|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 68084077611
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: ASR ASR |
$3.63
|
| Rate for Payer: ASR Commercial |
$3.63
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCN Commercial |
$2.90
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$3.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.74
|
| Rate for Payer: Healthscope Whirlpool |
$3.63
|
| Rate for Payer: Mclaren Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: Nomi Health Commercial |
$3.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.29
|
|
|
DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$396.48
|
|
|
Service Code
|
NDC 00904636361
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.71 |
| Max. Negotiated Rate |
$396.48 |
| Rate for Payer: Aetna Commercial |
$356.83
|
| Rate for Payer: ASR ASR |
$384.59
|
| Rate for Payer: ASR Commercial |
$384.59
|
| Rate for Payer: BCBS Trust/PPO |
$323.09
|
| Rate for Payer: BCN Commercial |
$307.39
|
| Rate for Payer: Cash Price |
$317.18
|
| Rate for Payer: Cofinity Commercial |
$372.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$317.18
|
| Rate for Payer: Healthscope Commercial |
$396.48
|
| Rate for Payer: Healthscope Whirlpool |
$384.59
|
| Rate for Payer: Mclaren Commercial |
$356.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$337.01
|
| Rate for Payer: Nomi Health Commercial |
$325.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$348.90
|
|
|
DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$4.36
|
|
|
Service Code
|
NDC 68084031011
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Aetna Medicare |
$2.18
|
| Rate for Payer: ASR ASR |
$4.23
|
| Rate for Payer: ASR Commercial |
$4.23
|
| Rate for Payer: BCBS Complete |
$1.74
|
| Rate for Payer: BCBS Trust/PPO |
$3.57
|
| Rate for Payer: BCN Commercial |
$3.38
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$4.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$4.36
|
| Rate for Payer: Healthscope Whirlpool |
$4.23
|
| Rate for Payer: Mclaren Commercial |
$3.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: Nomi Health Commercial |
$3.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.82
|
| Rate for Payer: Priority Health Narrow Network |
$3.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.84
|
|
|
DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$435.84
|
|
|
Service Code
|
NDC 68084031001
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$283.30 |
| Max. Negotiated Rate |
$435.84 |
| Rate for Payer: Aetna Commercial |
$392.26
|
| Rate for Payer: ASR ASR |
$422.76
|
| Rate for Payer: ASR Commercial |
$422.76
|
| Rate for Payer: BCBS Trust/PPO |
$355.17
|
| Rate for Payer: BCN Commercial |
$337.91
|
| Rate for Payer: Cash Price |
$348.67
|
| Rate for Payer: Cofinity Commercial |
$409.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$348.67
|
| Rate for Payer: Healthscope Commercial |
$435.84
|
| Rate for Payer: Healthscope Whirlpool |
$422.76
|
| Rate for Payer: Mclaren Commercial |
$392.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$370.46
|
| Rate for Payer: Nomi Health Commercial |
$357.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$283.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$383.54
|
|
|
DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$435.84
|
|
|
Service Code
|
NDC 68084031001
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.34 |
| Max. Negotiated Rate |
$435.84 |
| Rate for Payer: Aetna Commercial |
$392.26
|
| Rate for Payer: Aetna Medicare |
$217.92
|
| Rate for Payer: ASR ASR |
$422.76
|
| Rate for Payer: ASR Commercial |
$422.76
|
| Rate for Payer: BCBS Complete |
$174.34
|
| Rate for Payer: BCBS Trust/PPO |
$356.91
|
| Rate for Payer: BCN Commercial |
$337.91
|
| Rate for Payer: Cash Price |
$348.67
|
| Rate for Payer: Cofinity Commercial |
$409.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$348.67
|
| Rate for Payer: Healthscope Commercial |
$435.84
|
| Rate for Payer: Healthscope Whirlpool |
$422.76
|
| Rate for Payer: Mclaren Commercial |
$392.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$370.46
|
| Rate for Payer: Nomi Health Commercial |
$357.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$283.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$381.88
|
| Rate for Payer: Priority Health Narrow Network |
$305.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$383.54
|
|
|
DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$396.48
|
|
|
Service Code
|
NDC 00904636361
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.59 |
| Max. Negotiated Rate |
$396.48 |
| Rate for Payer: Aetna Commercial |
$356.83
|
| Rate for Payer: Aetna Medicare |
$198.24
|
| Rate for Payer: ASR ASR |
$384.59
|
| Rate for Payer: ASR Commercial |
$384.59
|
| Rate for Payer: BCBS Complete |
$158.59
|
| Rate for Payer: BCBS Trust/PPO |
$324.68
|
| Rate for Payer: BCN Commercial |
$307.39
|
| Rate for Payer: Cash Price |
$317.18
|
| Rate for Payer: Cofinity Commercial |
$372.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$317.18
|
| Rate for Payer: Healthscope Commercial |
$396.48
|
| Rate for Payer: Healthscope Whirlpool |
$384.59
|
| Rate for Payer: Mclaren Commercial |
$356.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$337.01
|
| Rate for Payer: Nomi Health Commercial |
$325.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$347.40
|
| Rate for Payer: Priority Health Narrow Network |
$277.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$348.90
|
|
|
DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4.36
|
|
|
Service Code
|
NDC 68084031011
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: ASR ASR |
$4.23
|
| Rate for Payer: ASR Commercial |
$4.23
|
| Rate for Payer: BCBS Trust/PPO |
$3.55
|
| Rate for Payer: BCN Commercial |
$3.38
|
| Rate for Payer: Cash Price |
$3.49
|
| Rate for Payer: Cofinity Commercial |
$4.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.49
|
| Rate for Payer: Healthscope Commercial |
$4.36
|
| Rate for Payer: Healthscope Whirlpool |
$4.23
|
| Rate for Payer: Mclaren Commercial |
$3.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.71
|
| Rate for Payer: Nomi Health Commercial |
$3.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.84
|
|
|
DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$228.95
|
|
|
Service Code
|
NDC 65162075510
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.82 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna Commercial |
$206.06
|
| Rate for Payer: ASR ASR |
$222.08
|
| Rate for Payer: ASR Commercial |
$222.08
|
| Rate for Payer: BCBS Trust/PPO |
$186.57
|
| Rate for Payer: BCN Commercial |
$177.50
|
| Rate for Payer: Cash Price |
$183.16
|
| Rate for Payer: Cofinity Commercial |
$215.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.16
|
| Rate for Payer: Healthscope Commercial |
$228.95
|
| Rate for Payer: Healthscope Whirlpool |
$222.08
|
| Rate for Payer: Mclaren Commercial |
$206.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.61
|
| Rate for Payer: Nomi Health Commercial |
$187.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.48
|
|
|
DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$228.95
|
|
|
Service Code
|
NDC 65162075510
|
| Hospital Charge Code |
34418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.58 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna Commercial |
$206.06
|
| Rate for Payer: Aetna Medicare |
$114.47
|
| Rate for Payer: ASR ASR |
$222.08
|
| Rate for Payer: ASR Commercial |
$222.08
|
| Rate for Payer: BCBS Complete |
$91.58
|
| Rate for Payer: BCBS Trust/PPO |
$187.49
|
| Rate for Payer: BCN Commercial |
$177.50
|
| Rate for Payer: Cash Price |
$183.16
|
| Rate for Payer: Cofinity Commercial |
$215.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.16
|
| Rate for Payer: Healthscope Commercial |
$228.95
|
| Rate for Payer: Healthscope Whirlpool |
$222.08
|
| Rate for Payer: Mclaren Commercial |
$206.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$194.61
|
| Rate for Payer: Nomi Health Commercial |
$187.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$200.61
|
| Rate for Payer: Priority Health Narrow Network |
$160.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$201.48
|
|
|
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$27.06
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
9892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.59 |
| Max. Negotiated Rate |
$27.06 |
| Rate for Payer: Aetna Commercial |
$24.35
|
| Rate for Payer: Aetna Commercial |
$19.45
|
| Rate for Payer: ASR ASR |
$20.96
|
| Rate for Payer: ASR ASR |
$26.25
|
| Rate for Payer: ASR Commercial |
$20.96
|
| Rate for Payer: ASR Commercial |
$26.25
|
| Rate for Payer: BCBS Trust/PPO |
$17.61
|
| Rate for Payer: BCBS Trust/PPO |
$22.05
|
| Rate for Payer: BCN Commercial |
$20.98
|
| Rate for Payer: BCN Commercial |
$16.75
|
| Rate for Payer: Cash Price |
$21.64
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cofinity Commercial |
$20.31
|
| Rate for Payer: Cofinity Commercial |
$25.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.65
|
| Rate for Payer: Healthscope Commercial |
$21.61
|
| Rate for Payer: Healthscope Commercial |
$27.06
|
| Rate for Payer: Healthscope Whirlpool |
$26.25
|
| Rate for Payer: Healthscope Whirlpool |
$20.96
|
| Rate for Payer: Mclaren Commercial |
$19.45
|
| Rate for Payer: Mclaren Commercial |
$24.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.37
|
| Rate for Payer: Nomi Health Commercial |
$22.19
|
| Rate for Payer: Nomi Health Commercial |
$17.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.81
|
|
|
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$21.61
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
9892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$21.61 |
| Rate for Payer: Aetna Commercial |
$19.45
|
| Rate for Payer: Aetna Commercial |
$24.35
|
| Rate for Payer: Aetna Medicare |
$10.80
|
| Rate for Payer: Aetna Medicare |
$13.53
|
| Rate for Payer: ASR ASR |
$20.96
|
| Rate for Payer: ASR ASR |
$26.25
|
| Rate for Payer: ASR Commercial |
$26.25
|
| Rate for Payer: ASR Commercial |
$20.96
|
| Rate for Payer: BCBS Complete |
$8.64
|
| Rate for Payer: BCBS Complete |
$10.82
|
| Rate for Payer: BCBS Trust/PPO |
$17.70
|
| Rate for Payer: BCBS Trust/PPO |
$22.16
|
| Rate for Payer: BCN Commercial |
$20.98
|
| Rate for Payer: BCN Commercial |
$16.75
|
| Rate for Payer: Cash Price |
$17.29
|
| Rate for Payer: Cash Price |
$21.64
|
| Rate for Payer: Cofinity Commercial |
$20.31
|
| Rate for Payer: Cofinity Commercial |
$25.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.65
|
| Rate for Payer: Healthscope Commercial |
$21.61
|
| Rate for Payer: Healthscope Commercial |
$27.06
|
| Rate for Payer: Healthscope Whirlpool |
$20.96
|
| Rate for Payer: Healthscope Whirlpool |
$26.25
|
| Rate for Payer: Mclaren Commercial |
$19.45
|
| Rate for Payer: Mclaren Commercial |
$24.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.37
|
| Rate for Payer: Nomi Health Commercial |
$17.72
|
| Rate for Payer: Nomi Health Commercial |
$22.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.71
|
| Rate for Payer: Priority Health Narrow Network |
$18.97
|
| Rate for Payer: Priority Health Narrow Network |
$15.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.02
|
|
|
DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV
|
Facility
|
OP
|
$80.33
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
18315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.13 |
| Max. Negotiated Rate |
$80.33 |
| Rate for Payer: Aetna Commercial |
$72.30
|
| Rate for Payer: Aetna Medicare |
$40.16
|
| Rate for Payer: ASR ASR |
$77.92
|
| Rate for Payer: ASR Commercial |
$77.92
|
| Rate for Payer: BCBS Complete |
$32.13
|
| Rate for Payer: BCBS Trust/PPO |
$65.78
|
| Rate for Payer: BCN Commercial |
$62.28
|
| Rate for Payer: Cash Price |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$75.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.26
|
| Rate for Payer: Healthscope Commercial |
$80.33
|
| Rate for Payer: Healthscope Whirlpool |
$77.92
|
| Rate for Payer: Mclaren Commercial |
$72.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.28
|
| Rate for Payer: Nomi Health Commercial |
$65.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$70.39
|
| Rate for Payer: Priority Health Narrow Network |
$56.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.69
|
|
|
DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV
|
Facility
|
IP
|
$80.33
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
18315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.21 |
| Max. Negotiated Rate |
$80.33 |
| Rate for Payer: Aetna Commercial |
$72.30
|
| Rate for Payer: ASR ASR |
$77.92
|
| Rate for Payer: ASR Commercial |
$77.92
|
| Rate for Payer: BCBS Trust/PPO |
$65.46
|
| Rate for Payer: BCN Commercial |
$62.28
|
| Rate for Payer: Cash Price |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$75.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.26
|
| Rate for Payer: Healthscope Commercial |
$80.33
|
| Rate for Payer: Healthscope Whirlpool |
$77.92
|
| Rate for Payer: Mclaren Commercial |
$72.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.28
|
| Rate for Payer: Nomi Health Commercial |
$65.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.69
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$1.88
|
|
|
Service Code
|
NDC 60687012911
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna Commercial |
$1.69
|
| Rate for Payer: ASR ASR |
$1.82
|
| Rate for Payer: ASR Commercial |
$1.82
|
| Rate for Payer: BCBS Trust/PPO |
$1.53
|
| Rate for Payer: BCN Commercial |
$1.46
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cofinity Commercial |
$1.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.50
|
| Rate for Payer: Healthscope Commercial |
$1.88
|
| Rate for Payer: Healthscope Whirlpool |
$1.82
|
| Rate for Payer: Mclaren Commercial |
$1.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.60
|
| Rate for Payer: Nomi Health Commercial |
$1.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.65
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
NDC 63739047810
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.60 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: Aetna Medicare |
$94.50
|
| Rate for Payer: ASR ASR |
$183.33
|
| Rate for Payer: ASR Commercial |
$183.33
|
| Rate for Payer: BCBS Complete |
$75.60
|
| Rate for Payer: BCBS Trust/PPO |
$154.77
|
| Rate for Payer: BCN Commercial |
$146.53
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cofinity Commercial |
$177.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.20
|
| Rate for Payer: Healthscope Commercial |
$189.00
|
| Rate for Payer: Healthscope Whirlpool |
$183.33
|
| Rate for Payer: Mclaren Commercial |
$170.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.65
|
| Rate for Payer: Nomi Health Commercial |
$154.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$165.60
|
| Rate for Payer: Priority Health Narrow Network |
$132.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$166.32
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
OP
|
$1.88
|
|
|
Service Code
|
NDC 60687012911
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna Commercial |
$1.69
|
| Rate for Payer: Aetna Medicare |
$0.94
|
| Rate for Payer: ASR ASR |
$1.82
|
| Rate for Payer: ASR Commercial |
$1.82
|
| Rate for Payer: BCBS Complete |
$0.75
|
| Rate for Payer: BCBS Trust/PPO |
$1.54
|
| Rate for Payer: BCN Commercial |
$1.46
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cofinity Commercial |
$1.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.50
|
| Rate for Payer: Healthscope Commercial |
$1.88
|
| Rate for Payer: Healthscope Whirlpool |
$1.82
|
| Rate for Payer: Mclaren Commercial |
$1.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.60
|
| Rate for Payer: Nomi Health Commercial |
$1.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.65
|
| Rate for Payer: Priority Health Narrow Network |
$1.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.65
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$188.10
|
|
|
Service Code
|
NDC 60687012901
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.27 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$169.29
|
| Rate for Payer: ASR ASR |
$182.46
|
| Rate for Payer: ASR Commercial |
$182.46
|
| Rate for Payer: BCBS Trust/PPO |
$153.28
|
| Rate for Payer: BCN Commercial |
$145.83
|
| Rate for Payer: Cash Price |
$150.48
|
| Rate for Payer: Cofinity Commercial |
$176.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.48
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Healthscope Whirlpool |
$182.46
|
| Rate for Payer: Mclaren Commercial |
$169.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.88
|
| Rate for Payer: Nomi Health Commercial |
$154.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.53
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
OP
|
$88.20
|
|
|
Service Code
|
NDC 00904699860
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna Commercial |
$79.38
|
| Rate for Payer: Aetna Medicare |
$44.10
|
| Rate for Payer: ASR ASR |
$85.55
|
| Rate for Payer: ASR Commercial |
$85.55
|
| Rate for Payer: BCBS Complete |
$35.28
|
| Rate for Payer: BCBS Trust/PPO |
$72.23
|
| Rate for Payer: BCN Commercial |
$68.38
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$82.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$88.20
|
| Rate for Payer: Healthscope Whirlpool |
$85.55
|
| Rate for Payer: Mclaren Commercial |
$79.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: Nomi Health Commercial |
$72.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$77.28
|
| Rate for Payer: Priority Health Narrow Network |
$61.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$77.62
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
OP
|
$188.10
|
|
|
Service Code
|
NDC 60687012901
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.24 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$169.29
|
| Rate for Payer: Aetna Medicare |
$94.05
|
| Rate for Payer: ASR ASR |
$182.46
|
| Rate for Payer: ASR Commercial |
$182.46
|
| Rate for Payer: BCBS Complete |
$75.24
|
| Rate for Payer: BCBS Trust/PPO |
$154.04
|
| Rate for Payer: BCN Commercial |
$145.83
|
| Rate for Payer: Cash Price |
$150.48
|
| Rate for Payer: Cofinity Commercial |
$176.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.48
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Healthscope Whirlpool |
$182.46
|
| Rate for Payer: Mclaren Commercial |
$169.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.88
|
| Rate for Payer: Nomi Health Commercial |
$154.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$164.81
|
| Rate for Payer: Priority Health Narrow Network |
$131.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.53
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
NDC 63739047810
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.85 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: ASR ASR |
$183.33
|
| Rate for Payer: ASR Commercial |
$183.33
|
| Rate for Payer: BCBS Trust/PPO |
$154.02
|
| Rate for Payer: BCN Commercial |
$146.53
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cofinity Commercial |
$177.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.20
|
| Rate for Payer: Healthscope Commercial |
$189.00
|
| Rate for Payer: Healthscope Whirlpool |
$183.33
|
| Rate for Payer: Mclaren Commercial |
$170.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.65
|
| Rate for Payer: Nomi Health Commercial |
$154.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$166.32
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$88.20
|
|
|
Service Code
|
NDC 00904699860
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.33 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna Commercial |
$79.38
|
| Rate for Payer: ASR ASR |
$85.55
|
| Rate for Payer: ASR Commercial |
$85.55
|
| Rate for Payer: BCBS Trust/PPO |
$71.87
|
| Rate for Payer: BCN Commercial |
$68.38
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$82.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$88.20
|
| Rate for Payer: Healthscope Whirlpool |
$85.55
|
| Rate for Payer: Mclaren Commercial |
$79.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.97
|
| Rate for Payer: Nomi Health Commercial |
$72.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$77.62
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 00904647861
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.64 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: ASR Commercial |
$218.83
|
| Rate for Payer: BCBS Trust/PPO |
$183.84
|
| Rate for Payer: BCN Commercial |
$174.91
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$225.60
|
| Rate for Payer: Healthscope Whirlpool |
$218.83
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 00904647861
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.24 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: Aetna Medicare |
$112.80
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: ASR Commercial |
$218.83
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: BCBS Trust/PPO |
$184.74
|
| Rate for Payer: BCN Commercial |
$174.91
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$225.60
|
| Rate for Payer: Healthscope Whirlpool |
$218.83
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$197.67
|
| Rate for Payer: Priority Health Narrow Network |
$158.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
OP
|
$71.14
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.46 |
| Max. Negotiated Rate |
$71.14 |
| Rate for Payer: Aetna Commercial |
$64.03
|
| Rate for Payer: Aetna Medicare |
$35.57
|
| Rate for Payer: ASR ASR |
$69.01
|
| Rate for Payer: ASR Commercial |
$69.01
|
| Rate for Payer: BCBS Complete |
$28.46
|
| Rate for Payer: BCBS Trust/PPO |
$58.26
|
| Rate for Payer: BCN Commercial |
$55.15
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$66.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.91
|
| Rate for Payer: Healthscope Commercial |
$71.14
|
| Rate for Payer: Healthscope Whirlpool |
$69.01
|
| Rate for Payer: Mclaren Commercial |
$64.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.47
|
| Rate for Payer: Nomi Health Commercial |
$58.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$62.33
|
| Rate for Payer: Priority Health Narrow Network |
$49.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.60
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
IP
|
$71.14
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.24 |
| Max. Negotiated Rate |
$71.14 |
| Rate for Payer: Aetna Commercial |
$64.03
|
| Rate for Payer: ASR ASR |
$69.01
|
| Rate for Payer: ASR Commercial |
$69.01
|
| Rate for Payer: BCBS Trust/PPO |
$57.97
|
| Rate for Payer: BCN Commercial |
$55.15
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$66.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.91
|
| Rate for Payer: Healthscope Commercial |
$71.14
|
| Rate for Payer: Healthscope Whirlpool |
$69.01
|
| Rate for Payer: Mclaren Commercial |
$64.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.47
|
| Rate for Payer: Nomi Health Commercial |
$58.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.60
|
|
