|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.01
|
|
|
Service Code
|
NDC 67457043300
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$12.01 |
| Rate for Payer: Aetna Commercial |
$10.81
|
| Rate for Payer: Aetna Medicare |
$6.00
|
| Rate for Payer: ASR ASR |
$11.65
|
| Rate for Payer: ASR Commercial |
$11.65
|
| Rate for Payer: BCBS Complete |
$4.80
|
| Rate for Payer: BCBS Trust/PPO |
$9.83
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$11.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.61
|
| Rate for Payer: Healthscope Commercial |
$12.01
|
| Rate for Payer: Healthscope Whirlpool |
$11.65
|
| Rate for Payer: Mclaren Commercial |
$10.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.21
|
| Rate for Payer: Nomi Health Commercial |
$9.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.52
|
| Rate for Payer: Priority Health Narrow Network |
$8.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.57
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.30
|
|
|
Service Code
|
NDC 63323073912
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$16.30 |
| Rate for Payer: Aetna Commercial |
$14.67
|
| Rate for Payer: Aetna Medicare |
$8.15
|
| Rate for Payer: ASR ASR |
$15.81
|
| Rate for Payer: ASR Commercial |
$15.81
|
| Rate for Payer: BCBS Complete |
$6.52
|
| Rate for Payer: BCBS Trust/PPO |
$13.35
|
| Rate for Payer: BCN Commercial |
$12.64
|
| Rate for Payer: Cash Price |
$13.04
|
| Rate for Payer: Cofinity Commercial |
$15.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.04
|
| Rate for Payer: Healthscope Commercial |
$16.30
|
| Rate for Payer: Healthscope Whirlpool |
$15.81
|
| Rate for Payer: Mclaren Commercial |
$14.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.86
|
| Rate for Payer: Nomi Health Commercial |
$13.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.28
|
| Rate for Payer: Priority Health Narrow Network |
$11.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.34
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
NDC 00641602225
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.42 |
| Max. Negotiated Rate |
$12.95 |
| Rate for Payer: Aetna Commercial |
$11.65
|
| Rate for Payer: ASR ASR |
$12.56
|
| Rate for Payer: ASR Commercial |
$12.56
|
| Rate for Payer: BCBS Trust/PPO |
$10.55
|
| Rate for Payer: BCN Commercial |
$10.04
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$12.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$12.95
|
| Rate for Payer: Healthscope Whirlpool |
$12.56
|
| Rate for Payer: Mclaren Commercial |
$11.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: Nomi Health Commercial |
$10.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.40
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.01
|
|
|
Service Code
|
NDC 67457043322
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$12.01 |
| Rate for Payer: Aetna Commercial |
$10.81
|
| Rate for Payer: Aetna Medicare |
$6.00
|
| Rate for Payer: ASR ASR |
$11.65
|
| Rate for Payer: ASR Commercial |
$11.65
|
| Rate for Payer: BCBS Complete |
$4.80
|
| Rate for Payer: BCBS Trust/PPO |
$9.83
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$11.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.61
|
| Rate for Payer: Healthscope Commercial |
$12.01
|
| Rate for Payer: Healthscope Whirlpool |
$11.65
|
| Rate for Payer: Mclaren Commercial |
$10.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.21
|
| Rate for Payer: Nomi Health Commercial |
$9.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.52
|
| Rate for Payer: Priority Health Narrow Network |
$8.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.57
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.30
|
|
|
Service Code
|
NDC 70860075141
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: Aetna Medicare |
$7.65
|
| Rate for Payer: ASR ASR |
$14.84
|
| Rate for Payer: ASR Commercial |
$14.84
|
| Rate for Payer: BCBS Complete |
$6.12
|
| Rate for Payer: BCBS Trust/PPO |
$12.53
|
| Rate for Payer: BCN Commercial |
$11.86
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Healthscope Commercial |
$15.30
|
| Rate for Payer: Healthscope Whirlpool |
$14.84
|
| Rate for Payer: Mclaren Commercial |
$13.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: Nomi Health Commercial |
$12.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.41
|
| Rate for Payer: Priority Health Narrow Network |
$10.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.46
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
NDC 00641602201
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.42 |
| Max. Negotiated Rate |
$12.95 |
| Rate for Payer: Aetna Commercial |
$11.65
|
| Rate for Payer: ASR ASR |
$12.56
|
| Rate for Payer: ASR Commercial |
$12.56
|
| Rate for Payer: BCBS Trust/PPO |
$10.55
|
| Rate for Payer: BCN Commercial |
$10.04
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$12.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$12.95
|
| Rate for Payer: Healthscope Whirlpool |
$12.56
|
| Rate for Payer: Mclaren Commercial |
$11.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: Nomi Health Commercial |
$10.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.40
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.30
|
|
|
Service Code
|
NDC 70860075102
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: Aetna Medicare |
$7.65
|
| Rate for Payer: ASR ASR |
$14.84
|
| Rate for Payer: ASR Commercial |
$14.84
|
| Rate for Payer: BCBS Complete |
$6.12
|
| Rate for Payer: BCBS Trust/PPO |
$12.53
|
| Rate for Payer: BCN Commercial |
$11.86
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Healthscope Commercial |
$15.30
|
| Rate for Payer: Healthscope Whirlpool |
$14.84
|
| Rate for Payer: Mclaren Commercial |
$13.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: Nomi Health Commercial |
$12.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.41
|
| Rate for Payer: Priority Health Narrow Network |
$10.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.46
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
NDC 00641602225
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$12.95 |
| Rate for Payer: Aetna Commercial |
$11.65
|
| Rate for Payer: Aetna Medicare |
$6.47
|
| Rate for Payer: ASR ASR |
$12.56
|
| Rate for Payer: ASR Commercial |
$12.56
|
| Rate for Payer: BCBS Complete |
$5.18
|
| Rate for Payer: BCBS Trust/PPO |
$10.60
|
| Rate for Payer: BCN Commercial |
$10.04
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$12.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$12.95
|
| Rate for Payer: Healthscope Whirlpool |
$12.56
|
| Rate for Payer: Mclaren Commercial |
$11.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: Nomi Health Commercial |
$10.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.35
|
| Rate for Payer: Priority Health Narrow Network |
$9.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.40
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.01
|
|
|
Service Code
|
NDC 67457043300
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$12.01 |
| Rate for Payer: Aetna Commercial |
$10.81
|
| Rate for Payer: ASR ASR |
$11.65
|
| Rate for Payer: ASR Commercial |
$11.65
|
| Rate for Payer: BCBS Trust/PPO |
$9.79
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$11.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.61
|
| Rate for Payer: Healthscope Commercial |
$12.01
|
| Rate for Payer: Healthscope Whirlpool |
$11.65
|
| Rate for Payer: Mclaren Commercial |
$10.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.21
|
| Rate for Payer: Nomi Health Commercial |
$9.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.57
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.30
|
|
|
Service Code
|
NDC 63323073912
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$16.30 |
| Rate for Payer: Aetna Commercial |
$14.67
|
| Rate for Payer: ASR ASR |
$15.81
|
| Rate for Payer: ASR Commercial |
$15.81
|
| Rate for Payer: BCBS Trust/PPO |
$13.28
|
| Rate for Payer: BCN Commercial |
$12.64
|
| Rate for Payer: Cash Price |
$13.04
|
| Rate for Payer: Cofinity Commercial |
$15.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.04
|
| Rate for Payer: Healthscope Commercial |
$16.30
|
| Rate for Payer: Healthscope Whirlpool |
$15.81
|
| Rate for Payer: Mclaren Commercial |
$14.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.86
|
| Rate for Payer: Nomi Health Commercial |
$13.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.34
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$15.30
|
|
|
Service Code
|
NDC 70860075102
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: ASR ASR |
$14.84
|
| Rate for Payer: ASR Commercial |
$14.84
|
| Rate for Payer: BCBS Trust/PPO |
$12.47
|
| Rate for Payer: BCN Commercial |
$11.86
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Healthscope Commercial |
$15.30
|
| Rate for Payer: Healthscope Whirlpool |
$14.84
|
| Rate for Payer: Mclaren Commercial |
$13.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: Nomi Health Commercial |
$12.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.46
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
NDC 00641602201
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$12.95 |
| Rate for Payer: Aetna Commercial |
$11.65
|
| Rate for Payer: Aetna Medicare |
$6.47
|
| Rate for Payer: ASR ASR |
$12.56
|
| Rate for Payer: ASR Commercial |
$12.56
|
| Rate for Payer: BCBS Complete |
$5.18
|
| Rate for Payer: BCBS Trust/PPO |
$10.60
|
| Rate for Payer: BCN Commercial |
$10.04
|
| Rate for Payer: Cash Price |
$10.36
|
| Rate for Payer: Cofinity Commercial |
$12.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.36
|
| Rate for Payer: Healthscope Commercial |
$12.95
|
| Rate for Payer: Healthscope Whirlpool |
$12.56
|
| Rate for Payer: Mclaren Commercial |
$11.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.01
|
| Rate for Payer: Nomi Health Commercial |
$10.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.35
|
| Rate for Payer: Priority Health Narrow Network |
$9.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.40
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$15.30
|
|
|
Service Code
|
NDC 70860075141
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: ASR ASR |
$14.84
|
| Rate for Payer: ASR Commercial |
$14.84
|
| Rate for Payer: BCBS Trust/PPO |
$12.47
|
| Rate for Payer: BCN Commercial |
$11.86
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Healthscope Commercial |
$15.30
|
| Rate for Payer: Healthscope Whirlpool |
$14.84
|
| Rate for Payer: Mclaren Commercial |
$13.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: Nomi Health Commercial |
$12.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.46
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.01
|
|
|
Service Code
|
NDC 67457043322
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$12.01 |
| Rate for Payer: Aetna Commercial |
$10.81
|
| Rate for Payer: ASR ASR |
$11.65
|
| Rate for Payer: ASR Commercial |
$11.65
|
| Rate for Payer: BCBS Trust/PPO |
$9.79
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$11.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.61
|
| Rate for Payer: Healthscope Commercial |
$12.01
|
| Rate for Payer: Healthscope Whirlpool |
$11.65
|
| Rate for Payer: Mclaren Commercial |
$10.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.21
|
| Rate for Payer: Nomi Health Commercial |
$9.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.57
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
OP
|
$12.90
|
|
|
Service Code
|
NDC 65219053101
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.16 |
| Max. Negotiated Rate |
$12.90 |
| Rate for Payer: Aetna Commercial |
$11.61
|
| Rate for Payer: Aetna Medicare |
$6.45
|
| Rate for Payer: ASR ASR |
$12.51
|
| Rate for Payer: ASR Commercial |
$12.51
|
| Rate for Payer: BCBS Complete |
$5.16
|
| Rate for Payer: BCBS Trust/PPO |
$10.56
|
| Rate for Payer: BCN Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$10.32
|
| Rate for Payer: Cofinity Commercial |
$12.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.32
|
| Rate for Payer: Healthscope Commercial |
$12.90
|
| Rate for Payer: Healthscope Whirlpool |
$12.51
|
| Rate for Payer: Mclaren Commercial |
$11.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.96
|
| Rate for Payer: Nomi Health Commercial |
$10.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.30
|
| Rate for Payer: Priority Health Narrow Network |
$9.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.35
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 00338051958
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Medicare |
$4.75
|
| Rate for Payer: ASR ASR |
$9.21
|
| Rate for Payer: ASR Commercial |
$9.21
|
| Rate for Payer: BCBS Complete |
$3.80
|
| Rate for Payer: BCBS Trust/PPO |
$7.78
|
| Rate for Payer: BCN Commercial |
$7.37
|
| Rate for Payer: Cash Price |
$7.60
|
| Rate for Payer: Cofinity Commercial |
$8.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.60
|
| Rate for Payer: Healthscope Commercial |
$9.50
|
| Rate for Payer: Healthscope Whirlpool |
$9.21
|
| Rate for Payer: Mclaren Commercial |
$8.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.07
|
| Rate for Payer: Nomi Health Commercial |
$7.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.32
|
| Rate for Payer: Priority Health Narrow Network |
$6.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.36
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
NDC 00338051913
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: ASR ASR |
$194.00
|
| Rate for Payer: ASR Commercial |
$194.00
|
| Rate for Payer: BCBS Trust/PPO |
$162.98
|
| Rate for Payer: BCN Commercial |
$155.06
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cofinity Commercial |
$188.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.00
|
| Rate for Payer: Healthscope Commercial |
$200.00
|
| Rate for Payer: Healthscope Whirlpool |
$194.00
|
| Rate for Payer: Mclaren Commercial |
$180.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.00
|
| Rate for Payer: Nomi Health Commercial |
$164.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.00
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 00338051958
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$9.50 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: ASR ASR |
$9.21
|
| Rate for Payer: ASR Commercial |
$9.21
|
| Rate for Payer: BCBS Trust/PPO |
$7.74
|
| Rate for Payer: BCN Commercial |
$7.37
|
| Rate for Payer: Cash Price |
$7.60
|
| Rate for Payer: Cofinity Commercial |
$8.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.60
|
| Rate for Payer: Healthscope Commercial |
$9.50
|
| Rate for Payer: Healthscope Whirlpool |
$9.21
|
| Rate for Payer: Mclaren Commercial |
$8.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.07
|
| Rate for Payer: Nomi Health Commercial |
$7.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.36
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
OP
|
$12.90
|
|
|
Service Code
|
NDC 65219053110
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.16 |
| Max. Negotiated Rate |
$12.90 |
| Rate for Payer: Aetna Commercial |
$11.61
|
| Rate for Payer: Aetna Medicare |
$6.45
|
| Rate for Payer: ASR ASR |
$12.51
|
| Rate for Payer: ASR Commercial |
$12.51
|
| Rate for Payer: BCBS Complete |
$5.16
|
| Rate for Payer: BCBS Trust/PPO |
$10.56
|
| Rate for Payer: BCN Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$10.32
|
| Rate for Payer: Cofinity Commercial |
$12.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.32
|
| Rate for Payer: Healthscope Commercial |
$12.90
|
| Rate for Payer: Healthscope Whirlpool |
$12.51
|
| Rate for Payer: Mclaren Commercial |
$11.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.96
|
| Rate for Payer: Nomi Health Commercial |
$10.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.30
|
| Rate for Payer: Priority Health Narrow Network |
$9.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.35
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$12.90
|
|
|
Service Code
|
NDC 65219053110
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.38 |
| Max. Negotiated Rate |
$12.90 |
| Rate for Payer: Aetna Commercial |
$11.61
|
| Rate for Payer: ASR ASR |
$12.51
|
| Rate for Payer: ASR Commercial |
$12.51
|
| Rate for Payer: BCBS Trust/PPO |
$10.51
|
| Rate for Payer: BCN Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$10.32
|
| Rate for Payer: Cofinity Commercial |
$12.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.32
|
| Rate for Payer: Healthscope Commercial |
$12.90
|
| Rate for Payer: Healthscope Whirlpool |
$12.51
|
| Rate for Payer: Mclaren Commercial |
$11.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.96
|
| Rate for Payer: Nomi Health Commercial |
$10.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.35
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
NDC 00338051913
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Medicare |
$100.00
|
| Rate for Payer: ASR ASR |
$194.00
|
| Rate for Payer: ASR Commercial |
$194.00
|
| Rate for Payer: BCBS Complete |
$80.00
|
| Rate for Payer: BCBS Trust/PPO |
$163.78
|
| Rate for Payer: BCN Commercial |
$155.06
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cofinity Commercial |
$188.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.00
|
| Rate for Payer: Healthscope Commercial |
$200.00
|
| Rate for Payer: Healthscope Whirlpool |
$194.00
|
| Rate for Payer: Mclaren Commercial |
$180.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.00
|
| Rate for Payer: Nomi Health Commercial |
$164.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$175.24
|
| Rate for Payer: Priority Health Narrow Network |
$140.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.00
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$12.90
|
|
|
Service Code
|
NDC 65219053101
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.38 |
| Max. Negotiated Rate |
$12.90 |
| Rate for Payer: Aetna Commercial |
$11.61
|
| Rate for Payer: ASR ASR |
$12.51
|
| Rate for Payer: ASR Commercial |
$12.51
|
| Rate for Payer: BCBS Trust/PPO |
$10.51
|
| Rate for Payer: BCN Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$10.32
|
| Rate for Payer: Cofinity Commercial |
$12.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.32
|
| Rate for Payer: Healthscope Commercial |
$12.90
|
| Rate for Payer: Healthscope Whirlpool |
$12.51
|
| Rate for Payer: Mclaren Commercial |
$11.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.96
|
| Rate for Payer: Nomi Health Commercial |
$10.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.35
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
OP
|
$13.50
|
|
|
Service Code
|
NDC 00338954003
|
| Hospital Charge Code |
191280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna Commercial |
$12.15
|
| Rate for Payer: Aetna Medicare |
$6.75
|
| Rate for Payer: ASR ASR |
$13.10
|
| Rate for Payer: ASR Commercial |
$13.10
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: BCBS Trust/PPO |
$11.06
|
| Rate for Payer: BCN Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cofinity Commercial |
$12.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.80
|
| Rate for Payer: Healthscope Commercial |
$13.50
|
| Rate for Payer: Healthscope Whirlpool |
$13.10
|
| Rate for Payer: Mclaren Commercial |
$12.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Nomi Health Commercial |
$11.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.83
|
| Rate for Payer: Priority Health Narrow Network |
$9.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.88
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
IP
|
$13.50
|
|
|
Service Code
|
NDC 00338954003
|
| Hospital Charge Code |
191280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna Commercial |
$12.15
|
| Rate for Payer: ASR ASR |
$13.10
|
| Rate for Payer: ASR Commercial |
$13.10
|
| Rate for Payer: BCBS Trust/PPO |
$11.00
|
| Rate for Payer: BCN Commercial |
$10.47
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cofinity Commercial |
$12.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.80
|
| Rate for Payer: Healthscope Commercial |
$13.50
|
| Rate for Payer: Healthscope Whirlpool |
$13.10
|
| Rate for Payer: Mclaren Commercial |
$12.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Nomi Health Commercial |
$11.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.88
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 63323082074
|
| Hospital Charge Code |
179808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$21.60
|
| Rate for Payer: ASR ASR |
$23.28
|
| Rate for Payer: ASR Commercial |
$23.28
|
| Rate for Payer: BCBS Trust/PPO |
$19.56
|
| Rate for Payer: BCN Commercial |
$18.61
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cofinity Commercial |
$22.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.20
|
| Rate for Payer: Healthscope Commercial |
$24.00
|
| Rate for Payer: Healthscope Whirlpool |
$23.28
|
| Rate for Payer: Mclaren Commercial |
$21.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.40
|
| Rate for Payer: Nomi Health Commercial |
$19.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.12
|
|
