|
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 |
$7.96
|
| Rate for Payer: Aetna Medicare |
$28.48
|
| Rate for Payer: ASR ASR |
$55.25
|
| Rate for Payer: ASR ASR |
$15.43
|
| Rate for Payer: ASR Commercial |
$15.43
|
| Rate for Payer: ASR Commercial |
$55.25
|
| Rate for Payer: BCBS Complete |
$22.78
|
| Rate for Payer: BCBS Complete |
$6.36
|
| Rate for Payer: BCBS Trust/PPO |
$46.64
|
| Rate for Payer: BCBS Trust/PPO |
$13.03
|
| Rate for Payer: BCN Commercial |
$12.34
|
| Rate for Payer: BCN Commercial |
$44.16
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Cash Price |
$45.57
|
| 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 |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$15.91
|
| Rate for Payer: Healthscope Whirlpool |
$55.25
|
| Rate for Payer: Healthscope Whirlpool |
$15.43
|
| Rate for Payer: Mclaren Commercial |
$14.32
|
| Rate for Payer: Mclaren Commercial |
$51.26
|
| 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: Priority Health Cigna Priority Health |
$37.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: 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 (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION
|
Facility
|
IP
|
$56.96
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
105635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.02 |
| Max. Negotiated Rate |
$56.96 |
| Rate for Payer: Aetna Commercial |
$51.26
|
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: ASR ASR |
$55.25
|
| Rate for Payer: ASR ASR |
$15.43
|
| Rate for Payer: ASR Commercial |
$15.43
|
| Rate for Payer: ASR Commercial |
$55.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.97
|
| Rate for Payer: BCBS Trust/PPO |
$46.42
|
| Rate for Payer: BCN Commercial |
$44.16
|
| Rate for Payer: BCN Commercial |
$12.34
|
| 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 |
$12.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.57
|
| Rate for Payer: Healthscope Commercial |
$15.91
|
| Rate for Payer: Healthscope Commercial |
$56.96
|
| Rate for Payer: Healthscope Whirlpool |
$15.43
|
| Rate for Payer: Healthscope Whirlpool |
$55.25
|
| Rate for Payer: Mclaren Commercial |
$14.32
|
| Rate for Payer: Mclaren Commercial |
$51.26
|
| 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: Priority Health Cigna Priority Health |
$37.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.34
|
| 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 00496088205
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$10.49 |
| Rate for Payer: Aetna Commercial |
$9.44
|
| Rate for Payer: ASR ASR |
$10.18
|
| Rate for Payer: ASR Commercial |
$10.18
|
| Rate for Payer: BCBS Trust/PPO |
$8.55
|
| Rate for Payer: BCN Commercial |
$8.13
|
| Rate for Payer: Cash Price |
$8.39
|
| Rate for Payer: Cofinity Commercial |
$9.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.39
|
| Rate for Payer: Healthscope Commercial |
$10.49
|
| Rate for Payer: Healthscope Whirlpool |
$10.18
|
| Rate for Payer: Mclaren Commercial |
$9.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.92
|
| Rate for Payer: Nomi Health Commercial |
$8.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.82
|
| 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 |
$38.75 |
| Max. Negotiated Rate |
$59.61 |
| Rate for Payer: Aetna Commercial |
$53.65
|
| Rate for Payer: ASR ASR |
$57.82
|
| Rate for Payer: ASR Commercial |
$57.82
|
| Rate for Payer: BCBS Trust/PPO |
$48.58
|
| Rate for Payer: BCN Commercial |
$46.22
|
| 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 |
$59.61
|
| Rate for Payer: Healthscope Whirlpool |
$57.82
|
| 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: Priority Health Cigna Priority Health |
$38.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.46
|
|
|
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 |
$23.84 |
| Max. Negotiated Rate |
$59.61 |
| Rate for Payer: Aetna Commercial |
$53.65
|
| Rate for Payer: Aetna Medicare |
$29.80
|
| Rate for Payer: ASR ASR |
$57.82
|
| Rate for Payer: ASR Commercial |
$57.82
|
| Rate for Payer: BCBS Complete |
$23.84
|
| Rate for Payer: BCBS Trust/PPO |
$48.81
|
| Rate for Payer: BCN Commercial |
$46.22
|
| 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 |
$59.61
|
| Rate for Payer: Healthscope Whirlpool |
$57.82
|
| 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: Priority Health Cigna Priority Health |
$38.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$52.23
|
| Rate for Payer: Priority Health Narrow Network |
$41.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.46
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
OP
|
$10.49
|
|
|
Service Code
|
NDC 00496088205
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$10.49 |
| Rate for Payer: Aetna Commercial |
$9.44
|
| Rate for Payer: Aetna Medicare |
$5.24
|
| Rate for Payer: ASR ASR |
$10.18
|
| Rate for Payer: ASR Commercial |
$10.18
|
| Rate for Payer: BCBS Complete |
$4.20
|
| Rate for Payer: BCBS Trust/PPO |
$8.59
|
| Rate for Payer: BCN Commercial |
$8.13
|
| Rate for Payer: Cash Price |
$8.39
|
| Rate for Payer: Cofinity Commercial |
$9.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.39
|
| Rate for Payer: Healthscope Commercial |
$10.49
|
| Rate for Payer: Healthscope Whirlpool |
$10.18
|
| Rate for Payer: Mclaren Commercial |
$9.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.92
|
| Rate for Payer: Nomi Health Commercial |
$8.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.82
|
| Rate for Payer: 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
|
|
|
LINACLOTIDE 72 MCG CAPSULE
|
Facility
|
OP
|
$1,953.38
|
|
|
Service Code
|
NDC 00456120330
|
| Hospital Charge Code |
182047
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$781.35 |
| Max. Negotiated Rate |
$1,953.38 |
| Rate for Payer: Aetna Commercial |
$1,758.04
|
| Rate for Payer: Aetna Medicare |
$976.69
|
| Rate for Payer: ASR ASR |
$1,894.78
|
| Rate for Payer: ASR Commercial |
$1,894.78
|
| Rate for Payer: BCBS Complete |
$781.35
|
| Rate for Payer: BCBS Trust/PPO |
$1,599.62
|
| Rate for Payer: BCN Commercial |
$1,514.46
|
| Rate for Payer: Cash Price |
$1,562.70
|
| Rate for Payer: Cofinity Commercial |
$1,836.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,562.70
|
| Rate for Payer: Healthscope Commercial |
$1,953.38
|
| Rate for Payer: Healthscope Whirlpool |
$1,894.78
|
| Rate for Payer: Mclaren Commercial |
$1,758.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,660.37
|
| Rate for Payer: Nomi Health Commercial |
$1,601.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,269.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,711.55
|
| Rate for Payer: Priority Health Narrow Network |
$1,369.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,718.97
|
|
|
LINACLOTIDE 72 MCG CAPSULE
|
Facility
|
IP
|
$1,953.38
|
|
|
Service Code
|
NDC 00456120330
|
| Hospital Charge Code |
182047
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,269.70 |
| Max. Negotiated Rate |
$1,953.38 |
| Rate for Payer: Aetna Commercial |
$1,758.04
|
| Rate for Payer: ASR ASR |
$1,894.78
|
| Rate for Payer: ASR Commercial |
$1,894.78
|
| Rate for Payer: BCBS Trust/PPO |
$1,591.81
|
| Rate for Payer: BCN Commercial |
$1,514.46
|
| Rate for Payer: Cash Price |
$1,562.70
|
| Rate for Payer: Cofinity Commercial |
$1,836.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,562.70
|
| Rate for Payer: Healthscope Commercial |
$1,953.38
|
| Rate for Payer: Healthscope Whirlpool |
$1,894.78
|
| Rate for Payer: Mclaren Commercial |
$1,758.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,660.37
|
| Rate for Payer: Nomi Health Commercial |
$1,601.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,269.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,718.97
|
|
|
LINEZOLID 600 MG TABLET
|
Facility
|
OP
|
$275.39
|
|
|
Service Code
|
NDC 00904655304
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.16 |
| Max. Negotiated Rate |
$275.39 |
| Rate for Payer: Aetna Commercial |
$247.85
|
| Rate for Payer: Aetna Medicare |
$137.70
|
| Rate for Payer: ASR ASR |
$267.13
|
| Rate for Payer: ASR Commercial |
$267.13
|
| Rate for Payer: BCBS Complete |
$110.16
|
| Rate for Payer: BCBS Trust/PPO |
$225.52
|
| Rate for Payer: BCN Commercial |
$213.51
|
| Rate for Payer: Cash Price |
$220.31
|
| Rate for Payer: Cofinity Commercial |
$258.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.31
|
| Rate for Payer: Healthscope Commercial |
$275.39
|
| Rate for Payer: Healthscope Whirlpool |
$267.13
|
| Rate for Payer: Mclaren Commercial |
$247.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.08
|
| Rate for Payer: Nomi Health Commercial |
$225.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$241.30
|
| Rate for Payer: Priority Health Narrow Network |
$193.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.34
|
|
|
LINEZOLID 600 MG TABLET
|
Facility
|
IP
|
$275.39
|
|
|
Service Code
|
NDC 00904655304
|
| Hospital Charge Code |
28224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.00 |
| Max. Negotiated Rate |
$275.39 |
| Rate for Payer: Aetna Commercial |
$247.85
|
| Rate for Payer: ASR ASR |
$267.13
|
| Rate for Payer: ASR Commercial |
$267.13
|
| Rate for Payer: BCBS Trust/PPO |
$224.42
|
| Rate for Payer: BCN Commercial |
$213.51
|
| Rate for Payer: Cash Price |
$220.31
|
| Rate for Payer: Cofinity Commercial |
$258.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.31
|
| Rate for Payer: Healthscope Commercial |
$275.39
|
| Rate for Payer: Healthscope Whirlpool |
$267.13
|
| Rate for Payer: Mclaren Commercial |
$247.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.08
|
| Rate for Payer: Nomi Health Commercial |
$225.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.34
|
|
|
LIOTHYRONINE 5 MCG TABLET
|
Facility
|
OP
|
$245.28
|
|
|
Service Code
|
NDC 62756058988
|
| Hospital Charge Code |
10443
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.11 |
| Max. Negotiated Rate |
$245.28 |
| Rate for Payer: Aetna Commercial |
$220.75
|
| Rate for Payer: Aetna Medicare |
$122.64
|
| Rate for Payer: ASR ASR |
$237.92
|
| Rate for Payer: ASR Commercial |
$237.92
|
| Rate for Payer: BCBS Complete |
$98.11
|
| Rate for Payer: BCBS Trust/PPO |
$200.86
|
| Rate for Payer: BCN Commercial |
$190.17
|
| 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 |
$245.28
|
| Rate for Payer: Healthscope Whirlpool |
$237.92
|
| 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: Priority Health Cigna Priority Health |
$159.43
|
| Rate for Payer: 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 |
$159.43 |
| Max. Negotiated Rate |
$245.28 |
| Rate for Payer: Aetna Commercial |
$220.75
|
| Rate for Payer: ASR ASR |
$237.92
|
| Rate for Payer: ASR Commercial |
$237.92
|
| Rate for Payer: BCBS Trust/PPO |
$199.88
|
| Rate for Payer: BCN Commercial |
$190.17
|
| 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 |
$245.28
|
| Rate for Payer: Healthscope Whirlpool |
$237.92
|
| 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: Priority Health Cigna Priority Health |
$159.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$215.85
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
IP
|
$2,832.72
|
|
|
Service Code
|
NDC 00032122401
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,841.27 |
| 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: ASR Commercial |
$2,747.74
|
| Rate for Payer: BCBS Trust/PPO |
$2,308.38
|
| Rate for Payer: BCN Commercial |
$2,196.21
|
| Rate for Payer: Cash Price |
$2,266.18
|
| Rate for Payer: Cofinity Commercial |
$2,662.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,266.18
|
| Rate for Payer: Healthscope Commercial |
$2,832.72
|
| Rate for Payer: Healthscope Whirlpool |
$2,747.74
|
| Rate for Payer: Mclaren Commercial |
$2,549.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,407.81
|
| Rate for Payer: Nomi Health Commercial |
$2,322.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,841.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,492.79
|
|
|
LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL
|
Facility
|
OP
|
$2,832.72
|
|
|
Service Code
|
NDC 00032122401
|
| Hospital Charge Code |
98036
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,133.09 |
| Max. Negotiated Rate |
$2,832.72 |
| Rate for Payer: Aetna Commercial |
$2,549.45
|
| Rate for Payer: Aetna Medicare |
$1,416.36
|
| Rate for Payer: ASR ASR |
$2,747.74
|
| Rate for Payer: ASR Commercial |
$2,747.74
|
| Rate for Payer: BCBS Complete |
$1,133.09
|
| Rate for Payer: BCBS Trust/PPO |
$2,319.71
|
| Rate for Payer: BCN Commercial |
$2,196.21
|
| Rate for Payer: Cash Price |
$2,266.18
|
| Rate for Payer: Cofinity Commercial |
$2,662.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,266.18
|
| Rate for Payer: Healthscope Commercial |
$2,832.72
|
| Rate for Payer: Healthscope Whirlpool |
$2,747.74
|
| Rate for Payer: Mclaren Commercial |
$2,549.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,407.81
|
| Rate for Payer: Nomi Health Commercial |
$2,322.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,841.27
|
| Rate for Payer: 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
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 00904679961
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.23 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.24
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: ASR Commercial |
$143.61
|
| Rate for Payer: BCBS Trust/PPO |
$120.65
|
| Rate for Payer: BCN Commercial |
$114.78
|
| 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 |
$148.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.61
|
| Rate for Payer: Mclaren Commercial |
$133.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.28
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 00904679961
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.22 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.24
|
| Rate for Payer: Aetna Medicare |
$74.02
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: ASR Commercial |
$143.61
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: BCBS Trust/PPO |
$121.24
|
| Rate for Payer: BCN Commercial |
$114.78
|
| 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 |
$148.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.61
|
| Rate for Payer: Mclaren Commercial |
$133.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: 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 5 MG TABLET
|
Facility
|
IP
|
$37.60
|
|
|
Service Code
|
NDC 68180051301
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.44 |
| Max. Negotiated Rate |
$37.60 |
| Rate for Payer: Aetna Commercial |
$33.84
|
| Rate for Payer: ASR ASR |
$36.47
|
| Rate for Payer: ASR Commercial |
$36.47
|
| Rate for Payer: BCBS Trust/PPO |
$30.64
|
| Rate for Payer: BCN Commercial |
$29.15
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cofinity Commercial |
$35.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.08
|
| Rate for Payer: Healthscope Commercial |
$37.60
|
| Rate for Payer: Healthscope Whirlpool |
$36.47
|
| Rate for Payer: Mclaren Commercial |
$33.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.96
|
| Rate for Payer: Nomi Health Commercial |
$30.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.09
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
NDC 00904679761
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.65 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: ASR ASR |
$136.77
|
| Rate for Payer: ASR Commercial |
$136.77
|
| Rate for Payer: BCBS Trust/PPO |
$114.90
|
| Rate for Payer: BCN Commercial |
$109.32
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$132.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$141.00
|
| Rate for Payer: Healthscope Whirlpool |
$136.77
|
| Rate for Payer: Mclaren Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: Nomi Health Commercial |
$115.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.08
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
NDC 68084019611
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Aetna Medicare |
$1.86
|
| Rate for Payer: ASR ASR |
$3.60
|
| Rate for Payer: ASR Commercial |
$3.60
|
| Rate for Payer: BCBS Complete |
$1.48
|
| Rate for Payer: BCBS Trust/PPO |
$3.04
|
| Rate for Payer: BCN Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cofinity Commercial |
$3.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.97
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Healthscope Whirlpool |
$3.60
|
| Rate for Payer: Mclaren Commercial |
$3.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.15
|
| Rate for Payer: Nomi Health Commercial |
$3.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.25
|
| Rate for Payer: Priority Health Narrow Network |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.26
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 68084019611
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: ASR ASR |
$3.60
|
| Rate for Payer: ASR Commercial |
$3.60
|
| Rate for Payer: BCBS Trust/PPO |
$3.02
|
| Rate for Payer: BCN Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cofinity Commercial |
$3.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.97
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Healthscope Whirlpool |
$3.60
|
| Rate for Payer: Mclaren Commercial |
$3.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.15
|
| Rate for Payer: Nomi Health Commercial |
$3.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.26
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
NDC 00904679761
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.40 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Aetna Medicare |
$70.50
|
| Rate for Payer: ASR ASR |
$136.77
|
| Rate for Payer: ASR Commercial |
$136.77
|
| Rate for Payer: BCBS Complete |
$56.40
|
| Rate for Payer: BCBS Trust/PPO |
$115.46
|
| Rate for Payer: BCN Commercial |
$109.32
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$132.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$141.00
|
| Rate for Payer: Healthscope Whirlpool |
$136.77
|
| Rate for Payer: Mclaren Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: Nomi Health Commercial |
$115.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$123.54
|
| Rate for Payer: Priority Health Narrow Network |
$98.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.08
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
IP
|
$371.30
|
|
|
Service Code
|
NDC 68084019601
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.34 |
| Max. Negotiated Rate |
$371.30 |
| Rate for Payer: Aetna Commercial |
$334.17
|
| Rate for Payer: ASR ASR |
$360.16
|
| Rate for Payer: ASR Commercial |
$360.16
|
| Rate for Payer: BCBS Trust/PPO |
$302.57
|
| Rate for Payer: BCN Commercial |
$287.87
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Commercial |
$349.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$371.30
|
| Rate for Payer: Healthscope Whirlpool |
$360.16
|
| Rate for Payer: Mclaren Commercial |
$334.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.60
|
| Rate for Payer: Nomi Health Commercial |
$304.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$326.74
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
OP
|
$371.30
|
|
|
Service Code
|
NDC 68084019601
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.52 |
| Max. Negotiated Rate |
$371.30 |
| Rate for Payer: Aetna Commercial |
$334.17
|
| Rate for Payer: Aetna Medicare |
$185.65
|
| Rate for Payer: ASR ASR |
$360.16
|
| Rate for Payer: ASR Commercial |
$360.16
|
| Rate for Payer: BCBS Complete |
$148.52
|
| Rate for Payer: BCBS Trust/PPO |
$304.06
|
| Rate for Payer: BCN Commercial |
$287.87
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Commercial |
$349.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$371.30
|
| Rate for Payer: Healthscope Whirlpool |
$360.16
|
| Rate for Payer: Mclaren Commercial |
$334.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.60
|
| Rate for Payer: Nomi Health Commercial |
$304.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$325.33
|
| Rate for Payer: Priority Health Narrow Network |
$260.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$326.74
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
OP
|
$37.60
|
|
|
Service Code
|
NDC 68180051301
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.04 |
| Max. Negotiated Rate |
$37.60 |
| Rate for Payer: Aetna Commercial |
$33.84
|
| Rate for Payer: Aetna Medicare |
$18.80
|
| Rate for Payer: ASR ASR |
$36.47
|
| Rate for Payer: ASR Commercial |
$36.47
|
| Rate for Payer: BCBS Complete |
$15.04
|
| Rate for Payer: BCBS Trust/PPO |
$30.79
|
| Rate for Payer: BCN Commercial |
$29.15
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cofinity Commercial |
$35.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.08
|
| Rate for Payer: Healthscope Commercial |
$37.60
|
| Rate for Payer: Healthscope Whirlpool |
$36.47
|
| Rate for Payer: Mclaren Commercial |
$33.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.96
|
| Rate for Payer: Nomi Health Commercial |
$30.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.95
|
| Rate for Payer: Priority Health Narrow Network |
$26.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.09
|
|
|
LITHIUM CARBONATE 300 MG CAPSULE
|
Facility
|
IP
|
$25.93
|
|
|
Service Code
|
NDC 00054852725
|
| Hospital Charge Code |
4529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.85 |
| Max. Negotiated Rate |
$25.93 |
| Rate for Payer: Aetna Commercial |
$23.34
|
| Rate for Payer: ASR ASR |
$25.15
|
| Rate for Payer: ASR Commercial |
$25.15
|
| Rate for Payer: BCBS Trust/PPO |
$21.13
|
| Rate for Payer: BCN Commercial |
$20.10
|
| Rate for Payer: Cash Price |
$20.75
|
| Rate for Payer: Cofinity Commercial |
$24.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.74
|
| Rate for Payer: Healthscope Commercial |
$25.93
|
| Rate for Payer: Healthscope Whirlpool |
$25.15
|
| Rate for Payer: Mclaren Commercial |
$23.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.04
|
| Rate for Payer: Nomi Health Commercial |
$21.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.82
|
|
