|
NASAL MUCOSAL ATOMIZATION DEVICE
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 09900000401
|
| Hospital Charge Code |
169209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna Commercial |
$2.87
|
| Rate for Payer: ASR ASR |
$3.09
|
| Rate for Payer: ASR Commercial |
$3.09
|
| Rate for Payer: BCBS Trust/PPO |
$2.60
|
| Rate for Payer: BCN Commercial |
$2.47
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Commercial |
$3.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$3.19
|
| Rate for Payer: Healthscope Whirlpool |
$3.09
|
| Rate for Payer: Mclaren Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: Nomi Health Commercial |
$2.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.81
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS
|
Facility
|
OP
|
$166.15
|
|
|
Service Code
|
NDC 24208079062
|
| Hospital Charge Code |
5474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.46 |
| Max. Negotiated Rate |
$166.15 |
| Rate for Payer: Aetna Commercial |
$149.53
|
| Rate for Payer: Aetna Medicare |
$83.08
|
| Rate for Payer: ASR ASR |
$161.17
|
| Rate for Payer: ASR Commercial |
$161.17
|
| Rate for Payer: BCBS Complete |
$66.46
|
| Rate for Payer: BCBS Trust/PPO |
$136.06
|
| Rate for Payer: BCN Commercial |
$128.82
|
| Rate for Payer: Cash Price |
$132.92
|
| Rate for Payer: Cofinity Commercial |
$156.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.92
|
| Rate for Payer: Healthscope Commercial |
$166.15
|
| Rate for Payer: Healthscope Whirlpool |
$161.17
|
| Rate for Payer: Mclaren Commercial |
$149.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.23
|
| Rate for Payer: Nomi Health Commercial |
$136.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$145.58
|
| Rate for Payer: Priority Health Narrow Network |
$116.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$146.21
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS
|
Facility
|
IP
|
$166.15
|
|
|
Service Code
|
NDC 24208079062
|
| Hospital Charge Code |
5474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.00 |
| Max. Negotiated Rate |
$166.15 |
| Rate for Payer: Aetna Commercial |
$149.53
|
| Rate for Payer: ASR ASR |
$161.17
|
| Rate for Payer: ASR Commercial |
$161.17
|
| Rate for Payer: BCBS Trust/PPO |
$135.40
|
| Rate for Payer: BCN Commercial |
$128.82
|
| Rate for Payer: Cash Price |
$132.92
|
| Rate for Payer: Cofinity Commercial |
$156.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.92
|
| Rate for Payer: Healthscope Commercial |
$166.15
|
| Rate for Payer: Healthscope Whirlpool |
$161.17
|
| Rate for Payer: Mclaren Commercial |
$149.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.23
|
| Rate for Payer: Nomi Health Commercial |
$136.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$146.21
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$41.33
|
|
|
Service Code
|
NDC 00574416035
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.86 |
| Max. Negotiated Rate |
$41.33 |
| Rate for Payer: Aetna Commercial |
$37.20
|
| Rate for Payer: ASR ASR |
$40.09
|
| Rate for Payer: ASR Commercial |
$40.09
|
| Rate for Payer: BCBS Trust/PPO |
$33.68
|
| Rate for Payer: BCN Commercial |
$32.04
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cofinity Commercial |
$38.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.06
|
| Rate for Payer: Healthscope Commercial |
$41.33
|
| Rate for Payer: Healthscope Whirlpool |
$40.09
|
| 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: Priority Health Cigna Priority Health |
$26.86
|
| 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
|
OP
|
$46.72
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.69 |
| Max. Negotiated Rate |
$46.72 |
| Rate for Payer: Aetna Commercial |
$42.05
|
| Rate for Payer: Aetna Medicare |
$23.36
|
| Rate for Payer: ASR ASR |
$45.32
|
| Rate for Payer: ASR Commercial |
$45.32
|
| Rate for Payer: BCBS Complete |
$18.69
|
| Rate for Payer: BCBS Trust/PPO |
$38.26
|
| Rate for Payer: BCN Commercial |
$36.22
|
| Rate for Payer: Cash Price |
$37.38
|
| Rate for Payer: Cofinity Commercial |
$43.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.38
|
| Rate for Payer: Healthscope Commercial |
$46.72
|
| Rate for Payer: Healthscope Whirlpool |
$45.32
|
| Rate for Payer: Mclaren Commercial |
$42.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.71
|
| Rate for Payer: Nomi Health Commercial |
$38.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.94
|
| Rate for Payer: Priority Health Narrow Network |
$32.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.11
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
IP
|
$46.72
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.37 |
| Max. Negotiated Rate |
$46.72 |
| Rate for Payer: Aetna Commercial |
$42.05
|
| Rate for Payer: ASR ASR |
$45.32
|
| Rate for Payer: ASR Commercial |
$45.32
|
| Rate for Payer: BCBS Trust/PPO |
$38.07
|
| Rate for Payer: BCN Commercial |
$36.22
|
| Rate for Payer: Cash Price |
$37.38
|
| Rate for Payer: Cofinity Commercial |
$43.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.38
|
| Rate for Payer: Healthscope Commercial |
$46.72
|
| Rate for Payer: Healthscope Whirlpool |
$45.32
|
| Rate for Payer: Mclaren Commercial |
$42.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.71
|
| Rate for Payer: Nomi Health Commercial |
$38.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.11
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT
|
Facility
|
OP
|
$41.33
|
|
|
Service Code
|
NDC 00574416035
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.53 |
| Max. Negotiated Rate |
$41.33 |
| Rate for Payer: Aetna Commercial |
$37.20
|
| Rate for Payer: Aetna Medicare |
$20.66
|
| Rate for Payer: ASR ASR |
$40.09
|
| Rate for Payer: ASR Commercial |
$40.09
|
| Rate for Payer: BCBS Complete |
$16.53
|
| Rate for Payer: BCBS Trust/PPO |
$33.85
|
| Rate for Payer: BCN Commercial |
$32.04
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cofinity Commercial |
$38.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.06
|
| Rate for Payer: Healthscope Commercial |
$41.33
|
| Rate for Payer: Healthscope Whirlpool |
$40.09
|
| 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: Priority Health Cigna Priority Health |
$26.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$36.21
|
| 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
|
OP
|
$58.59
|
|
|
Service Code
|
NDC 61314063136
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$52.73
|
| Rate for Payer: Aetna Medicare |
$29.30
|
| Rate for Payer: ASR ASR |
$56.83
|
| Rate for Payer: ASR Commercial |
$56.83
|
| Rate for Payer: BCBS Complete |
$23.44
|
| Rate for Payer: BCBS Trust/PPO |
$47.98
|
| Rate for Payer: BCN Commercial |
$45.42
|
| Rate for Payer: Cash Price |
$46.87
|
| Rate for Payer: Cofinity Commercial |
$55.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.87
|
| Rate for Payer: Healthscope Commercial |
$58.59
|
| Rate for Payer: Healthscope Whirlpool |
$56.83
|
| Rate for Payer: Mclaren Commercial |
$52.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.80
|
| Rate for Payer: Nomi Health Commercial |
$48.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.08
|
| Rate for Payer: 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
|
IP
|
$58.59
|
|
|
Service Code
|
NDC 61314063136
|
| Hospital Charge Code |
19495
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.08 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$52.73
|
| Rate for Payer: ASR ASR |
$56.83
|
| Rate for Payer: ASR Commercial |
$56.83
|
| Rate for Payer: BCBS Trust/PPO |
$47.74
|
| Rate for Payer: BCN Commercial |
$45.42
|
| Rate for Payer: Cash Price |
$46.87
|
| Rate for Payer: Cofinity Commercial |
$55.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.87
|
| Rate for Payer: Healthscope Commercial |
$58.59
|
| Rate for Payer: Healthscope Whirlpool |
$56.83
|
| Rate for Payer: Mclaren Commercial |
$52.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.80
|
| Rate for Payer: Nomi Health Commercial |
$48.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.08
|
| 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
|
IP
|
$85.64
|
|
|
Service Code
|
NDC 24208078555
|
| Hospital Charge Code |
849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.67 |
| Max. Negotiated Rate |
$85.64 |
| Rate for Payer: Aetna Commercial |
$77.08
|
| Rate for Payer: ASR ASR |
$83.07
|
| Rate for Payer: ASR Commercial |
$83.07
|
| Rate for Payer: BCBS Trust/PPO |
$69.79
|
| Rate for Payer: BCN Commercial |
$66.40
|
| Rate for Payer: Cash Price |
$68.51
|
| Rate for Payer: Cofinity Commercial |
$80.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.51
|
| Rate for Payer: Healthscope Commercial |
$85.64
|
| Rate for Payer: Healthscope Whirlpool |
$83.07
|
| Rate for Payer: Mclaren Commercial |
$77.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.79
|
| Rate for Payer: Nomi Health Commercial |
$70.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.36
|
|
|
NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT
|
Facility
|
OP
|
$85.64
|
|
|
Service Code
|
NDC 24208078555
|
| Hospital Charge Code |
849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.26 |
| Max. Negotiated Rate |
$85.64 |
| Rate for Payer: Aetna Commercial |
$77.08
|
| Rate for Payer: Aetna Medicare |
$42.82
|
| Rate for Payer: ASR ASR |
$83.07
|
| Rate for Payer: ASR Commercial |
$83.07
|
| Rate for Payer: BCBS Complete |
$34.26
|
| Rate for Payer: BCBS Trust/PPO |
$70.13
|
| Rate for Payer: BCN Commercial |
$66.40
|
| Rate for Payer: Cash Price |
$68.51
|
| Rate for Payer: Cofinity Commercial |
$80.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.51
|
| Rate for Payer: Healthscope Commercial |
$85.64
|
| Rate for Payer: Healthscope Whirlpool |
$83.07
|
| Rate for Payer: Mclaren Commercial |
$77.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$72.79
|
| Rate for Payer: Nomi Health Commercial |
$70.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.04
|
| Rate for Payer: Priority Health Narrow Network |
$60.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.36
|
|
|
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 |
$3.83 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$8.62
|
| Rate for Payer: Aetna Medicare |
$4.79
|
| Rate for Payer: ASR ASR |
$9.29
|
| Rate for Payer: ASR Commercial |
$9.29
|
| Rate for Payer: BCBS Complete |
$3.83
|
| Rate for Payer: BCBS Trust/PPO |
$7.85
|
| Rate for Payer: BCN Commercial |
$7.43
|
| Rate for Payer: Cash Price |
$7.66
|
| Rate for Payer: Cofinity Commercial |
$9.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.66
|
| Rate for Payer: Healthscope Commercial |
$9.58
|
| Rate for Payer: Healthscope Whirlpool |
$9.29
|
| Rate for Payer: Mclaren Commercial |
$8.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.14
|
| Rate for Payer: Nomi Health Commercial |
$7.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.39
|
| Rate for Payer: Priority Health Narrow Network |
$6.72
|
| 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
|
$9.58
|
|
|
Service Code
|
NDC 45802014301
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.23 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna Commercial |
$8.62
|
| Rate for Payer: ASR ASR |
$9.29
|
| Rate for Payer: ASR Commercial |
$9.29
|
| Rate for Payer: BCBS Trust/PPO |
$7.81
|
| Rate for Payer: BCN Commercial |
$7.43
|
| Rate for Payer: Cash Price |
$7.66
|
| Rate for Payer: Cofinity Commercial |
$9.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.66
|
| Rate for Payer: Healthscope Commercial |
$9.58
|
| Rate for Payer: Healthscope Whirlpool |
$9.29
|
| Rate for Payer: Mclaren Commercial |
$8.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.14
|
| Rate for Payer: Nomi Health Commercial |
$7.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.23
|
| 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
|
$10.12
|
|
|
Service Code
|
NDC 00713026831
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.05 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.11
|
| Rate for Payer: Aetna Medicare |
$5.06
|
| Rate for Payer: ASR ASR |
$9.82
|
| Rate for Payer: ASR Commercial |
$9.82
|
| Rate for Payer: BCBS Complete |
$4.05
|
| Rate for Payer: BCBS Trust/PPO |
$8.29
|
| Rate for Payer: BCN Commercial |
$7.85
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cofinity Commercial |
$9.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.10
|
| Rate for Payer: Healthscope Commercial |
$10.12
|
| Rate for Payer: Healthscope Whirlpool |
$9.82
|
| Rate for Payer: Mclaren Commercial |
$9.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.60
|
| Rate for Payer: Nomi Health Commercial |
$8.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.87
|
| Rate for Payer: Priority Health Narrow Network |
$7.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.91
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT
|
Facility
|
IP
|
$10.12
|
|
|
Service Code
|
NDC 00713026831
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.58 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.11
|
| Rate for Payer: ASR ASR |
$9.82
|
| Rate for Payer: ASR Commercial |
$9.82
|
| Rate for Payer: BCBS Trust/PPO |
$8.25
|
| Rate for Payer: BCN Commercial |
$7.85
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cofinity Commercial |
$9.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.10
|
| Rate for Payer: Healthscope Commercial |
$10.12
|
| Rate for Payer: Healthscope Whirlpool |
$9.82
|
| Rate for Payer: Mclaren Commercial |
$9.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.60
|
| Rate for Payer: Nomi Health Commercial |
$8.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.91
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT
|
Facility
|
OP
|
$10.26
|
|
|
Service Code
|
NDC 00904073431
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.10 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Aetna Commercial |
$9.23
|
| Rate for Payer: Aetna Medicare |
$5.13
|
| Rate for Payer: ASR ASR |
$9.95
|
| Rate for Payer: ASR Commercial |
$9.95
|
| Rate for Payer: BCBS Complete |
$4.10
|
| Rate for Payer: BCBS Trust/PPO |
$8.40
|
| Rate for Payer: BCN Commercial |
$7.95
|
| 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 |
$10.26
|
| Rate for Payer: Healthscope Whirlpool |
$9.95
|
| 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: Priority Health Cigna Priority Health |
$6.67
|
| Rate for Payer: 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
|
$10.26
|
|
|
Service Code
|
NDC 00904073431
|
| Hospital Charge Code |
854
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.67 |
| Max. Negotiated Rate |
$10.26 |
| Rate for Payer: Aetna Commercial |
$9.23
|
| Rate for Payer: ASR ASR |
$9.95
|
| Rate for Payer: ASR Commercial |
$9.95
|
| Rate for Payer: BCBS Trust/PPO |
$8.36
|
| Rate for Payer: BCN Commercial |
$7.95
|
| 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 |
$10.26
|
| Rate for Payer: Healthscope Whirlpool |
$9.95
|
| 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: Priority Health Cigna Priority Health |
$6.67
|
| 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
|
OP
|
$372.24
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.90 |
| Max. Negotiated Rate |
$372.24 |
| Rate for Payer: Aetna Commercial |
$335.02
|
| Rate for Payer: Aetna Medicare |
$186.12
|
| Rate for Payer: ASR ASR |
$361.07
|
| Rate for Payer: ASR Commercial |
$361.07
|
| Rate for Payer: BCBS Complete |
$148.90
|
| Rate for Payer: BCBS Trust/PPO |
$304.83
|
| Rate for Payer: BCN Commercial |
$288.60
|
| Rate for Payer: Cash Price |
$297.79
|
| Rate for Payer: Cofinity Commercial |
$349.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.79
|
| Rate for Payer: Healthscope Commercial |
$372.24
|
| Rate for Payer: Healthscope Whirlpool |
$361.07
|
| Rate for Payer: Mclaren Commercial |
$335.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$316.40
|
| Rate for Payer: Nomi Health Commercial |
$305.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$326.16
|
| Rate for Payer: Priority Health Narrow Network |
$260.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$327.57
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
IP
|
$504.22
|
|
|
Service Code
|
NDC 47682022335
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$327.74 |
| Max. Negotiated Rate |
$504.22 |
| Rate for Payer: Aetna Commercial |
$453.80
|
| Rate for Payer: ASR ASR |
$489.09
|
| Rate for Payer: ASR Commercial |
$489.09
|
| Rate for Payer: BCBS Trust/PPO |
$410.89
|
| Rate for Payer: BCN Commercial |
$390.92
|
| Rate for Payer: Cash Price |
$403.37
|
| Rate for Payer: Cofinity Commercial |
$473.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$403.38
|
| Rate for Payer: Healthscope Commercial |
$504.22
|
| Rate for Payer: Healthscope Whirlpool |
$489.09
|
| Rate for Payer: Mclaren Commercial |
$453.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$428.59
|
| Rate for Payer: Nomi Health Commercial |
$413.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$327.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$443.71
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
NDC 47682022399
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Aetna Medicare |
$1.75
|
| Rate for Payer: ASR ASR |
$3.40
|
| Rate for Payer: ASR Commercial |
$3.40
|
| Rate for Payer: BCBS Complete |
$1.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.87
|
| Rate for Payer: BCN Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.50
|
| Rate for Payer: Healthscope Whirlpool |
$3.40
|
| Rate for Payer: Mclaren Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.07
|
| Rate for Payer: Priority Health Narrow Network |
$2.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.08
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
OP
|
$504.22
|
|
|
Service Code
|
NDC 47682022335
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$201.69 |
| Max. Negotiated Rate |
$504.22 |
| Rate for Payer: Aetna Commercial |
$453.80
|
| Rate for Payer: Aetna Medicare |
$252.11
|
| Rate for Payer: ASR ASR |
$489.09
|
| Rate for Payer: ASR Commercial |
$489.09
|
| Rate for Payer: BCBS Complete |
$201.69
|
| Rate for Payer: BCBS Trust/PPO |
$412.91
|
| Rate for Payer: BCN Commercial |
$390.92
|
| Rate for Payer: Cash Price |
$403.37
|
| Rate for Payer: Cofinity Commercial |
$473.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$403.38
|
| Rate for Payer: Healthscope Commercial |
$504.22
|
| Rate for Payer: Healthscope Whirlpool |
$489.09
|
| Rate for Payer: Mclaren Commercial |
$453.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$428.59
|
| Rate for Payer: Nomi Health Commercial |
$413.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$327.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$441.80
|
| Rate for Payer: Priority Health Narrow Network |
$353.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$443.71
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
NDC 47682022399
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: ASR ASR |
$3.40
|
| Rate for Payer: ASR Commercial |
$3.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.85
|
| Rate for Payer: BCN Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.50
|
| Rate for Payer: Healthscope Whirlpool |
$3.40
|
| Rate for Payer: Mclaren Commercial |
$3.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.08
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT
|
Facility
|
IP
|
$372.24
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
116684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.96 |
| Max. Negotiated Rate |
$372.24 |
| Rate for Payer: Aetna Commercial |
$335.02
|
| Rate for Payer: ASR ASR |
$361.07
|
| Rate for Payer: ASR Commercial |
$361.07
|
| Rate for Payer: BCBS Trust/PPO |
$303.34
|
| Rate for Payer: BCN Commercial |
$288.60
|
| Rate for Payer: Cash Price |
$297.79
|
| Rate for Payer: Cofinity Commercial |
$349.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.79
|
| Rate for Payer: Healthscope Commercial |
$372.24
|
| Rate for Payer: Healthscope Whirlpool |
$361.07
|
| Rate for Payer: Mclaren Commercial |
$335.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$316.40
|
| Rate for Payer: Nomi Health Commercial |
$305.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$327.57
|
|
|
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 |
$295.58 |
| Max. Negotiated Rate |
$738.96 |
| Rate for Payer: Aetna Commercial |
$665.06
|
| Rate for Payer: Aetna Medicare |
$369.48
|
| Rate for Payer: ASR ASR |
$716.79
|
| Rate for Payer: ASR Commercial |
$716.79
|
| Rate for Payer: BCBS Complete |
$295.58
|
| Rate for Payer: BCBS Trust/PPO |
$605.13
|
| Rate for Payer: BCN Commercial |
$572.92
|
| Rate for Payer: Cash Price |
$591.16
|
| Rate for Payer: Cofinity Commercial |
$694.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$591.17
|
| Rate for Payer: Healthscope Commercial |
$738.96
|
| Rate for Payer: Healthscope Whirlpool |
$716.79
|
| Rate for Payer: Mclaren Commercial |
$665.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$628.12
|
| Rate for Payer: Nomi Health Commercial |
$605.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$480.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$647.48
|
| 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 |
$480.32 |
| Max. Negotiated Rate |
$738.96 |
| Rate for Payer: Aetna Commercial |
$665.06
|
| Rate for Payer: ASR ASR |
$716.79
|
| Rate for Payer: ASR Commercial |
$716.79
|
| Rate for Payer: BCBS Trust/PPO |
$602.18
|
| Rate for Payer: BCN Commercial |
$572.92
|
| Rate for Payer: Cash Price |
$591.16
|
| Rate for Payer: Cofinity Commercial |
$694.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$591.17
|
| Rate for Payer: Healthscope Commercial |
$738.96
|
| Rate for Payer: Healthscope Whirlpool |
$716.79
|
| Rate for Payer: Mclaren Commercial |
$665.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$628.12
|
| Rate for Payer: Nomi Health Commercial |
$605.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$480.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$650.28
|
|
