|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$95.76
|
|
|
Service Code
|
NDC 51672-1263-2
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.40 |
| Max. Negotiated Rate |
$86.18 |
| Rate for Payer: Aetna Commercial |
$81.40
|
| Rate for Payer: BCBS Trust/PPO |
$74.00
|
| Rate for Payer: BCN Commercial |
$74.00
|
| Rate for Payer: Cash Price |
$76.61
|
| Rate for Payer: Cofinity Commercial |
$82.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.61
|
| Rate for Payer: Healthscope Commercial |
$86.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.40
|
| Rate for Payer: PHP Commercial |
$81.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$83.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$58.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.27
|
| Rate for Payer: UHC Core |
$79.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.82
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$40.74
|
|
|
Service Code
|
NDC 45802-880-94
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.85 |
| Max. Negotiated Rate |
$36.67 |
| Rate for Payer: Aetna Commercial |
$34.63
|
| Rate for Payer: BCBS Trust/PPO |
$31.48
|
| Rate for Payer: BCN Commercial |
$31.48
|
| Rate for Payer: Cash Price |
$32.59
|
| Rate for Payer: Cofinity Commercial |
$35.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.59
|
| Rate for Payer: Healthscope Commercial |
$36.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.63
|
| Rate for Payer: PHP Commercial |
$34.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$35.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$24.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.85
|
| Rate for Payer: UHC Core |
$34.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.56
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$95.76
|
|
|
Service Code
|
NDC 68462-314-35
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.40 |
| Max. Negotiated Rate |
$86.18 |
| Rate for Payer: Aetna Commercial |
$81.40
|
| Rate for Payer: BCBS Trust/PPO |
$74.00
|
| Rate for Payer: BCN Commercial |
$74.00
|
| Rate for Payer: Cash Price |
$76.61
|
| Rate for Payer: Cofinity Commercial |
$82.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.61
|
| Rate for Payer: Healthscope Commercial |
$86.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.40
|
| Rate for Payer: PHP Commercial |
$81.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$83.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$58.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.27
|
| Rate for Payer: UHC Core |
$79.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.82
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$170.94
|
|
|
Service Code
|
NDC 0168-0089-30
|
| Hospital Charge Code |
5755
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.26 |
| Max. Negotiated Rate |
$153.85 |
| Rate for Payer: Aetna Commercial |
$145.30
|
| Rate for Payer: BCBS Trust/PPO |
$132.10
|
| Rate for Payer: BCN Commercial |
$132.10
|
| Rate for Payer: Cash Price |
$136.75
|
| Rate for Payer: Cofinity Commercial |
$147.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.75
|
| Rate for Payer: Healthscope Commercial |
$153.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$128.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$145.30
|
| Rate for Payer: PHP Commercial |
$145.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$148.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$104.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$150.43
|
| Rate for Payer: UHC Core |
$142.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$128.20
|
|
|
OB/GYN SPEC KZOO ONLY - NITROUS OXIDE ADMIN
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 00563
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: BCBS Complete |
$24.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.00
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$17.21
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
91279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.49 |
| Rate for Payer: Aetna Commercial |
$14.63
|
| Rate for Payer: Aetna Commercial |
$20.18
|
| Rate for Payer: BCBS Trust/PPO |
$13.30
|
| Rate for Payer: BCBS Trust/PPO |
$18.35
|
| Rate for Payer: BCN Commercial |
$18.35
|
| Rate for Payer: BCN Commercial |
$13.30
|
| Rate for Payer: Cash Price |
$18.99
|
| Rate for Payer: Cash Price |
$13.77
|
| Rate for Payer: Cofinity Commercial |
$14.80
|
| Rate for Payer: Cofinity Commercial |
$20.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.77
|
| Rate for Payer: Healthscope Commercial |
$21.37
|
| Rate for Payer: Healthscope Commercial |
$15.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.63
|
| Rate for Payer: PHP Commercial |
$20.18
|
| Rate for Payer: PHP Commercial |
$14.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.89
|
| Rate for Payer: UHC Core |
$14.37
|
| Rate for Payer: UHC Core |
$19.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.91
|
|
|
OFLOXACIN 0.3 % EAR DROPS
|
Facility
|
IP
|
$56.42
|
|
|
Service Code
|
NDC 60505-0363-1
|
| Hospital Charge Code |
22257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.41 |
| Max. Negotiated Rate |
$50.78 |
| Rate for Payer: Aetna Commercial |
$47.96
|
| Rate for Payer: BCBS Trust/PPO |
$43.60
|
| Rate for Payer: BCN Commercial |
$43.60
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cofinity Commercial |
$48.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.14
|
| Rate for Payer: Healthscope Commercial |
$50.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.96
|
| Rate for Payer: PHP Commercial |
$47.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.65
|
| Rate for Payer: UHC Core |
$47.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.32
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$24.64
|
|
|
Service Code
|
NDC 64980-515-05
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.03 |
| Max. Negotiated Rate |
$22.18 |
| Rate for Payer: Aetna Commercial |
$20.94
|
| Rate for Payer: BCBS Trust/PPO |
$19.04
|
| Rate for Payer: BCN Commercial |
$19.04
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$21.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$22.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.94
|
| Rate for Payer: PHP Commercial |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.68
|
| Rate for Payer: UHC Core |
$20.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.48
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$31.75
|
|
|
Service Code
|
NDC 17478-713-10
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$28.58 |
| Rate for Payer: Aetna Commercial |
$26.99
|
| Rate for Payer: BCBS Trust/PPO |
$24.54
|
| Rate for Payer: BCN Commercial |
$24.54
|
| Rate for Payer: Cash Price |
$25.40
|
| Rate for Payer: Cofinity Commercial |
$27.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.40
|
| Rate for Payer: Healthscope Commercial |
$28.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.99
|
| Rate for Payer: PHP Commercial |
$26.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.94
|
| Rate for Payer: UHC Core |
$26.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.81
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$66.54
|
|
|
Service Code
|
NDC 24208-434-05
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.58 |
| Max. Negotiated Rate |
$59.89 |
| Rate for Payer: Aetna Commercial |
$56.56
|
| Rate for Payer: BCBS Trust/PPO |
$51.42
|
| Rate for Payer: BCN Commercial |
$51.42
|
| Rate for Payer: Cash Price |
$53.23
|
| Rate for Payer: Cofinity Commercial |
$57.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.23
|
| Rate for Payer: Healthscope Commercial |
$59.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.56
|
| Rate for Payer: PHP Commercial |
$56.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$57.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$40.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$58.56
|
| Rate for Payer: UHC Core |
$55.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.90
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$48.83
|
|
|
Service Code
|
NDC 70756-607-30
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.78 |
| Max. Negotiated Rate |
$43.95 |
| Rate for Payer: Aetna Commercial |
$41.51
|
| Rate for Payer: BCBS Trust/PPO |
$37.74
|
| Rate for Payer: BCN Commercial |
$37.74
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cofinity Commercial |
$41.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.06
|
| Rate for Payer: Healthscope Commercial |
$43.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.51
|
| Rate for Payer: PHP Commercial |
$41.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$42.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$29.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.97
|
| Rate for Payer: UHC Core |
$40.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.62
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$126.42
|
|
|
Service Code
|
NDC 24208-434-10
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.10 |
| Max. Negotiated Rate |
$113.78 |
| Rate for Payer: Aetna Commercial |
$107.46
|
| Rate for Payer: BCBS Trust/PPO |
$97.70
|
| Rate for Payer: BCN Commercial |
$97.70
|
| Rate for Payer: Cash Price |
$101.14
|
| Rate for Payer: Cofinity Commercial |
$108.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.14
|
| Rate for Payer: Healthscope Commercial |
$113.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.46
|
| Rate for Payer: PHP Commercial |
$107.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$109.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$111.25
|
| Rate for Payer: UHC Core |
$105.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.82
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$117.14
|
|
|
Service Code
|
NDC 33342-084-07
|
| Hospital Charge Code |
28160
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.44 |
| Max. Negotiated Rate |
$105.43 |
| Rate for Payer: Aetna Commercial |
$99.57
|
| Rate for Payer: BCBS Trust/PPO |
$90.53
|
| Rate for Payer: BCN Commercial |
$90.53
|
| Rate for Payer: Cash Price |
$93.71
|
| Rate for Payer: Cofinity Commercial |
$100.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.71
|
| Rate for Payer: Healthscope Commercial |
$105.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.57
|
| Rate for Payer: PHP Commercial |
$99.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$101.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$71.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$103.08
|
| Rate for Payer: UHC Core |
$97.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.86
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$77.88
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.50 |
| Max. Negotiated Rate |
$70.09 |
| Rate for Payer: Aetna Commercial |
$66.20
|
| Rate for Payer: Aetna Commercial |
$132.51
|
| Rate for Payer: Aetna Commercial |
$65.52
|
| Rate for Payer: BCBS Trust/PPO |
$60.19
|
| Rate for Payer: BCBS Trust/PPO |
$59.57
|
| Rate for Payer: BCBS Trust/PPO |
$120.47
|
| Rate for Payer: BCN Commercial |
$59.57
|
| Rate for Payer: BCN Commercial |
$120.47
|
| Rate for Payer: BCN Commercial |
$60.19
|
| Rate for Payer: Cash Price |
$62.30
|
| Rate for Payer: Cash Price |
$61.66
|
| Rate for Payer: Cash Price |
$124.71
|
| Rate for Payer: Cofinity Commercial |
$66.29
|
| Rate for Payer: Cofinity Commercial |
$134.07
|
| Rate for Payer: Cofinity Commercial |
$66.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.30
|
| Rate for Payer: Healthscope Commercial |
$69.37
|
| Rate for Payer: Healthscope Commercial |
$140.30
|
| Rate for Payer: Healthscope Commercial |
$70.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$132.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.20
|
| Rate for Payer: PHP Commercial |
$132.51
|
| Rate for Payer: PHP Commercial |
$65.52
|
| Rate for Payer: PHP Commercial |
$66.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$135.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$95.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.53
|
| Rate for Payer: UHC Core |
$130.17
|
| Rate for Payer: UHC Core |
$64.36
|
| Rate for Payer: UHC Core |
$65.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.92
|
|
|
OLANZAPINE 10 MG TABLET
|
Facility
|
IP
|
$57.11
|
|
|
Service Code
|
NDC 43598-166-30
|
| Hospital Charge Code |
17937
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.83 |
| Max. Negotiated Rate |
$51.40 |
| Rate for Payer: Aetna Commercial |
$48.54
|
| Rate for Payer: BCBS Trust/PPO |
$44.13
|
| Rate for Payer: BCN Commercial |
$44.13
|
| Rate for Payer: Cash Price |
$45.69
|
| Rate for Payer: Cofinity Commercial |
$49.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.69
|
| Rate for Payer: Healthscope Commercial |
$51.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.54
|
| Rate for Payer: PHP Commercial |
$48.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.26
|
| Rate for Payer: UHC Core |
$47.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.83
|
|
|
OLANZAPINE 2.5 MG TABLET
|
Facility
|
IP
|
$246.75
|
|
|
Service Code
|
NDC 0904-6283-61
|
| Hospital Charge Code |
21057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.49 |
| Max. Negotiated Rate |
$222.08 |
| Rate for Payer: Aetna Commercial |
$209.74
|
| Rate for Payer: BCBS Trust/PPO |
$190.69
|
| Rate for Payer: BCN Commercial |
$190.69
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$212.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.40
|
| Rate for Payer: Healthscope Commercial |
$222.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$209.74
|
| Rate for Payer: PHP Commercial |
$209.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$214.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$150.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$217.14
|
| Rate for Payer: UHC Core |
$206.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.06
|
|
|
OLANZAPINE 2.5 MG TABLET
|
Facility
|
IP
|
$246.75
|
|
|
Service Code
|
NDC 60505-3110-0
|
| Hospital Charge Code |
21057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.49 |
| Max. Negotiated Rate |
$222.08 |
| Rate for Payer: Aetna Commercial |
$209.74
|
| Rate for Payer: BCBS Trust/PPO |
$190.69
|
| Rate for Payer: BCN Commercial |
$190.69
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$212.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.40
|
| Rate for Payer: Healthscope Commercial |
$222.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$209.74
|
| Rate for Payer: PHP Commercial |
$209.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$214.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$150.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$217.14
|
| Rate for Payer: UHC Core |
$206.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.06
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$114.63
|
|
|
Service Code
|
NDC 49884-320-55
|
| Hospital Charge Code |
28159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.91 |
| Max. Negotiated Rate |
$103.17 |
| Rate for Payer: Aetna Commercial |
$97.44
|
| Rate for Payer: BCBS Trust/PPO |
$88.59
|
| Rate for Payer: BCN Commercial |
$88.59
|
| Rate for Payer: Cash Price |
$91.70
|
| Rate for Payer: Cofinity Commercial |
$98.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.70
|
| Rate for Payer: Healthscope Commercial |
$103.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$85.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$97.44
|
| Rate for Payer: PHP Commercial |
$97.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$99.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$69.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$100.87
|
| Rate for Payer: UHC Core |
$95.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$85.97
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$6.95
|
|
|
Service Code
|
NDC 55111-262-79
|
| Hospital Charge Code |
28159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.24 |
| Max. Negotiated Rate |
$6.26 |
| Rate for Payer: Aetna Commercial |
$5.91
|
| Rate for Payer: BCBS Trust/PPO |
$5.37
|
| Rate for Payer: BCN Commercial |
$5.37
|
| Rate for Payer: Cash Price |
$5.56
|
| Rate for Payer: Cofinity Commercial |
$5.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.56
|
| Rate for Payer: Healthscope Commercial |
$6.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.91
|
| Rate for Payer: PHP Commercial |
$5.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.12
|
| Rate for Payer: UHC Core |
$5.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.21
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$208.37
|
|
|
Service Code
|
NDC 55111-262-81
|
| Hospital Charge Code |
28159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.08 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$177.11
|
| Rate for Payer: BCBS Trust/PPO |
$161.03
|
| Rate for Payer: BCN Commercial |
$161.03
|
| Rate for Payer: Cash Price |
$166.70
|
| Rate for Payer: Cofinity Commercial |
$179.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.70
|
| Rate for Payer: Healthscope Commercial |
$187.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$177.11
|
| Rate for Payer: PHP Commercial |
$177.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$181.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$127.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$183.37
|
| Rate for Payer: UHC Core |
$173.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.28
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$57.57
|
|
|
Service Code
|
NDC 33342-083-07
|
| Hospital Charge Code |
28159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.11 |
| Max. Negotiated Rate |
$51.81 |
| Rate for Payer: Aetna Commercial |
$48.93
|
| Rate for Payer: BCBS Trust/PPO |
$44.49
|
| Rate for Payer: BCN Commercial |
$44.49
|
| Rate for Payer: Cash Price |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$49.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.06
|
| Rate for Payer: Healthscope Commercial |
$51.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.93
|
| Rate for Payer: PHP Commercial |
$48.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$50.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.66
|
| Rate for Payer: UHC Core |
$48.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.18
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$3.83
|
|
|
Service Code
|
NDC 49884-320-52
|
| Hospital Charge Code |
28159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.34 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: BCBS Trust/PPO |
$2.96
|
| Rate for Payer: BCN Commercial |
$2.96
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.26
|
| Rate for Payer: PHP Commercial |
$3.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.37
|
| Rate for Payer: UHC Core |
$3.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
OLANZAPINE 5 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$117.08
|
|
|
Service Code
|
NDC 0378-5510-93
|
| Hospital Charge Code |
28159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.41 |
| Max. Negotiated Rate |
$105.37 |
| Rate for Payer: Aetna Commercial |
$99.52
|
| Rate for Payer: BCBS Trust/PPO |
$90.48
|
| Rate for Payer: BCN Commercial |
$90.48
|
| Rate for Payer: Cash Price |
$93.66
|
| Rate for Payer: Cofinity Commercial |
$100.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.66
|
| Rate for Payer: Healthscope Commercial |
$105.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.52
|
| Rate for Payer: PHP Commercial |
$99.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$101.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$71.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$103.03
|
| Rate for Payer: UHC Core |
$97.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.81
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$289.05
|
|
|
Service Code
|
NDC 60505-3111-0
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.29 |
| Max. Negotiated Rate |
$260.14 |
| Rate for Payer: Aetna Commercial |
$245.69
|
| Rate for Payer: BCBS Trust/PPO |
$223.38
|
| Rate for Payer: BCN Commercial |
$223.38
|
| Rate for Payer: Cash Price |
$231.24
|
| Rate for Payer: Cofinity Commercial |
$248.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.24
|
| Rate for Payer: Healthscope Commercial |
$260.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$216.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$245.69
|
| Rate for Payer: PHP Commercial |
$245.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$251.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$176.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$254.36
|
| Rate for Payer: UHC Core |
$241.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$216.79
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$263.20
|
|
|
Service Code
|
NDC 0904-6377-61
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.53 |
| Max. Negotiated Rate |
$236.88 |
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: BCBS Trust/PPO |
$203.40
|
| Rate for Payer: BCN Commercial |
$203.40
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$226.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Healthscope Commercial |
$236.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$197.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$223.72
|
| Rate for Payer: PHP Commercial |
$223.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$228.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$160.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$231.62
|
| Rate for Payer: UHC Core |
$219.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$197.40
|
|
