|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$18.23
|
|
|
Service Code
|
NDC 60758018805
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$18.23 |
| Rate for Payer: Aetna Commercial |
$16.41
|
| Rate for Payer: ASR ASR |
$17.68
|
| Rate for Payer: ASR Commercial |
$17.68
|
| Rate for Payer: BCBS Trust/PPO |
$14.86
|
| 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: UHC All Payor (Choice/PPO) + Core |
$16.04
|
|
|
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 40 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$336.69
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.68 |
| Max. Negotiated Rate |
$336.69 |
| Rate for Payer: Aetna Commercial |
$303.02
|
| Rate for Payer: Aetna Commercial |
$41.27
|
| Rate for Payer: Aetna Commercial |
$18.68
|
| Rate for Payer: Aetna Commercial |
$31.18
|
| Rate for Payer: Aetna Medicare |
$22.93
|
| Rate for Payer: Aetna Medicare |
$168.34
|
| Rate for Payer: Aetna Medicare |
$17.32
|
| Rate for Payer: Aetna Medicare |
$10.38
|
| Rate for Payer: ASR ASR |
$33.61
|
| Rate for Payer: ASR ASR |
$20.13
|
| Rate for Payer: ASR ASR |
$44.47
|
| Rate for Payer: ASR ASR |
$326.59
|
| Rate for Payer: ASR Commercial |
$326.59
|
| Rate for Payer: ASR Commercial |
$33.61
|
| Rate for Payer: ASR Commercial |
$44.47
|
| Rate for Payer: ASR Commercial |
$20.13
|
| Rate for Payer: BCBS Complete |
$8.30
|
| Rate for Payer: BCBS Complete |
$18.34
|
| Rate for Payer: BCBS Complete |
$13.86
|
| Rate for Payer: BCBS Complete |
$134.68
|
| Rate for Payer: BCBS Trust/PPO |
$275.72
|
| Rate for Payer: BCBS Trust/PPO |
$37.55
|
| Rate for Payer: BCBS Trust/PPO |
$16.99
|
| Rate for Payer: BCBS Trust/PPO |
$28.37
|
| Rate for Payer: BCN Commercial |
$35.55
|
| Rate for Payer: BCN Commercial |
$261.04
|
| Rate for Payer: BCN Commercial |
$16.09
|
| Rate for Payer: BCN Commercial |
$26.86
|
| Rate for Payer: Cash Price |
$269.35
|
| Rate for Payer: Cash Price |
$16.60
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cash Price |
$36.68
|
| Rate for Payer: Cofinity Commercial |
$19.50
|
| Rate for Payer: Cofinity Commercial |
$316.49
|
| Rate for Payer: Cofinity Commercial |
$32.57
|
| Rate for Payer: Cofinity Commercial |
$43.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.35
|
| Rate for Payer: Healthscope Commercial |
$34.65
|
| Rate for Payer: Healthscope Commercial |
$20.75
|
| Rate for Payer: Healthscope Commercial |
$336.69
|
| Rate for Payer: Healthscope Commercial |
$45.85
|
| Rate for Payer: Healthscope Whirlpool |
$44.47
|
| Rate for Payer: Healthscope Whirlpool |
$33.61
|
| Rate for Payer: Healthscope Whirlpool |
$326.59
|
| Rate for Payer: Healthscope Whirlpool |
$20.13
|
| Rate for Payer: Mclaren Commercial |
$18.68
|
| Rate for Payer: Mclaren Commercial |
$303.02
|
| Rate for Payer: Mclaren Commercial |
$31.18
|
| Rate for Payer: Mclaren Commercial |
$41.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$286.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.45
|
| Rate for Payer: Nomi Health Commercial |
$28.41
|
| Rate for Payer: Nomi Health Commercial |
$276.09
|
| Rate for Payer: Nomi Health Commercial |
$37.60
|
| Rate for Payer: Nomi Health Commercial |
$17.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$30.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$295.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.18
|
| Rate for Payer: Priority Health Narrow Network |
$24.29
|
| Rate for Payer: Priority Health Narrow Network |
$236.02
|
| Rate for Payer: Priority Health Narrow Network |
$32.14
|
| Rate for Payer: Priority Health Narrow Network |
$14.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$296.29
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$34.65
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.52 |
| Max. Negotiated Rate |
$34.65 |
| Rate for Payer: Aetna Commercial |
$31.18
|
| Rate for Payer: Aetna Commercial |
$303.02
|
| Rate for Payer: Aetna Commercial |
$41.27
|
| Rate for Payer: Aetna Commercial |
$18.68
|
| Rate for Payer: ASR ASR |
$20.13
|
| Rate for Payer: ASR ASR |
$33.61
|
| Rate for Payer: ASR ASR |
$326.59
|
| Rate for Payer: ASR ASR |
$44.47
|
| Rate for Payer: ASR Commercial |
$33.61
|
| Rate for Payer: ASR Commercial |
$44.47
|
| Rate for Payer: ASR Commercial |
$326.59
|
| Rate for Payer: ASR Commercial |
$20.13
|
| Rate for Payer: BCBS Trust/PPO |
$37.36
|
| Rate for Payer: BCBS Trust/PPO |
$16.91
|
| Rate for Payer: BCBS Trust/PPO |
$274.37
|
| Rate for Payer: BCBS Trust/PPO |
$28.24
|
| Rate for Payer: BCN Commercial |
$35.55
|
| Rate for Payer: BCN Commercial |
$16.09
|
| Rate for Payer: BCN Commercial |
$26.86
|
| Rate for Payer: BCN Commercial |
$261.04
|
| Rate for Payer: Cash Price |
$269.35
|
| Rate for Payer: Cash Price |
$16.60
|
| Rate for Payer: Cash Price |
$36.68
|
| Rate for Payer: Cash Price |
$27.72
|
| Rate for Payer: Cofinity Commercial |
$32.57
|
| Rate for Payer: Cofinity Commercial |
$316.49
|
| Rate for Payer: Cofinity Commercial |
$43.10
|
| Rate for Payer: Cofinity Commercial |
$19.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.72
|
| Rate for Payer: Healthscope Commercial |
$336.69
|
| Rate for Payer: Healthscope Commercial |
$20.75
|
| Rate for Payer: Healthscope Commercial |
$34.65
|
| Rate for Payer: Healthscope Commercial |
$45.85
|
| Rate for Payer: Healthscope Whirlpool |
$44.47
|
| Rate for Payer: Healthscope Whirlpool |
$326.59
|
| Rate for Payer: Healthscope Whirlpool |
$33.61
|
| Rate for Payer: Healthscope Whirlpool |
$20.13
|
| Rate for Payer: Mclaren Commercial |
$31.18
|
| Rate for Payer: Mclaren Commercial |
$41.27
|
| Rate for Payer: Mclaren Commercial |
$303.02
|
| Rate for Payer: Mclaren Commercial |
$18.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$286.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.64
|
| Rate for Payer: Nomi Health Commercial |
$17.02
|
| Rate for Payer: Nomi Health Commercial |
$37.60
|
| Rate for Payer: Nomi Health Commercial |
$28.41
|
| Rate for Payer: Nomi Health Commercial |
$276.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$296.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.26
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION
|
Facility
|
IP
|
$28.04
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
117665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.23 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Aetna Commercial |
$25.24
|
| Rate for Payer: ASR ASR |
$27.20
|
| Rate for Payer: ASR Commercial |
$27.20
|
| Rate for Payer: BCBS Trust/PPO |
$22.85
|
| Rate for Payer: BCN Commercial |
$21.74
|
| Rate for Payer: Cash Price |
$22.43
|
| Rate for Payer: Cofinity Commercial |
$26.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.43
|
| Rate for Payer: Healthscope Commercial |
$28.04
|
| Rate for Payer: Healthscope Whirlpool |
$27.20
|
| Rate for Payer: Mclaren Commercial |
$25.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.83
|
| Rate for Payer: Nomi Health Commercial |
$22.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.68
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION
|
Facility
|
OP
|
$28.04
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
117665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.22 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Aetna Commercial |
$25.24
|
| Rate for Payer: Aetna Medicare |
$14.02
|
| Rate for Payer: ASR ASR |
$27.20
|
| Rate for Payer: ASR Commercial |
$27.20
|
| Rate for Payer: BCBS Complete |
$11.22
|
| Rate for Payer: BCBS Trust/PPO |
$22.96
|
| Rate for Payer: BCN Commercial |
$21.74
|
| Rate for Payer: Cash Price |
$22.43
|
| Rate for Payer: Cofinity Commercial |
$26.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.43
|
| Rate for Payer: Healthscope Commercial |
$28.04
|
| Rate for Payer: Healthscope Whirlpool |
$27.20
|
| Rate for Payer: Mclaren Commercial |
$25.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.83
|
| Rate for Payer: Nomi Health Commercial |
$22.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24.57
|
| Rate for Payer: Priority Health Narrow Network |
$19.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.68
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 16729000201
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.03
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: ASR Commercial |
$79.78
|
| Rate for Payer: BCBS Trust/PPO |
$67.03
|
| Rate for Payer: BCN Commercial |
$63.77
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$77.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Healthscope Whirlpool |
$79.78
|
| Rate for Payer: Mclaren Commercial |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
OP
|
$418.00
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.20 |
| Max. Negotiated Rate |
$418.00 |
| Rate for Payer: Aetna Commercial |
$376.20
|
| Rate for Payer: Aetna Medicare |
$209.00
|
| Rate for Payer: ASR ASR |
$405.46
|
| Rate for Payer: ASR Commercial |
$405.46
|
| Rate for Payer: BCBS Complete |
$167.20
|
| Rate for Payer: BCBS Trust/PPO |
$342.30
|
| Rate for Payer: BCN Commercial |
$324.08
|
| Rate for Payer: Cash Price |
$334.40
|
| Rate for Payer: Cofinity Commercial |
$392.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.40
|
| Rate for Payer: Healthscope Commercial |
$418.00
|
| Rate for Payer: Healthscope Whirlpool |
$405.46
|
| Rate for Payer: Mclaren Commercial |
$376.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.30
|
| Rate for Payer: Nomi Health Commercial |
$342.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$366.25
|
| Rate for Payer: Priority Health Narrow Network |
$293.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$367.84
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 55111032101
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.74 |
| Max. Negotiated Rate |
$105.75 |
| Rate for Payer: Aetna Commercial |
$95.17
|
| Rate for Payer: ASR ASR |
$102.58
|
| Rate for Payer: ASR Commercial |
$102.58
|
| Rate for Payer: BCBS Trust/PPO |
$86.18
|
| Rate for Payer: BCN Commercial |
$81.99
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$99.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$105.75
|
| Rate for Payer: Healthscope Whirlpool |
$102.58
|
| Rate for Payer: Mclaren Commercial |
$95.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: Nomi Health Commercial |
$86.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$93.06
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
OP
|
$82.25
|
|
|
Service Code
|
NDC 16729000201
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.03
|
| Rate for Payer: Aetna Medicare |
$41.12
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: ASR Commercial |
$79.78
|
| Rate for Payer: BCBS Complete |
$32.90
|
| Rate for Payer: BCBS Trust/PPO |
$67.35
|
| Rate for Payer: BCN Commercial |
$63.77
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$77.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Healthscope Whirlpool |
$79.78
|
| Rate for Payer: Mclaren Commercial |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$72.07
|
| Rate for Payer: Priority Health Narrow Network |
$57.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$418.00
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.70 |
| Max. Negotiated Rate |
$418.00 |
| Rate for Payer: Aetna Commercial |
$376.20
|
| Rate for Payer: ASR ASR |
$405.46
|
| Rate for Payer: ASR Commercial |
$405.46
|
| Rate for Payer: BCBS Trust/PPO |
$340.63
|
| Rate for Payer: BCN Commercial |
$324.08
|
| Rate for Payer: Cash Price |
$334.40
|
| Rate for Payer: Cofinity Commercial |
$392.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.40
|
| Rate for Payer: Healthscope Commercial |
$418.00
|
| Rate for Payer: Healthscope Whirlpool |
$405.46
|
| Rate for Payer: Mclaren Commercial |
$376.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.30
|
| Rate for Payer: Nomi Health Commercial |
$342.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$367.84
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
IP
|
$4.18
|
|
|
Service Code
|
NDC 68084032611
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: ASR ASR |
$4.05
|
| Rate for Payer: ASR Commercial |
$4.05
|
| Rate for Payer: BCBS Trust/PPO |
$3.41
|
| Rate for Payer: BCN Commercial |
$3.24
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cofinity Commercial |
$3.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.34
|
| Rate for Payer: Healthscope Commercial |
$4.18
|
| Rate for Payer: Healthscope Whirlpool |
$4.05
|
| Rate for Payer: Mclaren Commercial |
$3.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.55
|
| Rate for Payer: Nomi Health Commercial |
$3.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.68
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
OP
|
$4.18
|
|
|
Service Code
|
NDC 68084032611
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Aetna Medicare |
$2.09
|
| Rate for Payer: ASR ASR |
$4.05
|
| Rate for Payer: ASR Commercial |
$4.05
|
| Rate for Payer: BCBS Complete |
$1.67
|
| Rate for Payer: BCBS Trust/PPO |
$3.42
|
| Rate for Payer: BCN Commercial |
$3.24
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cofinity Commercial |
$3.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.34
|
| Rate for Payer: Healthscope Commercial |
$4.18
|
| Rate for Payer: Healthscope Whirlpool |
$4.05
|
| Rate for Payer: Mclaren Commercial |
$3.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.55
|
| Rate for Payer: Nomi Health Commercial |
$3.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.66
|
| Rate for Payer: Priority Health Narrow Network |
$2.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.68
|
|
|
GLIMEPIRIDE 2 MG TABLET
|
Facility
|
OP
|
$105.75
|
|
|
Service Code
|
NDC 55111032101
|
| Hospital Charge Code |
16356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$105.75 |
| Rate for Payer: Aetna Commercial |
$95.17
|
| Rate for Payer: Aetna Medicare |
$52.88
|
| Rate for Payer: ASR ASR |
$102.58
|
| Rate for Payer: ASR Commercial |
$102.58
|
| Rate for Payer: BCBS Complete |
$42.30
|
| Rate for Payer: BCBS Trust/PPO |
$86.60
|
| Rate for Payer: BCN Commercial |
$81.99
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$99.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$105.75
|
| Rate for Payer: Healthscope Whirlpool |
$102.58
|
| Rate for Payer: Mclaren Commercial |
$95.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: Nomi Health Commercial |
$86.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$92.66
|
| Rate for Payer: Priority Health Narrow Network |
$74.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$93.06
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
IP
|
$232.75
|
|
|
Service Code
|
NDC 00904663761
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.29 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Aetna Commercial |
$209.47
|
| Rate for Payer: ASR ASR |
$225.77
|
| Rate for Payer: ASR Commercial |
$225.77
|
| Rate for Payer: BCBS Trust/PPO |
$189.67
|
| Rate for Payer: BCN Commercial |
$180.45
|
| Rate for Payer: Cash Price |
$186.20
|
| Rate for Payer: Cofinity Commercial |
$218.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.20
|
| Rate for Payer: Healthscope Commercial |
$232.75
|
| Rate for Payer: Healthscope Whirlpool |
$225.77
|
| Rate for Payer: Mclaren Commercial |
$209.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.84
|
| Rate for Payer: Nomi Health Commercial |
$190.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$204.82
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
OP
|
$206.15
|
|
|
Service Code
|
NDC 51079081020
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.46 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Aetna Commercial |
$185.53
|
| Rate for Payer: Aetna Medicare |
$103.08
|
| Rate for Payer: ASR ASR |
$199.97
|
| Rate for Payer: ASR Commercial |
$199.97
|
| Rate for Payer: BCBS Complete |
$82.46
|
| Rate for Payer: BCBS Trust/PPO |
$168.82
|
| Rate for Payer: BCN Commercial |
$159.83
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Cofinity Commercial |
$193.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.92
|
| Rate for Payer: Healthscope Commercial |
$206.15
|
| Rate for Payer: Healthscope Whirlpool |
$199.97
|
| Rate for Payer: Mclaren Commercial |
$185.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.23
|
| Rate for Payer: Nomi Health Commercial |
$169.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$180.63
|
| Rate for Payer: Priority Health Narrow Network |
$144.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.41
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
OP
|
$2.06
|
|
|
Service Code
|
NDC 51079081001
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna Commercial |
$1.85
|
| Rate for Payer: Aetna Medicare |
$1.03
|
| Rate for Payer: ASR ASR |
$2.00
|
| Rate for Payer: ASR Commercial |
$2.00
|
| Rate for Payer: BCBS Complete |
$0.82
|
| Rate for Payer: BCBS Trust/PPO |
$1.69
|
| Rate for Payer: BCN Commercial |
$1.60
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cofinity Commercial |
$1.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.65
|
| Rate for Payer: Healthscope Commercial |
$2.06
|
| Rate for Payer: Healthscope Whirlpool |
$2.00
|
| Rate for Payer: Mclaren Commercial |
$1.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.75
|
| Rate for Payer: Nomi Health Commercial |
$1.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.80
|
| Rate for Payer: Priority Health Narrow Network |
$1.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.81
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
IP
|
$2.06
|
|
|
Service Code
|
NDC 51079081001
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna Commercial |
$1.85
|
| Rate for Payer: ASR ASR |
$2.00
|
| Rate for Payer: ASR Commercial |
$2.00
|
| Rate for Payer: BCBS Trust/PPO |
$1.68
|
| Rate for Payer: BCN Commercial |
$1.60
|
| Rate for Payer: Cash Price |
$1.65
|
| Rate for Payer: Cofinity Commercial |
$1.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.65
|
| Rate for Payer: Healthscope Commercial |
$2.06
|
| Rate for Payer: Healthscope Whirlpool |
$2.00
|
| Rate for Payer: Mclaren Commercial |
$1.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.75
|
| Rate for Payer: Nomi Health Commercial |
$1.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.81
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
IP
|
$206.15
|
|
|
Service Code
|
NDC 51079081020
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.00 |
| Max. Negotiated Rate |
$206.15 |
| Rate for Payer: Aetna Commercial |
$185.53
|
| Rate for Payer: ASR ASR |
$199.97
|
| Rate for Payer: ASR Commercial |
$199.97
|
| Rate for Payer: BCBS Trust/PPO |
$167.99
|
| Rate for Payer: BCN Commercial |
$159.83
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Cofinity Commercial |
$193.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.92
|
| Rate for Payer: Healthscope Commercial |
$206.15
|
| Rate for Payer: Healthscope Whirlpool |
$199.97
|
| Rate for Payer: Mclaren Commercial |
$185.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.23
|
| Rate for Payer: Nomi Health Commercial |
$169.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.41
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
OP
|
$232.75
|
|
|
Service Code
|
NDC 00904663761
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.10 |
| Max. Negotiated Rate |
$232.75 |
| Rate for Payer: Aetna Commercial |
$209.47
|
| Rate for Payer: Aetna Medicare |
$116.38
|
| Rate for Payer: ASR ASR |
$225.77
|
| Rate for Payer: ASR Commercial |
$225.77
|
| Rate for Payer: BCBS Complete |
$93.10
|
| Rate for Payer: BCBS Trust/PPO |
$190.60
|
| Rate for Payer: BCN Commercial |
$180.45
|
| Rate for Payer: Cash Price |
$186.20
|
| Rate for Payer: Cofinity Commercial |
$218.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.20
|
| Rate for Payer: Healthscope Commercial |
$232.75
|
| Rate for Payer: Healthscope Whirlpool |
$225.77
|
| Rate for Payer: Mclaren Commercial |
$209.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.84
|
| Rate for Payer: Nomi Health Commercial |
$190.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$203.94
|
| Rate for Payer: Priority Health Narrow Network |
$163.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$204.82
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$256.50
|
|
|
Service Code
|
NDC 00591084401
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.72 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna Commercial |
$230.85
|
| Rate for Payer: ASR ASR |
$248.81
|
| Rate for Payer: ASR Commercial |
$248.81
|
| Rate for Payer: BCBS Trust/PPO |
$209.02
|
| Rate for Payer: BCN Commercial |
$198.86
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cofinity Commercial |
$241.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.20
|
| Rate for Payer: Healthscope Commercial |
$256.50
|
| Rate for Payer: Healthscope Whirlpool |
$248.81
|
| Rate for Payer: Mclaren Commercial |
$230.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$218.03
|
| Rate for Payer: Nomi Health Commercial |
$210.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$225.72
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$256.50
|
|
|
Service Code
|
NDC 00591084401
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.60 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna Commercial |
$230.85
|
| Rate for Payer: Aetna Medicare |
$128.25
|
| Rate for Payer: ASR ASR |
$248.81
|
| Rate for Payer: ASR Commercial |
$248.81
|
| Rate for Payer: BCBS Complete |
$102.60
|
| Rate for Payer: BCBS Trust/PPO |
$210.05
|
| Rate for Payer: BCN Commercial |
$198.86
|
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Cofinity Commercial |
$241.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.20
|
| Rate for Payer: Healthscope Commercial |
$256.50
|
| Rate for Payer: Healthscope Whirlpool |
$248.81
|
| Rate for Payer: Mclaren Commercial |
$230.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$218.03
|
| Rate for Payer: Nomi Health Commercial |
$210.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$224.75
|
| Rate for Payer: Priority Health Narrow Network |
$179.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$225.72
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$213.85
|
|
|
Service Code
|
NDC 59651026901
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.00 |
| Max. Negotiated Rate |
$213.85 |
| Rate for Payer: Aetna Commercial |
$192.47
|
| Rate for Payer: ASR ASR |
$207.43
|
| Rate for Payer: ASR Commercial |
$207.43
|
| Rate for Payer: BCBS Trust/PPO |
$174.27
|
| Rate for Payer: BCN Commercial |
$165.80
|
| Rate for Payer: Cash Price |
$171.08
|
| Rate for Payer: Cofinity Commercial |
$201.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.08
|
| Rate for Payer: Healthscope Commercial |
$213.85
|
| Rate for Payer: Healthscope Whirlpool |
$207.43
|
| Rate for Payer: Mclaren Commercial |
$192.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.77
|
| Rate for Payer: Nomi Health Commercial |
$175.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$188.19
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$2.68
|
|
|
Service Code
|
NDC 68084011111
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Aetna Commercial |
$2.41
|
| Rate for Payer: ASR ASR |
$2.60
|
| Rate for Payer: ASR Commercial |
$2.60
|
| Rate for Payer: BCBS Trust/PPO |
$2.18
|
| Rate for Payer: BCN Commercial |
$2.08
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.14
|
| Rate for Payer: Healthscope Commercial |
$2.68
|
| Rate for Payer: Healthscope Whirlpool |
$2.60
|
| Rate for Payer: Mclaren Commercial |
$2.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.28
|
| Rate for Payer: Nomi Health Commercial |
$2.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.36
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$2.68
|
|
|
Service Code
|
NDC 68084011111
|
| Hospital Charge Code |
37649
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Aetna Commercial |
$2.41
|
| Rate for Payer: Aetna Medicare |
$1.34
|
| Rate for Payer: ASR ASR |
$2.60
|
| Rate for Payer: ASR Commercial |
$2.60
|
| Rate for Payer: BCBS Complete |
$1.07
|
| Rate for Payer: BCBS Trust/PPO |
$2.19
|
| Rate for Payer: BCN Commercial |
$2.08
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.14
|
| Rate for Payer: Healthscope Commercial |
$2.68
|
| Rate for Payer: Healthscope Whirlpool |
$2.60
|
| Rate for Payer: Mclaren Commercial |
$2.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.28
|
| Rate for Payer: Nomi Health Commercial |
$2.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.35
|
| Rate for Payer: Priority Health Narrow Network |
$1.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.36
|
|
