|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS
|
Facility
|
OP
|
$167.13
|
|
|
Service Code
|
NDC 24208079062
|
| Hospital Charge Code |
5474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.84 |
| Max. Negotiated Rate |
$167.12 |
| Rate for Payer: Aetna Commercial |
$150.41
|
| Rate for Payer: Aetna Medicare |
$61.84
|
| Rate for Payer: ASR ASR |
$162.11
|
| Rate for Payer: BCBS Complete |
$66.85
|
| Rate for Payer: BCBS Trust/PPO |
$137.79
|
| Rate for Payer: BCN Commercial |
$137.79
|
| Rate for Payer: Cash Price |
$133.70
|
| Rate for Payer: Cofinity Commercial |
$157.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.70
|
| Rate for Payer: Healthscope Commercial |
$162.11
|
| Rate for Payer: Healthscope Whirlpool |
$167.12
|
| Rate for Payer: Mclaren Commercial |
$150.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$133.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.06
|
| Rate for Payer: Nomi Health Commercial |
$137.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$146.43
|
| Rate for Payer: Priority Health Narrow Network |
$117.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$147.07
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
OP
|
$41.33
|
|
|
Service Code
|
NDC 574416035
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$41.33 |
| Rate for Payer: Aetna Commercial |
$37.20
|
| Rate for Payer: Aetna Medicare |
$15.29
|
| Rate for Payer: ASR ASR |
$40.09
|
| Rate for Payer: BCBS Complete |
$16.53
|
| Rate for Payer: BCBS Trust/PPO |
$34.08
|
| Rate for Payer: BCN Commercial |
$34.08
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cofinity Commercial |
$38.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.07
|
| Rate for Payer: Healthscope Commercial |
$40.09
|
| Rate for Payer: Healthscope Whirlpool |
$41.33
|
| Rate for Payer: Mclaren Commercial |
$37.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.13
|
| Rate for Payer: Nomi Health Commercial |
$33.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$36.22
|
| Rate for Payer: Priority Health Narrow Network |
$28.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.37
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$43.05
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.29 |
| Max. Negotiated Rate |
$43.05 |
| Rate for Payer: Aetna Commercial |
$38.74
|
| Rate for Payer: ASR ASR |
$41.76
|
| Rate for Payer: BCBS Trust/PPO |
$35.35
|
| Rate for Payer: BCN Commercial |
$35.35
|
| Rate for Payer: Cash Price |
$34.44
|
| Rate for Payer: Cofinity Commercial |
$40.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.44
|
| Rate for Payer: Healthscope Commercial |
$41.76
|
| Rate for Payer: Healthscope Whirlpool |
$43.05
|
| Rate for Payer: Mclaren Commercial |
$38.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.59
|
| Rate for Payer: Nomi Health Commercial |
$35.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.88
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
OP
|
$58.59
|
|
|
Service Code
|
NDC 61314063136
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.68 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$52.73
|
| Rate for Payer: Aetna Medicare |
$21.68
|
| Rate for Payer: ASR ASR |
$56.83
|
| Rate for Payer: BCBS Complete |
$23.44
|
| Rate for Payer: BCBS Trust/PPO |
$48.31
|
| Rate for Payer: BCN Commercial |
$48.31
|
| Rate for Payer: Cash Price |
$46.87
|
| Rate for Payer: Cofinity Commercial |
$55.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.87
|
| Rate for Payer: Healthscope Commercial |
$56.83
|
| Rate for Payer: Healthscope Whirlpool |
$58.59
|
| Rate for Payer: Mclaren Commercial |
$52.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$46.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.80
|
| Rate for Payer: Nomi Health Commercial |
$48.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$51.34
|
| Rate for Payer: Priority Health Narrow Network |
$41.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$51.56
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
OP
|
$43.05
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.93 |
| Max. Negotiated Rate |
$43.05 |
| Rate for Payer: Aetna Commercial |
$38.74
|
| Rate for Payer: Aetna Medicare |
$15.93
|
| Rate for Payer: ASR ASR |
$41.76
|
| Rate for Payer: BCBS Complete |
$17.22
|
| Rate for Payer: BCBS Trust/PPO |
$35.49
|
| Rate for Payer: BCN Commercial |
$35.49
|
| Rate for Payer: Cash Price |
$34.44
|
| Rate for Payer: Cofinity Commercial |
$40.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.44
|
| Rate for Payer: Healthscope Commercial |
$41.76
|
| Rate for Payer: Healthscope Whirlpool |
$43.05
|
| Rate for Payer: Mclaren Commercial |
$38.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.59
|
| Rate for Payer: Nomi Health Commercial |
$35.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.29
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$37.72
|
| Rate for Payer: Priority Health Narrow Network |
$30.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$37.88
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$41.33
|
|
|
Service Code
|
NDC 574416035
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.00 |
| Max. Negotiated Rate |
$41.33 |
| Rate for Payer: Aetna Commercial |
$37.20
|
| Rate for Payer: ASR ASR |
$40.09
|
| Rate for Payer: BCBS Trust/PPO |
$33.94
|
| Rate for Payer: BCN Commercial |
$33.94
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cofinity Commercial |
$38.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.07
|
| Rate for Payer: Healthscope Commercial |
$40.09
|
| Rate for Payer: Healthscope Whirlpool |
$41.33
|
| Rate for Payer: Mclaren Commercial |
$37.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.13
|
| Rate for Payer: Nomi Health Commercial |
$33.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.37
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$58.59
|
|
|
Service Code
|
NDC 61314063136
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.94 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$52.73
|
| Rate for Payer: ASR ASR |
$56.83
|
| Rate for Payer: BCBS Trust/PPO |
$48.12
|
| Rate for Payer: BCN Commercial |
$48.12
|
| Rate for Payer: Cash Price |
$46.87
|
| Rate for Payer: Cofinity Commercial |
$55.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.87
|
| Rate for Payer: Healthscope Commercial |
$56.83
|
| Rate for Payer: Healthscope Whirlpool |
$58.59
|
| Rate for Payer: Mclaren Commercial |
$52.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.80
|
| Rate for Payer: Nomi Health Commercial |
$48.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$51.56
|
|
|
NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT
|
Facility
|
OP
|
$69.37
|
|
|
Service Code
|
NDC 24208078555
|
| Hospital Charge Code |
849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.67 |
| Max. Negotiated Rate |
$69.37 |
| Rate for Payer: Aetna Commercial |
$62.43
|
| Rate for Payer: Aetna Medicare |
$25.67
|
| Rate for Payer: ASR ASR |
$67.29
|
| Rate for Payer: BCBS Complete |
$27.75
|
| Rate for Payer: BCBS Trust/PPO |
$57.20
|
| Rate for Payer: BCN Commercial |
$57.20
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cofinity Commercial |
$65.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.50
|
| Rate for Payer: Healthscope Commercial |
$67.29
|
| Rate for Payer: Healthscope Whirlpool |
$69.37
|
| Rate for Payer: Mclaren Commercial |
$62.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.97
|
| Rate for Payer: Nomi Health Commercial |
$56.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$60.78
|
| Rate for Payer: Priority Health Narrow Network |
$48.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.05
|
|
|
NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT
|
Facility
|
IP
|
$69.37
|
|
|
Service Code
|
NDC 24208078555
|
| Hospital Charge Code |
849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.03 |
| Max. Negotiated Rate |
$69.37 |
| Rate for Payer: Aetna Commercial |
$62.43
|
| Rate for Payer: ASR ASR |
$67.29
|
| Rate for Payer: BCBS Trust/PPO |
$56.97
|
| Rate for Payer: BCN Commercial |
$56.97
|
| Rate for Payer: Cash Price |
$55.50
|
| Rate for Payer: Cofinity Commercial |
$65.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.50
|
| Rate for Payer: Healthscope Commercial |
$67.29
|
| Rate for Payer: Healthscope Whirlpool |
$69.37
|
| Rate for Payer: Mclaren Commercial |
$62.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.97
|
| Rate for Payer: Nomi Health Commercial |
$56.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.05
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 713026831
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Aetna Commercial |
$9.23
|
| Rate for Payer: ASR ASR |
$9.95
|
| Rate for Payer: BCBS Trust/PPO |
$8.43
|
| Rate for Payer: BCN Commercial |
$8.43
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.95
|
| Rate for Payer: Healthscope Whirlpool |
$10.26
|
| Rate for Payer: Mclaren Commercial |
$9.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: Nomi Health Commercial |
$8.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.03
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$10.26
|
|
|
Service Code
|
NDC 713026831
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Aetna Commercial |
$9.23
|
| Rate for Payer: Aetna Medicare |
$3.80
|
| Rate for Payer: ASR ASR |
$9.95
|
| Rate for Payer: BCBS Complete |
$4.10
|
| Rate for Payer: BCBS Trust/PPO |
$8.46
|
| Rate for Payer: BCN Commercial |
$8.46
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.95
|
| Rate for Payer: Healthscope Whirlpool |
$10.26
|
| Rate for Payer: Mclaren Commercial |
$9.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: Nomi Health Commercial |
$8.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.70
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.99
|
| Rate for Payer: Priority Health Narrow Network |
$7.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.03
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$10.26
|
|
|
Service Code
|
NDC 904073431
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Aetna Commercial |
$9.23
|
| Rate for Payer: Aetna Medicare |
$3.80
|
| Rate for Payer: ASR ASR |
$9.95
|
| Rate for Payer: BCBS Complete |
$4.10
|
| Rate for Payer: BCBS Trust/PPO |
$8.46
|
| Rate for Payer: BCN Commercial |
$8.46
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.95
|
| Rate for Payer: Healthscope Whirlpool |
$10.26
|
| Rate for Payer: Mclaren Commercial |
$9.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: Nomi Health Commercial |
$8.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.70
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.99
|
| Rate for Payer: Priority Health Narrow Network |
$7.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.03
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$9.58
|
|
|
Service Code
|
NDC 45802014301
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$8.62
|
| Rate for Payer: ASR ASR |
$9.29
|
| Rate for Payer: BCBS Trust/PPO |
$7.86
|
| Rate for Payer: BCN Commercial |
$7.86
|
| Rate for Payer: Cash Price |
$7.66
|
| Rate for Payer: Cofinity Commercial |
$9.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.66
|
| Rate for Payer: Healthscope Commercial |
$9.29
|
| Rate for Payer: Healthscope Whirlpool |
$9.58
|
| Rate for Payer: Mclaren Commercial |
$8.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.14
|
| Rate for Payer: Nomi Health Commercial |
$7.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.43
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$9.58
|
|
|
Service Code
|
NDC 45802014301
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.54 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$8.62
|
| Rate for Payer: Aetna Medicare |
$3.54
|
| Rate for Payer: ASR ASR |
$9.29
|
| Rate for Payer: BCBS Complete |
$3.83
|
| Rate for Payer: BCBS Trust/PPO |
$7.90
|
| Rate for Payer: BCN Commercial |
$7.90
|
| Rate for Payer: Cash Price |
$7.66
|
| Rate for Payer: Cofinity Commercial |
$9.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.66
|
| Rate for Payer: Healthscope Commercial |
$9.29
|
| Rate for Payer: Healthscope Whirlpool |
$9.58
|
| Rate for Payer: Mclaren Commercial |
$8.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.14
|
| Rate for Payer: Nomi Health Commercial |
$7.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.18
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.39
|
| Rate for Payer: Priority Health Narrow Network |
$6.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.43
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$10.26
|
|
|
Service Code
|
NDC 904073431
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Aetna Commercial |
$9.23
|
| Rate for Payer: ASR ASR |
$9.95
|
| Rate for Payer: BCBS Trust/PPO |
$8.43
|
| Rate for Payer: BCN Commercial |
$8.43
|
| Rate for Payer: Cash Price |
$8.21
|
| Rate for Payer: Cofinity Commercial |
$9.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.21
|
| Rate for Payer: Healthscope Commercial |
$9.95
|
| Rate for Payer: Healthscope Whirlpool |
$10.26
|
| Rate for Payer: Mclaren Commercial |
$9.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.72
|
| Rate for Payer: Nomi Health Commercial |
$8.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.03
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
IP
|
$399.31
|
|
|
Service Code
|
NDC 904880567
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$299.48 |
| Max. Negotiated Rate |
$399.31 |
| Rate for Payer: Aetna Commercial |
$359.38
|
| Rate for Payer: ASR ASR |
$387.33
|
| Rate for Payer: BCBS Trust/PPO |
$327.92
|
| Rate for Payer: BCN Commercial |
$327.92
|
| Rate for Payer: Cash Price |
$319.45
|
| Rate for Payer: Cofinity Commercial |
$375.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$319.45
|
| Rate for Payer: Healthscope Commercial |
$387.33
|
| Rate for Payer: Healthscope Whirlpool |
$399.31
|
| Rate for Payer: Mclaren Commercial |
$359.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$339.42
|
| Rate for Payer: Nomi Health Commercial |
$327.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$299.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$351.39
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
IP
|
$517.75
|
|
|
Service Code
|
NDC 47682022335
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$388.31 |
| Max. Negotiated Rate |
$517.75 |
| Rate for Payer: Aetna Commercial |
$465.98
|
| Rate for Payer: ASR ASR |
$502.22
|
| Rate for Payer: BCBS Trust/PPO |
$425.18
|
| Rate for Payer: BCN Commercial |
$425.18
|
| Rate for Payer: Cash Price |
$414.20
|
| Rate for Payer: Cofinity Commercial |
$486.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.20
|
| Rate for Payer: Healthscope Commercial |
$502.22
|
| Rate for Payer: Healthscope Whirlpool |
$517.75
|
| Rate for Payer: Mclaren Commercial |
$465.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$440.09
|
| Rate for Payer: Nomi Health Commercial |
$424.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$388.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$455.62
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 47682022399
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Aetna Commercial |
$3.24
|
| Rate for Payer: ASR ASR |
$3.49
|
| Rate for Payer: BCBS Trust/PPO |
$2.95
|
| Rate for Payer: BCN Commercial |
$2.95
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$3.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.88
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Healthscope Whirlpool |
$3.60
|
| Rate for Payer: Mclaren Commercial |
$3.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.06
|
| Rate for Payer: Nomi Health Commercial |
$2.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.16
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
OP
|
$517.75
|
|
|
Service Code
|
NDC 47682022335
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.57 |
| Max. Negotiated Rate |
$517.75 |
| Rate for Payer: Aetna Commercial |
$465.98
|
| Rate for Payer: Aetna Medicare |
$191.57
|
| Rate for Payer: ASR ASR |
$502.22
|
| Rate for Payer: BCBS Complete |
$207.10
|
| Rate for Payer: BCBS Trust/PPO |
$426.89
|
| Rate for Payer: BCN Commercial |
$426.89
|
| Rate for Payer: Cash Price |
$414.20
|
| Rate for Payer: Cofinity Commercial |
$486.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.20
|
| Rate for Payer: Healthscope Commercial |
$502.22
|
| Rate for Payer: Healthscope Whirlpool |
$517.75
|
| Rate for Payer: Mclaren Commercial |
$465.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$414.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$440.09
|
| Rate for Payer: Nomi Health Commercial |
$424.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$388.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$453.65
|
| Rate for Payer: Priority Health Narrow Network |
$362.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$455.62
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
OP
|
$399.31
|
|
|
Service Code
|
NDC 904880567
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.75 |
| Max. Negotiated Rate |
$399.31 |
| Rate for Payer: Aetna Commercial |
$359.38
|
| Rate for Payer: Aetna Medicare |
$147.75
|
| Rate for Payer: ASR ASR |
$387.33
|
| Rate for Payer: BCBS Complete |
$159.72
|
| Rate for Payer: BCBS Trust/PPO |
$329.23
|
| Rate for Payer: BCN Commercial |
$329.23
|
| Rate for Payer: Cash Price |
$319.45
|
| Rate for Payer: Cofinity Commercial |
$375.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$319.45
|
| Rate for Payer: Healthscope Commercial |
$387.33
|
| Rate for Payer: Healthscope Whirlpool |
$399.31
|
| Rate for Payer: Mclaren Commercial |
$359.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$319.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$339.42
|
| Rate for Payer: Nomi Health Commercial |
$327.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$299.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$349.88
|
| Rate for Payer: Priority Health Narrow Network |
$279.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$351.39
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 47682022399
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$3.60 |
| Rate for Payer: Aetna Commercial |
$3.24
|
| Rate for Payer: Aetna Medicare |
$1.33
|
| Rate for Payer: ASR ASR |
$3.49
|
| Rate for Payer: BCBS Complete |
$1.44
|
| Rate for Payer: BCBS Trust/PPO |
$2.96
|
| Rate for Payer: BCN Commercial |
$2.96
|
| Rate for Payer: Cash Price |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$3.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.88
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Healthscope Whirlpool |
$3.60
|
| Rate for Payer: Mclaren Commercial |
$3.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.06
|
| Rate for Payer: Nomi Health Commercial |
$2.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.70
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.15
|
| Rate for Payer: Priority Health Narrow Network |
$2.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.16
|
|
|
NEOMYCIN-COLIST-HC-THONZONM 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSP
|
Facility
|
OP
|
$738.96
|
|
|
Service Code
|
NDC 63481052910
|
| Hospital Charge Code |
108037
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.41 |
| Max. Negotiated Rate |
$738.96 |
| Rate for Payer: Aetna Commercial |
$665.06
|
| Rate for Payer: Aetna Medicare |
$273.41
|
| Rate for Payer: ASR ASR |
$716.79
|
| Rate for Payer: BCBS Complete |
$295.58
|
| Rate for Payer: BCBS Trust/PPO |
$609.27
|
| Rate for Payer: BCN Commercial |
$609.27
|
| Rate for Payer: Cash Price |
$591.16
|
| Rate for Payer: Cofinity Commercial |
$694.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$591.16
|
| Rate for Payer: Healthscope Commercial |
$716.79
|
| Rate for Payer: Healthscope Whirlpool |
$738.96
|
| Rate for Payer: Mclaren Commercial |
$665.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$591.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$628.11
|
| Rate for Payer: Nomi Health Commercial |
$605.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$554.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$647.47
|
| Rate for Payer: Priority Health Narrow Network |
$518.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$650.28
|
|
|
NEOMYCIN-COLIST-HC-THONZONM 3.3 MG-3 MG-10 MG-0.5 MG/ML EAR DROPS,SUSP
|
Facility
|
IP
|
$738.96
|
|
|
Service Code
|
NDC 63481052910
|
| Hospital Charge Code |
108037
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$554.22 |
| Max. Negotiated Rate |
$738.96 |
| Rate for Payer: Aetna Commercial |
$665.06
|
| Rate for Payer: ASR ASR |
$716.79
|
| Rate for Payer: BCBS Trust/PPO |
$606.83
|
| Rate for Payer: BCN Commercial |
$606.83
|
| Rate for Payer: Cash Price |
$591.16
|
| Rate for Payer: Cofinity Commercial |
$694.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$591.16
|
| Rate for Payer: Healthscope Commercial |
$716.79
|
| Rate for Payer: Healthscope Whirlpool |
$738.96
|
| Rate for Payer: Mclaren Commercial |
$665.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$628.11
|
| Rate for Payer: Nomi Health Commercial |
$605.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$554.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$650.28
|
|
|
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS
|
Facility
|
IP
|
$36.51
|
|
|
Service Code
|
NDC 61314063006
|
| Hospital Charge Code |
10708
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.38 |
| Max. Negotiated Rate |
$36.51 |
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: ASR ASR |
$35.41
|
| Rate for Payer: BCBS Trust/PPO |
$29.98
|
| Rate for Payer: BCN Commercial |
$29.98
|
| Rate for Payer: Cash Price |
$29.20
|
| Rate for Payer: Cofinity Commercial |
$34.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.20
|
| Rate for Payer: Healthscope Commercial |
$35.41
|
| Rate for Payer: Healthscope Whirlpool |
$36.51
|
| Rate for Payer: Mclaren Commercial |
$32.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.03
|
| Rate for Payer: Nomi Health Commercial |
$29.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$27.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.12
|
|
|
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS
|
Facility
|
IP
|
$51.73
|
|
|
Service Code
|
NDC 24208083060
|
| Hospital Charge Code |
10708
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.80 |
| Max. Negotiated Rate |
$51.73 |
| Rate for Payer: Aetna Commercial |
$46.56
|
| Rate for Payer: ASR ASR |
$50.18
|
| Rate for Payer: BCBS Trust/PPO |
$42.48
|
| Rate for Payer: BCN Commercial |
$42.48
|
| Rate for Payer: Cash Price |
$41.38
|
| Rate for Payer: Cofinity Commercial |
$48.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.38
|
| Rate for Payer: Healthscope Commercial |
$50.18
|
| Rate for Payer: Healthscope Whirlpool |
$51.73
|
| Rate for Payer: Mclaren Commercial |
$46.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.97
|
| Rate for Payer: Nomi Health Commercial |
$42.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.52
|
|
