|
LORAZEPAM 2 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$164.84
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
10467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.94 |
| Max. Negotiated Rate |
$164.84 |
| Rate for Payer: Aetna Commercial |
$148.36
|
| Rate for Payer: Aetna Commercial |
$25.62
|
| Rate for Payer: Aetna Commercial |
$29.29
|
| Rate for Payer: Aetna Commercial |
$16.42
|
| Rate for Payer: Aetna Commercial |
$19.04
|
| Rate for Payer: Aetna Medicare |
$9.12
|
| Rate for Payer: Aetna Medicare |
$10.58
|
| Rate for Payer: Aetna Medicare |
$82.42
|
| Rate for Payer: Aetna Medicare |
$16.27
|
| Rate for Payer: Aetna Medicare |
$14.23
|
| Rate for Payer: ASR ASR |
$31.56
|
| Rate for Payer: ASR ASR |
$20.53
|
| Rate for Payer: ASR ASR |
$159.89
|
| Rate for Payer: ASR ASR |
$27.62
|
| Rate for Payer: ASR ASR |
$17.69
|
| Rate for Payer: ASR Commercial |
$31.56
|
| Rate for Payer: ASR Commercial |
$17.69
|
| Rate for Payer: ASR Commercial |
$20.53
|
| Rate for Payer: ASR Commercial |
$27.62
|
| Rate for Payer: ASR Commercial |
$159.89
|
| Rate for Payer: BCBS Complete |
$13.02
|
| Rate for Payer: BCBS Complete |
$7.30
|
| Rate for Payer: BCBS Complete |
$8.46
|
| Rate for Payer: BCBS Complete |
$11.39
|
| Rate for Payer: BCBS Complete |
$65.94
|
| Rate for Payer: BCBS Trust/PPO |
$23.31
|
| Rate for Payer: BCBS Trust/PPO |
$134.99
|
| Rate for Payer: BCBS Trust/PPO |
$14.94
|
| Rate for Payer: BCBS Trust/PPO |
$17.33
|
| Rate for Payer: BCBS Trust/PPO |
$26.65
|
| Rate for Payer: BCN Commercial |
$25.23
|
| Rate for Payer: BCN Commercial |
$22.07
|
| Rate for Payer: BCN Commercial |
$14.14
|
| Rate for Payer: BCN Commercial |
$127.80
|
| Rate for Payer: BCN Commercial |
$16.41
|
| Rate for Payer: Cash Price |
$26.03
|
| Rate for Payer: Cash Price |
$14.59
|
| Rate for Payer: Cash Price |
$22.78
|
| Rate for Payer: Cash Price |
$16.93
|
| Rate for Payer: Cash Price |
$131.87
|
| Rate for Payer: Cofinity Commercial |
$30.59
|
| Rate for Payer: Cofinity Commercial |
$26.76
|
| Rate for Payer: Cofinity Commercial |
$19.89
|
| Rate for Payer: Cofinity Commercial |
$17.15
|
| Rate for Payer: Cofinity Commercial |
$154.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.78
|
| Rate for Payer: Healthscope Commercial |
$21.16
|
| Rate for Payer: Healthscope Commercial |
$28.47
|
| Rate for Payer: Healthscope Commercial |
$32.54
|
| Rate for Payer: Healthscope Commercial |
$164.84
|
| Rate for Payer: Healthscope Commercial |
$18.24
|
| Rate for Payer: Healthscope Whirlpool |
$27.62
|
| Rate for Payer: Healthscope Whirlpool |
$20.53
|
| Rate for Payer: Healthscope Whirlpool |
$17.69
|
| Rate for Payer: Healthscope Whirlpool |
$159.89
|
| Rate for Payer: Healthscope Whirlpool |
$31.56
|
| Rate for Payer: Mclaren Commercial |
$29.29
|
| Rate for Payer: Mclaren Commercial |
$19.04
|
| Rate for Payer: Mclaren Commercial |
$16.42
|
| Rate for Payer: Mclaren Commercial |
$25.62
|
| Rate for Payer: Mclaren Commercial |
$148.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.66
|
| Rate for Payer: Nomi Health Commercial |
$23.35
|
| Rate for Payer: Nomi Health Commercial |
$17.35
|
| Rate for Payer: Nomi Health Commercial |
$135.17
|
| Rate for Payer: Nomi Health Commercial |
$14.96
|
| Rate for Payer: Nomi Health Commercial |
$26.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$144.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.51
|
| Rate for Payer: Priority Health Narrow Network |
$22.81
|
| Rate for Payer: Priority Health Narrow Network |
$19.96
|
| Rate for Payer: Priority Health Narrow Network |
$12.79
|
| Rate for Payer: Priority Health Narrow Network |
$115.55
|
| Rate for Payer: Priority Health Narrow Network |
$14.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$25.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$145.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.62
|
|
|
LORAZEPAM 2 MG/ML INJECTION SYRINGE
|
Facility
|
OP
|
$17.86
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
112180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$17.86 |
| Rate for Payer: Aetna Commercial |
$16.07
|
| Rate for Payer: Aetna Medicare |
$8.93
|
| Rate for Payer: ASR ASR |
$17.32
|
| Rate for Payer: ASR Commercial |
$17.32
|
| Rate for Payer: BCBS Complete |
$7.14
|
| Rate for Payer: BCBS Trust/PPO |
$14.63
|
| Rate for Payer: BCN Commercial |
$13.85
|
| Rate for Payer: Cash Price |
$14.29
|
| Rate for Payer: Cofinity Commercial |
$16.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.29
|
| Rate for Payer: Healthscope Commercial |
$17.86
|
| Rate for Payer: Healthscope Whirlpool |
$17.32
|
| Rate for Payer: Mclaren Commercial |
$16.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.18
|
| Rate for Payer: Nomi Health Commercial |
$14.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.65
|
| Rate for Payer: Priority Health Narrow Network |
$12.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.72
|
|
|
LORAZEPAM 2 MG/ML INJECTION SYRINGE
|
Facility
|
IP
|
$17.86
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
112180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.61 |
| Max. Negotiated Rate |
$17.86 |
| Rate for Payer: Aetna Commercial |
$16.07
|
| Rate for Payer: ASR ASR |
$17.32
|
| Rate for Payer: ASR Commercial |
$17.32
|
| Rate for Payer: BCBS Trust/PPO |
$14.55
|
| Rate for Payer: BCN Commercial |
$13.85
|
| Rate for Payer: Cash Price |
$14.29
|
| Rate for Payer: Cofinity Commercial |
$16.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.29
|
| Rate for Payer: Healthscope Commercial |
$17.86
|
| Rate for Payer: Healthscope Whirlpool |
$17.32
|
| Rate for Payer: Mclaren Commercial |
$16.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.18
|
| Rate for Payer: Nomi Health Commercial |
$14.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.72
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
IP
|
$253.65
|
|
|
Service Code
|
NDC 68084034711
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.87 |
| Max. Negotiated Rate |
$253.65 |
| Rate for Payer: Aetna Commercial |
$228.28
|
| Rate for Payer: ASR ASR |
$246.04
|
| Rate for Payer: ASR Commercial |
$246.04
|
| Rate for Payer: BCBS Trust/PPO |
$206.70
|
| Rate for Payer: BCN Commercial |
$196.65
|
| Rate for Payer: Cash Price |
$202.92
|
| Rate for Payer: Cofinity Commercial |
$238.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.92
|
| Rate for Payer: Healthscope Commercial |
$253.65
|
| Rate for Payer: Healthscope Whirlpool |
$246.04
|
| Rate for Payer: Mclaren Commercial |
$228.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.60
|
| Rate for Payer: Nomi Health Commercial |
$207.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.21
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
IP
|
$230.85
|
|
|
Service Code
|
NDC 00904704861
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.05 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Aetna Commercial |
$207.76
|
| Rate for Payer: ASR ASR |
$223.92
|
| Rate for Payer: ASR Commercial |
$223.92
|
| Rate for Payer: BCBS Trust/PPO |
$188.12
|
| Rate for Payer: BCN Commercial |
$178.98
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$217.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$230.85
|
| Rate for Payer: Healthscope Whirlpool |
$223.92
|
| Rate for Payer: Mclaren Commercial |
$207.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: Nomi Health Commercial |
$189.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$203.15
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
OP
|
$253.65
|
|
|
Service Code
|
NDC 68084034711
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.46 |
| Max. Negotiated Rate |
$253.65 |
| Rate for Payer: Aetna Commercial |
$228.28
|
| Rate for Payer: Aetna Medicare |
$126.83
|
| Rate for Payer: ASR ASR |
$246.04
|
| Rate for Payer: ASR Commercial |
$246.04
|
| Rate for Payer: BCBS Complete |
$101.46
|
| Rate for Payer: BCBS Trust/PPO |
$207.71
|
| Rate for Payer: BCN Commercial |
$196.65
|
| Rate for Payer: Cash Price |
$202.92
|
| Rate for Payer: Cofinity Commercial |
$238.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.92
|
| Rate for Payer: Healthscope Commercial |
$253.65
|
| Rate for Payer: Healthscope Whirlpool |
$246.04
|
| Rate for Payer: Mclaren Commercial |
$228.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.60
|
| Rate for Payer: Nomi Health Commercial |
$207.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$222.25
|
| Rate for Payer: Priority Health Narrow Network |
$177.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$223.21
|
|
|
LOSARTAN 50 MG TABLET
|
Facility
|
OP
|
$230.85
|
|
|
Service Code
|
NDC 00904704861
|
| Hospital Charge Code |
14824
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.34 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Aetna Commercial |
$207.76
|
| Rate for Payer: Aetna Medicare |
$115.42
|
| Rate for Payer: ASR ASR |
$223.92
|
| Rate for Payer: ASR Commercial |
$223.92
|
| Rate for Payer: BCBS Complete |
$92.34
|
| Rate for Payer: BCBS Trust/PPO |
$189.04
|
| Rate for Payer: BCN Commercial |
$178.98
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$217.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$230.85
|
| Rate for Payer: Healthscope Whirlpool |
$223.92
|
| Rate for Payer: Mclaren Commercial |
$207.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: Nomi Health Commercial |
$189.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$202.27
|
| Rate for Payer: Priority Health Narrow Network |
$161.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$203.15
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$10,484.47
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$10,484.47 |
| Rate for Payer: Aetna Commercial |
$9,436.02
|
| Rate for Payer: Aetna Medicare |
$41.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.48
|
| Rate for Payer: ASR ASR |
$10,169.94
|
| Rate for Payer: ASR Commercial |
$10,169.94
|
| Rate for Payer: BCBS Complete |
$23.63
|
| Rate for Payer: BCBS MAPPO |
$41.98
|
| Rate for Payer: BCBS Trust/PPO |
$8,585.73
|
| Rate for Payer: BCN Commercial |
$8,128.61
|
| Rate for Payer: BCN Medicare Advantage |
$41.98
|
| Rate for Payer: Cash Price |
$8,387.58
|
| Rate for Payer: Cash Price |
$8,387.58
|
| Rate for Payer: Cofinity Commercial |
$9,855.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,387.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.98
|
| Rate for Payer: Healthscope Commercial |
$10,484.47
|
| Rate for Payer: Healthscope Whirlpool |
$10,169.94
|
| Rate for Payer: Humana Choice PPO Medicare |
$41.98
|
| Rate for Payer: Mclaren Commercial |
$9,436.02
|
| Rate for Payer: Mclaren Medicaid |
$22.50
|
| Rate for Payer: Mclaren Medicare |
$41.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$44.08
|
| Rate for Payer: Meridian Medicaid |
$23.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,911.80
|
| Rate for Payer: Nomi Health Commercial |
$8,597.27
|
| Rate for Payer: PACE Medicare |
$39.88
|
| Rate for Payer: PACE SWMI |
$41.98
|
| Rate for Payer: PHP Commercial |
$46.18
|
| Rate for Payer: PHP Medicaid |
$22.50
|
| Rate for Payer: PHP Medicare Advantage |
$41.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$22.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,814.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,186.49
|
| Rate for Payer: Priority Health Medicare |
$41.98
|
| Rate for Payer: Priority Health Narrow Network |
$7,349.61
|
| Rate for Payer: Railroad Medicare Medicare |
$41.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9,226.33
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.98
|
| Rate for Payer: UHC Exchange |
$65.07
|
| Rate for Payer: UHC Medicare Advantage |
$41.98
|
| Rate for Payer: UHCCP DNSP |
$41.98
|
| Rate for Payer: UHCCP Medicaid |
$22.50
|
| Rate for Payer: VA VA |
$41.98
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$10,484.47
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,814.91 |
| Max. Negotiated Rate |
$10,484.47 |
| Rate for Payer: Aetna Commercial |
$9,436.02
|
| Rate for Payer: ASR ASR |
$10,169.94
|
| Rate for Payer: ASR Commercial |
$10,169.94
|
| Rate for Payer: BCBS Trust/PPO |
$8,543.79
|
| Rate for Payer: BCN Commercial |
$8,128.61
|
| Rate for Payer: Cash Price |
$8,387.58
|
| Rate for Payer: Cofinity Commercial |
$9,855.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,387.58
|
| Rate for Payer: Healthscope Commercial |
$10,484.47
|
| Rate for Payer: Healthscope Whirlpool |
$10,169.94
|
| Rate for Payer: Mclaren Commercial |
$9,436.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,911.80
|
| Rate for Payer: Nomi Health Commercial |
$8,597.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,814.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9,226.33
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION
|
Facility
|
OP
|
$31,453.29
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$31,453.29 |
| Rate for Payer: Aetna Commercial |
$28,307.96
|
| Rate for Payer: Aetna Medicare |
$41.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.48
|
| Rate for Payer: ASR ASR |
$30,509.69
|
| Rate for Payer: ASR Commercial |
$30,509.69
|
| Rate for Payer: BCBS Complete |
$23.63
|
| Rate for Payer: BCBS MAPPO |
$41.98
|
| Rate for Payer: BCBS Trust/PPO |
$25,757.10
|
| Rate for Payer: BCN Commercial |
$24,385.74
|
| Rate for Payer: BCN Medicare Advantage |
$41.98
|
| Rate for Payer: Cash Price |
$25,162.63
|
| Rate for Payer: Cash Price |
$25,162.63
|
| Rate for Payer: Cofinity Commercial |
$29,566.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25,162.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.98
|
| Rate for Payer: Healthscope Commercial |
$31,453.29
|
| Rate for Payer: Healthscope Whirlpool |
$30,509.69
|
| Rate for Payer: Humana Choice PPO Medicare |
$41.98
|
| Rate for Payer: Mclaren Commercial |
$28,307.96
|
| Rate for Payer: Mclaren Medicaid |
$22.50
|
| Rate for Payer: Mclaren Medicare |
$41.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$44.08
|
| Rate for Payer: Meridian Medicaid |
$23.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26,735.30
|
| Rate for Payer: Nomi Health Commercial |
$25,791.70
|
| Rate for Payer: PACE Medicare |
$39.88
|
| Rate for Payer: PACE SWMI |
$41.98
|
| Rate for Payer: PHP Commercial |
$46.18
|
| Rate for Payer: PHP Medicaid |
$22.50
|
| Rate for Payer: PHP Medicare Advantage |
$41.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$22.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,444.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27,559.37
|
| Rate for Payer: Priority Health Medicare |
$41.98
|
| Rate for Payer: Priority Health Narrow Network |
$22,048.76
|
| Rate for Payer: Railroad Medicare Medicare |
$41.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27,678.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.98
|
| Rate for Payer: UHC Exchange |
$65.07
|
| Rate for Payer: UHC Medicare Advantage |
$41.98
|
| Rate for Payer: UHCCP DNSP |
$41.98
|
| Rate for Payer: UHCCP Medicaid |
$22.50
|
| Rate for Payer: VA VA |
$41.98
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$31,453.29
|
|
|
Service Code
|
HCPCS J0896
|
| Hospital Charge Code |
192115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20,444.64 |
| Max. Negotiated Rate |
$31,453.29 |
| Rate for Payer: Aetna Commercial |
$28,307.96
|
| Rate for Payer: ASR ASR |
$30,509.69
|
| Rate for Payer: ASR Commercial |
$30,509.69
|
| Rate for Payer: BCBS Trust/PPO |
$25,631.29
|
| Rate for Payer: BCN Commercial |
$24,385.74
|
| Rate for Payer: Cash Price |
$25,162.63
|
| Rate for Payer: Cofinity Commercial |
$29,566.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25,162.63
|
| Rate for Payer: Healthscope Commercial |
$31,453.29
|
| Rate for Payer: Healthscope Whirlpool |
$30,509.69
|
| Rate for Payer: Mclaren Commercial |
$28,307.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26,735.30
|
| Rate for Payer: Nomi Health Commercial |
$25,791.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,444.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27,678.90
|
|
|
LYSINE HCL 500 MG TABLET
|
Facility
|
OP
|
$68.15
|
|
|
Service Code
|
NDC 96295013583
|
| Hospital Charge Code |
119069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.26 |
| Max. Negotiated Rate |
$68.15 |
| Rate for Payer: Aetna Commercial |
$61.34
|
| Rate for Payer: Aetna Medicare |
$34.08
|
| Rate for Payer: ASR ASR |
$66.11
|
| Rate for Payer: ASR Commercial |
$66.11
|
| Rate for Payer: BCBS Complete |
$27.26
|
| Rate for Payer: BCBS Trust/PPO |
$55.81
|
| Rate for Payer: BCN Commercial |
$52.84
|
| Rate for Payer: Cash Price |
$54.52
|
| Rate for Payer: Cofinity Commercial |
$64.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.52
|
| Rate for Payer: Healthscope Commercial |
$68.15
|
| Rate for Payer: Healthscope Whirlpool |
$66.11
|
| Rate for Payer: Mclaren Commercial |
$61.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.93
|
| Rate for Payer: Nomi Health Commercial |
$55.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$59.71
|
| Rate for Payer: Priority Health Narrow Network |
$47.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.97
|
|
|
LYSINE HCL 500 MG TABLET
|
Facility
|
IP
|
$68.15
|
|
|
Service Code
|
NDC 96295013583
|
| Hospital Charge Code |
119069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.30 |
| Max. Negotiated Rate |
$68.15 |
| Rate for Payer: Aetna Commercial |
$61.34
|
| Rate for Payer: ASR ASR |
$66.11
|
| Rate for Payer: ASR Commercial |
$66.11
|
| Rate for Payer: BCBS Trust/PPO |
$55.54
|
| Rate for Payer: BCN Commercial |
$52.84
|
| Rate for Payer: Cash Price |
$54.52
|
| Rate for Payer: Cofinity Commercial |
$64.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.52
|
| Rate for Payer: Healthscope Commercial |
$68.15
|
| Rate for Payer: Healthscope Whirlpool |
$66.11
|
| Rate for Payer: Mclaren Commercial |
$61.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.93
|
| Rate for Payer: Nomi Health Commercial |
$55.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.97
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
OP
|
$17.32
|
|
|
Service Code
|
NDC 71399005101
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna Commercial |
$15.59
|
| Rate for Payer: Aetna Medicare |
$8.66
|
| Rate for Payer: ASR ASR |
$16.80
|
| Rate for Payer: ASR Commercial |
$16.80
|
| Rate for Payer: BCBS Complete |
$6.93
|
| Rate for Payer: BCBS Trust/PPO |
$14.18
|
| Rate for Payer: BCN Commercial |
$13.43
|
| Rate for Payer: Cash Price |
$13.85
|
| Rate for Payer: Cofinity Commercial |
$16.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$17.32
|
| Rate for Payer: Healthscope Whirlpool |
$16.80
|
| Rate for Payer: Mclaren Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.72
|
| Rate for Payer: Nomi Health Commercial |
$14.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.18
|
| Rate for Payer: Priority Health Narrow Network |
$12.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.24
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
OP
|
$17.32
|
|
|
Service Code
|
NDC 71399788901
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna Commercial |
$15.59
|
| Rate for Payer: Aetna Medicare |
$8.66
|
| Rate for Payer: ASR ASR |
$16.80
|
| Rate for Payer: ASR Commercial |
$16.80
|
| Rate for Payer: BCBS Complete |
$6.93
|
| Rate for Payer: BCBS Trust/PPO |
$14.18
|
| Rate for Payer: BCN Commercial |
$13.43
|
| Rate for Payer: Cash Price |
$13.85
|
| Rate for Payer: Cofinity Commercial |
$16.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$17.32
|
| Rate for Payer: Healthscope Whirlpool |
$16.80
|
| Rate for Payer: Mclaren Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.72
|
| Rate for Payer: Nomi Health Commercial |
$14.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.18
|
| Rate for Payer: Priority Health Narrow Network |
$12.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.24
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 71399005101
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna Commercial |
$15.59
|
| Rate for Payer: ASR ASR |
$16.80
|
| Rate for Payer: ASR Commercial |
$16.80
|
| Rate for Payer: BCBS Trust/PPO |
$14.11
|
| Rate for Payer: BCN Commercial |
$13.43
|
| Rate for Payer: Cash Price |
$13.85
|
| Rate for Payer: Cofinity Commercial |
$16.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$17.32
|
| Rate for Payer: Healthscope Whirlpool |
$16.80
|
| Rate for Payer: Mclaren Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.72
|
| Rate for Payer: Nomi Health Commercial |
$14.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.24
|
|
|
MAGNESIUM CITRATE ORAL SOLUTION
|
Facility
|
IP
|
$17.32
|
|
|
Service Code
|
NDC 71399788901
|
| Hospital Charge Code |
4712
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna Commercial |
$15.59
|
| Rate for Payer: ASR ASR |
$16.80
|
| Rate for Payer: ASR Commercial |
$16.80
|
| Rate for Payer: BCBS Trust/PPO |
$14.11
|
| Rate for Payer: BCN Commercial |
$13.43
|
| Rate for Payer: Cash Price |
$13.85
|
| Rate for Payer: Cofinity Commercial |
$16.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.86
|
| Rate for Payer: Healthscope Commercial |
$17.32
|
| Rate for Payer: Healthscope Whirlpool |
$16.80
|
| Rate for Payer: Mclaren Commercial |
$15.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.72
|
| Rate for Payer: Nomi Health Commercial |
$14.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.24
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$10.50
|
|
|
Service Code
|
NDC 00904078816
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$10.50 |
| Rate for Payer: Aetna Commercial |
$9.45
|
| Rate for Payer: ASR ASR |
$10.19
|
| Rate for Payer: ASR Commercial |
$10.19
|
| Rate for Payer: BCBS Trust/PPO |
$8.56
|
| Rate for Payer: BCN Commercial |
$8.14
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cofinity Commercial |
$9.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.40
|
| Rate for Payer: Healthscope Commercial |
$10.50
|
| Rate for Payer: Healthscope Whirlpool |
$10.19
|
| Rate for Payer: Mclaren Commercial |
$9.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.93
|
| Rate for Payer: Nomi Health Commercial |
$8.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.24
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
NDC 09900000340
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna Commercial |
$0.63
|
| Rate for Payer: Aetna Medicare |
$0.35
|
| Rate for Payer: ASR ASR |
$0.68
|
| Rate for Payer: ASR Commercial |
$0.68
|
| Rate for Payer: BCBS Complete |
$0.28
|
| Rate for Payer: BCBS Trust/PPO |
$0.57
|
| Rate for Payer: BCN Commercial |
$0.54
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cofinity Commercial |
$0.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.56
|
| Rate for Payer: Healthscope Commercial |
$0.70
|
| Rate for Payer: Healthscope Whirlpool |
$0.68
|
| Rate for Payer: Mclaren Commercial |
$0.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.60
|
| Rate for Payer: Nomi Health Commercial |
$0.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.61
|
| Rate for Payer: Priority Health Narrow Network |
$0.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.62
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
NDC 09900000340
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna Commercial |
$0.63
|
| Rate for Payer: ASR ASR |
$0.68
|
| Rate for Payer: ASR Commercial |
$0.68
|
| Rate for Payer: BCBS Trust/PPO |
$0.57
|
| Rate for Payer: BCN Commercial |
$0.54
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cofinity Commercial |
$0.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.56
|
| Rate for Payer: Healthscope Commercial |
$0.70
|
| Rate for Payer: Healthscope Whirlpool |
$0.68
|
| Rate for Payer: Mclaren Commercial |
$0.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.60
|
| Rate for Payer: Nomi Health Commercial |
$0.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.62
|
|
|
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$10.50
|
|
|
Service Code
|
NDC 00904078816
|
| Hospital Charge Code |
108978
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$10.50 |
| Rate for Payer: Aetna Commercial |
$9.45
|
| Rate for Payer: Aetna Medicare |
$5.25
|
| Rate for Payer: ASR ASR |
$10.19
|
| Rate for Payer: ASR Commercial |
$10.19
|
| Rate for Payer: BCBS Complete |
$4.20
|
| Rate for Payer: BCBS Trust/PPO |
$8.60
|
| Rate for Payer: BCN Commercial |
$8.14
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cofinity Commercial |
$9.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.40
|
| Rate for Payer: Healthscope Commercial |
$10.50
|
| Rate for Payer: Healthscope Whirlpool |
$10.19
|
| Rate for Payer: Mclaren Commercial |
$9.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.93
|
| Rate for Payer: Nomi Health Commercial |
$8.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9.20
|
| Rate for Payer: Priority Health Narrow Network |
$7.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.24
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 64980033990
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna Commercial |
$0.97
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: ASR ASR |
$1.05
|
| Rate for Payer: ASR Commercial |
$1.05
|
| Rate for Payer: BCBS Complete |
$0.43
|
| Rate for Payer: BCBS Trust/PPO |
$0.88
|
| Rate for Payer: BCN Commercial |
$0.84
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cofinity Commercial |
$1.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.86
|
| Rate for Payer: Healthscope Commercial |
$1.08
|
| Rate for Payer: Healthscope Whirlpool |
$1.05
|
| Rate for Payer: Mclaren Commercial |
$0.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.92
|
| Rate for Payer: Nomi Health Commercial |
$0.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.95
|
| Rate for Payer: Priority Health Narrow Network |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.95
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
IP
|
$1.08
|
|
|
Service Code
|
NDC 64980033990
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.08 |
| Rate for Payer: Aetna Commercial |
$0.97
|
| Rate for Payer: ASR ASR |
$1.05
|
| Rate for Payer: ASR Commercial |
$1.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.88
|
| Rate for Payer: BCN Commercial |
$0.84
|
| Rate for Payer: Cash Price |
$0.86
|
| Rate for Payer: Cofinity Commercial |
$1.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.86
|
| Rate for Payer: Healthscope Commercial |
$1.08
|
| Rate for Payer: Healthscope Whirlpool |
$1.05
|
| Rate for Payer: Mclaren Commercial |
$0.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.92
|
| Rate for Payer: Nomi Health Commercial |
$0.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.95
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$256.00
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.40 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Aetna Commercial |
$230.40
|
| Rate for Payer: Aetna Medicare |
$128.00
|
| Rate for Payer: ASR ASR |
$248.32
|
| Rate for Payer: ASR Commercial |
$248.32
|
| Rate for Payer: BCBS Complete |
$102.40
|
| Rate for Payer: BCBS Trust/PPO |
$209.64
|
| Rate for Payer: BCN Commercial |
$198.48
|
| Rate for Payer: Cash Price |
$204.80
|
| Rate for Payer: Cofinity Commercial |
$240.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.80
|
| Rate for Payer: Healthscope Commercial |
$256.00
|
| Rate for Payer: Healthscope Whirlpool |
$248.32
|
| Rate for Payer: Mclaren Commercial |
$230.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.60
|
| Rate for Payer: Nomi Health Commercial |
$209.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$224.31
|
| Rate for Payer: Priority Health Narrow Network |
$179.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$225.28
|
|
|
MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET
|
Facility
|
OP
|
$107.80
|
|
|
Service Code
|
NDC 64980033901
|
| Hospital Charge Code |
10491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$107.80 |
| Rate for Payer: Aetna Commercial |
$97.02
|
| Rate for Payer: Aetna Medicare |
$53.90
|
| Rate for Payer: ASR ASR |
$104.57
|
| Rate for Payer: ASR Commercial |
$104.57
|
| Rate for Payer: BCBS Complete |
$43.12
|
| Rate for Payer: BCBS Trust/PPO |
$88.28
|
| Rate for Payer: BCN Commercial |
$83.58
|
| Rate for Payer: Cash Price |
$86.24
|
| Rate for Payer: Cofinity Commercial |
$101.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.24
|
| Rate for Payer: Healthscope Commercial |
$107.80
|
| Rate for Payer: Healthscope Whirlpool |
$104.57
|
| Rate for Payer: Mclaren Commercial |
$97.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.63
|
| Rate for Payer: Nomi Health Commercial |
$88.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$94.45
|
| Rate for Payer: Priority Health Narrow Network |
$75.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$94.86
|
|
