27.41
|
| Rate for Payer: BCN Commercial |
$27.41
|
| Rate for Payer: BCN Commercial |
$18.23
|
| Rate for Payer: BCN Commercial |
$31.06
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cofinity Commercial |
$20.87
|
| Rate for Payer: Cofinity Commercial |
$31.37
|
| Rate for Payer: Cofinity Commercial |
$35.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.70
|
| Rate for Payer: Healthscope Commercial |
$32.37
|
| Rate for Payer: Healthscope Commercial |
$21.53
|
| Rate for Payer: Healthscope Commercial |
$36.69
|
| Rate for Payer: Healthscope Whirlpool |
$33.38
|
| Rate for Payer: Healthscope Whirlpool |
$37.83
|
| Rate for Payer: Healthscope Whirlpool |
$22.20
|
| Rate for Payer: Mclaren Commercial |
$30.04
|
| Rate for Payer: Mclaren Commercial |
$19.98
|
| Rate for Payer: Mclaren Commercial |
$34.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Nomi Health Commercial |
$27.37
|
| Rate for Payer: Nomi Health Commercial |
$18.20
|
| Rate for Payer: Nomi Health Commercial |
$31.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.54
|
|
|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$22.20
|
|
|
Service Code
|
HCPCS J2002
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.21 |
| Max. Negotiated Rate |
$22.20 |
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: Aetna Commercial |
$30.04
|
| Rate for Payer: Aetna Commercial |
$34.04
|
| Rate for Payer: Aetna Medicare |
$12.35
|
| Rate for Payer: Aetna Medicare |
$14.00
|
| Rate for Payer: Aetna Medicare |
$8.21
|
| Rate for Payer: ASR ASR |
$32.37
|
| Rate for Payer: ASR ASR |
$21.53
|
| Rate for Payer: ASR ASR |
$36.69
|
| Rate for Payer: BCBS Complete |
$15.13
|
| Rate for Payer: BCBS Complete |
$13.35
|
| Rate for Payer: BCBS Complete |
$8.88
|
| Rate for Payer: BCBS Trust/PPO |
$18.30
|
| Rate for Payer: BCBS Trust/PPO |
$27.52
|
| Rate for Payer: BCBS Trust/PPO |
$31.19
|
| Rate for Payer: BCN Commercial |
$18.30
|
| Rate for Payer: BCN Commercial |
$27.52
|
| Rate for Payer: BCN Commercial |
$31.19
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cofinity Commercial |
$31.37
|
| Rate for Payer: Cofinity Commercial |
$20.87
|
| Rate for Payer: Cofinity Commercial |
$35.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.70
|
| Rate for Payer: Healthscope Commercial |
$32.37
|
| Rate for Payer: Healthscope Commercial |
$21.53
|
| Rate for Payer: Healthscope Commercial |
$36.69
|
| Rate for Payer: Healthscope Whirlpool |
$22.20
|
| Rate for Payer: Healthscope Whirlpool |
$33.38
|
| Rate for Payer: Healthscope Whirlpool |
$37.83
|
| Rate for Payer: Mclaren Commercial |
$30.04
|
| Rate for Payer: Mclaren Commercial |
$19.98
|
| Rate for Payer: Mclaren Commercial |
$34.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.15
|
| Rate for Payer: Nomi Health Commercial |
$18.20
|
| Rate for Payer: Nomi Health Commercial |
$27.37
|
| Rate for Payer: Nomi Health Commercial |
$31.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.65
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$29.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$19.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$33.14
|
| Rate for Payer: Priority Health Narrow Network |
$26.52
|
| Rate for Payer: Priority Health Narrow Network |
$15.56
|
| Rate for Payer: Priority Health Narrow Network |
$23.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.29
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION
|
Facility
|
IP
|
$15.91
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
105635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$15.91 |
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Commercial |
$51.26
|
| Rate for Payer: ASR ASR |
$55.25
|
| Rate for Payer: ASR ASR |
$15.43
|
| Rate for Payer: BCBS Trust/PPO |
$46.78
|
| Rate for Payer: BCBS Trust/PPO |
$13.07
|
| Rate for Payer: BCN Commercial |
$46.78
|
| Rate for Payer: BCN Commercial |
$13.07
|
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$53.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.73
|
| Rate for Payer: Healthscope Commercial |
$15.43
|
| Rate for Payer: Healthscope Commercial |
$55.25
|
| Rate for Payer: Healthscope Whirlpool |
$56.96
|
| Rate for Payer: Healthscope Whirlpool |
$15.91
|
| Rate for Payer: Mclaren Commercial |
$51.26
|
| Rate for Payer: Mclaren Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.52
|
| Rate for Payer: Nomi Health Commercial |
$46.71
|
| Rate for Payer: Nomi Health Commercial |
$13.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$50.12
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION
|
Facility
|
OP
|
$56.96
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
105635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$56.96 |
| Rate for Payer: Aetna Commercial |
$51.26
|
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Medicare |
$5.89
|
| Rate for Payer: Aetna Medicare |
$21.08
|
| Rate for Payer: ASR ASR |
$55.25
|
| Rate for Payer: ASR ASR |
$15.43
|
| Rate for Payer: BCBS Complete |
$6.36
|
| Rate for Payer: BCBS Complete |
$22.78
|
| Rate for Payer: BCBS Trust/PPO |
$46.96
|
| Rate for Payer: BCBS Trust/PPO |
$13.12
|
| Rate for Payer: BCN Commercial |
$13.12
|
| Rate for Payer: BCN Commercial |
$46.96
|
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$53.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.73
|
| Rate for Payer: Healthscope Commercial |
$55.25
|
| Rate for Payer: Healthscope Commercial |
$15.43
|
| Rate for Payer: Healthscope Whirlpool |
$56.96
|
| Rate for Payer: Healthscope Whirlpool |
$15.91
|
| Rate for Payer: Mclaren Commercial |
$51.26
|
| Rate for Payer: Mclaren Commercial |
$14.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.42
|
| Rate for Payer: Nomi Health Commercial |
$13.05
|
| Rate for Payer: Nomi Health Commercial |
$46.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$50.12
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$10.49
|
|
|
Service Code
|
NDC 496088205
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$10.49 |
| Rate for Payer: Aetna Commercial |
$9.44
|
| Rate for Payer: ASR ASR |
$10.18
|
| Rate for Payer: BCBS Trust/PPO |
$8.61
|
| Rate for Payer: BCN Commercial |
$8.61
|
| Rate for Payer: Cash Price |
$8.39
|
| Rate for Payer: Cofinity Commercial |
$9.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.39
|
| Rate for Payer: Healthscope Commercial |
$10.18
|
| Rate for Payer: Healthscope Whirlpool |
$10.49
|
| Rate for Payer: Mclaren Commercial |
$9.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.92
|
| Rate for Payer: Nomi Health Commercial |
$8.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.23
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
OP
|
$59.61
|
|
|
Service Code
|
NDC 24357070107
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$59.61 |
| Rate for Payer: Aetna Commercial |
$53.65
|
| Rate for Payer: Aetna Medicare |
$22.05
|
| Rate for Payer: ASR ASR |
$57.82
|
| Rate for Payer: BCBS Complete |
$23.84
|
| Rate for Payer: BCBS Trust/PPO |
$49.15
|
| Rate for Payer: BCN Commercial |
$49.15
|
| Rate for Payer: Cash Price |
$47.69
|
| Rate for Payer: Cofinity Commercial |
$56.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.69
|
| Rate for Payer: Healthscope Commercial |
$57.82
|
| Rate for Payer: Healthscope Whirlpool |
$59.61
|
| Rate for Payer: Mclaren Commercial |
$53.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.67
|
| Rate for Payer: Nomi Health Commercial |
$48.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$52.23
|
| Rate for Payer: Priority Health Narrow Network |
$41.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.45
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$14.89
|
|
|
Service Code
|
NDC 496088207
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.17 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Aetna Commercial |
$13.40
|
| Rate for Payer: ASR ASR |
$14.44
|
| Rate for Payer: BCBS Trust/PPO |
$12.23
|
| Rate for Payer: BCN Commercial |
$12.23
|
| Rate for Payer: Cash Price |
$11.91
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.91
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Healthscope Whirlpool |
$14.89
|
| Rate for Payer: Mclaren Commercial |
$13.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.66
|
| Rate for Payer: Nomi Health Commercial |
$12.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.10
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
OP
|
$14.89
|
|
|
Service Code
|
NDC 496088207
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.51 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Aetna Commercial |
$13.40
|
| Rate for Payer: Aetna Medicare |
$5.51
|
| Rate for Payer: ASR ASR |
$14.44
|
| Rate for Payer: BCBS Complete |
$5.96
|
| Rate for Payer: BCBS Trust/PPO |
$12.28
|
| Rate for Payer: BCN Commercial |
$12.28
|
| Rate for Payer: Cash Price |
$11.91
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.91
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Healthscope Whirlpool |
$14.89
|
| Rate for Payer: Mclaren Commercial |
$13.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.66
|
| Rate for Payer: Nomi Health Commercial |
$12.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$13.05
|
| Rate for Payer: Priority Health Narrow Network |
$10.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.10
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
OP
|
$10.49
|
|
|
Service Code
|
NDC 496088205
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$10.49 |
| Rate for Payer: Aetna Commercial |
$9.44
|
| Rate for Payer: Aetna Medicare |
$3.88
|
| Rate for Payer: ASR ASR |
$10.18
|
| Rate for Payer: BCBS Complete |
$4.20
|
| Rate for Payer: BCBS Trust/PPO |
$8.65
|
| Rate for Payer: BCN Commercial |
$8.65
|
| Rate for Payer: Cash Price |
$8.39
|
| Rate for Payer: Cofinity Commercial |
$9.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.39
|
| Rate for Payer: Healthscope Commercial |
$10.18
|
| Rate for Payer: Healthscope Whirlpool |
$10.49
|
| Rate for Payer: Mclaren Commercial |
$9.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.92
|
| Rate for Payer: Nomi Health Commercial |
$8.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$9.19
|
| Rate for Payer: Priority Health Narrow Network |
$7.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.23
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$59.61
|
|
|
Service Code
|
NDC 24357070107
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.71 |
| Max. Negotiated Rate |
$59.61 |
| Rate for Payer: Aetna Commercial |
$53.65
|
| Rate for Payer: ASR ASR |
$57.82
|
| Rate for Payer: BCBS Trust/PPO |
$48.95
|
| Rate for Payer: BCN Commercial |
$48.95
|
| Rate for Payer: Cash Price |
$47.69
|
| Rate for Payer: Cofinity Commercial |
$56.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.69
|
| Rate for Payer: Healthscope Commercial |
$57.82
|
| Rate for Payer: Healthscope Whirlpool |
$59.61
|
| Rate for Payer: Mclaren Commercial |
$53.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.67
|
| Rate for Payer: Nomi Health Commercial |
$48.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.45
|
|
|
LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$51,699.10
|
|
|
Service Code
|
MSDRG 956
|
| Min. Negotiated Rate |
$27,410.11 |
| Max. Negotiated Rate |
$51,699.10 |
| Rate for Payer: Aetna Medicare |
$28,852.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$36,065.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$36,065.94
|
| Rate for Payer: BCBS MAPPO |
$28,852.75
|
| Rate for Payer: BCN Medicare Advantage |
$28,852.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$28,852.75
|
| Rate for Payer: Humana Choice PPO Medicare |
$28,852.75
|
| Rate for Payer: Mclaren Medicare |
$28,852.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$30,295.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33,180.66
|
| Rate for Payer: Molina Medicare/Medicaid |
$31,738.03
|
| Rate for Payer: PACE Medicare |
$27,410.11
|
| Rate for Payer: PACE SWMI |
$28,852.75
|
| Rate for Payer: PHP Commercial |
$31,738.03
|
| Rate for Payer: PHP Medicare Advantage |
$28,852.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$51,699.10
|
| Rate for Payer: Priority Health Medicare |
$28,852.75
|
| Rate for Payer: Priority Health Narrow Network |
$41,359.28
|
| Rate for Payer: Railroad Medicare Medicare |
$28,852.75
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$28,852.75
|
| Rate for Payer: UHC Exchange |
$44,721.76
|
| Rate for Payer: UHCCP DNSP |
$28,852.75
|
| Rate for Payer: VA VA |
$28,852.75
|
|
|
LINACLOTIDE 72 MCG CAPSULE
|
Facility
|
IP
|
$971.58
|
|
|
Service Code
|
NDC 456120330
|
| Hospital Charge Code |
182047
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$728.69 |
| Max. Negotiated Rate |
$971.58 |
| Rate for Payer: Aetna Commercial |
$874.42
|
| Rate for Payer: ASR ASR |
$942.44
|
| Rate for Payer: BCBS Trust/PPO |
$797.86
|
| Rate for Payer: BCN Commercial |
$797.86
|
| Rate for Payer: Cash Price |
$777.27
|
| Rate for Payer: Cofinity Commercial |
$913.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$777.27
|
| Rate for Payer: Healthscope Commercial |
$942.44
|
| Rate for Payer: Healthscope Whirlpool |
$971.58
|
| Rate for Payer: Mclaren Commercial |
$874.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$825.85
|
| Rate for Payer: Nomi Health Commercial |
$796.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$728.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$854.99
|
|
|
LINACLOTIDE 72 MCG CAPSULE
|
Facility
|
OP
|
$971.58
|
|
|
Service Code
|
NDC 456120330
|
| Hospital Charge Code |
182047
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$359.49 |
| Max. Negotiated Rate |
$971.58 |
| Rate for Payer: Aetna Commercial |
$874.42
|
| Rate for Payer: Aetna Medicare |
$359.49
|
| Rate for Payer: ASR ASR |
$942.44
|
| Rate for Payer: BCBS Complete |
$388.63
|
| Rate for Payer: BCBS Trust/PPO |
$801.07
|
| Rate for Payer: BCN Commercial |
$801.07
|
| Rate for Payer: Cash Price |
$777.27
|
| Rate for Payer: Cofinity Commercial |
$913.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$777.27
|
| Rate for Payer: Healthscope Commercial |
$942.44
|
| Rate for Payer: Healthscope Whirlpool |
$971.58
|
| Rate for Payer: Mclaren Commercial |
$874.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$777.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$825.85
|
| Rate for Payer: Nomi Health Commercial |
$796.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$728.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$851.30
|
| Rate for Payer: Priority Health Narrow Network |
$681.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$854.99
|
|
|
LINEZOLID 600 MG TABLET
|
Facility
|
IP
|
$339.55
|
|
|
Service Code
|
NDC 904655304
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.66 |
| Max. Negotiated Rate |
$339.55 |
| Rate for Payer: Aetna Commercial |
$305.59
|
| Rate for Payer: ASR ASR |
$329.36
|
| Rate for Payer: BCBS Trust/PPO |
$278.84
|
| Rate for Payer: BCN Commercial |
$278.84
|
| Rate for Payer: Cash Price |
$271.64
|
| Rate for Payer: Cofinity Commercial |
$319.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.64
|
| Rate for Payer: Healthscope Commercial |
$329.36
|
| Rate for Payer: Healthscope Whirlpool |
$339.55
|
| Rate for Payer: Mclaren Commercial |
$305.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.62
|
| Rate for Payer: Nomi Health Commercial |
$278.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$254.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$298.80
|
|
|
LINEZOLID 600 MG TABLET
|
Facility
|
OP
|
$339.55
|
|
|
Service Code
|
NDC 904655304
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.63 |
| Max. Negotiated Rate |
$339.55 |
| Rate for Payer: Aetna Commercial |
$305.59
|
| Rate for Payer: Aetna Medicare |
$125.63
|
| Rate for Payer: ASR ASR |
$329.36
|
| Rate for Payer: BCBS Complete |
$135.82
|
| Rate for Payer: BCBS Trust/PPO |
$279.96
|
| Rate for Payer: BCN Commercial |
$279.96
|
| Rate for Payer: Cash Price |
$271.64
|
| Rate for Payer: Cofinity Commercial |
$319.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.64
|
| Rate for Payer: Healthscope Commercial |
$329.36
|
| Rate for Payer: Healthscope Whirlpool |
$339.55
|
| Rate for Payer: Mclaren Commercial |
$305.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$271.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.62
|
| Rate for Payer: Nomi Health Commercial |
$278.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$254.66
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$297.51
|
| Rate for Payer: Priority Health Narrow Network |
$238.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$298.80
|
|
|
LIOTHYRONINE 5 MCG TABLET
|
Facility
|
OP
|
$245.28
|
|
|
Service Code
|
NDC 62756058988
|
| Hospital Charge Code |
10443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.75 |
| Max. Negotiated Rate |
$245.28 |
| Rate for Payer: Aetna Commercial |
$220.75
|
| Rate for Payer: Aetna Medicare |
$90.75
|
| Rate for Payer: ASR ASR |
$237.92
|
| Rate for Payer: BCBS Complete |
$98.11
|
| Rate for Payer: BCBS Trust/PPO |
$202.23
|
| Rate for Payer: BCN Commercial |
$202.23
|
| Rate for Payer: Cash Price |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$230.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.22
|
| Rate for Payer: Healthscope Commercial |
$237.92
|
| Rate for Payer: Healthscope Whirlpool |
$245.28
|
| Rate for Payer: Mclaren Commercial |
$220.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$196.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.49
|
| Rate for Payer: Nomi Health Commercial |
$201.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$214.91
|
| Rate for Payer: Priority Health Narrow Network |
$171.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$215.85
|
|
|
LIOTHYRONINE 5 MCG TABLET
|
Facility
|
IP
|
$245.28
|
|
|
Service Code
|
NDC 62756058988
|
| Hospital Charge Code |
10443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.96 |
| Max. Negotiated Rate |
$245.28 |
| Rate for Payer: Aetna Commercial |
$220.75
|
| Rate for Payer: ASR ASR |
$237.92
|
| Rate for Payer: BCBS Trust/PPO |
$201.42
|
| Rate for Payer: BCN Commercial |
$201.42
|
| Rate for Payer: Cash Price |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$230.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.22
|
| Rate for Payer: Healthscope Commercial |
$237.92
|
| Rate for Payer: Healthscope Whirlpool |
$245.28
|
| Rate for Payer: Mclaren Commercial |
$220.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.49
|
| Rate for Payer: Nomi Health Commercial |
$201.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$215.85
|
|
|
LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL
|
Facility
|
IP
|
$2,832.72
|
|
|
Service Code
|
NDC 32122401
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,124.54 |
| Max. Negotiated Rate |
$2,832.72 |
| Rate for Payer: Aetna Commercial |
$2,549.45
|
| Rate for Payer: ASR ASR |
$2,747.74
|
| Rate for Payer: BCBS Trust/PPO |
$2,326.23
|
| Rate for Payer: BCN Commercial |
$2,326.23
|
| Rate for Payer: Cash Price |
$2,266.18
|
| Rate for Payer: Cofinity Commercial |
$2,662.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,266.18
|
| Rate for Payer: Healthscope Commercial |
$2,747.74
|
| Rate for Payer: Healthscope Whirlpool |
$2,832.72
|
| Rate for Payer: Mclaren Commercial |
$2,549.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,407.81
|
| Rate for Payer: Nomi Health Commercial |
$2,322.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,124.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,492.79
|
|
|
LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL
|
Facility
|
OP
|
$3,002.55
|
|
|
Service Code
|
NDC 32263601
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,110.94 |
| Max. Negotiated Rate |
$3,002.55 |
| Rate for Payer: Aetna Commercial |
$2,702.30
|
| Rate for Payer: Aetna Medicare |
$1,110.94
|
| Rate for Payer: ASR ASR |
$2,912.47
|
| Rate for Payer: BCBS Complete |
$1,201.02
|
| Rate for Payer: BCBS Trust/PPO |
$2,475.60
|
| Rate for Payer: BCN Commercial |
$2,475.60
|
| Rate for Payer: Cash Price |
$2,402.04
|
| Rate for Payer: Cofinity Commercial |
$2,822.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,402.04
|
| Rate for Payer: Healthscope Commercial |
$2,912.47
|
| Rate for Payer: Healthscope Whirlpool |
$3,002.55
|
| Rate for Payer: Mclaren Commercial |
$2,702.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,402.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,552.17
|
| Rate for Payer: Nomi Health Commercial |
$2,462.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,251.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2,630.83
|
| Rate for Payer: Priority Health Narrow Network |
$2,104.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,642.24
|
|
|
LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL
|
Facility
|
IP
|
$3,002.55
|
|
|
Service Code
|
NDC 32263601
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,251.91 |
| Max. Negotiated Rate |
$3,002.55 |
| Rate for Payer: Aetna Commercial |
$2,702.30
|
| Rate for Payer: ASR ASR |
$2,912.47
|
| Rate for Payer: BCBS Trust/PPO |
$2,465.69
|
| Rate for Payer: BCN Commercial |
$2,465.69
|
| Rate for Payer: Cash Price |
$2,402.04
|
| Rate for Payer: Cofinity Commercial |
$2,822.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,402.04
|
| Rate for Payer: Healthscope Commercial |
$2,912.47
|
| Rate for Payer: Healthscope Whirlpool |
$3,002.55
|
| Rate for Payer: Mclaren Commercial |
$2,702.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,552.17
|
| Rate for Payer: Nomi Health Commercial |
$2,462.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,251.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,642.24
|
|
|
LIPASE-PROTEASE-AMYLAS(PORK)24,000-76,000-120,000 UNIT CAPSULE,DEL REL
|
Facility
|
OP
|
$2,832.72
|
|
|
Service Code
|
NDC 32122401
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,048.11 |
| Max. Negotiated Rate |
$2,832.72 |
| Rate for Payer: Aetna Commercial |
$2,549.45
|
| Rate for Payer: Aetna Medicare |
$1,048.11
|
| Rate for Payer: ASR ASR |
$2,747.74
|
| Rate for Payer: BCBS Complete |
$1,133.09
|
| Rate for Payer: BCBS Trust/PPO |
$2,335.58
|
| Rate for Payer: BCN Commercial |
$2,335.58
|
| Rate for Payer: Cash Price |
$2,266.18
|
| Rate for Payer: Cofinity Commercial |
$2,662.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,266.18
|
| Rate for Payer: Healthscope Commercial |
$2,747.74
|
| Rate for Payer: Healthscope Whirlpool |
$2,832.72
|
| Rate for Payer: Mclaren Commercial |
$2,549.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,266.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,407.81
|
| Rate for Payer: Nomi Health Commercial |
$2,322.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,124.54
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2,482.03
|
| Rate for Payer: Priority Health Narrow Network |
$1,985.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,492.79
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 904679961
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.78 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.25
|
| Rate for Payer: Aetna Medicare |
$54.78
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: BCBS Trust/PPO |
$122.07
|
| Rate for Payer: BCN Commercial |
$122.07
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$143.61
|
| Rate for Payer: Healthscope Whirlpool |
$148.05
|
| Rate for Payer: Mclaren Commercial |
$133.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$118.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$129.72
|
| Rate for Payer: Priority Health Narrow Network |
$103.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.28
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 904679961
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.04 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.25
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: BCBS Trust/PPO |
$121.58
|
| Rate for Payer: BCN Commercial |
$121.58
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$143.61
|
| Rate for Payer: Healthscope Whirlpool |
$148.05
|
| Rate for Payer: Mclaren Commercial |
$133.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.28
|
|
