|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$32.10
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$32.10 |
| Rate for Payer: Aetna Commercial |
$28.89
|
| Rate for Payer: Aetna Commercial |
$115.56
|
| Rate for Payer: Aetna Commercial |
$86.67
|
| Rate for Payer: ASR ASR |
$124.55
|
| Rate for Payer: ASR ASR |
$31.14
|
| Rate for Payer: ASR ASR |
$93.41
|
| Rate for Payer: ASR Commercial |
$31.14
|
| Rate for Payer: ASR Commercial |
$124.55
|
| Rate for Payer: ASR Commercial |
$93.41
|
| Rate for Payer: BCBS Trust/PPO |
$78.47
|
| Rate for Payer: BCBS Trust/PPO |
$104.63
|
| Rate for Payer: BCBS Trust/PPO |
$26.16
|
| Rate for Payer: BCN Commercial |
$99.55
|
| Rate for Payer: BCN Commercial |
$74.66
|
| Rate for Payer: BCN Commercial |
$24.89
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Cofinity Commercial |
$90.52
|
| Rate for Payer: Cofinity Commercial |
$120.70
|
| Rate for Payer: Cofinity Commercial |
$30.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.04
|
| Rate for Payer: Healthscope Commercial |
$128.40
|
| Rate for Payer: Healthscope Commercial |
$32.10
|
| Rate for Payer: Healthscope Commercial |
$96.30
|
| Rate for Payer: Healthscope Whirlpool |
$31.14
|
| Rate for Payer: Healthscope Whirlpool |
$124.55
|
| Rate for Payer: Healthscope Whirlpool |
$93.41
|
| Rate for Payer: Mclaren Commercial |
$28.89
|
| Rate for Payer: Mclaren Commercial |
$115.56
|
| Rate for Payer: Mclaren Commercial |
$86.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.14
|
| Rate for Payer: Nomi Health Commercial |
$26.32
|
| Rate for Payer: Nomi Health Commercial |
$105.29
|
| Rate for Payer: Nomi Health Commercial |
$78.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$84.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$112.99
|
|
|
GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$428.36
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$278.43 |
| Max. Negotiated Rate |
$428.36 |
| Rate for Payer: Aetna Commercial |
$385.52
|
| Rate for Payer: Aetna Commercial |
$1,602.00
|
| Rate for Payer: ASR ASR |
$1,726.60
|
| Rate for Payer: ASR ASR |
$415.51
|
| Rate for Payer: ASR Commercial |
$1,726.60
|
| Rate for Payer: ASR Commercial |
$415.51
|
| Rate for Payer: BCBS Trust/PPO |
$1,450.52
|
| Rate for Payer: BCBS Trust/PPO |
$349.07
|
| Rate for Payer: BCN Commercial |
$332.11
|
| Rate for Payer: BCN Commercial |
$1,380.03
|
| Rate for Payer: Cash Price |
$342.69
|
| Rate for Payer: Cash Price |
$1,424.00
|
| Rate for Payer: Cofinity Commercial |
$1,673.20
|
| Rate for Payer: Cofinity Commercial |
$402.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,424.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.69
|
| Rate for Payer: Healthscope Commercial |
$1,780.00
|
| Rate for Payer: Healthscope Commercial |
$428.36
|
| Rate for Payer: Healthscope Whirlpool |
$415.51
|
| Rate for Payer: Healthscope Whirlpool |
$1,726.60
|
| Rate for Payer: Mclaren Commercial |
$1,602.00
|
| Rate for Payer: Mclaren Commercial |
$385.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,513.00
|
| Rate for Payer: Nomi Health Commercial |
$351.26
|
| Rate for Payer: Nomi Health Commercial |
$1,459.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,157.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,566.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$376.96
|
|
|
GADODIAMIDE 10 MMOL/20 ML (287 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,780.00
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$712.00 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$1,602.00
|
| Rate for Payer: Aetna Commercial |
$385.52
|
| Rate for Payer: Aetna Medicare |
$890.00
|
| Rate for Payer: Aetna Medicare |
$214.18
|
| Rate for Payer: ASR ASR |
$1,726.60
|
| Rate for Payer: ASR ASR |
$415.51
|
| Rate for Payer: ASR Commercial |
$415.51
|
| Rate for Payer: ASR Commercial |
$1,726.60
|
| Rate for Payer: BCBS Complete |
$712.00
|
| Rate for Payer: BCBS Complete |
$171.34
|
| Rate for Payer: BCBS Trust/PPO |
$1,457.64
|
| Rate for Payer: BCBS Trust/PPO |
$350.78
|
| Rate for Payer: BCN Commercial |
$332.11
|
| Rate for Payer: BCN Commercial |
$1,380.03
|
| Rate for Payer: Cash Price |
$1,424.00
|
| Rate for Payer: Cash Price |
$342.69
|
| Rate for Payer: Cofinity Commercial |
$1,673.20
|
| Rate for Payer: Cofinity Commercial |
$402.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,424.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.69
|
| Rate for Payer: Healthscope Commercial |
$1,780.00
|
| Rate for Payer: Healthscope Commercial |
$428.36
|
| Rate for Payer: Healthscope Whirlpool |
$1,726.60
|
| Rate for Payer: Healthscope Whirlpool |
$415.51
|
| Rate for Payer: Mclaren Commercial |
$1,602.00
|
| Rate for Payer: Mclaren Commercial |
$385.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,513.00
|
| Rate for Payer: Nomi Health Commercial |
$1,459.60
|
| Rate for Payer: Nomi Health Commercial |
$351.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,157.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,559.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$375.33
|
| Rate for Payer: Priority Health Narrow Network |
$300.28
|
| Rate for Payer: Priority Health Narrow Network |
$1,247.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$376.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,566.40
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$1,080.00
|
| Rate for Payer: Aetna Medicare |
$600.00
|
| Rate for Payer: ASR ASR |
$1,164.00
|
| Rate for Payer: ASR Commercial |
$1,164.00
|
| Rate for Payer: BCBS Complete |
$480.00
|
| Rate for Payer: BCBS Trust/PPO |
$982.68
|
| Rate for Payer: BCN Commercial |
$930.36
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Cofinity Commercial |
$1,128.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$960.00
|
| Rate for Payer: Healthscope Commercial |
$1,200.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,164.00
|
| Rate for Payer: Mclaren Commercial |
$1,080.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,020.00
|
| Rate for Payer: Nomi Health Commercial |
$984.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$780.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,051.44
|
| Rate for Payer: Priority Health Narrow Network |
$841.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,056.00
|
|
|
GADODIAMIDE 7.5 MMOL/15 ML (287 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$780.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$1,080.00
|
| Rate for Payer: ASR ASR |
$1,164.00
|
| Rate for Payer: ASR Commercial |
$1,164.00
|
| Rate for Payer: BCBS Trust/PPO |
$977.88
|
| Rate for Payer: BCN Commercial |
$930.36
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Cofinity Commercial |
$1,128.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$960.00
|
| Rate for Payer: Healthscope Commercial |
$1,200.00
|
| Rate for Payer: Healthscope Whirlpool |
$1,164.00
|
| Rate for Payer: Mclaren Commercial |
$1,080.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,020.00
|
| Rate for Payer: Nomi Health Commercial |
$984.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$780.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,056.00
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$631.72
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$410.62 |
| Max. Negotiated Rate |
$631.72 |
| Rate for Payer: Aetna Commercial |
$568.55
|
| Rate for Payer: ASR ASR |
$612.77
|
| Rate for Payer: ASR Commercial |
$612.77
|
| Rate for Payer: BCBS Trust/PPO |
$514.79
|
| Rate for Payer: BCN Commercial |
$489.77
|
| Rate for Payer: Cash Price |
$505.38
|
| Rate for Payer: Cofinity Commercial |
$593.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.38
|
| Rate for Payer: Healthscope Commercial |
$631.72
|
| Rate for Payer: Healthscope Whirlpool |
$612.77
|
| Rate for Payer: Mclaren Commercial |
$568.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.96
|
| Rate for Payer: Nomi Health Commercial |
$518.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$410.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$555.91
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$631.72
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$252.69 |
| Max. Negotiated Rate |
$631.72 |
| Rate for Payer: Aetna Commercial |
$568.55
|
| Rate for Payer: Aetna Medicare |
$315.86
|
| Rate for Payer: ASR ASR |
$612.77
|
| Rate for Payer: ASR Commercial |
$612.77
|
| Rate for Payer: BCBS Complete |
$252.69
|
| Rate for Payer: BCBS Trust/PPO |
$517.32
|
| Rate for Payer: BCN Commercial |
$489.77
|
| Rate for Payer: Cash Price |
$505.38
|
| Rate for Payer: Cofinity Commercial |
$593.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.38
|
| Rate for Payer: Healthscope Commercial |
$631.72
|
| Rate for Payer: Healthscope Whirlpool |
$612.77
|
| Rate for Payer: Mclaren Commercial |
$568.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.96
|
| Rate for Payer: Nomi Health Commercial |
$518.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$410.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$553.51
|
| Rate for Payer: Priority Health Narrow Network |
$442.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$555.91
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$130.57
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$84.87 |
| Max. Negotiated Rate |
$130.57 |
| Rate for Payer: Aetna Commercial |
$117.51
|
| Rate for Payer: ASR ASR |
$126.65
|
| Rate for Payer: ASR Commercial |
$126.65
|
| Rate for Payer: BCBS Trust/PPO |
$106.40
|
| Rate for Payer: BCN Commercial |
$101.23
|
| Rate for Payer: Cash Price |
$104.45
|
| Rate for Payer: Cofinity Commercial |
$122.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.46
|
| Rate for Payer: Healthscope Commercial |
$130.57
|
| Rate for Payer: Healthscope Whirlpool |
$126.65
|
| Rate for Payer: Mclaren Commercial |
$117.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.98
|
| Rate for Payer: Nomi Health Commercial |
$107.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$114.90
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$130.57
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.23 |
| Max. Negotiated Rate |
$130.57 |
| Rate for Payer: Aetna Commercial |
$117.51
|
| Rate for Payer: Aetna Medicare |
$65.28
|
| Rate for Payer: ASR ASR |
$126.65
|
| Rate for Payer: ASR Commercial |
$126.65
|
| Rate for Payer: BCBS Complete |
$52.23
|
| Rate for Payer: BCBS Trust/PPO |
$106.92
|
| Rate for Payer: BCN Commercial |
$101.23
|
| Rate for Payer: Cash Price |
$104.45
|
| Rate for Payer: Cofinity Commercial |
$122.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.46
|
| Rate for Payer: Healthscope Commercial |
$130.57
|
| Rate for Payer: Healthscope Whirlpool |
$126.65
|
| Rate for Payer: Mclaren Commercial |
$117.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.98
|
| Rate for Payer: Nomi Health Commercial |
$107.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$114.41
|
| Rate for Payer: Priority Health Narrow Network |
$91.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$114.90
|
|
|
GAUZE BANDAGE 1/2" X 5 YARD
|
Facility
|
OP
|
$13.28
|
|
|
Service Code
|
NDC 08080763200
|
| Hospital Charge Code |
111441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$13.28 |
| Rate for Payer: Aetna Commercial |
$11.95
|
| Rate for Payer: Aetna Medicare |
$6.64
|
| Rate for Payer: ASR ASR |
$12.88
|
| Rate for Payer: ASR Commercial |
$12.88
|
| Rate for Payer: BCBS Complete |
$5.31
|
| Rate for Payer: BCBS Trust/PPO |
$10.87
|
| Rate for Payer: BCN Commercial |
$10.30
|
| Rate for Payer: Cash Price |
$10.63
|
| Rate for Payer: Cofinity Commercial |
$12.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.62
|
| Rate for Payer: Healthscope Commercial |
$13.28
|
| Rate for Payer: Healthscope Whirlpool |
$12.88
|
| Rate for Payer: Mclaren Commercial |
$11.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.29
|
| Rate for Payer: Nomi Health Commercial |
$10.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.64
|
| Rate for Payer: Priority Health Narrow Network |
$9.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.69
|
|
|
GAUZE BANDAGE 1/2" X 5 YARD
|
Facility
|
IP
|
$13.28
|
|
|
Service Code
|
NDC 08080763200
|
| Hospital Charge Code |
111441
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$13.28 |
| Rate for Payer: Aetna Commercial |
$11.95
|
| Rate for Payer: ASR ASR |
$12.88
|
| Rate for Payer: ASR Commercial |
$12.88
|
| Rate for Payer: BCBS Trust/PPO |
$10.82
|
| Rate for Payer: BCN Commercial |
$10.30
|
| Rate for Payer: Cash Price |
$10.63
|
| Rate for Payer: Cofinity Commercial |
$12.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.62
|
| Rate for Payer: Healthscope Commercial |
$13.28
|
| Rate for Payer: Healthscope Whirlpool |
$12.88
|
| Rate for Payer: Mclaren Commercial |
$11.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.29
|
| Rate for Payer: Nomi Health Commercial |
$10.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.69
|
|
|
GAUZE BANDAGE 1/4" X 5 YARD
|
Facility
|
IP
|
$13.43
|
|
|
Service Code
|
NDC 08080763100
|
| Hospital Charge Code |
111543
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.73 |
| Max. Negotiated Rate |
$13.43 |
| Rate for Payer: Aetna Commercial |
$12.09
|
| Rate for Payer: ASR ASR |
$13.03
|
| Rate for Payer: ASR Commercial |
$13.03
|
| Rate for Payer: BCBS Trust/PPO |
$10.94
|
| Rate for Payer: BCN Commercial |
$10.41
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: Cofinity Commercial |
$12.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.74
|
| Rate for Payer: Healthscope Commercial |
$13.43
|
| Rate for Payer: Healthscope Whirlpool |
$13.03
|
| Rate for Payer: Mclaren Commercial |
$12.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.42
|
| Rate for Payer: Nomi Health Commercial |
$11.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.82
|
|
|
GAUZE BANDAGE 1/4" X 5 YARD
|
Facility
|
OP
|
$13.43
|
|
|
Service Code
|
NDC 08080763100
|
| Hospital Charge Code |
111543
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$13.43 |
| Rate for Payer: Aetna Commercial |
$12.09
|
| Rate for Payer: Aetna Medicare |
$6.71
|
| Rate for Payer: ASR ASR |
$13.03
|
| Rate for Payer: ASR Commercial |
$13.03
|
| Rate for Payer: BCBS Complete |
$5.37
|
| Rate for Payer: BCBS Trust/PPO |
$11.00
|
| Rate for Payer: BCN Commercial |
$10.41
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: Cofinity Commercial |
$12.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.74
|
| Rate for Payer: Healthscope Commercial |
$13.43
|
| Rate for Payer: Healthscope Whirlpool |
$13.03
|
| Rate for Payer: Mclaren Commercial |
$12.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.42
|
| Rate for Payer: Nomi Health Commercial |
$11.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.77
|
| Rate for Payer: Priority Health Narrow Network |
$9.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.82
|
|
|
GAUZE BANDAGE 1" X 5 YARD
|
Facility
|
OP
|
$16.50
|
|
|
Service Code
|
NDC 08080763300
|
| Hospital Charge Code |
111451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$16.50 |
| Rate for Payer: Aetna Commercial |
$14.85
|
| Rate for Payer: Aetna Medicare |
$8.25
|
| Rate for Payer: ASR ASR |
$16.00
|
| Rate for Payer: ASR Commercial |
$16.00
|
| Rate for Payer: BCBS Complete |
$6.60
|
| Rate for Payer: BCBS Trust/PPO |
$13.51
|
| Rate for Payer: BCN Commercial |
$12.79
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cofinity Commercial |
$15.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.20
|
| Rate for Payer: Healthscope Commercial |
$16.50
|
| Rate for Payer: Healthscope Whirlpool |
$16.00
|
| Rate for Payer: Mclaren Commercial |
$14.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.03
|
| Rate for Payer: Nomi Health Commercial |
$13.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.46
|
| Rate for Payer: Priority Health Narrow Network |
$11.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.52
|
|
|
GAUZE BANDAGE 1" X 5 YARD
|
Facility
|
IP
|
$16.50
|
|
|
Service Code
|
NDC 08080763300
|
| Hospital Charge Code |
111451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.72 |
| Max. Negotiated Rate |
$16.50 |
| Rate for Payer: Aetna Commercial |
$14.85
|
| Rate for Payer: ASR ASR |
$16.00
|
| Rate for Payer: ASR Commercial |
$16.00
|
| Rate for Payer: BCBS Trust/PPO |
$13.45
|
| Rate for Payer: BCN Commercial |
$12.79
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cofinity Commercial |
$15.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.20
|
| Rate for Payer: Healthscope Commercial |
$16.50
|
| Rate for Payer: Healthscope Whirlpool |
$16.00
|
| Rate for Payer: Mclaren Commercial |
$14.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.03
|
| Rate for Payer: Nomi Health Commercial |
$13.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.52
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
IP
|
$898.28
|
|
|
Service Code
|
NDC 00009034201
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$583.88 |
| Max. Negotiated Rate |
$898.28 |
| Rate for Payer: Aetna Commercial |
$808.45
|
| Rate for Payer: ASR ASR |
$871.33
|
| Rate for Payer: ASR Commercial |
$871.33
|
| Rate for Payer: BCBS Trust/PPO |
$732.01
|
| Rate for Payer: BCN Commercial |
$696.44
|
| Rate for Payer: Cash Price |
$718.62
|
| Rate for Payer: Cofinity Commercial |
$844.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$718.62
|
| Rate for Payer: Healthscope Commercial |
$898.28
|
| Rate for Payer: Healthscope Whirlpool |
$871.33
|
| Rate for Payer: Mclaren Commercial |
$808.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$763.54
|
| Rate for Payer: Nomi Health Commercial |
$736.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$790.49
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
OP
|
$898.28
|
|
|
Service Code
|
NDC 00009034201
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$359.31 |
| Max. Negotiated Rate |
$898.28 |
| Rate for Payer: Aetna Commercial |
$808.45
|
| Rate for Payer: Aetna Medicare |
$449.14
|
| Rate for Payer: ASR ASR |
$871.33
|
| Rate for Payer: ASR Commercial |
$871.33
|
| Rate for Payer: BCBS Complete |
$359.31
|
| Rate for Payer: BCBS Trust/PPO |
$735.60
|
| Rate for Payer: BCN Commercial |
$696.44
|
| Rate for Payer: Cash Price |
$718.62
|
| Rate for Payer: Cofinity Commercial |
$844.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$718.62
|
| Rate for Payer: Healthscope Commercial |
$898.28
|
| Rate for Payer: Healthscope Whirlpool |
$871.33
|
| Rate for Payer: Mclaren Commercial |
$808.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$763.54
|
| Rate for Payer: Nomi Health Commercial |
$736.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$583.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$787.07
|
| Rate for Payer: Priority Health Narrow Network |
$629.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$790.49
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
IP
|
$370.87
|
|
|
Service Code
|
NDC 00009031508
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$241.07 |
| Max. Negotiated Rate |
$370.87 |
| Rate for Payer: Aetna Commercial |
$333.78
|
| Rate for Payer: ASR ASR |
$359.74
|
| Rate for Payer: ASR Commercial |
$359.74
|
| Rate for Payer: BCBS Trust/PPO |
$302.22
|
| Rate for Payer: BCN Commercial |
$287.54
|
| Rate for Payer: Cash Price |
$296.70
|
| Rate for Payer: Cofinity Commercial |
$348.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$296.70
|
| Rate for Payer: Healthscope Commercial |
$370.87
|
| Rate for Payer: Healthscope Whirlpool |
$359.74
|
| Rate for Payer: Mclaren Commercial |
$333.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.24
|
| Rate for Payer: Nomi Health Commercial |
$304.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$326.37
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
IP
|
$270.31
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$175.70 |
| Max. Negotiated Rate |
$270.31 |
| Rate for Payer: Aetna Commercial |
$243.28
|
| Rate for Payer: ASR ASR |
$262.20
|
| Rate for Payer: ASR Commercial |
$262.20
|
| Rate for Payer: BCBS Trust/PPO |
$220.28
|
| Rate for Payer: BCN Commercial |
$209.57
|
| Rate for Payer: Cash Price |
$216.25
|
| Rate for Payer: Cofinity Commercial |
$254.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.25
|
| Rate for Payer: Healthscope Commercial |
$270.31
|
| Rate for Payer: Healthscope Whirlpool |
$262.20
|
| Rate for Payer: Mclaren Commercial |
$243.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.76
|
| Rate for Payer: Nomi Health Commercial |
$221.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$237.87
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
OP
|
$370.87
|
|
|
Service Code
|
NDC 00009031508
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.35 |
| Max. Negotiated Rate |
$370.87 |
| Rate for Payer: Aetna Commercial |
$333.78
|
| Rate for Payer: Aetna Medicare |
$185.44
|
| Rate for Payer: ASR ASR |
$359.74
|
| Rate for Payer: ASR Commercial |
$359.74
|
| Rate for Payer: BCBS Complete |
$148.35
|
| Rate for Payer: BCBS Trust/PPO |
$303.71
|
| Rate for Payer: BCN Commercial |
$287.54
|
| Rate for Payer: Cash Price |
$296.70
|
| Rate for Payer: Cofinity Commercial |
$348.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$296.70
|
| Rate for Payer: Healthscope Commercial |
$370.87
|
| Rate for Payer: Healthscope Whirlpool |
$359.74
|
| Rate for Payer: Mclaren Commercial |
$333.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.24
|
| Rate for Payer: Nomi Health Commercial |
$304.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$324.96
|
| Rate for Payer: Priority Health Narrow Network |
$259.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$326.37
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
OP
|
$270.31
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.12 |
| Max. Negotiated Rate |
$270.31 |
| Rate for Payer: Aetna Commercial |
$243.28
|
| Rate for Payer: Aetna Medicare |
$135.16
|
| Rate for Payer: ASR ASR |
$262.20
|
| Rate for Payer: ASR Commercial |
$262.20
|
| Rate for Payer: BCBS Complete |
$108.12
|
| Rate for Payer: BCBS Trust/PPO |
$221.36
|
| Rate for Payer: BCN Commercial |
$209.57
|
| Rate for Payer: Cash Price |
$216.25
|
| Rate for Payer: Cofinity Commercial |
$254.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.25
|
| Rate for Payer: Healthscope Commercial |
$270.31
|
| Rate for Payer: Healthscope Whirlpool |
$262.20
|
| Rate for Payer: Mclaren Commercial |
$243.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.76
|
| Rate for Payer: Nomi Health Commercial |
$221.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$236.85
|
| Rate for Payer: Priority Health Narrow Network |
$189.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$237.87
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$18.23
|
|
|
Service Code
|
NDC 60758018805
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$18.23 |
| Rate for Payer: Aetna Commercial |
$16.41
|
| Rate for Payer: Aetna Medicare |
$9.12
|
| Rate for Payer: ASR ASR |
$17.68
|
| Rate for Payer: ASR Commercial |
$17.68
|
| Rate for Payer: BCBS Complete |
$7.29
|
| Rate for Payer: BCBS Trust/PPO |
$14.93
|
| Rate for Payer: BCN Commercial |
$14.13
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Commercial |
$17.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$18.23
|
| Rate for Payer: Healthscope Whirlpool |
$17.68
|
| Rate for Payer: Mclaren Commercial |
$16.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.50
|
| Rate for Payer: Nomi Health Commercial |
$14.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.97
|
| Rate for Payer: Priority Health Narrow Network |
$12.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.04
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$116.24
|
|
|
Service Code
|
NDC 24208058060
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.56 |
| Max. Negotiated Rate |
$116.24 |
| Rate for Payer: Aetna Commercial |
$104.62
|
| Rate for Payer: ASR ASR |
$112.75
|
| Rate for Payer: ASR Commercial |
$112.75
|
| Rate for Payer: BCBS Trust/PPO |
$94.72
|
| Rate for Payer: BCN Commercial |
$90.12
|
| Rate for Payer: Cash Price |
$92.99
|
| Rate for Payer: Cofinity Commercial |
$109.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.99
|
| Rate for Payer: Healthscope Commercial |
$116.24
|
| Rate for Payer: Healthscope Whirlpool |
$112.75
|
| Rate for Payer: Mclaren Commercial |
$104.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.80
|
| Rate for Payer: Nomi Health Commercial |
$95.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.29
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$116.24
|
|
|
Service Code
|
NDC 24208058060
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$116.24 |
| Rate for Payer: Aetna Commercial |
$104.62
|
| Rate for Payer: Aetna Medicare |
$58.12
|
| Rate for Payer: ASR ASR |
$112.75
|
| Rate for Payer: ASR Commercial |
$112.75
|
| Rate for Payer: BCBS Complete |
$46.50
|
| Rate for Payer: BCBS Trust/PPO |
$95.19
|
| Rate for Payer: BCN Commercial |
$90.12
|
| Rate for Payer: Cash Price |
$92.99
|
| Rate for Payer: Cofinity Commercial |
$109.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.99
|
| Rate for Payer: Healthscope Commercial |
$116.24
|
| Rate for Payer: Healthscope Whirlpool |
$112.75
|
| Rate for Payer: Mclaren Commercial |
$104.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.80
|
| Rate for Payer: Nomi Health Commercial |
$95.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$101.85
|
| Rate for Payer: Priority Health Narrow Network |
$81.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.29
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$19.22
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$19.22 |
| Rate for Payer: Aetna Commercial |
$17.30
|
| Rate for Payer: Aetna Medicare |
$9.61
|
| Rate for Payer: ASR ASR |
$18.64
|
| Rate for Payer: ASR Commercial |
$18.64
|
| Rate for Payer: BCBS Complete |
$7.69
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCN Commercial |
$14.90
|
| Rate for Payer: Cash Price |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Healthscope Commercial |
$19.22
|
| Rate for Payer: Healthscope Whirlpool |
$18.64
|
| Rate for Payer: Mclaren Commercial |
$17.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.34
|
| Rate for Payer: Nomi Health Commercial |
$15.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.84
|
| Rate for Payer: Priority Health Narrow Network |
$13.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.91
|
|
