|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.24
|
|
|
Service Code
|
NDC 36000-162-10
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: BCBS Trust/PPO |
$15.69
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.37
|
|
|
Service Code
|
NDC 67457-852-00
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.86 |
| Max. Negotiated Rate |
$18.37 |
| Rate for Payer: Aetna Commercial |
$16.53
|
| Rate for Payer: ASR ASR |
$17.82
|
| Rate for Payer: BCBS Trust/PPO |
$14.24
|
| Rate for Payer: BCN Commercial |
$14.24
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cofinity Commercial |
$17.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.70
|
| Rate for Payer: Healthscope Commercial |
$18.37
|
| Rate for Payer: Healthscope Whirlpool |
$17.82
|
| Rate for Payer: Mclaren Commercial |
$16.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.17
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.45
|
|
|
Service Code
|
NDC 0143-9318-10
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.82 |
| Max. Negotiated Rate |
$25.45 |
| Rate for Payer: Aetna Commercial |
$22.90
|
| Rate for Payer: ASR ASR |
$24.69
|
| Rate for Payer: BCBS Trust/PPO |
$19.73
|
| Rate for Payer: BCN Commercial |
$19.73
|
| Rate for Payer: Cash Price |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$23.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.36
|
| Rate for Payer: Healthscope Commercial |
$25.45
|
| Rate for Payer: Healthscope Whirlpool |
$24.69
|
| Rate for Payer: Mclaren Commercial |
$22.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.40
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.37
|
|
|
Service Code
|
NDC 67457-852-04
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.86 |
| Max. Negotiated Rate |
$18.37 |
| Rate for Payer: Aetna Commercial |
$16.53
|
| Rate for Payer: ASR ASR |
$17.82
|
| Rate for Payer: BCBS Trust/PPO |
$14.24
|
| Rate for Payer: BCN Commercial |
$14.24
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cofinity Commercial |
$17.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.70
|
| Rate for Payer: Healthscope Commercial |
$18.37
|
| Rate for Payer: Healthscope Whirlpool |
$17.82
|
| Rate for Payer: Mclaren Commercial |
$16.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.17
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.10
|
|
|
Service Code
|
NDC 51991-983-17
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.57 |
| Max. Negotiated Rate |
$25.10 |
| Rate for Payer: Aetna Commercial |
$22.59
|
| Rate for Payer: ASR ASR |
$24.35
|
| Rate for Payer: BCBS Trust/PPO |
$19.46
|
| Rate for Payer: BCN Commercial |
$19.46
|
| Rate for Payer: Cash Price |
$20.08
|
| Rate for Payer: Cofinity Commercial |
$23.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.08
|
| Rate for Payer: Healthscope Commercial |
$25.10
|
| Rate for Payer: Healthscope Whirlpool |
$24.35
|
| Rate for Payer: Mclaren Commercial |
$22.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.09
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$36.17
|
|
|
Service Code
|
NDC 47335-615-44
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.32 |
| Max. Negotiated Rate |
$36.17 |
| Rate for Payer: Aetna Commercial |
$32.55
|
| Rate for Payer: ASR ASR |
$35.08
|
| Rate for Payer: BCBS Trust/PPO |
$28.04
|
| Rate for Payer: BCN Commercial |
$28.04
|
| Rate for Payer: Cash Price |
$28.94
|
| Rate for Payer: Cofinity Commercial |
$34.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.94
|
| Rate for Payer: Healthscope Commercial |
$36.17
|
| Rate for Payer: Healthscope Whirlpool |
$35.08
|
| Rate for Payer: Mclaren Commercial |
$32.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.83
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$74.58
|
|
|
Service Code
|
NDC 0703-1153-01
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.21 |
| Max. Negotiated Rate |
$74.58 |
| Rate for Payer: Aetna Commercial |
$67.12
|
| Rate for Payer: ASR ASR |
$72.34
|
| Rate for Payer: BCBS Trust/PPO |
$57.82
|
| Rate for Payer: BCN Commercial |
$57.82
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: Cofinity Commercial |
$70.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.66
|
| Rate for Payer: Healthscope Commercial |
$74.58
|
| Rate for Payer: Healthscope Whirlpool |
$72.34
|
| Rate for Payer: Mclaren Commercial |
$67.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.63
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.24
|
|
|
Service Code
|
NDC 36000-162-01
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: BCBS Trust/PPO |
$15.69
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.36
|
|
|
Service Code
|
NDC 70121-1576-7
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$23.36 |
| Rate for Payer: Aetna Commercial |
$21.02
|
| Rate for Payer: ASR ASR |
$22.66
|
| Rate for Payer: BCBS Trust/PPO |
$18.11
|
| Rate for Payer: BCN Commercial |
$18.11
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cofinity Commercial |
$21.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.69
|
| Rate for Payer: Healthscope Commercial |
$23.36
|
| Rate for Payer: Healthscope Whirlpool |
$22.66
|
| Rate for Payer: Mclaren Commercial |
$21.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.56
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.36
|
|
|
Service Code
|
NDC 70121-1576-1
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$23.36 |
| Rate for Payer: Aetna Commercial |
$21.02
|
| Rate for Payer: ASR ASR |
$22.66
|
| Rate for Payer: BCBS Trust/PPO |
$18.11
|
| Rate for Payer: BCN Commercial |
$18.11
|
| Rate for Payer: Cash Price |
$18.68
|
| Rate for Payer: Cofinity Commercial |
$21.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.69
|
| Rate for Payer: Healthscope Commercial |
$23.36
|
| Rate for Payer: Healthscope Whirlpool |
$22.66
|
| Rate for Payer: Mclaren Commercial |
$21.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.56
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$25.45
|
|
|
Service Code
|
NDC 0143-9318-01
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.82 |
| Max. Negotiated Rate |
$25.45 |
| Rate for Payer: Aetna Commercial |
$22.90
|
| Rate for Payer: ASR ASR |
$24.69
|
| Rate for Payer: BCBS Trust/PPO |
$19.73
|
| Rate for Payer: BCN Commercial |
$19.73
|
| Rate for Payer: Cash Price |
$20.36
|
| Rate for Payer: Cofinity Commercial |
$23.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.36
|
| Rate for Payer: Healthscope Commercial |
$25.45
|
| Rate for Payer: Healthscope Whirlpool |
$24.69
|
| Rate for Payer: Mclaren Commercial |
$22.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.40
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$36.17
|
|
|
Service Code
|
NDC 47335-615-40
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.32 |
| Max. Negotiated Rate |
$36.17 |
| Rate for Payer: Aetna Commercial |
$32.55
|
| Rate for Payer: ASR ASR |
$35.08
|
| Rate for Payer: BCBS Trust/PPO |
$28.04
|
| Rate for Payer: BCN Commercial |
$28.04
|
| Rate for Payer: Cash Price |
$28.94
|
| Rate for Payer: Cofinity Commercial |
$34.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.94
|
| Rate for Payer: Healthscope Commercial |
$36.17
|
| Rate for Payer: Healthscope Whirlpool |
$35.08
|
| Rate for Payer: Mclaren Commercial |
$32.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.83
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$107.05
|
|
|
Service Code
|
NDC 0409-3375-04
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.94 |
| Max. Negotiated Rate |
$107.05 |
| Rate for Payer: Aetna Commercial |
$96.34
|
| Rate for Payer: ASR ASR |
$103.84
|
| Rate for Payer: BCBS Trust/PPO |
$83.00
|
| Rate for Payer: BCN Commercial |
$83.00
|
| Rate for Payer: Cash Price |
$85.64
|
| Rate for Payer: Cofinity Commercial |
$100.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.64
|
| Rate for Payer: Healthscope Commercial |
$107.05
|
| Rate for Payer: Healthscope Whirlpool |
$103.84
|
| Rate for Payer: Mclaren Commercial |
$96.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$94.20
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$74.58
|
|
|
Service Code
|
NDC 0703-1153-03
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.21 |
| Max. Negotiated Rate |
$74.58 |
| Rate for Payer: Aetna Commercial |
$67.12
|
| Rate for Payer: ASR ASR |
$72.34
|
| Rate for Payer: BCBS Trust/PPO |
$57.82
|
| Rate for Payer: BCN Commercial |
$57.82
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: Cofinity Commercial |
$70.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.66
|
| Rate for Payer: Healthscope Commercial |
$74.58
|
| Rate for Payer: Healthscope Whirlpool |
$72.34
|
| Rate for Payer: Mclaren Commercial |
$67.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.63
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV
|
Facility
|
IP
|
$31.50
|
|
|
Service Code
|
NDC 44567-641-01
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$28.35
|
| Rate for Payer: ASR ASR |
$30.56
|
| Rate for Payer: BCBS Trust/PPO |
$24.42
|
| Rate for Payer: BCN Commercial |
$24.42
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cofinity Commercial |
$29.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Healthscope Whirlpool |
$30.56
|
| Rate for Payer: Mclaren Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.72
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) IN 0.9 % NACL IV
|
Facility
|
IP
|
$31.50
|
|
|
Service Code
|
NDC 44567-641-10
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$28.35
|
| Rate for Payer: ASR ASR |
$30.56
|
| Rate for Payer: BCBS Trust/PPO |
$24.42
|
| Rate for Payer: BCN Commercial |
$24.42
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cofinity Commercial |
$29.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Healthscope Whirlpool |
$30.56
|
| Rate for Payer: Mclaren Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.72
|
|
|
NORMAL NEWBORN
|
Facility
|
IP
|
$4,235.76
|
|
|
Service Code
|
MS-DRG 795
|
| Min. Negotiated Rate |
$2,071.86 |
| Max. Negotiated Rate |
$4,235.76 |
| Rate for Payer: Aetna Medicare |
$3,388.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,235.76
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,235.76
|
| Rate for Payer: BCBS MAPPO |
$3,388.61
|
| Rate for Payer: BCN Medicare Advantage |
$3,388.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,388.61
|
| Rate for Payer: Humana Choice PPO Medicare |
$3,388.61
|
| Rate for Payer: Mclaren Medicare |
$3,388.61
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,558.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,896.90
|
| Rate for Payer: PACE Medicare |
$3,219.18
|
| Rate for Payer: PACE SWMI |
$3,388.61
|
| Rate for Payer: PHP Commercial |
$3,727.47
|
| Rate for Payer: PHP Medicare Advantage |
$3,388.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,589.83
|
| Rate for Payer: Priority Health Medicare |
$3,388.61
|
| Rate for Payer: Priority Health Narrow Network |
$2,071.86
|
| Rate for Payer: Railroad Medicare Medicare |
$3,388.61
|
| Rate for Payer: UHC Medicare Advantage |
$3,490.27
|
| Rate for Payer: VA VA |
$3,388.61
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$132.05
|
|
|
Service Code
|
NDC 50268-603-15
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.44 |
| Max. Negotiated Rate |
$132.05 |
| Rate for Payer: Aetna Commercial |
$118.84
|
| Rate for Payer: ASR ASR |
$128.09
|
| Rate for Payer: BCBS Trust/PPO |
$102.38
|
| Rate for Payer: BCN Commercial |
$102.38
|
| Rate for Payer: Cash Price |
$105.64
|
| Rate for Payer: Cofinity Commercial |
$124.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.64
|
| Rate for Payer: Healthscope Commercial |
$132.05
|
| Rate for Payer: Healthscope Whirlpool |
$128.09
|
| Rate for Payer: Mclaren Commercial |
$118.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$116.20
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$281.30
|
|
|
Service Code
|
NDC 51672-4002-5
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.91 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$253.17
|
| Rate for Payer: ASR ASR |
$272.86
|
| Rate for Payer: BCBS Trust/PPO |
$218.09
|
| Rate for Payer: BCN Commercial |
$218.09
|
| Rate for Payer: Cash Price |
$225.04
|
| Rate for Payer: Cofinity Commercial |
$264.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.04
|
| Rate for Payer: Healthscope Commercial |
$281.30
|
| Rate for Payer: Healthscope Whirlpool |
$272.86
|
| Rate for Payer: Mclaren Commercial |
$253.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$247.54
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$202.10
|
|
|
Service Code
|
NDC 51672-4002-1
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.47 |
| Max. Negotiated Rate |
$202.10 |
| Rate for Payer: Aetna Commercial |
$181.89
|
| Rate for Payer: ASR ASR |
$196.04
|
| Rate for Payer: BCBS Trust/PPO |
$156.69
|
| Rate for Payer: BCN Commercial |
$156.69
|
| Rate for Payer: Cash Price |
$161.68
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.68
|
| Rate for Payer: Healthscope Commercial |
$202.10
|
| Rate for Payer: Healthscope Whirlpool |
$196.04
|
| Rate for Payer: Mclaren Commercial |
$181.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$177.85
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$161.98
|
|
|
Service Code
|
NDC 50268-604-15
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.39 |
| Max. Negotiated Rate |
$161.98 |
| Rate for Payer: Aetna Commercial |
$145.78
|
| Rate for Payer: ASR ASR |
$157.12
|
| Rate for Payer: BCBS Trust/PPO |
$125.58
|
| Rate for Payer: BCN Commercial |
$125.58
|
| Rate for Payer: Cash Price |
$129.58
|
| Rate for Payer: Cofinity Commercial |
$152.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.58
|
| Rate for Payer: Healthscope Commercial |
$161.98
|
| Rate for Payer: Healthscope Whirlpool |
$157.12
|
| Rate for Payer: Mclaren Commercial |
$145.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.54
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$3.24
|
|
|
Service Code
|
NDC 50268-604-11
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$3.24 |
| Rate for Payer: Aetna Commercial |
$2.92
|
| Rate for Payer: ASR ASR |
$3.14
|
| Rate for Payer: BCBS Trust/PPO |
$2.51
|
| Rate for Payer: BCN Commercial |
$2.51
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cofinity Commercial |
$3.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.59
|
| Rate for Payer: Healthscope Commercial |
$3.24
|
| Rate for Payer: Healthscope Whirlpool |
$3.14
|
| Rate for Payer: Mclaren Commercial |
$2.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.85
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$354.35
|
|
|
Service Code
|
NDC 60687-293-01
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$248.04 |
| Max. Negotiated Rate |
$354.35 |
| Rate for Payer: Aetna Commercial |
$318.92
|
| Rate for Payer: ASR ASR |
$343.72
|
| Rate for Payer: BCBS Trust/PPO |
$274.73
|
| Rate for Payer: BCN Commercial |
$274.73
|
| Rate for Payer: Cash Price |
$283.48
|
| Rate for Payer: Cofinity Commercial |
$333.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.48
|
| Rate for Payer: Healthscope Commercial |
$354.35
|
| Rate for Payer: Healthscope Whirlpool |
$343.72
|
| Rate for Payer: Mclaren Commercial |
$318.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$301.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$311.83
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$3.54
|
|
|
Service Code
|
NDC 60687-293-11
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: ASR ASR |
$3.43
|
| Rate for Payer: BCBS Trust/PPO |
$2.74
|
| Rate for Payer: BCN Commercial |
$2.74
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cofinity Commercial |
$3.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.83
|
| Rate for Payer: Healthscope Commercial |
$3.54
|
| Rate for Payer: Healthscope Whirlpool |
$3.43
|
| Rate for Payer: Mclaren Commercial |
$3.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.12
|
|
|
NOVASOURCE RENAL BOLUS FEED
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 4390035111
|
| Hospital Charge Code |
150853
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.98 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: BCBS Trust/PPO |
$4.41
|
| Rate for Payer: BCN Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Commercial |
$5.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Healthscope Whirlpool |
$5.52
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
