|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
IP
|
$9.34
|
|
|
Service Code
|
NDC 50268005411
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.07 |
| Max. Negotiated Rate |
$9.34 |
| Rate for Payer: Aetna Commercial |
$8.41
|
| Rate for Payer: ASR ASR |
$9.06
|
| Rate for Payer: ASR Commercial |
$9.06
|
| Rate for Payer: BCBS Trust/PPO |
$7.61
|
| Rate for Payer: BCN Commercial |
$7.24
|
| Rate for Payer: Cash Price |
$7.47
|
| Rate for Payer: Cofinity Commercial |
$8.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.47
|
| Rate for Payer: Healthscope Commercial |
$9.34
|
| Rate for Payer: Healthscope Whirlpool |
$9.06
|
| Rate for Payer: Mclaren Commercial |
$8.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.94
|
| Rate for Payer: Nomi Health Commercial |
$7.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.22
|
|
|
ACETAZOLAMIDE 250 MG TABLET
|
Facility
|
OP
|
$309.70
|
|
|
Service Code
|
NDC 23155028801
|
| Hospital Charge Code |
113
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.88 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$278.73
|
| Rate for Payer: Aetna Medicare |
$154.85
|
| Rate for Payer: ASR ASR |
$300.41
|
| Rate for Payer: ASR Commercial |
$300.41
|
| Rate for Payer: BCBS Complete |
$123.88
|
| Rate for Payer: BCBS Trust/PPO |
$253.61
|
| Rate for Payer: BCN Commercial |
$240.11
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$291.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$309.70
|
| Rate for Payer: Healthscope Whirlpool |
$300.41
|
| Rate for Payer: Mclaren Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.24
|
| Rate for Payer: Nomi Health Commercial |
$253.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$271.36
|
| Rate for Payer: Priority Health Narrow Network |
$217.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$272.54
|
|
|
ACETIC ACID (BULK) 3 % LIQUID
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
NDC 51552005106
|
| Hospital Charge Code |
15091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.80 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: Aetna Medicare |
$96.00
|
| Rate for Payer: ASR ASR |
$186.24
|
| Rate for Payer: ASR Commercial |
$186.24
|
| Rate for Payer: BCBS Complete |
$76.80
|
| Rate for Payer: BCBS Trust/PPO |
$157.23
|
| Rate for Payer: BCN Commercial |
$148.86
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Cofinity Commercial |
$180.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.60
|
| Rate for Payer: Healthscope Commercial |
$192.00
|
| Rate for Payer: Healthscope Whirlpool |
$186.24
|
| Rate for Payer: Mclaren Commercial |
$172.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.20
|
| Rate for Payer: Nomi Health Commercial |
$157.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$168.23
|
| Rate for Payer: Priority Health Narrow Network |
$134.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$168.96
|
|
|
ACETIC ACID (BULK) 3 % LIQUID
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
NDC 51552005106
|
| Hospital Charge Code |
15091
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.80 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$172.80
|
| Rate for Payer: ASR ASR |
$186.24
|
| Rate for Payer: ASR Commercial |
$186.24
|
| Rate for Payer: BCBS Trust/PPO |
$156.46
|
| Rate for Payer: BCN Commercial |
$148.86
|
| Rate for Payer: Cash Price |
$153.60
|
| Rate for Payer: Cofinity Commercial |
$180.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.60
|
| Rate for Payer: Healthscope Commercial |
$192.00
|
| Rate for Payer: Healthscope Whirlpool |
$186.24
|
| Rate for Payer: Mclaren Commercial |
$172.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.20
|
| Rate for Payer: Nomi Health Commercial |
$157.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$168.96
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$677.02
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$440.06 |
| Max. Negotiated Rate |
$677.02 |
| Rate for Payer: Aetna Commercial |
$609.32
|
| Rate for Payer: Aetna Commercial |
$154.64
|
| Rate for Payer: Aetna Commercial |
$85.67
|
| Rate for Payer: Aetna Commercial |
$121.11
|
| Rate for Payer: ASR ASR |
$130.53
|
| Rate for Payer: ASR ASR |
$656.71
|
| Rate for Payer: ASR ASR |
$166.67
|
| Rate for Payer: ASR ASR |
$92.33
|
| Rate for Payer: ASR Commercial |
$656.71
|
| Rate for Payer: ASR Commercial |
$92.33
|
| Rate for Payer: ASR Commercial |
$166.67
|
| Rate for Payer: ASR Commercial |
$130.53
|
| Rate for Payer: BCBS Trust/PPO |
$77.57
|
| Rate for Payer: BCBS Trust/PPO |
$109.66
|
| Rate for Payer: BCBS Trust/PPO |
$140.02
|
| Rate for Payer: BCBS Trust/PPO |
$551.70
|
| Rate for Payer: BCN Commercial |
$73.80
|
| Rate for Payer: BCN Commercial |
$104.33
|
| Rate for Payer: BCN Commercial |
$524.89
|
| Rate for Payer: BCN Commercial |
$133.21
|
| Rate for Payer: Cash Price |
$137.45
|
| Rate for Payer: Cash Price |
$107.65
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$541.62
|
| Rate for Payer: Cofinity Commercial |
$636.40
|
| Rate for Payer: Cofinity Commercial |
$161.51
|
| Rate for Payer: Cofinity Commercial |
$89.48
|
| Rate for Payer: Cofinity Commercial |
$126.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$137.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$541.62
|
| Rate for Payer: Healthscope Commercial |
$171.82
|
| Rate for Payer: Healthscope Commercial |
$134.57
|
| Rate for Payer: Healthscope Commercial |
$677.02
|
| Rate for Payer: Healthscope Commercial |
$95.19
|
| Rate for Payer: Healthscope Whirlpool |
$92.33
|
| Rate for Payer: Healthscope Whirlpool |
$166.67
|
| Rate for Payer: Healthscope Whirlpool |
$656.71
|
| Rate for Payer: Healthscope Whirlpool |
$130.53
|
| Rate for Payer: Mclaren Commercial |
$609.32
|
| Rate for Payer: Mclaren Commercial |
$85.67
|
| Rate for Payer: Mclaren Commercial |
$154.64
|
| Rate for Payer: Mclaren Commercial |
$121.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$575.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.38
|
| Rate for Payer: Nomi Health Commercial |
$110.35
|
| Rate for Payer: Nomi Health Commercial |
$78.06
|
| Rate for Payer: Nomi Health Commercial |
$555.16
|
| Rate for Payer: Nomi Health Commercial |
$140.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$440.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$151.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$595.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$118.42
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$95.19
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
38303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$95.19 |
| Rate for Payer: Aetna Commercial |
$85.67
|
| Rate for Payer: Aetna Commercial |
$609.32
|
| Rate for Payer: Aetna Commercial |
$121.11
|
| Rate for Payer: Aetna Commercial |
$154.64
|
| Rate for Payer: Aetna Medicare |
$338.51
|
| Rate for Payer: Aetna Medicare |
$67.28
|
| Rate for Payer: Aetna Medicare |
$85.91
|
| Rate for Payer: Aetna Medicare |
$47.60
|
| Rate for Payer: ASR ASR |
$130.53
|
| Rate for Payer: ASR ASR |
$166.67
|
| Rate for Payer: ASR ASR |
$656.71
|
| Rate for Payer: ASR ASR |
$92.33
|
| Rate for Payer: ASR Commercial |
$130.53
|
| Rate for Payer: ASR Commercial |
$656.71
|
| Rate for Payer: ASR Commercial |
$92.33
|
| Rate for Payer: ASR Commercial |
$166.67
|
| Rate for Payer: BCBS Complete |
$270.81
|
| Rate for Payer: BCBS Complete |
$38.08
|
| Rate for Payer: BCBS Complete |
$53.83
|
| Rate for Payer: BCBS Complete |
$68.73
|
| Rate for Payer: BCBS Trust/PPO |
$77.95
|
| Rate for Payer: BCBS Trust/PPO |
$140.70
|
| Rate for Payer: BCBS Trust/PPO |
$110.20
|
| Rate for Payer: BCBS Trust/PPO |
$554.41
|
| Rate for Payer: BCN Commercial |
$104.33
|
| Rate for Payer: BCN Commercial |
$73.80
|
| Rate for Payer: BCN Commercial |
$133.21
|
| Rate for Payer: BCN Commercial |
$524.89
|
| Rate for Payer: Cash Price |
$541.62
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cash Price |
$107.65
|
| Rate for Payer: Cash Price |
$137.45
|
| Rate for Payer: Cash Price |
$137.45
|
| Rate for Payer: Cash Price |
$107.65
|
| Rate for Payer: Cash Price |
$541.62
|
| Rate for Payer: Cash Price |
$76.15
|
| Rate for Payer: Cofinity Commercial |
$161.51
|
| Rate for Payer: Cofinity Commercial |
$126.50
|
| Rate for Payer: Cofinity Commercial |
$636.40
|
| Rate for Payer: Cofinity Commercial |
$89.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$137.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$541.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.66
|
| Rate for Payer: Healthscope Commercial |
$95.19
|
| Rate for Payer: Healthscope Commercial |
$171.82
|
| Rate for Payer: Healthscope Commercial |
$134.57
|
| Rate for Payer: Healthscope Commercial |
$677.02
|
| Rate for Payer: Healthscope Whirlpool |
$166.67
|
| Rate for Payer: Healthscope Whirlpool |
$130.53
|
| Rate for Payer: Healthscope Whirlpool |
$656.71
|
| Rate for Payer: Healthscope Whirlpool |
$92.33
|
| Rate for Payer: Mclaren Commercial |
$609.32
|
| Rate for Payer: Mclaren Commercial |
$85.67
|
| Rate for Payer: Mclaren Commercial |
$121.11
|
| Rate for Payer: Mclaren Commercial |
$154.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$575.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$146.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.91
|
| Rate for Payer: Nomi Health Commercial |
$140.89
|
| Rate for Payer: Nomi Health Commercial |
$555.16
|
| Rate for Payer: Nomi Health Commercial |
$78.06
|
| Rate for Payer: Nomi Health Commercial |
$110.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$440.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.46
|
| Rate for Payer: Priority Health Narrow Network |
$0.37
|
| Rate for Payer: Priority Health Narrow Network |
$0.37
|
| Rate for Payer: Priority Health Narrow Network |
$0.37
|
| Rate for Payer: Priority Health Narrow Network |
$0.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$595.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$118.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$151.20
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION
|
Facility
|
IP
|
$24.56
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$24.56 |
| Rate for Payer: Aetna Commercial |
$22.10
|
| Rate for Payer: Aetna Commercial |
$104.45
|
| Rate for Payer: Aetna Commercial |
$77.20
|
| Rate for Payer: ASR ASR |
$112.58
|
| Rate for Payer: ASR ASR |
$23.82
|
| Rate for Payer: ASR ASR |
$83.21
|
| Rate for Payer: ASR Commercial |
$23.82
|
| Rate for Payer: ASR Commercial |
$112.58
|
| Rate for Payer: ASR Commercial |
$83.21
|
| Rate for Payer: BCBS Trust/PPO |
$69.90
|
| Rate for Payer: BCBS Trust/PPO |
$94.58
|
| Rate for Payer: BCBS Trust/PPO |
$20.01
|
| Rate for Payer: BCN Commercial |
$89.98
|
| Rate for Payer: BCN Commercial |
$66.51
|
| Rate for Payer: BCN Commercial |
$19.04
|
| Rate for Payer: Cash Price |
$19.65
|
| Rate for Payer: Cash Price |
$92.85
|
| Rate for Payer: Cash Price |
$68.63
|
| Rate for Payer: Cofinity Commercial |
$80.63
|
| Rate for Payer: Cofinity Commercial |
$109.10
|
| Rate for Payer: Cofinity Commercial |
$23.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.62
|
| Rate for Payer: Healthscope Commercial |
$116.06
|
| Rate for Payer: Healthscope Commercial |
$24.56
|
| Rate for Payer: Healthscope Commercial |
$85.78
|
| Rate for Payer: Healthscope Whirlpool |
$23.82
|
| Rate for Payer: Healthscope Whirlpool |
$112.58
|
| Rate for Payer: Healthscope Whirlpool |
$83.21
|
| Rate for Payer: Mclaren Commercial |
$22.10
|
| Rate for Payer: Mclaren Commercial |
$104.45
|
| Rate for Payer: Mclaren Commercial |
$77.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.65
|
| Rate for Payer: Nomi Health Commercial |
$20.14
|
| Rate for Payer: Nomi Health Commercial |
$95.17
|
| Rate for Payer: Nomi Health Commercial |
$70.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.13
|
|
|
ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION
|
Facility
|
OP
|
$116.06
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$116.06 |
| Rate for Payer: Aetna Commercial |
$104.45
|
| Rate for Payer: Aetna Commercial |
$77.20
|
| Rate for Payer: Aetna Commercial |
$22.10
|
| Rate for Payer: Aetna Medicare |
$42.89
|
| Rate for Payer: Aetna Medicare |
$58.03
|
| Rate for Payer: Aetna Medicare |
$12.28
|
| Rate for Payer: ASR ASR |
$23.82
|
| Rate for Payer: ASR ASR |
$112.58
|
| Rate for Payer: ASR ASR |
$83.21
|
| Rate for Payer: ASR Commercial |
$23.82
|
| Rate for Payer: ASR Commercial |
$112.58
|
| Rate for Payer: ASR Commercial |
$83.21
|
| Rate for Payer: BCBS Complete |
$46.42
|
| Rate for Payer: BCBS Complete |
$9.82
|
| Rate for Payer: BCBS Complete |
$34.31
|
| Rate for Payer: BCBS Trust/PPO |
$70.25
|
| Rate for Payer: BCBS Trust/PPO |
$95.04
|
| Rate for Payer: BCBS Trust/PPO |
$20.11
|
| Rate for Payer: BCN Commercial |
$19.04
|
| Rate for Payer: BCN Commercial |
$66.51
|
| Rate for Payer: BCN Commercial |
$89.98
|
| Rate for Payer: Cash Price |
$92.85
|
| Rate for Payer: Cash Price |
$92.85
|
| Rate for Payer: Cash Price |
$19.65
|
| Rate for Payer: Cash Price |
$19.65
|
| Rate for Payer: Cash Price |
$68.63
|
| Rate for Payer: Cash Price |
$68.63
|
| Rate for Payer: Cofinity Commercial |
$80.63
|
| Rate for Payer: Cofinity Commercial |
$109.10
|
| Rate for Payer: Cofinity Commercial |
$23.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.65
|
| Rate for Payer: Healthscope Commercial |
$85.78
|
| Rate for Payer: Healthscope Commercial |
$24.56
|
| Rate for Payer: Healthscope Commercial |
$116.06
|
| Rate for Payer: Healthscope Whirlpool |
$83.21
|
| Rate for Payer: Healthscope Whirlpool |
$23.82
|
| Rate for Payer: Healthscope Whirlpool |
$112.58
|
| Rate for Payer: Mclaren Commercial |
$22.10
|
| Rate for Payer: Mclaren Commercial |
$77.20
|
| Rate for Payer: Mclaren Commercial |
$104.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.65
|
| Rate for Payer: Nomi Health Commercial |
$95.17
|
| Rate for Payer: Nomi Health Commercial |
$70.34
|
| Rate for Payer: Nomi Health Commercial |
$20.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.76
|
| Rate for Payer: Priority Health Narrow Network |
$7.01
|
| Rate for Payer: Priority Health Narrow Network |
$7.01
|
| Rate for Payer: Priority Health Narrow Network |
$7.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.49
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION
|
Facility
|
IP
|
$473.76
|
|
|
Service Code
|
NDC 66689020204
|
| Hospital Charge Code |
115332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$307.94 |
| Max. Negotiated Rate |
$473.76 |
| Rate for Payer: Aetna Commercial |
$426.38
|
| Rate for Payer: ASR ASR |
$459.55
|
| Rate for Payer: ASR Commercial |
$459.55
|
| Rate for Payer: BCBS Trust/PPO |
$386.07
|
| Rate for Payer: BCN Commercial |
$367.31
|
| Rate for Payer: Cash Price |
$379.01
|
| Rate for Payer: Cofinity Commercial |
$445.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$379.01
|
| Rate for Payer: Healthscope Commercial |
$473.76
|
| Rate for Payer: Healthscope Whirlpool |
$459.55
|
| Rate for Payer: Mclaren Commercial |
$426.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$402.70
|
| Rate for Payer: Nomi Health Commercial |
$388.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$307.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$416.91
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION
|
Facility
|
IP
|
$366.60
|
|
|
Service Code
|
NDC 00574052104
|
| Hospital Charge Code |
115332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$238.29 |
| Max. Negotiated Rate |
$366.60 |
| Rate for Payer: Aetna Commercial |
$329.94
|
| Rate for Payer: ASR ASR |
$355.60
|
| Rate for Payer: ASR Commercial |
$355.60
|
| Rate for Payer: BCBS Trust/PPO |
$298.74
|
| Rate for Payer: BCN Commercial |
$284.22
|
| Rate for Payer: Cash Price |
$293.28
|
| Rate for Payer: Cofinity Commercial |
$344.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.28
|
| Rate for Payer: Healthscope Commercial |
$366.60
|
| Rate for Payer: Healthscope Whirlpool |
$355.60
|
| Rate for Payer: Mclaren Commercial |
$329.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.61
|
| Rate for Payer: Nomi Health Commercial |
$300.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$322.61
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION
|
Facility
|
OP
|
$473.76
|
|
|
Service Code
|
NDC 66689020204
|
| Hospital Charge Code |
115332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.50 |
| Max. Negotiated Rate |
$473.76 |
| Rate for Payer: Aetna Commercial |
$426.38
|
| Rate for Payer: Aetna Medicare |
$236.88
|
| Rate for Payer: ASR ASR |
$459.55
|
| Rate for Payer: ASR Commercial |
$459.55
|
| Rate for Payer: BCBS Complete |
$189.50
|
| Rate for Payer: BCBS Trust/PPO |
$387.96
|
| Rate for Payer: BCN Commercial |
$367.31
|
| Rate for Payer: Cash Price |
$379.01
|
| Rate for Payer: Cofinity Commercial |
$445.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$379.01
|
| Rate for Payer: Healthscope Commercial |
$473.76
|
| Rate for Payer: Healthscope Whirlpool |
$459.55
|
| Rate for Payer: Mclaren Commercial |
$426.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$402.70
|
| Rate for Payer: Nomi Health Commercial |
$388.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$307.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$415.11
|
| Rate for Payer: Priority Health Narrow Network |
$332.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$416.91
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION
|
Facility
|
OP
|
$366.60
|
|
|
Service Code
|
NDC 00574052104
|
| Hospital Charge Code |
115332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.64 |
| Max. Negotiated Rate |
$366.60 |
| Rate for Payer: Aetna Commercial |
$329.94
|
| Rate for Payer: Aetna Medicare |
$183.30
|
| Rate for Payer: ASR ASR |
$355.60
|
| Rate for Payer: ASR Commercial |
$355.60
|
| Rate for Payer: BCBS Complete |
$146.64
|
| Rate for Payer: BCBS Trust/PPO |
$300.21
|
| Rate for Payer: BCN Commercial |
$284.22
|
| Rate for Payer: Cash Price |
$293.28
|
| Rate for Payer: Cofinity Commercial |
$344.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.28
|
| Rate for Payer: Healthscope Commercial |
$366.60
|
| Rate for Payer: Healthscope Whirlpool |
$355.60
|
| Rate for Payer: Mclaren Commercial |
$329.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.61
|
| Rate for Payer: Nomi Health Commercial |
$300.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$321.21
|
| Rate for Payer: Priority Health Narrow Network |
$256.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$322.61
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION
|
Facility
|
IP
|
$273.54
|
|
|
Service Code
|
NDC 00574012104
|
| Hospital Charge Code |
115332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.80 |
| Max. Negotiated Rate |
$273.54 |
| Rate for Payer: Aetna Commercial |
$246.19
|
| Rate for Payer: ASR ASR |
$265.33
|
| Rate for Payer: ASR Commercial |
$265.33
|
| Rate for Payer: BCBS Trust/PPO |
$222.91
|
| Rate for Payer: BCN Commercial |
$212.08
|
| Rate for Payer: Cash Price |
$218.83
|
| Rate for Payer: Cofinity Commercial |
$257.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.83
|
| Rate for Payer: Healthscope Commercial |
$273.54
|
| Rate for Payer: Healthscope Whirlpool |
$265.33
|
| Rate for Payer: Mclaren Commercial |
$246.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.51
|
| Rate for Payer: Nomi Health Commercial |
$224.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$240.72
|
|
|
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION
|
Facility
|
OP
|
$273.54
|
|
|
Service Code
|
NDC 00574012104
|
| Hospital Charge Code |
115332
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.42 |
| Max. Negotiated Rate |
$273.54 |
| Rate for Payer: Aetna Commercial |
$246.19
|
| Rate for Payer: Aetna Medicare |
$136.77
|
| Rate for Payer: ASR ASR |
$265.33
|
| Rate for Payer: ASR Commercial |
$265.33
|
| Rate for Payer: BCBS Complete |
$109.42
|
| Rate for Payer: BCBS Trust/PPO |
$224.00
|
| Rate for Payer: BCN Commercial |
$212.08
|
| Rate for Payer: Cash Price |
$218.83
|
| Rate for Payer: Cofinity Commercial |
$257.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.83
|
| Rate for Payer: Healthscope Commercial |
$273.54
|
| Rate for Payer: Healthscope Whirlpool |
$265.33
|
| Rate for Payer: Mclaren Commercial |
$246.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.51
|
| Rate for Payer: Nomi Health Commercial |
$224.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$239.68
|
| Rate for Payer: Priority Health Narrow Network |
$191.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$240.72
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
OP
|
$63.84
|
|
|
Service Code
|
NDC 00574052176
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.54 |
| Max. Negotiated Rate |
$63.84 |
| Rate for Payer: Aetna Commercial |
$57.46
|
| Rate for Payer: Aetna Medicare |
$31.92
|
| Rate for Payer: ASR ASR |
$61.92
|
| Rate for Payer: ASR Commercial |
$61.92
|
| Rate for Payer: BCBS Complete |
$25.54
|
| Rate for Payer: BCBS Trust/PPO |
$52.28
|
| Rate for Payer: BCN Commercial |
$49.50
|
| Rate for Payer: Cash Price |
$51.07
|
| Rate for Payer: Cofinity Commercial |
$60.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.07
|
| Rate for Payer: Healthscope Commercial |
$63.84
|
| Rate for Payer: Healthscope Whirlpool |
$61.92
|
| Rate for Payer: Mclaren Commercial |
$57.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.26
|
| Rate for Payer: Nomi Health Commercial |
$52.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.94
|
| Rate for Payer: Priority Health Narrow Network |
$44.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.18
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
IP
|
$63.84
|
|
|
Service Code
|
NDC 00574052176
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.50 |
| Max. Negotiated Rate |
$63.84 |
| Rate for Payer: Aetna Commercial |
$57.46
|
| Rate for Payer: ASR ASR |
$61.92
|
| Rate for Payer: ASR Commercial |
$61.92
|
| Rate for Payer: BCBS Trust/PPO |
$52.02
|
| Rate for Payer: BCN Commercial |
$49.50
|
| Rate for Payer: Cash Price |
$51.07
|
| Rate for Payer: Cofinity Commercial |
$60.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.07
|
| Rate for Payer: Healthscope Commercial |
$63.84
|
| Rate for Payer: Healthscope Whirlpool |
$61.92
|
| Rate for Payer: Mclaren Commercial |
$57.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.26
|
| Rate for Payer: Nomi Health Commercial |
$52.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.18
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
OP
|
$85.68
|
|
|
Service Code
|
NDC 66689020208
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.27 |
| Max. Negotiated Rate |
$85.68 |
| Rate for Payer: Aetna Commercial |
$77.11
|
| Rate for Payer: Aetna Medicare |
$42.84
|
| Rate for Payer: ASR ASR |
$83.11
|
| Rate for Payer: ASR Commercial |
$83.11
|
| Rate for Payer: BCBS Complete |
$34.27
|
| Rate for Payer: BCBS Trust/PPO |
$70.16
|
| Rate for Payer: BCN Commercial |
$66.43
|
| Rate for Payer: Cash Price |
$68.54
|
| Rate for Payer: Cofinity Commercial |
$80.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.54
|
| Rate for Payer: Healthscope Commercial |
$85.68
|
| Rate for Payer: Healthscope Whirlpool |
$83.11
|
| Rate for Payer: Mclaren Commercial |
$77.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.83
|
| Rate for Payer: Nomi Health Commercial |
$70.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.07
|
| Rate for Payer: Priority Health Narrow Network |
$60.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.40
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
IP
|
$85.68
|
|
|
Service Code
|
NDC 66689020208
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.69 |
| Max. Negotiated Rate |
$85.68 |
| Rate for Payer: Aetna Commercial |
$77.11
|
| Rate for Payer: ASR ASR |
$83.11
|
| Rate for Payer: ASR Commercial |
$83.11
|
| Rate for Payer: BCBS Trust/PPO |
$69.82
|
| Rate for Payer: BCN Commercial |
$66.43
|
| Rate for Payer: Cash Price |
$68.54
|
| Rate for Payer: Cofinity Commercial |
$80.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.54
|
| Rate for Payer: Healthscope Commercial |
$85.68
|
| Rate for Payer: Healthscope Whirlpool |
$83.11
|
| Rate for Payer: Mclaren Commercial |
$77.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.83
|
| Rate for Payer: Nomi Health Commercial |
$70.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.40
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
IP
|
$97.44
|
|
|
Service Code
|
NDC 66689020108
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.34 |
| Max. Negotiated Rate |
$97.44 |
| Rate for Payer: Aetna Commercial |
$87.70
|
| Rate for Payer: ASR ASR |
$94.52
|
| Rate for Payer: ASR Commercial |
$94.52
|
| Rate for Payer: BCBS Trust/PPO |
$79.40
|
| Rate for Payer: BCN Commercial |
$75.55
|
| Rate for Payer: Cash Price |
$77.95
|
| Rate for Payer: Cofinity Commercial |
$91.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.95
|
| Rate for Payer: Healthscope Commercial |
$97.44
|
| Rate for Payer: Healthscope Whirlpool |
$94.52
|
| Rate for Payer: Mclaren Commercial |
$87.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.82
|
| Rate for Payer: Nomi Health Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$85.75
|
|
|
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION
|
Facility
|
OP
|
$97.44
|
|
|
Service Code
|
NDC 66689020108
|
| Hospital Charge Code |
115331
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.98 |
| Max. Negotiated Rate |
$97.44 |
| Rate for Payer: Aetna Commercial |
$87.70
|
| Rate for Payer: Aetna Medicare |
$48.72
|
| Rate for Payer: ASR ASR |
$94.52
|
| Rate for Payer: ASR Commercial |
$94.52
|
| Rate for Payer: BCBS Complete |
$38.98
|
| Rate for Payer: BCBS Trust/PPO |
$79.79
|
| Rate for Payer: BCN Commercial |
$75.55
|
| Rate for Payer: Cash Price |
$77.95
|
| Rate for Payer: Cofinity Commercial |
$91.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.95
|
| Rate for Payer: Healthscope Commercial |
$97.44
|
| Rate for Payer: Healthscope Whirlpool |
$94.52
|
| Rate for Payer: Mclaren Commercial |
$87.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.82
|
| Rate for Payer: Nomi Health Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$85.38
|
| Rate for Payer: Priority Health Narrow Network |
$68.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$85.75
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
OP
|
$293.75
|
|
|
Service Code
|
NDC 00904578961
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.50 |
| Max. Negotiated Rate |
$293.75 |
| Rate for Payer: Aetna Commercial |
$264.38
|
| Rate for Payer: Aetna Medicare |
$146.88
|
| Rate for Payer: ASR ASR |
$284.94
|
| Rate for Payer: ASR Commercial |
$284.94
|
| Rate for Payer: BCBS Complete |
$117.50
|
| Rate for Payer: BCBS Trust/PPO |
$240.55
|
| Rate for Payer: BCN Commercial |
$227.74
|
| Rate for Payer: Cash Price |
$235.00
|
| Rate for Payer: Cofinity Commercial |
$276.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.00
|
| Rate for Payer: Healthscope Commercial |
$293.75
|
| Rate for Payer: Healthscope Whirlpool |
$284.94
|
| Rate for Payer: Mclaren Commercial |
$264.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.69
|
| Rate for Payer: Nomi Health Commercial |
$240.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$257.38
|
| Rate for Payer: Priority Health Narrow Network |
$205.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$258.50
|
|
|
ACYCLOVIR 200 MG CAPSULE
|
Facility
|
IP
|
$293.75
|
|
|
Service Code
|
NDC 00904578961
|
| Hospital Charge Code |
8969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.94 |
| Max. Negotiated Rate |
$293.75 |
| Rate for Payer: Aetna Commercial |
$264.38
|
| Rate for Payer: ASR ASR |
$284.94
|
| Rate for Payer: ASR Commercial |
$284.94
|
| Rate for Payer: BCBS Trust/PPO |
$239.38
|
| Rate for Payer: BCN Commercial |
$227.74
|
| Rate for Payer: Cash Price |
$235.00
|
| Rate for Payer: Cofinity Commercial |
$276.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.00
|
| Rate for Payer: Healthscope Commercial |
$293.75
|
| Rate for Payer: Healthscope Whirlpool |
$284.94
|
| Rate for Payer: Mclaren Commercial |
$264.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.69
|
| Rate for Payer: Nomi Health Commercial |
$240.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$258.50
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.29
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
8974
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$26.29 |
| Rate for Payer: Aetna Commercial |
$23.66
|
| Rate for Payer: Aetna Medicare |
$13.14
|
| Rate for Payer: ASR ASR |
$25.50
|
| Rate for Payer: ASR Commercial |
$25.50
|
| Rate for Payer: BCBS Complete |
$10.52
|
| Rate for Payer: BCBS Trust/PPO |
$21.53
|
| Rate for Payer: BCN Commercial |
$20.38
|
| Rate for Payer: Cash Price |
$21.03
|
| Rate for Payer: Cash Price |
$21.03
|
| Rate for Payer: Cofinity Commercial |
$24.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.03
|
| Rate for Payer: Healthscope Commercial |
$26.29
|
| Rate for Payer: Healthscope Whirlpool |
$25.50
|
| Rate for Payer: Mclaren Commercial |
$23.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.35
|
| Rate for Payer: Nomi Health Commercial |
$21.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.04
|
| Rate for Payer: Priority Health Narrow Network |
$0.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.14
|
|
|
ACYCLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.29
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
8974
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.09 |
| Max. Negotiated Rate |
$26.29 |
| Rate for Payer: Aetna Commercial |
$23.66
|
| Rate for Payer: ASR ASR |
$25.50
|
| Rate for Payer: ASR Commercial |
$25.50
|
| Rate for Payer: BCBS Trust/PPO |
$21.42
|
| Rate for Payer: BCN Commercial |
$20.38
|
| Rate for Payer: Cash Price |
$21.03
|
| Rate for Payer: Cofinity Commercial |
$24.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.03
|
| Rate for Payer: Healthscope Commercial |
$26.29
|
| Rate for Payer: Healthscope Whirlpool |
$25.50
|
| Rate for Payer: Mclaren Commercial |
$23.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.35
|
| Rate for Payer: Nomi Health Commercial |
$21.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.14
|
|
|
ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$27.06
|
|
|
Service Code
|
HCPCS J0133
|
| Hospital Charge Code |
23128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$27.06 |
| Rate for Payer: Aetna Commercial |
$24.35
|
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Aetna Commercial |
$15.45
|
| Rate for Payer: Aetna Commercial |
$18.12
|
| Rate for Payer: Aetna Medicare |
$11.32
|
| Rate for Payer: Aetna Medicare |
$8.58
|
| Rate for Payer: Aetna Medicare |
$10.06
|
| Rate for Payer: Aetna Medicare |
$13.53
|
| Rate for Payer: ASR ASR |
$16.65
|
| Rate for Payer: ASR ASR |
$19.53
|
| Rate for Payer: ASR ASR |
$21.96
|
| Rate for Payer: ASR ASR |
$26.25
|
| Rate for Payer: ASR Commercial |
$16.65
|
| Rate for Payer: ASR Commercial |
$21.96
|
| Rate for Payer: ASR Commercial |
$26.25
|
| Rate for Payer: ASR Commercial |
$19.53
|
| Rate for Payer: BCBS Complete |
$9.06
|
| Rate for Payer: BCBS Complete |
$10.82
|
| Rate for Payer: BCBS Complete |
$6.87
|
| Rate for Payer: BCBS Complete |
$8.05
|
| Rate for Payer: BCBS Trust/PPO |
$22.16
|
| Rate for Payer: BCBS Trust/PPO |
$16.48
|
| Rate for Payer: BCBS Trust/PPO |
$14.06
|
| Rate for Payer: BCBS Trust/PPO |
$18.54
|
| Rate for Payer: BCN Commercial |
$13.31
|
| Rate for Payer: BCN Commercial |
$20.98
|
| Rate for Payer: BCN Commercial |
$15.61
|
| Rate for Payer: BCN Commercial |
$17.55
|
| Rate for Payer: Cash Price |
$18.12
|
| Rate for Payer: Cash Price |
$21.64
|
| Rate for Payer: Cash Price |
$13.73
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$13.73
|
| Rate for Payer: Cash Price |
$18.12
|
| Rate for Payer: Cash Price |
$21.64
|
| Rate for Payer: Cofinity Commercial |
$18.92
|
| Rate for Payer: Cofinity Commercial |
$16.14
|
| Rate for Payer: Cofinity Commercial |
$21.28
|
| Rate for Payer: Cofinity Commercial |
$25.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.74
|
| Rate for Payer: Healthscope Commercial |
$27.06
|
| Rate for Payer: Healthscope Commercial |
$20.13
|
| Rate for Payer: Healthscope Commercial |
$17.17
|
| Rate for Payer: Healthscope Commercial |
$22.64
|
| Rate for Payer: Healthscope Whirlpool |
$19.53
|
| Rate for Payer: Healthscope Whirlpool |
$16.65
|
| Rate for Payer: Healthscope Whirlpool |
$21.96
|
| Rate for Payer: Healthscope Whirlpool |
$26.25
|
| Rate for Payer: Mclaren Commercial |
$20.38
|
| Rate for Payer: Mclaren Commercial |
$24.35
|
| Rate for Payer: Mclaren Commercial |
$15.45
|
| Rate for Payer: Mclaren Commercial |
$18.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.00
|
| Rate for Payer: Nomi Health Commercial |
$16.51
|
| Rate for Payer: Nomi Health Commercial |
$18.56
|
| Rate for Payer: Nomi Health Commercial |
$22.19
|
| Rate for Payer: Nomi Health Commercial |
$14.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.04
|
| Rate for Payer: Priority Health Narrow Network |
$0.03
|
| Rate for Payer: Priority Health Narrow Network |
$0.03
|
| Rate for Payer: Priority Health Narrow Network |
$0.03
|
| Rate for Payer: Priority Health Narrow Network |
$0.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.71
|
|
