|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$23.83
|
|
|
Service Code
|
NDC 70121157607
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$23.83 |
| Rate for Payer: Aetna Commercial |
$21.45
|
| Rate for Payer: Aetna Medicare |
$8.82
|
| Rate for Payer: ASR ASR |
$23.11
|
| Rate for Payer: BCBS Complete |
$9.53
|
| Rate for Payer: BCBS Trust/PPO |
$19.65
|
| Rate for Payer: BCN Commercial |
$19.65
|
| Rate for Payer: Cash Price |
$19.06
|
| Rate for Payer: Cofinity Commercial |
$22.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.06
|
| Rate for Payer: Healthscope Commercial |
$23.11
|
| Rate for Payer: Healthscope Whirlpool |
$23.83
|
| Rate for Payer: Mclaren Commercial |
$21.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.25
|
| Rate for Payer: Nomi Health Commercial |
$19.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$20.88
|
| Rate for Payer: Priority Health Narrow Network |
$16.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.97
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$14.98
|
|
|
Service Code
|
NDC 67457085200
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$14.98 |
| Rate for Payer: Aetna Commercial |
$13.48
|
| Rate for Payer: ASR ASR |
$14.53
|
| Rate for Payer: BCBS Trust/PPO |
$12.30
|
| Rate for Payer: BCN Commercial |
$12.30
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cofinity Commercial |
$14.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.98
|
| Rate for Payer: Healthscope Commercial |
$14.53
|
| Rate for Payer: Healthscope Whirlpool |
$14.98
|
| Rate for Payer: Mclaren Commercial |
$13.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.73
|
| Rate for Payer: Nomi Health Commercial |
$12.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.18
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.97
|
|
|
Service Code
|
NDC 143931801
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$26.97 |
| Rate for Payer: Aetna Commercial |
$24.27
|
| Rate for Payer: Aetna Medicare |
$9.98
|
| Rate for Payer: ASR ASR |
$26.16
|
| Rate for Payer: BCBS Complete |
$10.79
|
| Rate for Payer: BCBS Trust/PPO |
$22.24
|
| Rate for Payer: BCN Commercial |
$22.24
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cofinity Commercial |
$25.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Healthscope Commercial |
$26.16
|
| Rate for Payer: Healthscope Whirlpool |
$26.97
|
| Rate for Payer: Mclaren Commercial |
$24.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Nomi Health Commercial |
$22.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.23
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23.63
|
| Rate for Payer: Priority Health Narrow Network |
$18.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.73
|
|
|
NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$74.58
|
|
|
Service Code
|
NDC 703115303
|
| Hospital Charge Code |
10734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.60 |
| Max. Negotiated Rate |
$74.58 |
| Rate for Payer: Aetna Commercial |
$67.12
|
| Rate for Payer: Aetna Medicare |
$27.60
|
| Rate for Payer: ASR ASR |
$72.34
|
| Rate for Payer: BCBS Complete |
$29.83
|
| Rate for Payer: BCBS Trust/PPO |
$61.49
|
| Rate for Payer: BCN Commercial |
$61.49
|
| Rate for Payer: Cash Price |
$59.67
|
| Rate for Payer: Cofinity Commercial |
$70.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.67
|
| Rate for Payer: Healthscope Commercial |
$72.34
|
| Rate for Payer: Healthscope Whirlpool |
$74.58
|
| Rate for Payer: Mclaren Commercial |
$67.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$59.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.39
|
| Rate for Payer: Nomi Health Commercial |
$61.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$65.35
|
| Rate for Payer: Priority Health Narrow Network |
$52.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.63
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
OP
|
$21.50
|
|
|
Service Code
|
NDC 44567064101
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.96 |
| Max. Negotiated Rate |
$21.50 |
| Rate for Payer: Aetna Commercial |
$19.35
|
| Rate for Payer: Aetna Medicare |
$7.96
|
| Rate for Payer: ASR ASR |
$20.86
|
| Rate for Payer: BCBS Complete |
$8.60
|
| Rate for Payer: BCBS Trust/PPO |
$17.73
|
| Rate for Payer: BCN Commercial |
$17.73
|
| Rate for Payer: Cash Price |
$17.20
|
| Rate for Payer: Cofinity Commercial |
$20.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.20
|
| Rate for Payer: Healthscope Commercial |
$20.86
|
| Rate for Payer: Healthscope Whirlpool |
$21.50
|
| Rate for Payer: Mclaren Commercial |
$19.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.27
|
| Rate for Payer: Nomi Health Commercial |
$17.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18.84
|
| Rate for Payer: Priority Health Narrow Network |
$15.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.92
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
OP
|
$21.50
|
|
|
Service Code
|
NDC 44567064110
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.96 |
| Max. Negotiated Rate |
$21.50 |
| Rate for Payer: Aetna Commercial |
$19.35
|
| Rate for Payer: Aetna Medicare |
$7.96
|
| Rate for Payer: ASR ASR |
$20.86
|
| Rate for Payer: BCBS Complete |
$8.60
|
| Rate for Payer: BCBS Trust/PPO |
$17.73
|
| Rate for Payer: BCN Commercial |
$17.73
|
| Rate for Payer: Cash Price |
$17.20
|
| Rate for Payer: Cofinity Commercial |
$20.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.20
|
| Rate for Payer: Healthscope Commercial |
$20.86
|
| Rate for Payer: Healthscope Whirlpool |
$21.50
|
| Rate for Payer: Mclaren Commercial |
$19.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.27
|
| Rate for Payer: Nomi Health Commercial |
$17.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18.84
|
| Rate for Payer: Priority Health Narrow Network |
$15.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.92
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
IP
|
$21.50
|
|
|
Service Code
|
NDC 44567064110
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.12 |
| Max. Negotiated Rate |
$21.50 |
| Rate for Payer: Aetna Commercial |
$19.35
|
| Rate for Payer: ASR ASR |
$20.86
|
| Rate for Payer: BCBS Trust/PPO |
$17.66
|
| Rate for Payer: BCN Commercial |
$17.66
|
| Rate for Payer: Cash Price |
$17.20
|
| Rate for Payer: Cofinity Commercial |
$20.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.20
|
| Rate for Payer: Healthscope Commercial |
$20.86
|
| Rate for Payer: Healthscope Whirlpool |
$21.50
|
| Rate for Payer: Mclaren Commercial |
$19.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.27
|
| Rate for Payer: Nomi Health Commercial |
$17.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.92
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
IP
|
$21.50
|
|
|
Service Code
|
NDC 44567064101
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.12 |
| Max. Negotiated Rate |
$21.50 |
| Rate for Payer: Aetna Commercial |
$19.35
|
| Rate for Payer: ASR ASR |
$20.86
|
| Rate for Payer: BCBS Trust/PPO |
$17.66
|
| Rate for Payer: BCN Commercial |
$17.66
|
| Rate for Payer: Cash Price |
$17.20
|
| Rate for Payer: Cofinity Commercial |
$20.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.20
|
| Rate for Payer: Healthscope Commercial |
$20.86
|
| Rate for Payer: Healthscope Whirlpool |
$21.50
|
| Rate for Payer: Mclaren Commercial |
$19.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.27
|
| Rate for Payer: Nomi Health Commercial |
$17.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.92
|
|
|
NORMAL NEWBORN
|
Facility
|
IP
|
$4,949.57
|
|
|
Service Code
|
MSDRG 795
|
| Min. Negotiated Rate |
$1,560.73 |
| Max. Negotiated Rate |
$4,949.57 |
| Rate for Payer: Aetna Medicare |
$3,193.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,991.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,991.59
|
| Rate for Payer: BCBS MAPPO |
$3,193.27
|
| Rate for Payer: BCN Medicare Advantage |
$3,193.27
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,193.27
|
| Rate for Payer: Humana Choice PPO Medicare |
$3,193.27
|
| Rate for Payer: Mclaren Medicare |
$3,193.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,352.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,672.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,512.60
|
| Rate for Payer: PACE Medicare |
$3,033.61
|
| Rate for Payer: PACE SWMI |
$3,193.27
|
| Rate for Payer: PHP Commercial |
$3,512.60
|
| Rate for Payer: PHP Medicare Advantage |
$3,193.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1,950.91
|
| Rate for Payer: Priority Health Medicare |
$3,193.27
|
| Rate for Payer: Priority Health Narrow Network |
$1,560.73
|
| Rate for Payer: Railroad Medicare Medicare |
$3,193.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,193.27
|
| Rate for Payer: UHC Exchange |
$4,949.57
|
| Rate for Payer: UHCCP DNSP |
$3,193.27
|
| Rate for Payer: VA VA |
$3,193.27
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$206.80
|
|
|
Service Code
|
NDC 51672400201
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$206.80 |
| Rate for Payer: Aetna Commercial |
$186.12
|
| Rate for Payer: Aetna Medicare |
$76.52
|
| Rate for Payer: ASR ASR |
$200.60
|
| Rate for Payer: BCBS Complete |
$82.72
|
| Rate for Payer: BCBS Trust/PPO |
$170.51
|
| Rate for Payer: BCN Commercial |
$170.51
|
| Rate for Payer: Cash Price |
$165.44
|
| Rate for Payer: Cofinity Commercial |
$194.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.44
|
| Rate for Payer: Healthscope Commercial |
$200.60
|
| Rate for Payer: Healthscope Whirlpool |
$206.80
|
| Rate for Payer: Mclaren Commercial |
$186.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$165.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.78
|
| Rate for Payer: Nomi Health Commercial |
$169.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$155.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$181.20
|
| Rate for Payer: Priority Health Narrow Network |
$144.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.98
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$217.08
|
|
|
Service Code
|
NDC 50268060415
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.32 |
| Max. Negotiated Rate |
$217.07 |
| Rate for Payer: Aetna Commercial |
$195.37
|
| Rate for Payer: Aetna Medicare |
$80.32
|
| Rate for Payer: ASR ASR |
$210.56
|
| Rate for Payer: BCBS Complete |
$86.83
|
| Rate for Payer: BCBS Trust/PPO |
$178.98
|
| Rate for Payer: BCN Commercial |
$178.98
|
| Rate for Payer: Cash Price |
$173.66
|
| Rate for Payer: Cofinity Commercial |
$204.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.66
|
| Rate for Payer: Healthscope Commercial |
$210.56
|
| Rate for Payer: Healthscope Whirlpool |
$217.07
|
| Rate for Payer: Mclaren Commercial |
$195.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$173.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.51
|
| Rate for Payer: Nomi Health Commercial |
$178.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$190.20
|
| Rate for Payer: Priority Health Narrow Network |
$152.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$191.03
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 93081101
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$289.05 |
| Max. Negotiated Rate |
$385.40 |
| Rate for Payer: Aetna Commercial |
$346.86
|
| Rate for Payer: ASR ASR |
$373.84
|
| Rate for Payer: BCBS Trust/PPO |
$316.49
|
| Rate for Payer: BCN Commercial |
$316.49
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$362.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$373.84
|
| Rate for Payer: Healthscope Whirlpool |
$385.40
|
| Rate for Payer: Mclaren Commercial |
$346.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: Nomi Health Commercial |
$316.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$339.15
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$281.30
|
|
|
Service Code
|
NDC 51672400205
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.08 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$253.17
|
| Rate for Payer: Aetna Medicare |
$104.08
|
| Rate for Payer: ASR ASR |
$272.86
|
| Rate for Payer: BCBS Complete |
$112.52
|
| Rate for Payer: BCBS Trust/PPO |
$231.93
|
| Rate for Payer: BCN Commercial |
$231.93
|
| 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 |
$272.86
|
| Rate for Payer: Healthscope Whirlpool |
$281.30
|
| Rate for Payer: Mclaren Commercial |
$253.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$225.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.10
|
| Rate for Payer: Nomi Health Commercial |
$230.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$210.97
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$246.47
|
| Rate for Payer: Priority Health Narrow Network |
$197.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$247.54
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 50268060411
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.91
|
| Rate for Payer: Aetna Medicare |
$1.61
|
| Rate for Payer: ASR ASR |
$4.21
|
| Rate for Payer: BCBS Complete |
$1.74
|
| Rate for Payer: BCBS Trust/PPO |
$3.58
|
| Rate for Payer: BCN Commercial |
$3.58
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.47
|
| Rate for Payer: Healthscope Commercial |
$4.21
|
| Rate for Payer: Healthscope Whirlpool |
$4.34
|
| Rate for Payer: Mclaren Commercial |
$3.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.69
|
| Rate for Payer: Nomi Health Commercial |
$3.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.26
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.80
|
| Rate for Payer: Priority Health Narrow Network |
$3.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.82
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$217.08
|
|
|
Service Code
|
NDC 50268060415
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.81 |
| Max. Negotiated Rate |
$217.07 |
| Rate for Payer: Aetna Commercial |
$195.37
|
| Rate for Payer: ASR ASR |
$210.56
|
| Rate for Payer: BCBS Trust/PPO |
$178.26
|
| Rate for Payer: BCN Commercial |
$178.26
|
| Rate for Payer: Cash Price |
$173.66
|
| Rate for Payer: Cofinity Commercial |
$204.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.66
|
| Rate for Payer: Healthscope Commercial |
$210.56
|
| Rate for Payer: Healthscope Whirlpool |
$217.07
|
| Rate for Payer: Mclaren Commercial |
$195.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.51
|
| Rate for Payer: Nomi Health Commercial |
$178.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$191.03
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$356.25
|
|
|
Service Code
|
NDC 60687029301
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.81 |
| Max. Negotiated Rate |
$356.25 |
| Rate for Payer: Aetna Commercial |
$320.62
|
| Rate for Payer: Aetna Medicare |
$131.81
|
| Rate for Payer: ASR ASR |
$345.56
|
| Rate for Payer: BCBS Complete |
$142.50
|
| Rate for Payer: BCBS Trust/PPO |
$293.73
|
| Rate for Payer: BCN Commercial |
$293.73
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Commercial |
$334.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$345.56
|
| Rate for Payer: Healthscope Whirlpool |
$356.25
|
| Rate for Payer: Mclaren Commercial |
$320.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$285.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Nomi Health Commercial |
$292.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$312.15
|
| Rate for Payer: Priority Health Narrow Network |
$249.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$313.50
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$385.40
|
|
|
Service Code
|
NDC 93081101
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.60 |
| Max. Negotiated Rate |
$385.40 |
| Rate for Payer: Aetna Commercial |
$346.86
|
| Rate for Payer: Aetna Medicare |
$142.60
|
| Rate for Payer: ASR ASR |
$373.84
|
| Rate for Payer: BCBS Complete |
$154.16
|
| Rate for Payer: BCBS Trust/PPO |
$317.76
|
| Rate for Payer: BCN Commercial |
$317.76
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$362.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$373.84
|
| Rate for Payer: Healthscope Whirlpool |
$385.40
|
| Rate for Payer: Mclaren Commercial |
$346.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$308.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: Nomi Health Commercial |
$316.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$337.69
|
| Rate for Payer: Priority Health Narrow Network |
$270.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$339.15
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 50268060411
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.91
|
| Rate for Payer: ASR ASR |
$4.21
|
| Rate for Payer: BCBS Trust/PPO |
$3.57
|
| Rate for Payer: BCN Commercial |
$3.57
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.47
|
| Rate for Payer: Healthscope Commercial |
$4.21
|
| Rate for Payer: Healthscope Whirlpool |
$4.34
|
| Rate for Payer: Mclaren Commercial |
$3.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.69
|
| Rate for Payer: Nomi Health Commercial |
$3.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.82
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$206.80
|
|
|
Service Code
|
NDC 51672400201
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.10 |
| Max. Negotiated Rate |
$206.80 |
| Rate for Payer: Aetna Commercial |
$186.12
|
| Rate for Payer: ASR ASR |
$200.60
|
| Rate for Payer: BCBS Trust/PPO |
$169.82
|
| Rate for Payer: BCN Commercial |
$169.82
|
| Rate for Payer: Cash Price |
$165.44
|
| Rate for Payer: Cofinity Commercial |
$194.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.44
|
| Rate for Payer: Healthscope Commercial |
$200.60
|
| Rate for Payer: Healthscope Whirlpool |
$206.80
|
| Rate for Payer: Mclaren Commercial |
$186.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.78
|
| Rate for Payer: Nomi Health Commercial |
$169.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$155.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.98
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$356.25
|
|
|
Service Code
|
NDC 60687029301
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.19 |
| Max. Negotiated Rate |
$356.25 |
| Rate for Payer: Aetna Commercial |
$320.62
|
| Rate for Payer: ASR ASR |
$345.56
|
| Rate for Payer: BCBS Trust/PPO |
$292.55
|
| Rate for Payer: BCN Commercial |
$292.55
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Commercial |
$334.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$345.56
|
| Rate for Payer: Healthscope Whirlpool |
$356.25
|
| Rate for Payer: Mclaren Commercial |
$320.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Nomi Health Commercial |
$292.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$313.50
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$3.56
|
|
|
Service Code
|
NDC 60687029311
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.21
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: ASR ASR |
$3.46
|
| Rate for Payer: BCBS Complete |
$1.43
|
| Rate for Payer: BCBS Trust/PPO |
$2.94
|
| Rate for Payer: BCN Commercial |
$2.94
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cofinity Commercial |
$3.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.85
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.56
|
| Rate for Payer: Mclaren Commercial |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$2.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.67
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.12
|
| Rate for Payer: Priority Health Narrow Network |
$2.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.14
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$3.56
|
|
|
Service Code
|
NDC 60687029311
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.21
|
| Rate for Payer: ASR ASR |
$3.46
|
| Rate for Payer: BCBS Trust/PPO |
$2.93
|
| Rate for Payer: BCN Commercial |
$2.93
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cofinity Commercial |
$3.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.85
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.56
|
| Rate for Payer: Mclaren Commercial |
$3.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$2.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.14
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$281.30
|
|
|
Service Code
|
NDC 51672400205
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.97 |
| 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 |
$231.00
|
| Rate for Payer: BCN Commercial |
$231.00
|
| 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 |
$272.86
|
| Rate for Payer: Healthscope Whirlpool |
$281.30
|
| Rate for Payer: Mclaren Commercial |
$253.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.10
|
| Rate for Payer: Nomi Health Commercial |
$230.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$210.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$247.54
|
|
|
NOVASOURCE RENAL BOLUS FEED
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
150853
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.27 |
| 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 |
$4.67
|
| Rate for Payer: BCN Commercial |
$4.67
|
| 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 |
$5.52
|
| Rate for Payer: Healthscope Whirlpool |
$5.69
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.83
|
| Rate for Payer: Nomi Health Commercial |
$4.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
|
NOVASOURCE RENAL BOLUS FEED
|
Facility
|
OP
|
$5.69
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
150853
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: Aetna Medicare |
$2.10
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: BCBS Complete |
$2.28
|
| Rate for Payer: BCBS Trust/PPO |
$4.69
|
| Rate for Payer: BCN Commercial |
$4.69
|
| 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 |
$5.52
|
| Rate for Payer: Healthscope Whirlpool |
$5.69
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.83
|
| Rate for Payer: Nomi Health Commercial |
$4.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.98
|
| Rate for Payer: Priority Health Narrow Network |
$3.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
