|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
IP
|
$31.50
|
|
|
Service Code
|
NDC 44567064101
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$28.35
|
| Rate for Payer: ASR ASR |
$30.56
|
| Rate for Payer: ASR Commercial |
$30.56
|
| Rate for Payer: BCBS Trust/PPO |
$25.67
|
| Rate for Payer: BCN Commercial |
$24.42
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cofinity Commercial |
$29.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Healthscope Whirlpool |
$30.56
|
| Rate for Payer: Mclaren Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.78
|
| Rate for Payer: Nomi Health Commercial |
$25.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.72
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
OP
|
$31.50
|
|
|
Service Code
|
NDC 44567064101
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$28.35
|
| Rate for Payer: Aetna Medicare |
$15.75
|
| Rate for Payer: ASR ASR |
$30.56
|
| Rate for Payer: ASR Commercial |
$30.56
|
| Rate for Payer: BCBS Complete |
$12.60
|
| Rate for Payer: BCBS Trust/PPO |
$25.80
|
| Rate for Payer: BCN Commercial |
$24.42
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cofinity Commercial |
$29.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Healthscope Whirlpool |
$30.56
|
| Rate for Payer: Mclaren Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.78
|
| Rate for Payer: Nomi Health Commercial |
$25.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.60
|
| Rate for Payer: Priority Health Narrow Network |
$22.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.72
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
OP
|
$31.50
|
|
|
Service Code
|
NDC 44567064110
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$28.35
|
| Rate for Payer: Aetna Medicare |
$15.75
|
| Rate for Payer: ASR ASR |
$30.56
|
| Rate for Payer: ASR Commercial |
$30.56
|
| Rate for Payer: BCBS Complete |
$12.60
|
| Rate for Payer: BCBS Trust/PPO |
$25.80
|
| Rate for Payer: BCN Commercial |
$24.42
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cofinity Commercial |
$29.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Healthscope Whirlpool |
$30.56
|
| Rate for Payer: Mclaren Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.78
|
| Rate for Payer: Nomi Health Commercial |
$25.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.60
|
| Rate for Payer: Priority Health Narrow Network |
$22.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.72
|
|
|
NOREPINEPHRINE BITARTRATE 8 MG/250 ML (32 MCG/ML) INFUSION
|
Facility
|
IP
|
$31.50
|
|
|
Service Code
|
NDC 44567064110
|
| Hospital Charge Code |
119763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$28.35
|
| Rate for Payer: ASR ASR |
$30.56
|
| Rate for Payer: ASR Commercial |
$30.56
|
| Rate for Payer: BCBS Trust/PPO |
$25.67
|
| Rate for Payer: BCN Commercial |
$24.42
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cofinity Commercial |
$29.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.20
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Healthscope Whirlpool |
$30.56
|
| Rate for Payer: Mclaren Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.78
|
| Rate for Payer: Nomi Health Commercial |
$25.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.72
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
IP
|
$173.38
|
|
|
Service Code
|
NDC 50268060315
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.70 |
| Max. Negotiated Rate |
$173.38 |
| Rate for Payer: Aetna Commercial |
$156.04
|
| Rate for Payer: ASR ASR |
$168.18
|
| Rate for Payer: ASR Commercial |
$168.18
|
| Rate for Payer: BCBS Trust/PPO |
$141.29
|
| Rate for Payer: BCN Commercial |
$134.42
|
| Rate for Payer: Cash Price |
$138.70
|
| Rate for Payer: Cofinity Commercial |
$162.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.70
|
| Rate for Payer: Healthscope Commercial |
$173.38
|
| Rate for Payer: Healthscope Whirlpool |
$168.18
|
| Rate for Payer: Mclaren Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.37
|
| Rate for Payer: Nomi Health Commercial |
$142.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$152.57
|
|
|
NORTRIPTYLINE 10 MG CAPSULE
|
Facility
|
OP
|
$173.38
|
|
|
Service Code
|
NDC 50268060315
|
| Hospital Charge Code |
5674
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.35 |
| Max. Negotiated Rate |
$173.38 |
| Rate for Payer: Aetna Commercial |
$156.04
|
| Rate for Payer: Aetna Medicare |
$86.69
|
| Rate for Payer: ASR ASR |
$168.18
|
| Rate for Payer: ASR Commercial |
$168.18
|
| Rate for Payer: BCBS Complete |
$69.35
|
| Rate for Payer: BCBS Trust/PPO |
$141.98
|
| Rate for Payer: BCN Commercial |
$134.42
|
| Rate for Payer: Cash Price |
$138.70
|
| Rate for Payer: Cofinity Commercial |
$162.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.70
|
| Rate for Payer: Healthscope Commercial |
$173.38
|
| Rate for Payer: Healthscope Whirlpool |
$168.18
|
| Rate for Payer: Mclaren Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.37
|
| Rate for Payer: Nomi Health Commercial |
$142.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$151.92
|
| Rate for Payer: Priority Health Narrow Network |
$121.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$152.57
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$3.66
|
|
|
Service Code
|
NDC 50268060411
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Aetna Medicare |
$1.83
|
| Rate for Payer: ASR ASR |
$3.55
|
| Rate for Payer: ASR Commercial |
$3.55
|
| Rate for Payer: BCBS Complete |
$1.46
|
| Rate for Payer: BCBS Trust/PPO |
$3.00
|
| Rate for Payer: BCN Commercial |
$2.84
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cofinity Commercial |
$3.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.93
|
| Rate for Payer: Healthscope Commercial |
$3.66
|
| Rate for Payer: Healthscope Whirlpool |
$3.55
|
| Rate for Payer: Mclaren Commercial |
$3.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.11
|
| Rate for Payer: Nomi Health Commercial |
$3.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.21
|
| Rate for Payer: Priority Health Narrow Network |
$2.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.22
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$206.80
|
|
|
Service Code
|
NDC 51672400201
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.42 |
| Max. Negotiated Rate |
$206.80 |
| Rate for Payer: Aetna Commercial |
$186.12
|
| Rate for Payer: ASR ASR |
$200.60
|
| Rate for Payer: ASR Commercial |
$200.60
|
| Rate for Payer: BCBS Trust/PPO |
$168.52
|
| Rate for Payer: BCN Commercial |
$160.33
|
| 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 |
$206.80
|
| Rate for Payer: Healthscope Whirlpool |
$200.60
|
| 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: Priority Health Cigna Priority Health |
$134.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.98
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$281.30
|
|
|
Service Code
|
NDC 51672400205
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.52 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$253.17
|
| Rate for Payer: Aetna Medicare |
$140.65
|
| Rate for Payer: ASR ASR |
$272.86
|
| Rate for Payer: ASR Commercial |
$272.86
|
| Rate for Payer: BCBS Complete |
$112.52
|
| Rate for Payer: BCBS Trust/PPO |
$230.36
|
| Rate for Payer: BCN Commercial |
$218.09
|
| Rate for Payer: Cash Price |
$225.04
|
| Rate for Payer: Cofinity Commercial |
$264.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.04
|
| Rate for Payer: Healthscope Commercial |
$281.30
|
| Rate for Payer: Healthscope Whirlpool |
$272.86
|
| Rate for Payer: Mclaren Commercial |
$253.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.10
|
| Rate for Payer: Nomi Health Commercial |
$230.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$246.48
|
| 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
|
IP
|
$356.25
|
|
|
Service Code
|
NDC 60687029301
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.56 |
| Max. Negotiated Rate |
$356.25 |
| Rate for Payer: Aetna Commercial |
$320.62
|
| Rate for Payer: ASR ASR |
$345.56
|
| Rate for Payer: ASR Commercial |
$345.56
|
| Rate for Payer: BCBS Trust/PPO |
$290.31
|
| Rate for Payer: BCN Commercial |
$276.20
|
| 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 |
$356.25
|
| Rate for Payer: Healthscope Whirlpool |
$345.56
|
| 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: Priority Health Cigna Priority Health |
$231.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$313.50
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$3.56
|
|
|
Service Code
|
NDC 60687029311
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.20
|
| Rate for Payer: ASR ASR |
$3.45
|
| Rate for Payer: ASR Commercial |
$3.45
|
| Rate for Payer: BCBS Trust/PPO |
$2.90
|
| Rate for Payer: BCN Commercial |
$2.76
|
| 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 |
$3.56
|
| Rate for Payer: Healthscope Whirlpool |
$3.45
|
| Rate for Payer: Mclaren Commercial |
$3.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$2.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.13
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$182.88
|
|
|
Service Code
|
NDC 50268060415
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.87 |
| Max. Negotiated Rate |
$182.88 |
| Rate for Payer: Aetna Commercial |
$164.59
|
| Rate for Payer: ASR ASR |
$177.39
|
| Rate for Payer: ASR Commercial |
$177.39
|
| Rate for Payer: BCBS Trust/PPO |
$149.03
|
| Rate for Payer: BCN Commercial |
$141.79
|
| Rate for Payer: Cash Price |
$146.30
|
| Rate for Payer: Cofinity Commercial |
$171.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.30
|
| Rate for Payer: Healthscope Commercial |
$182.88
|
| Rate for Payer: Healthscope Whirlpool |
$177.39
|
| Rate for Payer: Mclaren Commercial |
$164.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.45
|
| Rate for Payer: Nomi Health Commercial |
$149.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$160.93
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$3.56
|
|
|
Service Code
|
NDC 60687029311
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.20
|
| Rate for Payer: Aetna Medicare |
$1.78
|
| Rate for Payer: ASR ASR |
$3.45
|
| Rate for Payer: ASR Commercial |
$3.45
|
| Rate for Payer: BCBS Complete |
$1.42
|
| Rate for Payer: BCBS Trust/PPO |
$2.92
|
| Rate for Payer: BCN Commercial |
$2.76
|
| 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 |
$3.56
|
| Rate for Payer: Healthscope Whirlpool |
$3.45
|
| Rate for Payer: Mclaren Commercial |
$3.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$2.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.31
|
| Rate for Payer: 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 |
$3.13
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$356.25
|
|
|
Service Code
|
NDC 60687029301
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.50 |
| Max. Negotiated Rate |
$356.25 |
| Rate for Payer: Aetna Commercial |
$320.62
|
| Rate for Payer: Aetna Medicare |
$178.12
|
| Rate for Payer: ASR ASR |
$345.56
|
| Rate for Payer: ASR Commercial |
$345.56
|
| Rate for Payer: BCBS Complete |
$142.50
|
| Rate for Payer: BCBS Trust/PPO |
$291.73
|
| Rate for Payer: BCN Commercial |
$276.20
|
| 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 |
$356.25
|
| Rate for Payer: Healthscope Whirlpool |
$345.56
|
| 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: Priority Health Cigna Priority Health |
$231.56
|
| Rate for Payer: 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
|
$206.80
|
|
|
Service Code
|
NDC 51672400201
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.72 |
| Max. Negotiated Rate |
$206.80 |
| Rate for Payer: Aetna Commercial |
$186.12
|
| Rate for Payer: Aetna Medicare |
$103.40
|
| Rate for Payer: ASR ASR |
$200.60
|
| Rate for Payer: ASR Commercial |
$200.60
|
| Rate for Payer: BCBS Complete |
$82.72
|
| Rate for Payer: BCBS Trust/PPO |
$169.35
|
| Rate for Payer: BCN Commercial |
$160.33
|
| 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 |
$206.80
|
| Rate for Payer: Healthscope Whirlpool |
$200.60
|
| 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: Priority Health Cigna Priority Health |
$134.42
|
| Rate for Payer: 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
|
IP
|
$281.30
|
|
|
Service Code
|
NDC 51672400205
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.84 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$253.17
|
| Rate for Payer: ASR ASR |
$272.86
|
| Rate for Payer: ASR Commercial |
$272.86
|
| Rate for Payer: BCBS Trust/PPO |
$229.23
|
| Rate for Payer: BCN Commercial |
$218.09
|
| Rate for Payer: Cash Price |
$225.04
|
| Rate for Payer: Cofinity Commercial |
$264.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.04
|
| Rate for Payer: Healthscope Commercial |
$281.30
|
| Rate for Payer: Healthscope Whirlpool |
$272.86
|
| Rate for Payer: Mclaren Commercial |
$253.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.10
|
| Rate for Payer: Nomi Health Commercial |
$230.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$247.54
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
IP
|
$3.66
|
|
|
Service Code
|
NDC 50268060411
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: ASR ASR |
$3.55
|
| Rate for Payer: ASR Commercial |
$3.55
|
| Rate for Payer: BCBS Trust/PPO |
$2.98
|
| Rate for Payer: BCN Commercial |
$2.84
|
| Rate for Payer: Cash Price |
$2.93
|
| Rate for Payer: Cofinity Commercial |
$3.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.93
|
| Rate for Payer: Healthscope Commercial |
$3.66
|
| Rate for Payer: Healthscope Whirlpool |
$3.55
|
| Rate for Payer: Mclaren Commercial |
$3.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.11
|
| Rate for Payer: Nomi Health Commercial |
$3.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.22
|
|
|
NORTRIPTYLINE 25 MG CAPSULE
|
Facility
|
OP
|
$182.88
|
|
|
Service Code
|
NDC 50268060415
|
| Hospital Charge Code |
5675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.15 |
| Max. Negotiated Rate |
$182.88 |
| Rate for Payer: Aetna Commercial |
$164.59
|
| Rate for Payer: Aetna Medicare |
$91.44
|
| Rate for Payer: ASR ASR |
$177.39
|
| Rate for Payer: ASR Commercial |
$177.39
|
| Rate for Payer: BCBS Complete |
$73.15
|
| Rate for Payer: BCBS Trust/PPO |
$149.76
|
| Rate for Payer: BCN Commercial |
$141.79
|
| Rate for Payer: Cash Price |
$146.30
|
| Rate for Payer: Cofinity Commercial |
$171.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.30
|
| Rate for Payer: Healthscope Commercial |
$182.88
|
| Rate for Payer: Healthscope Whirlpool |
$177.39
|
| Rate for Payer: Mclaren Commercial |
$164.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.45
|
| Rate for Payer: Nomi Health Commercial |
$149.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$160.24
|
| Rate for Payer: Priority Health Narrow Network |
$128.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$160.93
|
|
|
NOVASOURCE RENAL BOLUS FEED
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
150853
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: ASR Commercial |
$5.52
|
| Rate for Payer: BCBS Trust/PPO |
$4.64
|
| Rate for Payer: BCN Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Commercial |
$5.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Healthscope Whirlpool |
$5.52
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Nomi Health Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| 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 |
$2.28 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: Aetna Medicare |
$2.84
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: ASR Commercial |
$5.52
|
| Rate for Payer: BCBS Complete |
$2.28
|
| Rate for Payer: BCBS Trust/PPO |
$4.66
|
| Rate for Payer: BCN Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Commercial |
$5.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Healthscope Whirlpool |
$5.52
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Nomi Health Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.99
|
| Rate for Payer: Priority Health Narrow Network |
$3.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
|
NOVASOURCE RENAL CONTINUOUS FEED
|
Facility
|
OP
|
$5.69
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
168945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: Aetna Medicare |
$2.84
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: ASR Commercial |
$5.52
|
| Rate for Payer: BCBS Complete |
$2.28
|
| Rate for Payer: BCBS Trust/PPO |
$4.66
|
| Rate for Payer: BCN Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Commercial |
$5.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Healthscope Whirlpool |
$5.52
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Nomi Health Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.99
|
| Rate for Payer: Priority Health Narrow Network |
$3.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
|
NOVASOURCE RENAL CONTINUOUS FEED
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
168945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: ASR Commercial |
$5.52
|
| Rate for Payer: BCBS Trust/PPO |
$4.64
|
| Rate for Payer: BCN Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Commercial |
$5.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Healthscope Whirlpool |
$5.52
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Nomi Health Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
|
NOVASOURCE RENAL CYCLIC FEED
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
200087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: ASR Commercial |
$5.52
|
| Rate for Payer: BCBS Trust/PPO |
$4.64
|
| Rate for Payer: BCN Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Commercial |
$5.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Healthscope Whirlpool |
$5.52
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Nomi Health Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
|
NOVASOURCE RENAL CYCLIC FEED
|
Facility
|
OP
|
$5.69
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
200087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: Aetna Medicare |
$2.84
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: ASR Commercial |
$5.52
|
| Rate for Payer: BCBS Complete |
$2.28
|
| Rate for Payer: BCBS Trust/PPO |
$4.66
|
| Rate for Payer: BCN Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Commercial |
$5.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Healthscope Whirlpool |
$5.52
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Nomi Health Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.99
|
| Rate for Payer: Priority Health Narrow Network |
$3.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
|
NOVASOURCE RENAL INTERMITTENT FEED
|
Facility
|
IP
|
$5.69
|
|
|
Service Code
|
NDC 43900035111
|
| Hospital Charge Code |
200086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.12
|
| Rate for Payer: ASR ASR |
$5.52
|
| Rate for Payer: ASR Commercial |
$5.52
|
| Rate for Payer: BCBS Trust/PPO |
$4.64
|
| Rate for Payer: BCN Commercial |
$4.41
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cofinity Commercial |
$5.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.55
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Healthscope Whirlpool |
$5.52
|
| Rate for Payer: Mclaren Commercial |
$5.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.84
|
| Rate for Payer: Nomi Health Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.01
|
|
