|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$188.00
|
|
|
Service Code
|
NDC 65162036110
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.20 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna Commercial |
$169.20
|
| Rate for Payer: Aetna Medicare |
$94.00
|
| Rate for Payer: ASR ASR |
$182.36
|
| Rate for Payer: ASR Commercial |
$182.36
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: BCBS Trust/PPO |
$153.95
|
| Rate for Payer: BCN Commercial |
$145.76
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cofinity Commercial |
$176.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.40
|
| Rate for Payer: Healthscope Commercial |
$188.00
|
| Rate for Payer: Healthscope Whirlpool |
$182.36
|
| Rate for Payer: Mclaren Commercial |
$169.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.80
|
| Rate for Payer: Nomi Health Commercial |
$154.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$164.73
|
| Rate for Payer: Priority Health Narrow Network |
$131.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.44
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
OP
|
$147.40
|
|
|
Service Code
|
NDC 00904722461
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.96 |
| Max. Negotiated Rate |
$147.40 |
| Rate for Payer: Aetna Commercial |
$132.66
|
| Rate for Payer: Aetna Medicare |
$73.70
|
| Rate for Payer: ASR ASR |
$142.98
|
| Rate for Payer: ASR Commercial |
$142.98
|
| Rate for Payer: BCBS Complete |
$58.96
|
| Rate for Payer: BCBS Trust/PPO |
$120.71
|
| Rate for Payer: BCN Commercial |
$114.28
|
| Rate for Payer: Cash Price |
$117.92
|
| Rate for Payer: Cofinity Commercial |
$138.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.92
|
| Rate for Payer: Healthscope Commercial |
$147.40
|
| Rate for Payer: Healthscope Whirlpool |
$142.98
|
| Rate for Payer: Mclaren Commercial |
$132.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.29
|
| Rate for Payer: Nomi Health Commercial |
$120.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$129.15
|
| Rate for Payer: Priority Health Narrow Network |
$103.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$129.71
|
|
|
FOLIC ACID 1 MG TABLET
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
NDC 69315012701
|
| Hospital Charge Code |
3233
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.60 |
| Max. Negotiated Rate |
$164.00 |
| Rate for Payer: Aetna Commercial |
$147.60
|
| Rate for Payer: ASR ASR |
$159.08
|
| Rate for Payer: ASR Commercial |
$159.08
|
| Rate for Payer: BCBS Trust/PPO |
$133.64
|
| Rate for Payer: BCN Commercial |
$127.15
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cofinity Commercial |
$154.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.20
|
| Rate for Payer: Healthscope Commercial |
$164.00
|
| Rate for Payer: Healthscope Whirlpool |
$159.08
|
| Rate for Payer: Mclaren Commercial |
$147.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.40
|
| Rate for Payer: Nomi Health Commercial |
$134.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$144.32
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 39822110001
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Aetna Commercial |
$185.81
|
| Rate for Payer: ASR ASR |
$200.27
|
| Rate for Payer: ASR Commercial |
$200.27
|
| Rate for Payer: BCBS Trust/PPO |
$168.24
|
| Rate for Payer: BCN Commercial |
$160.07
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$194.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$206.46
|
| Rate for Payer: Healthscope Whirlpool |
$200.27
|
| Rate for Payer: Mclaren Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.68
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 39822110001
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.58 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Aetna Commercial |
$185.81
|
| Rate for Payer: Aetna Medicare |
$103.23
|
| Rate for Payer: ASR ASR |
$200.27
|
| Rate for Payer: ASR Commercial |
$200.27
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: BCBS Trust/PPO |
$169.07
|
| Rate for Payer: BCN Commercial |
$160.07
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$194.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$206.46
|
| Rate for Payer: Healthscope Whirlpool |
$200.27
|
| Rate for Payer: Mclaren Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$180.90
|
| Rate for Payer: Priority Health Narrow Network |
$144.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.68
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$158.58
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.08 |
| Max. Negotiated Rate |
$158.58 |
| Rate for Payer: Aetna Commercial |
$142.72
|
| Rate for Payer: ASR ASR |
$153.82
|
| Rate for Payer: ASR Commercial |
$153.82
|
| Rate for Payer: BCBS Trust/PPO |
$129.23
|
| Rate for Payer: BCN Commercial |
$122.95
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cofinity Commercial |
$149.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.86
|
| Rate for Payer: Healthscope Commercial |
$158.58
|
| Rate for Payer: Healthscope Whirlpool |
$153.82
|
| Rate for Payer: Mclaren Commercial |
$142.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.79
|
| Rate for Payer: Nomi Health Commercial |
$130.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$139.55
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$158.58
|
|
|
Service Code
|
NDC 63323018410
|
| Hospital Charge Code |
3232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.43 |
| Max. Negotiated Rate |
$158.58 |
| Rate for Payer: Aetna Commercial |
$142.72
|
| Rate for Payer: Aetna Medicare |
$79.29
|
| Rate for Payer: ASR ASR |
$153.82
|
| Rate for Payer: ASR Commercial |
$153.82
|
| Rate for Payer: BCBS Complete |
$63.43
|
| Rate for Payer: BCBS Trust/PPO |
$129.86
|
| Rate for Payer: BCN Commercial |
$122.95
|
| Rate for Payer: Cash Price |
$126.87
|
| Rate for Payer: Cofinity Commercial |
$149.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.86
|
| Rate for Payer: Healthscope Commercial |
$158.58
|
| Rate for Payer: Healthscope Whirlpool |
$153.82
|
| Rate for Payer: Mclaren Commercial |
$142.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.79
|
| Rate for Payer: Nomi Health Commercial |
$130.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$138.95
|
| Rate for Payer: Priority Health Narrow Network |
$111.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$139.55
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$194.25
|
|
|
Service Code
|
NDC 70700026899
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$194.25 |
| Rate for Payer: Aetna Commercial |
$174.82
|
| Rate for Payer: Aetna Medicare |
$97.12
|
| Rate for Payer: ASR ASR |
$188.42
|
| Rate for Payer: ASR Commercial |
$188.42
|
| Rate for Payer: BCBS Complete |
$77.70
|
| Rate for Payer: BCBS Trust/PPO |
$159.07
|
| Rate for Payer: BCN Commercial |
$150.60
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$182.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Healthscope Commercial |
$194.25
|
| Rate for Payer: Healthscope Whirlpool |
$188.42
|
| Rate for Payer: Mclaren Commercial |
$174.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$170.20
|
| Rate for Payer: Priority Health Narrow Network |
$136.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$170.94
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 82036427401
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.58 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Aetna Commercial |
$185.81
|
| Rate for Payer: Aetna Medicare |
$103.23
|
| Rate for Payer: ASR ASR |
$200.27
|
| Rate for Payer: ASR Commercial |
$200.27
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: BCBS Trust/PPO |
$169.07
|
| Rate for Payer: BCN Commercial |
$160.07
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$194.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$206.46
|
| Rate for Payer: Healthscope Whirlpool |
$200.27
|
| Rate for Payer: Mclaren Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$180.90
|
| Rate for Payer: Priority Health Narrow Network |
$144.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.68
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$241.83
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.73 |
| Max. Negotiated Rate |
$241.83 |
| Rate for Payer: Aetna Commercial |
$217.65
|
| Rate for Payer: Aetna Medicare |
$120.92
|
| Rate for Payer: ASR ASR |
$234.58
|
| Rate for Payer: ASR Commercial |
$234.58
|
| Rate for Payer: BCBS Complete |
$96.73
|
| Rate for Payer: BCBS Trust/PPO |
$198.03
|
| Rate for Payer: BCN Commercial |
$187.49
|
| Rate for Payer: Cash Price |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$227.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.46
|
| Rate for Payer: Healthscope Commercial |
$241.83
|
| Rate for Payer: Healthscope Whirlpool |
$234.58
|
| Rate for Payer: Mclaren Commercial |
$217.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.56
|
| Rate for Payer: Nomi Health Commercial |
$198.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$211.89
|
| Rate for Payer: Priority Health Narrow Network |
$169.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$212.81
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 82036427408
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Aetna Commercial |
$185.81
|
| Rate for Payer: ASR ASR |
$200.27
|
| Rate for Payer: ASR Commercial |
$200.27
|
| Rate for Payer: BCBS Trust/PPO |
$168.24
|
| Rate for Payer: BCN Commercial |
$160.07
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$194.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$206.46
|
| Rate for Payer: Healthscope Whirlpool |
$200.27
|
| Rate for Payer: Mclaren Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.68
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$203.94
|
|
|
Service Code
|
NDC 67877074957
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.56 |
| Max. Negotiated Rate |
$203.94 |
| Rate for Payer: Aetna Commercial |
$183.55
|
| Rate for Payer: ASR ASR |
$197.82
|
| Rate for Payer: ASR Commercial |
$197.82
|
| Rate for Payer: BCBS Trust/PPO |
$166.19
|
| Rate for Payer: BCN Commercial |
$158.11
|
| Rate for Payer: Cash Price |
$163.16
|
| Rate for Payer: Cofinity Commercial |
$191.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.15
|
| Rate for Payer: Healthscope Commercial |
$203.94
|
| Rate for Payer: Healthscope Whirlpool |
$197.82
|
| Rate for Payer: Mclaren Commercial |
$183.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.35
|
| Rate for Payer: Nomi Health Commercial |
$167.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$179.47
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$203.94
|
|
|
Service Code
|
NDC 67877074957
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.58 |
| Max. Negotiated Rate |
$203.94 |
| Rate for Payer: Aetna Commercial |
$183.55
|
| Rate for Payer: Aetna Medicare |
$101.97
|
| Rate for Payer: ASR ASR |
$197.82
|
| Rate for Payer: ASR Commercial |
$197.82
|
| Rate for Payer: BCBS Complete |
$81.58
|
| Rate for Payer: BCBS Trust/PPO |
$167.01
|
| Rate for Payer: BCN Commercial |
$158.11
|
| Rate for Payer: Cash Price |
$163.16
|
| Rate for Payer: Cofinity Commercial |
$191.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.15
|
| Rate for Payer: Healthscope Commercial |
$203.94
|
| Rate for Payer: Healthscope Whirlpool |
$197.82
|
| Rate for Payer: Mclaren Commercial |
$183.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.35
|
| Rate for Payer: Nomi Health Commercial |
$167.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$178.69
|
| Rate for Payer: Priority Health Narrow Network |
$142.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$179.47
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$241.83
|
|
|
Service Code
|
NDC 00456430001
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.19 |
| Max. Negotiated Rate |
$241.83 |
| Rate for Payer: Aetna Commercial |
$217.65
|
| Rate for Payer: ASR ASR |
$234.58
|
| Rate for Payer: ASR Commercial |
$234.58
|
| Rate for Payer: BCBS Trust/PPO |
$197.07
|
| Rate for Payer: BCN Commercial |
$187.49
|
| Rate for Payer: Cash Price |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$227.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.46
|
| Rate for Payer: Healthscope Commercial |
$241.83
|
| Rate for Payer: Healthscope Whirlpool |
$234.58
|
| Rate for Payer: Mclaren Commercial |
$217.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.56
|
| Rate for Payer: Nomi Health Commercial |
$198.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$212.81
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 69097057967
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Aetna Commercial |
$185.81
|
| Rate for Payer: ASR ASR |
$200.27
|
| Rate for Payer: ASR Commercial |
$200.27
|
| Rate for Payer: BCBS Trust/PPO |
$168.24
|
| Rate for Payer: BCN Commercial |
$160.07
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$194.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$206.46
|
| Rate for Payer: Healthscope Whirlpool |
$200.27
|
| Rate for Payer: Mclaren Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.68
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$194.25
|
|
|
Service Code
|
NDC 70700026899
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$194.25 |
| Rate for Payer: Aetna Commercial |
$174.82
|
| Rate for Payer: ASR ASR |
$188.42
|
| Rate for Payer: ASR Commercial |
$188.42
|
| Rate for Payer: BCBS Trust/PPO |
$158.29
|
| Rate for Payer: BCN Commercial |
$150.60
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$182.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Healthscope Commercial |
$194.25
|
| Rate for Payer: Healthscope Whirlpool |
$188.42
|
| Rate for Payer: Mclaren Commercial |
$174.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$170.94
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 82036427408
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.58 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Aetna Commercial |
$185.81
|
| Rate for Payer: Aetna Medicare |
$103.23
|
| Rate for Payer: ASR ASR |
$200.27
|
| Rate for Payer: ASR Commercial |
$200.27
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: BCBS Trust/PPO |
$169.07
|
| Rate for Payer: BCN Commercial |
$160.07
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$194.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$206.46
|
| Rate for Payer: Healthscope Whirlpool |
$200.27
|
| Rate for Payer: Mclaren Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$180.90
|
| Rate for Payer: Priority Health Narrow Network |
$144.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.68
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$194.25
|
|
|
Service Code
|
NDC 70700026894
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.70 |
| Max. Negotiated Rate |
$194.25 |
| Rate for Payer: Aetna Commercial |
$174.82
|
| Rate for Payer: Aetna Medicare |
$97.12
|
| Rate for Payer: ASR ASR |
$188.42
|
| Rate for Payer: ASR Commercial |
$188.42
|
| Rate for Payer: BCBS Complete |
$77.70
|
| Rate for Payer: BCBS Trust/PPO |
$159.07
|
| Rate for Payer: BCN Commercial |
$150.60
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$182.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Healthscope Commercial |
$194.25
|
| Rate for Payer: Healthscope Whirlpool |
$188.42
|
| Rate for Payer: Mclaren Commercial |
$174.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$170.20
|
| Rate for Payer: Priority Health Narrow Network |
$136.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$170.94
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$194.25
|
|
|
Service Code
|
NDC 70700026894
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$194.25 |
| Rate for Payer: Aetna Commercial |
$174.82
|
| Rate for Payer: ASR ASR |
$188.42
|
| Rate for Payer: ASR Commercial |
$188.42
|
| Rate for Payer: BCBS Trust/PPO |
$158.29
|
| Rate for Payer: BCN Commercial |
$150.60
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$182.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Healthscope Commercial |
$194.25
|
| Rate for Payer: Healthscope Whirlpool |
$188.42
|
| Rate for Payer: Mclaren Commercial |
$174.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.11
|
| Rate for Payer: Nomi Health Commercial |
$159.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$170.94
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 82036427401
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.20 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Aetna Commercial |
$185.81
|
| Rate for Payer: ASR ASR |
$200.27
|
| Rate for Payer: ASR Commercial |
$200.27
|
| Rate for Payer: BCBS Trust/PPO |
$168.24
|
| Rate for Payer: BCN Commercial |
$160.07
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$194.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$206.46
|
| Rate for Payer: Healthscope Whirlpool |
$200.27
|
| Rate for Payer: Mclaren Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.68
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 69097057967
|
| Hospital Charge Code |
14825
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.58 |
| Max. Negotiated Rate |
$206.46 |
| Rate for Payer: Aetna Commercial |
$185.81
|
| Rate for Payer: Aetna Medicare |
$103.23
|
| Rate for Payer: ASR ASR |
$200.27
|
| Rate for Payer: ASR Commercial |
$200.27
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: BCBS Trust/PPO |
$169.07
|
| Rate for Payer: BCN Commercial |
$160.07
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$194.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$206.46
|
| Rate for Payer: Healthscope Whirlpool |
$200.27
|
| Rate for Payer: Mclaren Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: Nomi Health Commercial |
$169.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$180.90
|
| Rate for Payer: Priority Health Narrow Network |
$144.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.68
|
|
|
FOSINOPRIL 10 MG TABLET
|
Facility
|
OP
|
$247.46
|
|
|
Service Code
|
NDC 69097085605
|
| Hospital Charge Code |
10094
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.98 |
| Max. Negotiated Rate |
$247.46 |
| Rate for Payer: Aetna Commercial |
$222.71
|
| Rate for Payer: Aetna Medicare |
$123.73
|
| Rate for Payer: ASR ASR |
$240.04
|
| Rate for Payer: ASR Commercial |
$240.04
|
| Rate for Payer: BCBS Complete |
$98.98
|
| Rate for Payer: BCBS Trust/PPO |
$202.64
|
| Rate for Payer: BCN Commercial |
$191.86
|
| Rate for Payer: Cash Price |
$197.96
|
| Rate for Payer: Cofinity Commercial |
$232.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.97
|
| Rate for Payer: Healthscope Commercial |
$247.46
|
| Rate for Payer: Healthscope Whirlpool |
$240.04
|
| Rate for Payer: Mclaren Commercial |
$222.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.34
|
| Rate for Payer: Nomi Health Commercial |
$202.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$216.82
|
| Rate for Payer: Priority Health Narrow Network |
$173.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$217.76
|
|
|
FOSINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$247.46
|
|
|
Service Code
|
NDC 69097085605
|
| Hospital Charge Code |
10094
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.85 |
| Max. Negotiated Rate |
$247.46 |
| Rate for Payer: Aetna Commercial |
$222.71
|
| Rate for Payer: ASR ASR |
$240.04
|
| Rate for Payer: ASR Commercial |
$240.04
|
| Rate for Payer: BCBS Trust/PPO |
$201.66
|
| Rate for Payer: BCN Commercial |
$191.86
|
| Rate for Payer: Cash Price |
$197.96
|
| Rate for Payer: Cofinity Commercial |
$232.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.97
|
| Rate for Payer: Healthscope Commercial |
$247.46
|
| Rate for Payer: Healthscope Whirlpool |
$240.04
|
| Rate for Payer: Mclaren Commercial |
$222.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.34
|
| Rate for Payer: Nomi Health Commercial |
$202.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$217.76
|
|
|
FRAXEL ARMS - BILATERAL
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 00166
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$408.00 |
| Max. Negotiated Rate |
$663.00 |
| Rate for Payer: Aetna Medicare |
$510.00
|
| Rate for Payer: BCBS Complete |
$408.00
|
| Rate for Payer: Cash Price |
$816.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$663.00
|
|
|
FRAXEL CHEST
|
Professional
|
Both
|
$816.00
|
|
|
Service Code
|
HCPCS 00155
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$326.40 |
| Max. Negotiated Rate |
$530.40 |
| Rate for Payer: Aetna Medicare |
$408.00
|
| Rate for Payer: BCBS Complete |
$326.40
|
| Rate for Payer: Cash Price |
$652.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.40
|
|
