|
AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
|
OP
|
$115.70
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$115.70 |
| Rate for Payer: Aetna Commercial |
$104.13
|
| Rate for Payer: Aetna Medicare |
$42.81
|
| Rate for Payer: ASR ASR |
$112.23
|
| Rate for Payer: BCBS Complete |
$46.28
|
| Rate for Payer: BCBS Trust/PPO |
$95.39
|
| Rate for Payer: BCN Commercial |
$95.39
|
| Rate for Payer: Cash Price |
$92.56
|
| Rate for Payer: Cash Price |
$92.56
|
| Rate for Payer: Cofinity Commercial |
$108.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.56
|
| Rate for Payer: Healthscope Commercial |
$112.23
|
| Rate for Payer: Healthscope Whirlpool |
$115.70
|
| Rate for Payer: Mclaren Commercial |
$104.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$92.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.34
|
| Rate for Payer: Nomi Health Commercial |
$94.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$86.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.62
|
| Rate for Payer: Priority Health Narrow Network |
$2.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$101.82
|
|
|
AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
|
IP
|
$115.70
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$86.78 |
| Max. Negotiated Rate |
$115.70 |
| Rate for Payer: Aetna Commercial |
$104.13
|
| Rate for Payer: ASR ASR |
$112.23
|
| Rate for Payer: BCBS Trust/PPO |
$95.01
|
| Rate for Payer: BCN Commercial |
$95.01
|
| Rate for Payer: Cash Price |
$92.56
|
| Rate for Payer: Cofinity Commercial |
$108.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.56
|
| Rate for Payer: Healthscope Commercial |
$112.23
|
| Rate for Payer: Healthscope Whirlpool |
$115.70
|
| Rate for Payer: Mclaren Commercial |
$104.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.34
|
| Rate for Payer: Nomi Health Commercial |
$94.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$86.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$101.82
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.22
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
9065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.67 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna Commercial |
$16.40
|
| Rate for Payer: Aetna Commercial |
$23.29
|
| Rate for Payer: Aetna Commercial |
$19.54
|
| Rate for Payer: ASR ASR |
$25.11
|
| Rate for Payer: ASR ASR |
$17.68
|
| Rate for Payer: ASR ASR |
$21.06
|
| Rate for Payer: BCBS Trust/PPO |
$21.26
|
| Rate for Payer: BCBS Trust/PPO |
$14.96
|
| Rate for Payer: BCBS Trust/PPO |
$17.83
|
| Rate for Payer: BCN Commercial |
$17.83
|
| Rate for Payer: BCN Commercial |
$14.96
|
| Rate for Payer: BCN Commercial |
$21.26
|
| Rate for Payer: Cash Price |
$20.71
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cofinity Commercial |
$17.13
|
| Rate for Payer: Cofinity Commercial |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$24.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.37
|
| Rate for Payer: Healthscope Commercial |
$21.06
|
| Rate for Payer: Healthscope Commercial |
$17.68
|
| Rate for Payer: Healthscope Commercial |
$25.11
|
| Rate for Payer: Healthscope Whirlpool |
$21.71
|
| Rate for Payer: Healthscope Whirlpool |
$25.88
|
| Rate for Payer: Healthscope Whirlpool |
$18.22
|
| Rate for Payer: Mclaren Commercial |
$19.54
|
| Rate for Payer: Mclaren Commercial |
$16.40
|
| Rate for Payer: Mclaren Commercial |
$23.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.49
|
| Rate for Payer: Nomi Health Commercial |
$17.80
|
| Rate for Payer: Nomi Health Commercial |
$14.94
|
| Rate for Payer: Nomi Health Commercial |
$21.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.04
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18.22
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
9065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna Commercial |
$16.40
|
| Rate for Payer: Aetna Commercial |
$19.54
|
| Rate for Payer: Aetna Commercial |
$23.29
|
| Rate for Payer: Aetna Medicare |
$8.03
|
| Rate for Payer: Aetna Medicare |
$6.74
|
| Rate for Payer: Aetna Medicare |
$9.58
|
| Rate for Payer: ASR ASR |
$25.11
|
| Rate for Payer: ASR ASR |
$17.68
|
| Rate for Payer: ASR ASR |
$21.06
|
| Rate for Payer: BCBS Complete |
$7.29
|
| Rate for Payer: BCBS Complete |
$10.35
|
| Rate for Payer: BCBS Complete |
$8.68
|
| Rate for Payer: BCBS Trust/PPO |
$15.02
|
| Rate for Payer: BCBS Trust/PPO |
$17.90
|
| Rate for Payer: BCBS Trust/PPO |
$21.34
|
| Rate for Payer: BCN Commercial |
$15.02
|
| Rate for Payer: BCN Commercial |
$17.90
|
| Rate for Payer: BCN Commercial |
$21.34
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cash Price |
$20.71
|
| Rate for Payer: Cash Price |
$20.71
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Commercial |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$17.13
|
| Rate for Payer: Cofinity Commercial |
$24.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.37
|
| Rate for Payer: Healthscope Commercial |
$25.11
|
| Rate for Payer: Healthscope Commercial |
$17.68
|
| Rate for Payer: Healthscope Commercial |
$21.06
|
| Rate for Payer: Healthscope Whirlpool |
$21.71
|
| Rate for Payer: Healthscope Whirlpool |
$18.22
|
| Rate for Payer: Healthscope Whirlpool |
$25.88
|
| Rate for Payer: Mclaren Commercial |
$23.29
|
| Rate for Payer: Mclaren Commercial |
$19.54
|
| Rate for Payer: Mclaren Commercial |
$16.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.49
|
| Rate for Payer: Nomi Health Commercial |
$21.22
|
| Rate for Payer: Nomi Health Commercial |
$14.94
|
| Rate for Payer: Nomi Health Commercial |
$17.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.42
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.42
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.42
|
| Rate for Payer: Priority Health Narrow Network |
$0.34
|
| Rate for Payer: Priority Health Narrow Network |
$0.34
|
| Rate for Payer: Priority Health Narrow Network |
$0.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.04
|
|
|
AMIODARONE 50 MG/ML IV (CODE)
|
Facility
|
IP
|
$18.22
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
163703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.67 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna Commercial |
$16.40
|
| Rate for Payer: Aetna Commercial |
$19.54
|
| Rate for Payer: ASR ASR |
$21.06
|
| Rate for Payer: ASR ASR |
$17.68
|
| Rate for Payer: BCBS Trust/PPO |
$17.83
|
| Rate for Payer: BCBS Trust/PPO |
$14.96
|
| Rate for Payer: BCN Commercial |
$17.83
|
| Rate for Payer: BCN Commercial |
$14.96
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Commercial |
$17.13
|
| Rate for Payer: Cofinity Commercial |
$20.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$17.68
|
| Rate for Payer: Healthscope Commercial |
$21.06
|
| Rate for Payer: Healthscope Whirlpool |
$21.71
|
| Rate for Payer: Healthscope Whirlpool |
$18.22
|
| Rate for Payer: Mclaren Commercial |
$19.54
|
| Rate for Payer: Mclaren Commercial |
$16.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.49
|
| Rate for Payer: Nomi Health Commercial |
$17.80
|
| Rate for Payer: Nomi Health Commercial |
$14.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.10
|
|
|
AMIODARONE 50 MG/ML IV (CODE)
|
Facility
|
OP
|
$21.71
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
163703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$21.71 |
| Rate for Payer: Aetna Commercial |
$19.54
|
| Rate for Payer: Aetna Commercial |
$16.40
|
| Rate for Payer: Aetna Medicare |
$6.74
|
| Rate for Payer: Aetna Medicare |
$8.03
|
| Rate for Payer: ASR ASR |
$21.06
|
| Rate for Payer: ASR ASR |
$17.68
|
| Rate for Payer: BCBS Complete |
$7.29
|
| Rate for Payer: BCBS Complete |
$8.68
|
| Rate for Payer: BCBS Trust/PPO |
$17.90
|
| Rate for Payer: BCBS Trust/PPO |
$15.02
|
| Rate for Payer: BCN Commercial |
$15.02
|
| Rate for Payer: BCN Commercial |
$17.90
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Commercial |
$17.13
|
| Rate for Payer: Cofinity Commercial |
$20.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$21.06
|
| Rate for Payer: Healthscope Commercial |
$17.68
|
| Rate for Payer: Healthscope Whirlpool |
$21.71
|
| Rate for Payer: Healthscope Whirlpool |
$18.22
|
| Rate for Payer: Mclaren Commercial |
$19.54
|
| Rate for Payer: Mclaren Commercial |
$16.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.45
|
| Rate for Payer: Nomi Health Commercial |
$14.94
|
| Rate for Payer: Nomi Health Commercial |
$17.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.42
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.42
|
| Rate for Payer: Priority Health Narrow Network |
$0.34
|
| Rate for Payer: Priority Health Narrow Network |
$0.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.10
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
NDC 50268003711
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: ASR ASR |
$3.39
|
| Rate for Payer: BCBS Trust/PPO |
$2.87
|
| Rate for Payer: BCN Commercial |
$2.87
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.39
|
| Rate for Payer: Healthscope Whirlpool |
$3.50
|
| Rate for Payer: Mclaren Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.97
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.08
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
|
IP
|
$143.35
|
|
|
Service Code
|
NDC 16729017101
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.51 |
| Max. Negotiated Rate |
$143.35 |
| Rate for Payer: Aetna Commercial |
$129.01
|
| Rate for Payer: ASR ASR |
$139.05
|
| Rate for Payer: BCBS Trust/PPO |
$117.72
|
| Rate for Payer: BCN Commercial |
$117.72
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$134.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$139.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.35
|
| Rate for Payer: Mclaren Commercial |
$129.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Nomi Health Commercial |
$117.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$126.15
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
|
OP
|
$174.80
|
|
|
Service Code
|
NDC 50268003715
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.68 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Aetna Commercial |
$157.32
|
| Rate for Payer: Aetna Medicare |
$64.68
|
| Rate for Payer: ASR ASR |
$169.56
|
| Rate for Payer: BCBS Complete |
$69.92
|
| Rate for Payer: BCBS Trust/PPO |
$144.12
|
| Rate for Payer: BCN Commercial |
$144.12
|
| Rate for Payer: Cash Price |
$139.84
|
| Rate for Payer: Cofinity Commercial |
$164.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.84
|
| Rate for Payer: Healthscope Commercial |
$169.56
|
| Rate for Payer: Healthscope Whirlpool |
$174.80
|
| Rate for Payer: Mclaren Commercial |
$157.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$139.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.58
|
| Rate for Payer: Nomi Health Commercial |
$143.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$131.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$153.16
|
| Rate for Payer: Priority Health Narrow Network |
$122.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$153.82
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
|
IP
|
$174.80
|
|
|
Service Code
|
NDC 50268003715
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.10 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Aetna Commercial |
$157.32
|
| Rate for Payer: ASR ASR |
$169.56
|
| Rate for Payer: BCBS Trust/PPO |
$143.55
|
| Rate for Payer: BCN Commercial |
$143.55
|
| Rate for Payer: Cash Price |
$139.84
|
| Rate for Payer: Cofinity Commercial |
$164.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.84
|
| Rate for Payer: Healthscope Commercial |
$169.56
|
| Rate for Payer: Healthscope Whirlpool |
$174.80
|
| Rate for Payer: Mclaren Commercial |
$157.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$148.58
|
| Rate for Payer: Nomi Health Commercial |
$143.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$131.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$153.82
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
|
OP
|
$143.35
|
|
|
Service Code
|
NDC 16729017101
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$143.35 |
| Rate for Payer: Aetna Commercial |
$129.01
|
| Rate for Payer: Aetna Medicare |
$53.04
|
| Rate for Payer: ASR ASR |
$139.05
|
| Rate for Payer: BCBS Complete |
$57.34
|
| Rate for Payer: BCBS Trust/PPO |
$118.19
|
| Rate for Payer: BCN Commercial |
$118.19
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$134.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$139.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.35
|
| Rate for Payer: Mclaren Commercial |
$129.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$114.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Nomi Health Commercial |
$117.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$125.60
|
| Rate for Payer: Priority Health Narrow Network |
$100.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$126.15
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
NDC 50268003711
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Aetna Medicare |
$1.29
|
| Rate for Payer: ASR ASR |
$3.39
|
| Rate for Payer: BCBS Complete |
$1.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.88
|
| Rate for Payer: BCN Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.39
|
| Rate for Payer: Healthscope Whirlpool |
$3.50
|
| Rate for Payer: Mclaren Commercial |
$3.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.97
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.06
|
| Rate for Payer: Priority Health Narrow Network |
$2.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.08
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
IP
|
$225.15
|
|
|
Service Code
|
NDC 904718461
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.86 |
| Max. Negotiated Rate |
$225.15 |
| Rate for Payer: Aetna Commercial |
$202.63
|
| Rate for Payer: ASR ASR |
$218.40
|
| Rate for Payer: BCBS Trust/PPO |
$184.89
|
| Rate for Payer: BCN Commercial |
$184.89
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$211.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$218.40
|
| Rate for Payer: Healthscope Whirlpool |
$225.15
|
| Rate for Payer: Mclaren Commercial |
$202.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.38
|
| Rate for Payer: Nomi Health Commercial |
$184.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$168.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.13
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 60687043311
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: ASR ASR |
$3.26
|
| Rate for Payer: BCBS Complete |
$1.35
|
| Rate for Payer: BCBS Trust/PPO |
$2.77
|
| Rate for Payer: BCN Commercial |
$2.77
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.69
|
| Rate for Payer: Healthscope Commercial |
$3.26
|
| Rate for Payer: Healthscope Whirlpool |
$3.36
|
| Rate for Payer: Mclaren Commercial |
$3.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.86
|
| Rate for Payer: Nomi Health Commercial |
$2.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.95
|
| Rate for Payer: Priority Health Narrow Network |
$2.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.96
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 60687043311
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: ASR ASR |
$3.26
|
| Rate for Payer: BCBS Trust/PPO |
$2.76
|
| Rate for Payer: BCN Commercial |
$2.76
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.69
|
| Rate for Payer: Healthscope Commercial |
$3.26
|
| Rate for Payer: Healthscope Whirlpool |
$3.36
|
| Rate for Payer: Mclaren Commercial |
$3.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.86
|
| Rate for Payer: Nomi Health Commercial |
$2.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.96
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$336.30
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.43 |
| Max. Negotiated Rate |
$336.30 |
| Rate for Payer: Aetna Commercial |
$302.67
|
| Rate for Payer: Aetna Medicare |
$124.43
|
| Rate for Payer: ASR ASR |
$326.21
|
| Rate for Payer: BCBS Complete |
$134.52
|
| Rate for Payer: BCBS Trust/PPO |
$277.28
|
| Rate for Payer: BCN Commercial |
$277.28
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$316.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$326.21
|
| Rate for Payer: Healthscope Whirlpool |
$336.30
|
| Rate for Payer: Mclaren Commercial |
$302.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$269.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: Nomi Health Commercial |
$275.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$294.67
|
| Rate for Payer: Priority Health Narrow Network |
$235.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$295.94
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
OP
|
$225.15
|
|
|
Service Code
|
NDC 904718461
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.31 |
| Max. Negotiated Rate |
$225.15 |
| Rate for Payer: Aetna Commercial |
$202.63
|
| Rate for Payer: Aetna Medicare |
$83.31
|
| Rate for Payer: ASR ASR |
$218.40
|
| Rate for Payer: BCBS Complete |
$90.06
|
| Rate for Payer: BCBS Trust/PPO |
$185.64
|
| Rate for Payer: BCN Commercial |
$185.64
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$211.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$218.40
|
| Rate for Payer: Healthscope Whirlpool |
$225.15
|
| Rate for Payer: Mclaren Commercial |
$202.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$180.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.38
|
| Rate for Payer: Nomi Health Commercial |
$184.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$168.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$197.28
|
| Rate for Payer: Priority Health Narrow Network |
$157.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.13
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
|
IP
|
$336.30
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$252.22 |
| Max. Negotiated Rate |
$336.30 |
| Rate for Payer: Aetna Commercial |
$302.67
|
| Rate for Payer: ASR ASR |
$326.21
|
| Rate for Payer: BCBS Trust/PPO |
$276.17
|
| Rate for Payer: BCN Commercial |
$276.17
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$316.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$326.21
|
| Rate for Payer: Healthscope Whirlpool |
$336.30
|
| Rate for Payer: Mclaren Commercial |
$302.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: Nomi Health Commercial |
$275.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$295.94
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
OP
|
$1.83
|
|
|
Service Code
|
NDC 51079045101
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna Commercial |
$1.65
|
| Rate for Payer: Aetna Medicare |
$0.68
|
| Rate for Payer: ASR ASR |
$1.78
|
| Rate for Payer: BCBS Complete |
$0.73
|
| Rate for Payer: BCBS Trust/PPO |
$1.51
|
| Rate for Payer: BCN Commercial |
$1.51
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.47
|
| Rate for Payer: Healthscope Commercial |
$1.78
|
| Rate for Payer: Healthscope Whirlpool |
$1.83
|
| Rate for Payer: Mclaren Commercial |
$1.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.56
|
| Rate for Payer: Nomi Health Commercial |
$1.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.37
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1.61
|
| Rate for Payer: Priority Health Narrow Network |
$1.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.61
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
NDC 904637061
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.17 |
| Max. Negotiated Rate |
$195.05 |
| Rate for Payer: Aetna Commercial |
$175.54
|
| Rate for Payer: Aetna Medicare |
$72.17
|
| Rate for Payer: ASR ASR |
$189.20
|
| Rate for Payer: BCBS Complete |
$78.02
|
| Rate for Payer: BCBS Trust/PPO |
$160.82
|
| Rate for Payer: BCN Commercial |
$160.82
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$183.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$189.20
|
| Rate for Payer: Healthscope Whirlpool |
$195.05
|
| Rate for Payer: Mclaren Commercial |
$175.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Nomi Health Commercial |
$159.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$170.90
|
| Rate for Payer: Priority Health Narrow Network |
$136.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$171.64
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
IP
|
$1.83
|
|
|
Service Code
|
NDC 51079045101
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna Commercial |
$1.65
|
| Rate for Payer: ASR ASR |
$1.78
|
| Rate for Payer: BCBS Trust/PPO |
$1.51
|
| Rate for Payer: BCN Commercial |
$1.51
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.47
|
| Rate for Payer: Healthscope Commercial |
$1.78
|
| Rate for Payer: Healthscope Whirlpool |
$1.83
|
| Rate for Payer: Mclaren Commercial |
$1.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.56
|
| Rate for Payer: Nomi Health Commercial |
$1.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.61
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 904637061
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.29 |
| Max. Negotiated Rate |
$195.05 |
| Rate for Payer: Aetna Commercial |
$175.54
|
| Rate for Payer: ASR ASR |
$189.20
|
| Rate for Payer: BCBS Trust/PPO |
$160.18
|
| Rate for Payer: BCN Commercial |
$160.18
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$183.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$189.20
|
| Rate for Payer: Healthscope Whirlpool |
$195.05
|
| Rate for Payer: Mclaren Commercial |
$175.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Nomi Health Commercial |
$159.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$171.64
|
|
|
AMMONIUM LACTATE 12 % TOPICAL CREAM
|
Facility
|
IP
|
$21.42
|
|
|
Service Code
|
NDC 904598348
|
| Hospital Charge Code |
17997
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Aetna Commercial |
$19.28
|
| Rate for Payer: ASR ASR |
$20.78
|
| Rate for Payer: BCBS Trust/PPO |
$17.59
|
| Rate for Payer: BCN Commercial |
$17.59
|
| Rate for Payer: Cash Price |
$17.14
|
| Rate for Payer: Cofinity Commercial |
$20.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.14
|
| Rate for Payer: Healthscope Commercial |
$20.78
|
| Rate for Payer: Healthscope Whirlpool |
$21.42
|
| Rate for Payer: Mclaren Commercial |
$19.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.21
|
| Rate for Payer: Nomi Health Commercial |
$17.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.85
|
|
|
AMMONIUM LACTATE 12 % TOPICAL CREAM
|
Facility
|
OP
|
$21.42
|
|
|
Service Code
|
NDC 904598348
|
| Hospital Charge Code |
17997
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Aetna Commercial |
$19.28
|
| Rate for Payer: Aetna Medicare |
$7.93
|
| Rate for Payer: ASR ASR |
$20.78
|
| Rate for Payer: BCBS Complete |
$8.57
|
| Rate for Payer: BCBS Trust/PPO |
$17.66
|
| Rate for Payer: BCN Commercial |
$17.66
|
| Rate for Payer: Cash Price |
$17.14
|
| Rate for Payer: Cofinity Commercial |
$20.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.14
|
| Rate for Payer: Healthscope Commercial |
$20.78
|
| Rate for Payer: Healthscope Whirlpool |
$21.42
|
| Rate for Payer: Mclaren Commercial |
$19.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.21
|
| Rate for Payer: Nomi Health Commercial |
$17.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18.77
|
| Rate for Payer: Priority Health Narrow Network |
$15.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.85
|
|
|
AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 781603958
|
| Hospital Charge Code |
453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.25 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: ASR ASR |
$45.59
|
| Rate for Payer: BCBS Trust/PPO |
$38.60
|
| Rate for Payer: BCN Commercial |
$38.60
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Cofinity Commercial |
$44.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.60
|
| Rate for Payer: Healthscope Commercial |
$45.59
|
| Rate for Payer: Healthscope Whirlpool |
$47.00
|
| Rate for Payer: Mclaren Commercial |
$42.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.95
|
| Rate for Payer: Nomi Health Commercial |
$38.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.36
|
|
