|
ETOMIDATE 2 MG/ML IV (CODE)
|
Facility
|
OP
|
$22.92
|
|
|
Service Code
|
NDC 00409669501
|
| Hospital Charge Code |
163720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$22.92 |
| Rate for Payer: Aetna Commercial |
$20.63
|
| Rate for Payer: Aetna Medicare |
$11.46
|
| Rate for Payer: ASR ASR |
$22.23
|
| Rate for Payer: ASR Commercial |
$22.23
|
| Rate for Payer: BCBS Complete |
$9.17
|
| Rate for Payer: BCBS Trust/PPO |
$18.77
|
| Rate for Payer: BCN Commercial |
$17.77
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Cofinity Commercial |
$21.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.34
|
| Rate for Payer: Healthscope Commercial |
$22.92
|
| Rate for Payer: Healthscope Whirlpool |
$22.23
|
| Rate for Payer: Mclaren Commercial |
$20.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.48
|
| Rate for Payer: Nomi Health Commercial |
$18.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.08
|
| Rate for Payer: Priority Health Narrow Network |
$16.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.17
|
|
|
EUFLEXXA 10 MG/ML (MW 2.4-3.6 MILLION) INTRA-ARTICULAR SYRINGE
|
Facility
|
IP
|
$1,073.23
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
43247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$697.60 |
| Max. Negotiated Rate |
$1,073.23 |
| Rate for Payer: Aetna Commercial |
$965.91
|
| Rate for Payer: ASR ASR |
$1,041.03
|
| Rate for Payer: ASR Commercial |
$1,041.03
|
| Rate for Payer: BCBS Trust/PPO |
$874.58
|
| Rate for Payer: BCN Commercial |
$832.08
|
| Rate for Payer: Cash Price |
$858.58
|
| Rate for Payer: Cofinity Commercial |
$1,008.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$858.58
|
| Rate for Payer: Healthscope Commercial |
$1,073.23
|
| Rate for Payer: Healthscope Whirlpool |
$1,041.03
|
| Rate for Payer: Mclaren Commercial |
$965.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$912.25
|
| Rate for Payer: Nomi Health Commercial |
$880.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$697.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$944.44
|
|
|
EUFLEXXA 10 MG/ML (MW 2.4-3.6 MILLION) INTRA-ARTICULAR SYRINGE
|
Facility
|
OP
|
$1,073.23
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
43247
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$1,073.23 |
| Rate for Payer: Aetna Commercial |
$965.91
|
| Rate for Payer: Aetna Medicare |
$112.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$140.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$140.56
|
| Rate for Payer: ASR ASR |
$1,041.03
|
| Rate for Payer: ASR Commercial |
$1,041.03
|
| Rate for Payer: BCBS Complete |
$63.29
|
| Rate for Payer: BCBS MAPPO |
$112.45
|
| Rate for Payer: BCBS Trust/PPO |
$878.87
|
| Rate for Payer: BCN Commercial |
$832.08
|
| Rate for Payer: BCN Medicare Advantage |
$112.45
|
| Rate for Payer: Cash Price |
$858.58
|
| Rate for Payer: Cash Price |
$858.58
|
| Rate for Payer: Cofinity Commercial |
$1,008.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$858.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$112.45
|
| Rate for Payer: Healthscope Commercial |
$1,073.23
|
| Rate for Payer: Healthscope Whirlpool |
$1,041.03
|
| Rate for Payer: Humana Choice PPO Medicare |
$112.45
|
| Rate for Payer: Mclaren Commercial |
$965.91
|
| Rate for Payer: Mclaren Medicaid |
$60.27
|
| Rate for Payer: Mclaren Medicare |
$112.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$118.07
|
| Rate for Payer: Meridian Medicaid |
$63.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$129.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$912.25
|
| Rate for Payer: Nomi Health Commercial |
$880.05
|
| Rate for Payer: PACE Medicare |
$106.83
|
| Rate for Payer: PACE SWMI |
$112.45
|
| Rate for Payer: PHP Commercial |
$123.69
|
| Rate for Payer: PHP Medicaid |
$60.27
|
| Rate for Payer: PHP Medicare Advantage |
$112.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$60.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$697.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$940.36
|
| Rate for Payer: Priority Health Medicare |
$112.45
|
| Rate for Payer: Priority Health Narrow Network |
$752.33
|
| Rate for Payer: Railroad Medicare Medicare |
$112.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$944.44
|
| Rate for Payer: UHC Dual Complete DSNP |
$112.45
|
| Rate for Payer: UHC Exchange |
$174.30
|
| Rate for Payer: UHC Medicare Advantage |
$112.45
|
| Rate for Payer: UHCCP DNSP |
$112.45
|
| Rate for Payer: UHCCP Medicaid |
$60.27
|
| Rate for Payer: VA VA |
$112.45
|
|
|
EVOLOCUMAB 140 MG/ML SUBCUTANEOUS PEN INJECTOR
|
Facility
|
IP
|
$926.89
|
|
|
Service Code
|
NDC 72511076001
|
| Hospital Charge Code |
175551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$602.48 |
| Max. Negotiated Rate |
$926.89 |
| Rate for Payer: Aetna Commercial |
$834.20
|
| Rate for Payer: ASR ASR |
$899.08
|
| Rate for Payer: ASR Commercial |
$899.08
|
| Rate for Payer: BCBS Trust/PPO |
$755.32
|
| Rate for Payer: BCN Commercial |
$718.62
|
| Rate for Payer: Cash Price |
$741.51
|
| Rate for Payer: Cofinity Commercial |
$871.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$741.51
|
| Rate for Payer: Healthscope Commercial |
$926.89
|
| Rate for Payer: Healthscope Whirlpool |
$899.08
|
| Rate for Payer: Mclaren Commercial |
$834.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$787.86
|
| Rate for Payer: Nomi Health Commercial |
$760.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$602.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$815.66
|
|
|
EVOLOCUMAB 140 MG/ML SUBCUTANEOUS PEN INJECTOR
|
Facility
|
OP
|
$926.89
|
|
|
Service Code
|
NDC 72511076002
|
| Hospital Charge Code |
175551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$370.76 |
| Max. Negotiated Rate |
$926.89 |
| Rate for Payer: Aetna Commercial |
$834.20
|
| Rate for Payer: Aetna Medicare |
$463.44
|
| Rate for Payer: ASR ASR |
$899.08
|
| Rate for Payer: ASR Commercial |
$899.08
|
| Rate for Payer: BCBS Complete |
$370.76
|
| Rate for Payer: BCBS Trust/PPO |
$759.03
|
| Rate for Payer: BCN Commercial |
$718.62
|
| Rate for Payer: Cash Price |
$741.51
|
| Rate for Payer: Cofinity Commercial |
$871.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$741.51
|
| Rate for Payer: Healthscope Commercial |
$926.89
|
| Rate for Payer: Healthscope Whirlpool |
$899.08
|
| Rate for Payer: Mclaren Commercial |
$834.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$787.86
|
| Rate for Payer: Nomi Health Commercial |
$760.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$602.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$812.14
|
| Rate for Payer: Priority Health Narrow Network |
$649.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$815.66
|
|
|
EVOLOCUMAB 140 MG/ML SUBCUTANEOUS PEN INJECTOR
|
Facility
|
IP
|
$926.89
|
|
|
Service Code
|
NDC 72511076002
|
| Hospital Charge Code |
175551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$602.48 |
| Max. Negotiated Rate |
$926.89 |
| Rate for Payer: Aetna Commercial |
$834.20
|
| Rate for Payer: ASR ASR |
$899.08
|
| Rate for Payer: ASR Commercial |
$899.08
|
| Rate for Payer: BCBS Trust/PPO |
$755.32
|
| Rate for Payer: BCN Commercial |
$718.62
|
| Rate for Payer: Cash Price |
$741.51
|
| Rate for Payer: Cofinity Commercial |
$871.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$741.51
|
| Rate for Payer: Healthscope Commercial |
$926.89
|
| Rate for Payer: Healthscope Whirlpool |
$899.08
|
| Rate for Payer: Mclaren Commercial |
$834.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$787.86
|
| Rate for Payer: Nomi Health Commercial |
$760.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$602.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$815.66
|
|
|
EVOLOCUMAB 140 MG/ML SUBCUTANEOUS PEN INJECTOR
|
Facility
|
OP
|
$926.89
|
|
|
Service Code
|
NDC 72511076001
|
| Hospital Charge Code |
175551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$370.76 |
| Max. Negotiated Rate |
$926.89 |
| Rate for Payer: Aetna Commercial |
$834.20
|
| Rate for Payer: Aetna Medicare |
$463.44
|
| Rate for Payer: ASR ASR |
$899.08
|
| Rate for Payer: ASR Commercial |
$899.08
|
| Rate for Payer: BCBS Complete |
$370.76
|
| Rate for Payer: BCBS Trust/PPO |
$759.03
|
| Rate for Payer: BCN Commercial |
$718.62
|
| Rate for Payer: Cash Price |
$741.51
|
| Rate for Payer: Cofinity Commercial |
$871.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$741.51
|
| Rate for Payer: Healthscope Commercial |
$926.89
|
| Rate for Payer: Healthscope Whirlpool |
$899.08
|
| Rate for Payer: Mclaren Commercial |
$834.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$787.86
|
| Rate for Payer: Nomi Health Commercial |
$760.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$602.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$812.14
|
| Rate for Payer: Priority Health Narrow Network |
$649.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$815.66
|
|
|
EYELASH TINTING
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS 00176
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Medicare |
$15.50
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$66.27
|
|
|
Service Code
|
NDC 50228037930
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.08 |
| Max. Negotiated Rate |
$66.27 |
| Rate for Payer: Aetna Commercial |
$59.64
|
| Rate for Payer: ASR ASR |
$64.28
|
| Rate for Payer: ASR Commercial |
$64.28
|
| Rate for Payer: BCBS Trust/PPO |
$54.00
|
| Rate for Payer: BCN Commercial |
$51.38
|
| Rate for Payer: Cash Price |
$53.02
|
| Rate for Payer: Cofinity Commercial |
$62.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.02
|
| Rate for Payer: Healthscope Commercial |
$66.27
|
| Rate for Payer: Healthscope Whirlpool |
$64.28
|
| Rate for Payer: Mclaren Commercial |
$59.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.33
|
| Rate for Payer: Nomi Health Commercial |
$54.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$58.32
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$300.22
|
|
|
Service Code
|
NDC 00904710310
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.14 |
| Max. Negotiated Rate |
$300.22 |
| Rate for Payer: Aetna Commercial |
$270.20
|
| Rate for Payer: ASR ASR |
$291.21
|
| Rate for Payer: ASR Commercial |
$291.21
|
| Rate for Payer: BCBS Trust/PPO |
$244.65
|
| Rate for Payer: BCN Commercial |
$232.76
|
| Rate for Payer: Cash Price |
$240.17
|
| Rate for Payer: Cofinity Commercial |
$282.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.18
|
| Rate for Payer: Healthscope Commercial |
$300.22
|
| Rate for Payer: Healthscope Whirlpool |
$291.21
|
| Rate for Payer: Mclaren Commercial |
$270.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.19
|
| Rate for Payer: Nomi Health Commercial |
$246.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$264.19
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
OP
|
$81.80
|
|
|
Service Code
|
NDC 67877049030
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.72 |
| Max. Negotiated Rate |
$81.80 |
| Rate for Payer: Aetna Commercial |
$73.62
|
| Rate for Payer: Aetna Medicare |
$40.90
|
| Rate for Payer: ASR ASR |
$79.35
|
| Rate for Payer: ASR Commercial |
$79.35
|
| Rate for Payer: BCBS Complete |
$32.72
|
| Rate for Payer: BCBS Trust/PPO |
$66.99
|
| Rate for Payer: BCN Commercial |
$63.42
|
| Rate for Payer: Cash Price |
$65.44
|
| Rate for Payer: Cofinity Commercial |
$76.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.44
|
| Rate for Payer: Healthscope Commercial |
$81.80
|
| Rate for Payer: Healthscope Whirlpool |
$79.35
|
| Rate for Payer: Mclaren Commercial |
$73.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.53
|
| Rate for Payer: Nomi Health Commercial |
$67.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$71.67
|
| Rate for Payer: Priority Health Narrow Network |
$57.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$71.98
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
IP
|
$81.80
|
|
|
Service Code
|
NDC 67877049030
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.17 |
| Max. Negotiated Rate |
$81.80 |
| Rate for Payer: Aetna Commercial |
$73.62
|
| Rate for Payer: ASR ASR |
$79.35
|
| Rate for Payer: ASR Commercial |
$79.35
|
| Rate for Payer: BCBS Trust/PPO |
$66.66
|
| Rate for Payer: BCN Commercial |
$63.42
|
| Rate for Payer: Cash Price |
$65.44
|
| Rate for Payer: Cofinity Commercial |
$76.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.44
|
| Rate for Payer: Healthscope Commercial |
$81.80
|
| Rate for Payer: Healthscope Whirlpool |
$79.35
|
| Rate for Payer: Mclaren Commercial |
$73.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.53
|
| Rate for Payer: Nomi Health Commercial |
$67.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$71.98
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
OP
|
$66.27
|
|
|
Service Code
|
NDC 50228037930
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.51 |
| Max. Negotiated Rate |
$66.27 |
| Rate for Payer: Aetna Commercial |
$59.64
|
| Rate for Payer: Aetna Medicare |
$33.13
|
| Rate for Payer: ASR ASR |
$64.28
|
| Rate for Payer: ASR Commercial |
$64.28
|
| Rate for Payer: BCBS Complete |
$26.51
|
| Rate for Payer: BCBS Trust/PPO |
$54.27
|
| Rate for Payer: BCN Commercial |
$51.38
|
| Rate for Payer: Cash Price |
$53.02
|
| Rate for Payer: Cofinity Commercial |
$62.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.02
|
| Rate for Payer: Healthscope Commercial |
$66.27
|
| Rate for Payer: Healthscope Whirlpool |
$64.28
|
| Rate for Payer: Mclaren Commercial |
$59.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.33
|
| Rate for Payer: Nomi Health Commercial |
$54.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$58.07
|
| Rate for Payer: Priority Health Narrow Network |
$46.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$58.32
|
|
|
EZETIMIBE 10 MG TABLET
|
Facility
|
OP
|
$300.22
|
|
|
Service Code
|
NDC 00904710310
|
| Hospital Charge Code |
34153
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.09 |
| Max. Negotiated Rate |
$300.22 |
| Rate for Payer: Aetna Commercial |
$270.20
|
| Rate for Payer: Aetna Medicare |
$150.11
|
| Rate for Payer: ASR ASR |
$291.21
|
| Rate for Payer: ASR Commercial |
$291.21
|
| Rate for Payer: BCBS Complete |
$120.09
|
| Rate for Payer: BCBS Trust/PPO |
$245.85
|
| Rate for Payer: BCN Commercial |
$232.76
|
| Rate for Payer: Cash Price |
$240.17
|
| Rate for Payer: Cofinity Commercial |
$282.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.18
|
| Rate for Payer: Healthscope Commercial |
$300.22
|
| Rate for Payer: Healthscope Whirlpool |
$291.21
|
| Rate for Payer: Mclaren Commercial |
$270.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.19
|
| Rate for Payer: Nomi Health Commercial |
$246.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$263.05
|
| Rate for Payer: Priority Health Narrow Network |
$210.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$264.19
|
|
|
FACIAL
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
HCPCS 00174
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$42.90 |
| Rate for Payer: Aetna Medicare |
$33.00
|
| Rate for Payer: BCBS Complete |
$26.40
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.90
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 00904719361
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$162.15 |
| Rate for Payer: Aetna Commercial |
$145.94
|
| Rate for Payer: ASR ASR |
$157.29
|
| Rate for Payer: ASR Commercial |
$157.29
|
| Rate for Payer: BCBS Trust/PPO |
$132.14
|
| Rate for Payer: BCN Commercial |
$125.71
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$152.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$162.15
|
| Rate for Payer: Healthscope Whirlpool |
$157.29
|
| Rate for Payer: Mclaren Commercial |
$145.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Nomi Health Commercial |
$132.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.69
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 51079096601
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: ASR ASR |
$1.44
|
| Rate for Payer: ASR Commercial |
$1.44
|
| Rate for Payer: BCBS Trust/PPO |
$1.21
|
| Rate for Payer: BCN Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.18
|
| Rate for Payer: Healthscope Commercial |
$1.48
|
| Rate for Payer: Healthscope Whirlpool |
$1.44
|
| Rate for Payer: Mclaren Commercial |
$1.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.26
|
| Rate for Payer: Nomi Health Commercial |
$1.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.30
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 51079096620
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.22 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.25
|
| Rate for Payer: Aetna Medicare |
$74.03
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: ASR Commercial |
$143.61
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: BCBS Trust/PPO |
$121.24
|
| Rate for Payer: BCN Commercial |
$114.78
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.61
|
| Rate for Payer: Mclaren Commercial |
$133.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$129.72
|
| Rate for Payer: Priority Health Narrow Network |
$103.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.28
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 51079096601
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna Medicare |
$0.74
|
| Rate for Payer: ASR ASR |
$1.44
|
| Rate for Payer: ASR Commercial |
$1.44
|
| Rate for Payer: BCBS Complete |
$0.59
|
| Rate for Payer: BCBS Trust/PPO |
$1.21
|
| Rate for Payer: BCN Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.18
|
| Rate for Payer: Healthscope Commercial |
$1.48
|
| Rate for Payer: Healthscope Whirlpool |
$1.44
|
| Rate for Payer: Mclaren Commercial |
$1.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.26
|
| Rate for Payer: Nomi Health Commercial |
$1.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.30
|
| Rate for Payer: Priority Health Narrow Network |
$1.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.30
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$190.35
|
|
|
Service Code
|
NDC 00536129801
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.73 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna Commercial |
$171.31
|
| Rate for Payer: ASR ASR |
$184.64
|
| Rate for Payer: ASR Commercial |
$184.64
|
| Rate for Payer: BCBS Trust/PPO |
$155.12
|
| Rate for Payer: BCN Commercial |
$147.58
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$178.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Healthscope Whirlpool |
$184.64
|
| Rate for Payer: Mclaren Commercial |
$171.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.80
|
| Rate for Payer: Nomi Health Commercial |
$156.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$167.51
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079096620
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.23 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.25
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: ASR Commercial |
$143.61
|
| Rate for Payer: BCBS Trust/PPO |
$120.65
|
| Rate for Payer: BCN Commercial |
$114.78
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.61
|
| Rate for Payer: Mclaren Commercial |
$133.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.28
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
|
Service Code
|
NDC 61442012101
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.76 |
| Max. Negotiated Rate |
$150.40 |
| Rate for Payer: Aetna Commercial |
$135.36
|
| Rate for Payer: ASR ASR |
$145.89
|
| Rate for Payer: ASR Commercial |
$145.89
|
| Rate for Payer: BCBS Trust/PPO |
$122.56
|
| Rate for Payer: BCN Commercial |
$116.61
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$141.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$150.40
|
| Rate for Payer: Healthscope Whirlpool |
$145.89
|
| Rate for Payer: Mclaren Commercial |
$135.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.84
|
| Rate for Payer: Nomi Health Commercial |
$123.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$132.35
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$150.40
|
|
|
Service Code
|
NDC 61442012101
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.16 |
| Max. Negotiated Rate |
$150.40 |
| Rate for Payer: Aetna Commercial |
$135.36
|
| Rate for Payer: Aetna Medicare |
$75.20
|
| Rate for Payer: ASR ASR |
$145.89
|
| Rate for Payer: ASR Commercial |
$145.89
|
| Rate for Payer: BCBS Complete |
$60.16
|
| Rate for Payer: BCBS Trust/PPO |
$123.16
|
| Rate for Payer: BCN Commercial |
$116.61
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$141.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$150.40
|
| Rate for Payer: Healthscope Whirlpool |
$145.89
|
| Rate for Payer: Mclaren Commercial |
$135.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.84
|
| Rate for Payer: Nomi Health Commercial |
$123.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$131.78
|
| Rate for Payer: Priority Health Narrow Network |
$105.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$132.35
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$190.35
|
|
|
Service Code
|
NDC 00536129801
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.14 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna Commercial |
$171.31
|
| Rate for Payer: Aetna Medicare |
$95.17
|
| Rate for Payer: ASR ASR |
$184.64
|
| Rate for Payer: ASR Commercial |
$184.64
|
| Rate for Payer: BCBS Complete |
$76.14
|
| Rate for Payer: BCBS Trust/PPO |
$155.88
|
| Rate for Payer: BCN Commercial |
$147.58
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$178.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Healthscope Whirlpool |
$184.64
|
| Rate for Payer: Mclaren Commercial |
$171.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.80
|
| Rate for Payer: Nomi Health Commercial |
$156.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$166.78
|
| Rate for Payer: Priority Health Narrow Network |
$133.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$167.51
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$162.15
|
|
|
Service Code
|
NDC 00904719361
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.86 |
| Max. Negotiated Rate |
$162.15 |
| Rate for Payer: Aetna Commercial |
$145.94
|
| Rate for Payer: Aetna Medicare |
$81.08
|
| Rate for Payer: ASR ASR |
$157.29
|
| Rate for Payer: ASR Commercial |
$157.29
|
| Rate for Payer: BCBS Complete |
$64.86
|
| Rate for Payer: BCBS Trust/PPO |
$132.78
|
| Rate for Payer: BCN Commercial |
$125.71
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$152.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$162.15
|
| Rate for Payer: Healthscope Whirlpool |
$157.29
|
| Rate for Payer: Mclaren Commercial |
$145.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: Nomi Health Commercial |
$132.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$142.08
|
| Rate for Payer: Priority Health Narrow Network |
$113.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.69
|
|
