|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.93
|
|
|
Service Code
|
NDC 0904-7276-41
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: ASR ASR |
$3.81
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cofinity Commercial |
$3.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.14
|
| Rate for Payer: Healthscope Commercial |
$3.93
|
| Rate for Payer: Healthscope Whirlpool |
$3.81
|
| Rate for Payer: Mclaren Commercial |
$3.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.46
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 0121-0868-50
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna Commercial |
$4.37
|
| Rate for Payer: ASR ASR |
$4.71
|
| Rate for Payer: BCBS Trust/PPO |
$3.77
|
| Rate for Payer: BCN Commercial |
$3.77
|
| Rate for Payer: Cash Price |
$3.89
|
| Rate for Payer: Cofinity Commercial |
$4.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.89
|
| Rate for Payer: Healthscope Commercial |
$4.86
|
| Rate for Payer: Healthscope Whirlpool |
$4.71
|
| Rate for Payer: Mclaren Commercial |
$4.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.28
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$9.90
|
|
|
Service Code
|
NDC 68094-599-59
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Aetna Commercial |
$8.91
|
| Rate for Payer: ASR ASR |
$9.60
|
| Rate for Payer: BCBS Trust/PPO |
$7.68
|
| Rate for Payer: BCN Commercial |
$7.68
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cofinity Commercial |
$9.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.92
|
| Rate for Payer: Healthscope Commercial |
$9.90
|
| Rate for Payer: Healthscope Whirlpool |
$9.60
|
| Rate for Payer: Mclaren Commercial |
$8.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.71
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.72
|
|
|
Service Code
|
NDC 0121-0868-05
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: ASR ASR |
$3.61
|
| Rate for Payer: BCBS Trust/PPO |
$2.88
|
| Rate for Payer: BCN Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cofinity Commercial |
$3.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.98
|
| Rate for Payer: Healthscope Commercial |
$3.72
|
| Rate for Payer: Healthscope Whirlpool |
$3.61
|
| Rate for Payer: Mclaren Commercial |
$3.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.27
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 66689-037-50
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: ASR ASR |
$5.33
|
| Rate for Payer: BCBS Trust/PPO |
$4.26
|
| Rate for Payer: BCN Commercial |
$4.26
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$5.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$5.49
|
| Rate for Payer: Healthscope Whirlpool |
$5.33
|
| Rate for Payer: Mclaren Commercial |
$4.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.83
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 66689-037-01
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$5.49 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: ASR ASR |
$5.33
|
| Rate for Payer: BCBS Trust/PPO |
$4.26
|
| Rate for Payer: BCN Commercial |
$4.26
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$5.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$5.49
|
| Rate for Payer: Healthscope Whirlpool |
$5.33
|
| Rate for Payer: Mclaren Commercial |
$4.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.83
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION
|
Facility
|
IP
|
$3.93
|
|
|
Service Code
|
NDC 0904-7276-70
|
| Hospital Charge Code |
5751
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$3.93 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: ASR ASR |
$3.81
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCN Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cofinity Commercial |
$3.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.14
|
| Rate for Payer: Healthscope Commercial |
$3.93
|
| Rate for Payer: Healthscope Whirlpool |
$3.81
|
| Rate for Payer: Mclaren Commercial |
$3.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.46
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$95.76
|
|
|
Service Code
|
NDC 51672-1263-2
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.03 |
| Max. Negotiated Rate |
$95.76 |
| Rate for Payer: Aetna Commercial |
$86.18
|
| Rate for Payer: ASR ASR |
$92.89
|
| Rate for Payer: BCBS Trust/PPO |
$74.24
|
| Rate for Payer: BCN Commercial |
$74.24
|
| Rate for Payer: Cash Price |
$76.61
|
| Rate for Payer: Cofinity Commercial |
$90.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.61
|
| Rate for Payer: Healthscope Commercial |
$95.76
|
| Rate for Payer: Healthscope Whirlpool |
$92.89
|
| Rate for Payer: Mclaren Commercial |
$86.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$84.27
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$95.76
|
|
|
Service Code
|
NDC 68462-314-35
|
| Hospital Charge Code |
5754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.03 |
| Max. Negotiated Rate |
$95.76 |
| Rate for Payer: Aetna Commercial |
$86.18
|
| Rate for Payer: ASR ASR |
$92.89
|
| Rate for Payer: BCBS Trust/PPO |
$74.24
|
| Rate for Payer: BCN Commercial |
$74.24
|
| Rate for Payer: Cash Price |
$76.61
|
| Rate for Payer: Cofinity Commercial |
$90.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.61
|
| Rate for Payer: Healthscope Commercial |
$95.76
|
| Rate for Payer: Healthscope Whirlpool |
$92.89
|
| Rate for Payer: Mclaren Commercial |
$86.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$84.27
|
|
|
OB/GYN SPEC KZOO ONLY - NITROUS OXIDE ADMIN
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 00563
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: BCBS Complete |
$24.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.00
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$17.20
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
91279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.04 |
| Max. Negotiated Rate |
$17.20 |
| Rate for Payer: Aetna Commercial |
$15.48
|
| Rate for Payer: Aetna Commercial |
$18.25
|
| Rate for Payer: Aetna Commercial |
$16.10
|
| Rate for Payer: Aetna Commercial |
$46.40
|
| Rate for Payer: ASR ASR |
$16.68
|
| Rate for Payer: ASR ASR |
$50.00
|
| Rate for Payer: ASR ASR |
$19.67
|
| Rate for Payer: ASR ASR |
$17.35
|
| Rate for Payer: BCBS Trust/PPO |
$13.87
|
| Rate for Payer: BCBS Trust/PPO |
$13.34
|
| Rate for Payer: BCBS Trust/PPO |
$39.97
|
| Rate for Payer: BCBS Trust/PPO |
$15.72
|
| Rate for Payer: BCN Commercial |
$13.87
|
| Rate for Payer: BCN Commercial |
$13.34
|
| Rate for Payer: BCN Commercial |
$15.72
|
| Rate for Payer: BCN Commercial |
$39.97
|
| Rate for Payer: Cash Price |
$41.24
|
| Rate for Payer: Cash Price |
$14.32
|
| Rate for Payer: Cash Price |
$16.22
|
| Rate for Payer: Cash Price |
$13.76
|
| Rate for Payer: Cofinity Commercial |
$48.46
|
| Rate for Payer: Cofinity Commercial |
$16.17
|
| Rate for Payer: Cofinity Commercial |
$16.82
|
| Rate for Payer: Cofinity Commercial |
$19.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.24
|
| Rate for Payer: Healthscope Commercial |
$17.89
|
| Rate for Payer: Healthscope Commercial |
$20.28
|
| Rate for Payer: Healthscope Commercial |
$17.20
|
| Rate for Payer: Healthscope Commercial |
$51.55
|
| Rate for Payer: Healthscope Whirlpool |
$16.68
|
| Rate for Payer: Healthscope Whirlpool |
$50.00
|
| Rate for Payer: Healthscope Whirlpool |
$19.67
|
| Rate for Payer: Healthscope Whirlpool |
$17.35
|
| Rate for Payer: Mclaren Commercial |
$46.40
|
| Rate for Payer: Mclaren Commercial |
$16.10
|
| Rate for Payer: Mclaren Commercial |
$15.48
|
| Rate for Payer: Mclaren Commercial |
$18.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.36
|
|
|
OFLOXACIN 0.3 % EAR DROPS
|
Facility
|
IP
|
$427.49
|
|
|
Service Code
|
NDC 24208-410-05
|
| Hospital Charge Code |
22257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$299.24 |
| Max. Negotiated Rate |
$427.49 |
| Rate for Payer: Aetna Commercial |
$384.74
|
| Rate for Payer: ASR ASR |
$414.67
|
| Rate for Payer: BCBS Trust/PPO |
$331.43
|
| Rate for Payer: BCN Commercial |
$331.43
|
| Rate for Payer: Cash Price |
$341.99
|
| Rate for Payer: Cofinity Commercial |
$401.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.99
|
| Rate for Payer: Healthscope Commercial |
$427.49
|
| Rate for Payer: Healthscope Whirlpool |
$414.67
|
| Rate for Payer: Mclaren Commercial |
$384.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$363.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$376.19
|
|
|
OFLOXACIN 0.3 % EAR DROPS
|
Facility
|
IP
|
$56.42
|
|
|
Service Code
|
NDC 60505-0363-1
|
| Hospital Charge Code |
22257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.49 |
| Max. Negotiated Rate |
$56.42 |
| Rate for Payer: Aetna Commercial |
$50.78
|
| Rate for Payer: ASR ASR |
$54.73
|
| Rate for Payer: BCBS Trust/PPO |
$43.74
|
| Rate for Payer: BCN Commercial |
$43.74
|
| Rate for Payer: Cash Price |
$45.14
|
| Rate for Payer: Cofinity Commercial |
$53.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.14
|
| Rate for Payer: Healthscope Commercial |
$56.42
|
| Rate for Payer: Healthscope Whirlpool |
$54.73
|
| Rate for Payer: Mclaren Commercial |
$50.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.65
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$24.64
|
|
|
Service Code
|
NDC 64980-515-05
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Aetna Commercial |
$22.18
|
| Rate for Payer: ASR ASR |
$23.90
|
| Rate for Payer: BCBS Trust/PPO |
$19.10
|
| Rate for Payer: BCN Commercial |
$19.10
|
| Rate for Payer: Cash Price |
$19.71
|
| Rate for Payer: Cofinity Commercial |
$23.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.71
|
| Rate for Payer: Healthscope Commercial |
$24.64
|
| Rate for Payer: Healthscope Whirlpool |
$23.90
|
| Rate for Payer: Mclaren Commercial |
$22.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.68
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$48.83
|
|
|
Service Code
|
NDC 70756-607-30
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.18 |
| Max. Negotiated Rate |
$48.83 |
| Rate for Payer: Aetna Commercial |
$43.95
|
| Rate for Payer: ASR ASR |
$47.37
|
| Rate for Payer: BCBS Trust/PPO |
$37.86
|
| Rate for Payer: BCN Commercial |
$37.86
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cofinity Commercial |
$45.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.06
|
| Rate for Payer: Healthscope Commercial |
$48.83
|
| Rate for Payer: Healthscope Whirlpool |
$47.37
|
| Rate for Payer: Mclaren Commercial |
$43.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.97
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$403.83
|
|
|
Service Code
|
NDC 11980-779-05
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$282.68 |
| Max. Negotiated Rate |
$403.83 |
| Rate for Payer: Aetna Commercial |
$363.45
|
| Rate for Payer: ASR ASR |
$391.72
|
| Rate for Payer: BCBS Trust/PPO |
$313.09
|
| Rate for Payer: BCN Commercial |
$313.09
|
| Rate for Payer: Cash Price |
$323.06
|
| Rate for Payer: Cofinity Commercial |
$379.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.06
|
| Rate for Payer: Healthscope Commercial |
$403.83
|
| Rate for Payer: Healthscope Whirlpool |
$391.72
|
| Rate for Payer: Mclaren Commercial |
$363.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$343.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$282.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$355.37
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$44.76
|
|
|
Service Code
|
NDC 64980-515-01
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.33 |
| Max. Negotiated Rate |
$44.76 |
| Rate for Payer: Aetna Commercial |
$40.28
|
| Rate for Payer: ASR ASR |
$43.42
|
| Rate for Payer: BCBS Trust/PPO |
$34.70
|
| Rate for Payer: BCN Commercial |
$34.70
|
| Rate for Payer: Cash Price |
$35.81
|
| Rate for Payer: Cofinity Commercial |
$42.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.81
|
| Rate for Payer: Healthscope Commercial |
$44.76
|
| Rate for Payer: Healthscope Whirlpool |
$43.42
|
| Rate for Payer: Mclaren Commercial |
$40.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.39
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$66.53
|
|
|
Service Code
|
NDC 24208-434-05
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.57 |
| Max. Negotiated Rate |
$66.53 |
| Rate for Payer: Aetna Commercial |
$59.88
|
| Rate for Payer: ASR ASR |
$64.53
|
| Rate for Payer: BCBS Trust/PPO |
$51.58
|
| Rate for Payer: BCN Commercial |
$51.58
|
| Rate for Payer: Cash Price |
$53.23
|
| Rate for Payer: Cofinity Commercial |
$62.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.22
|
| Rate for Payer: Healthscope Commercial |
$66.53
|
| Rate for Payer: Healthscope Whirlpool |
$64.53
|
| Rate for Payer: Mclaren Commercial |
$59.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$58.55
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$80.28
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.20 |
| Max. Negotiated Rate |
$80.28 |
| Rate for Payer: Aetna Commercial |
$72.25
|
| Rate for Payer: Aetna Commercial |
$48.98
|
| Rate for Payer: ASR ASR |
$52.79
|
| Rate for Payer: ASR ASR |
$77.87
|
| Rate for Payer: BCBS Trust/PPO |
$42.19
|
| Rate for Payer: BCBS Trust/PPO |
$62.24
|
| Rate for Payer: BCN Commercial |
$42.19
|
| Rate for Payer: BCN Commercial |
$62.24
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Cash Price |
$43.54
|
| Rate for Payer: Cofinity Commercial |
$51.15
|
| Rate for Payer: Cofinity Commercial |
$75.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.54
|
| Rate for Payer: Healthscope Commercial |
$54.42
|
| Rate for Payer: Healthscope Commercial |
$80.28
|
| Rate for Payer: Healthscope Whirlpool |
$52.79
|
| Rate for Payer: Healthscope Whirlpool |
$77.87
|
| Rate for Payer: Mclaren Commercial |
$72.25
|
| Rate for Payer: Mclaren Commercial |
$48.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$46.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.65
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$263.20
|
|
|
Service Code
|
NDC 0904-6377-61
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.24 |
| Max. Negotiated Rate |
$263.20 |
| Rate for Payer: Aetna Commercial |
$236.88
|
| Rate for Payer: ASR ASR |
$255.30
|
| Rate for Payer: BCBS Trust/PPO |
$204.06
|
| Rate for Payer: BCN Commercial |
$204.06
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$247.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Healthscope Commercial |
$263.20
|
| Rate for Payer: Healthscope Whirlpool |
$255.30
|
| Rate for Payer: Mclaren Commercial |
$236.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$223.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.62
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$289.05
|
|
|
Service Code
|
NDC 60505-3111-0
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.34 |
| Max. Negotiated Rate |
$289.05 |
| Rate for Payer: Aetna Commercial |
$260.14
|
| Rate for Payer: ASR ASR |
$280.38
|
| Rate for Payer: BCBS Trust/PPO |
$224.10
|
| Rate for Payer: BCN Commercial |
$224.10
|
| Rate for Payer: Cash Price |
$231.24
|
| Rate for Payer: Cofinity Commercial |
$271.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.24
|
| Rate for Payer: Healthscope Commercial |
$289.05
|
| Rate for Payer: Healthscope Whirlpool |
$280.38
|
| Rate for Payer: Mclaren Commercial |
$260.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$245.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$254.36
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$35.25
|
|
|
Service Code
|
NDC 43598-164-30
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.68 |
| Max. Negotiated Rate |
$35.25 |
| Rate for Payer: Aetna Commercial |
$31.72
|
| Rate for Payer: ASR ASR |
$34.19
|
| Rate for Payer: BCBS Trust/PPO |
$27.33
|
| Rate for Payer: BCN Commercial |
$27.33
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cofinity Commercial |
$33.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.20
|
| Rate for Payer: Healthscope Commercial |
$35.25
|
| Rate for Payer: Healthscope Whirlpool |
$34.19
|
| Rate for Payer: Mclaren Commercial |
$31.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.02
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$1,625.93
|
|
|
Service Code
|
NDC 0002-4115-30
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,138.15 |
| Max. Negotiated Rate |
$1,625.93 |
| Rate for Payer: Aetna Commercial |
$1,463.34
|
| Rate for Payer: ASR ASR |
$1,577.15
|
| Rate for Payer: BCBS Trust/PPO |
$1,260.58
|
| Rate for Payer: BCN Commercial |
$1,260.58
|
| Rate for Payer: Cash Price |
$1,300.74
|
| Rate for Payer: Cofinity Commercial |
$1,528.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,300.74
|
| Rate for Payer: Healthscope Commercial |
$1,625.93
|
| Rate for Payer: Healthscope Whirlpool |
$1,577.15
|
| Rate for Payer: Mclaren Commercial |
$1,463.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,382.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,138.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,430.82
|
|
|
OLOPATADINE 0.1 % EYE DROPS
|
Facility
|
IP
|
$20.16
|
|
|
Service Code
|
NDC 17478-105-05
|
| Hospital Charge Code |
19452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$20.16 |
| Rate for Payer: Aetna Commercial |
$18.14
|
| Rate for Payer: ASR ASR |
$19.56
|
| Rate for Payer: BCBS Trust/PPO |
$15.63
|
| Rate for Payer: BCN Commercial |
$15.63
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Cofinity Commercial |
$18.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.13
|
| Rate for Payer: Healthscope Commercial |
$20.16
|
| Rate for Payer: Healthscope Whirlpool |
$19.56
|
| Rate for Payer: Mclaren Commercial |
$18.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.74
|
|
|
OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$4,431.87
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
188928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,102.31 |
| Max. Negotiated Rate |
$4,431.87 |
| Rate for Payer: Aetna Commercial |
$3,988.68
|
| Rate for Payer: ASR ASR |
$4,298.91
|
| Rate for Payer: BCBS Trust/PPO |
$3,436.03
|
| Rate for Payer: BCN Commercial |
$3,436.03
|
| Rate for Payer: Cash Price |
$3,545.50
|
| Rate for Payer: Cofinity Commercial |
$4,165.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,545.50
|
| Rate for Payer: Healthscope Commercial |
$4,431.87
|
| Rate for Payer: Healthscope Whirlpool |
$4,298.91
|
| Rate for Payer: Mclaren Commercial |
$3,988.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,767.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,102.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,900.05
|
|
