|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$25.34
|
|
|
Service Code
|
NDC 64980051505
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$25.34 |
| Rate for Payer: Aetna Commercial |
$22.81
|
| Rate for Payer: Aetna Medicare |
$12.67
|
| Rate for Payer: ASR ASR |
$24.58
|
| Rate for Payer: ASR Commercial |
$24.58
|
| Rate for Payer: BCBS Complete |
$10.14
|
| Rate for Payer: BCBS Trust/PPO |
$20.75
|
| Rate for Payer: BCN Commercial |
$19.65
|
| Rate for Payer: Cash Price |
$20.27
|
| Rate for Payer: Cofinity Commercial |
$23.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.27
|
| Rate for Payer: Healthscope Commercial |
$25.34
|
| Rate for Payer: Healthscope Whirlpool |
$24.58
|
| Rate for Payer: Mclaren Commercial |
$22.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.54
|
| Rate for Payer: Nomi Health Commercial |
$20.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.20
|
| Rate for Payer: Priority Health Narrow Network |
$17.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.30
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$66.53
|
|
|
Service Code
|
NDC 24208043405
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$66.53 |
| Rate for Payer: Aetna Commercial |
$59.88
|
| Rate for Payer: Aetna Medicare |
$33.27
|
| Rate for Payer: ASR ASR |
$64.53
|
| Rate for Payer: ASR Commercial |
$64.53
|
| Rate for Payer: BCBS Complete |
$26.61
|
| Rate for Payer: BCBS Trust/PPO |
$54.48
|
| Rate for Payer: BCN Commercial |
$51.58
|
| Rate for Payer: Cash Price |
$53.23
|
| Rate for Payer: Cofinity Commercial |
$62.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.22
|
| Rate for Payer: Healthscope Commercial |
$66.53
|
| Rate for Payer: Healthscope Whirlpool |
$64.53
|
| Rate for Payer: Mclaren Commercial |
$59.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.55
|
| Rate for Payer: Nomi Health Commercial |
$54.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$58.29
|
| Rate for Payer: Priority Health Narrow Network |
$46.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$58.55
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$48.83
|
|
|
Service Code
|
NDC 70756060730
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.53 |
| Max. Negotiated Rate |
$48.83 |
| Rate for Payer: Aetna Commercial |
$43.95
|
| Rate for Payer: Aetna Medicare |
$24.41
|
| Rate for Payer: ASR ASR |
$47.37
|
| Rate for Payer: ASR Commercial |
$47.37
|
| Rate for Payer: BCBS Complete |
$19.53
|
| Rate for Payer: BCBS Trust/PPO |
$39.99
|
| Rate for Payer: BCN Commercial |
$37.86
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cofinity Commercial |
$45.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.06
|
| Rate for Payer: Healthscope Commercial |
$48.83
|
| Rate for Payer: Healthscope Whirlpool |
$47.37
|
| Rate for Payer: Mclaren Commercial |
$43.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.51
|
| Rate for Payer: Nomi Health Commercial |
$40.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$42.78
|
| Rate for Payer: Priority Health Narrow Network |
$34.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.97
|
|
|
OFLOXACIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$45.29
|
|
|
Service Code
|
NDC 64980051501
|
| Hospital Charge Code |
19746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.12 |
| Max. Negotiated Rate |
$45.29 |
| Rate for Payer: Aetna Commercial |
$40.76
|
| Rate for Payer: Aetna Medicare |
$22.64
|
| Rate for Payer: ASR ASR |
$43.93
|
| Rate for Payer: ASR Commercial |
$43.93
|
| Rate for Payer: BCBS Complete |
$18.12
|
| Rate for Payer: BCBS Trust/PPO |
$37.09
|
| Rate for Payer: BCN Commercial |
$35.11
|
| Rate for Payer: Cash Price |
$36.23
|
| Rate for Payer: Cofinity Commercial |
$42.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.23
|
| Rate for Payer: Healthscope Commercial |
$45.29
|
| Rate for Payer: Healthscope Whirlpool |
$43.93
|
| Rate for Payer: Mclaren Commercial |
$40.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.50
|
| Rate for Payer: Nomi Health Commercial |
$37.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39.68
|
| Rate for Payer: Priority Health Narrow Network |
$31.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.86
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$80.28
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.18 |
| Max. Negotiated Rate |
$80.28 |
| Rate for Payer: Aetna Commercial |
$72.25
|
| Rate for Payer: Aetna Commercial |
$48.98
|
| Rate for Payer: ASR ASR |
$52.79
|
| Rate for Payer: ASR ASR |
$77.87
|
| Rate for Payer: ASR Commercial |
$52.79
|
| Rate for Payer: ASR Commercial |
$77.87
|
| Rate for Payer: BCBS Trust/PPO |
$65.42
|
| Rate for Payer: BCBS Trust/PPO |
$44.35
|
| Rate for Payer: BCN Commercial |
$62.24
|
| Rate for Payer: BCN Commercial |
$42.19
|
| Rate for Payer: Cash Price |
$43.54
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Cofinity Commercial |
$51.15
|
| Rate for Payer: Cofinity Commercial |
$75.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.54
|
| Rate for Payer: Healthscope Commercial |
$54.42
|
| Rate for Payer: Healthscope Commercial |
$80.28
|
| Rate for Payer: Healthscope Whirlpool |
$52.79
|
| Rate for Payer: Healthscope Whirlpool |
$77.87
|
| Rate for Payer: Mclaren Commercial |
$72.25
|
| Rate for Payer: Mclaren Commercial |
$48.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.24
|
| Rate for Payer: Nomi Health Commercial |
$44.62
|
| Rate for Payer: Nomi Health Commercial |
$65.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.65
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$54.42
|
|
|
Service Code
|
HCPCS J2359
|
| Hospital Charge Code |
38263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.77 |
| Max. Negotiated Rate |
$54.42 |
| Rate for Payer: Aetna Commercial |
$48.98
|
| Rate for Payer: Aetna Commercial |
$72.25
|
| Rate for Payer: Aetna Medicare |
$27.21
|
| Rate for Payer: Aetna Medicare |
$40.14
|
| Rate for Payer: ASR ASR |
$52.79
|
| Rate for Payer: ASR ASR |
$77.87
|
| Rate for Payer: ASR Commercial |
$52.79
|
| Rate for Payer: ASR Commercial |
$77.87
|
| Rate for Payer: BCBS Complete |
$32.11
|
| Rate for Payer: BCBS Complete |
$21.77
|
| Rate for Payer: BCBS Trust/PPO |
$65.74
|
| Rate for Payer: BCBS Trust/PPO |
$44.56
|
| Rate for Payer: BCN Commercial |
$42.19
|
| Rate for Payer: BCN Commercial |
$62.24
|
| Rate for Payer: Cash Price |
$43.54
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Cofinity Commercial |
$75.46
|
| Rate for Payer: Cofinity Commercial |
$51.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.54
|
| Rate for Payer: Healthscope Commercial |
$54.42
|
| Rate for Payer: Healthscope Commercial |
$80.28
|
| Rate for Payer: Healthscope Whirlpool |
$52.79
|
| Rate for Payer: Healthscope Whirlpool |
$77.87
|
| Rate for Payer: Mclaren Commercial |
$48.98
|
| Rate for Payer: Mclaren Commercial |
$72.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.24
|
| Rate for Payer: Nomi Health Commercial |
$44.62
|
| Rate for Payer: Nomi Health Commercial |
$65.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$47.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$70.34
|
| Rate for Payer: Priority Health Narrow Network |
$38.15
|
| Rate for Payer: Priority Health Narrow Network |
$56.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.65
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
OP
|
$265.55
|
|
|
Service Code
|
NDC 00904637761
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.22 |
| Max. Negotiated Rate |
$265.55 |
| Rate for Payer: Aetna Commercial |
$239.00
|
| Rate for Payer: Aetna Medicare |
$132.78
|
| Rate for Payer: ASR ASR |
$257.58
|
| Rate for Payer: ASR Commercial |
$257.58
|
| Rate for Payer: BCBS Complete |
$106.22
|
| Rate for Payer: BCBS Trust/PPO |
$217.46
|
| Rate for Payer: BCN Commercial |
$205.88
|
| Rate for Payer: Cash Price |
$212.44
|
| Rate for Payer: Cofinity Commercial |
$249.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.44
|
| Rate for Payer: Healthscope Commercial |
$265.55
|
| Rate for Payer: Healthscope Whirlpool |
$257.58
|
| Rate for Payer: Mclaren Commercial |
$239.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.72
|
| Rate for Payer: Nomi Health Commercial |
$217.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$232.67
|
| Rate for Payer: Priority Health Narrow Network |
$186.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$233.68
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$71.20
|
|
|
Service Code
|
NDC 43598016430
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.28 |
| Max. Negotiated Rate |
$71.20 |
| Rate for Payer: Aetna Commercial |
$64.08
|
| Rate for Payer: ASR ASR |
$69.06
|
| Rate for Payer: ASR Commercial |
$69.06
|
| Rate for Payer: BCBS Trust/PPO |
$58.02
|
| Rate for Payer: BCN Commercial |
$55.20
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$66.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$71.20
|
| Rate for Payer: Healthscope Whirlpool |
$69.06
|
| Rate for Payer: Mclaren Commercial |
$64.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: Nomi Health Commercial |
$58.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.66
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
OP
|
$305.50
|
|
|
Service Code
|
NDC 60505311100
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.20 |
| Max. Negotiated Rate |
$305.50 |
| Rate for Payer: Aetna Commercial |
$274.95
|
| Rate for Payer: Aetna Medicare |
$152.75
|
| Rate for Payer: ASR ASR |
$296.33
|
| Rate for Payer: ASR Commercial |
$296.33
|
| Rate for Payer: BCBS Complete |
$122.20
|
| Rate for Payer: BCBS Trust/PPO |
$250.17
|
| Rate for Payer: BCN Commercial |
$236.85
|
| Rate for Payer: Cash Price |
$244.40
|
| Rate for Payer: Cofinity Commercial |
$287.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.40
|
| Rate for Payer: Healthscope Commercial |
$305.50
|
| Rate for Payer: Healthscope Whirlpool |
$296.33
|
| Rate for Payer: Mclaren Commercial |
$274.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.68
|
| Rate for Payer: Nomi Health Commercial |
$250.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$267.68
|
| Rate for Payer: Priority Health Narrow Network |
$214.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$268.84
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$305.50
|
|
|
Service Code
|
NDC 60505311100
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.57 |
| Max. Negotiated Rate |
$305.50 |
| Rate for Payer: Aetna Commercial |
$274.95
|
| Rate for Payer: ASR ASR |
$296.33
|
| Rate for Payer: ASR Commercial |
$296.33
|
| Rate for Payer: BCBS Trust/PPO |
$248.95
|
| Rate for Payer: BCN Commercial |
$236.85
|
| Rate for Payer: Cash Price |
$244.40
|
| Rate for Payer: Cofinity Commercial |
$287.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.40
|
| Rate for Payer: Healthscope Commercial |
$305.50
|
| Rate for Payer: Healthscope Whirlpool |
$296.33
|
| Rate for Payer: Mclaren Commercial |
$274.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.68
|
| Rate for Payer: Nomi Health Commercial |
$250.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$268.84
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$265.55
|
|
|
Service Code
|
NDC 00904637761
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.61 |
| Max. Negotiated Rate |
$265.55 |
| Rate for Payer: Aetna Commercial |
$239.00
|
| Rate for Payer: ASR ASR |
$257.58
|
| Rate for Payer: ASR Commercial |
$257.58
|
| Rate for Payer: BCBS Trust/PPO |
$216.40
|
| Rate for Payer: BCN Commercial |
$205.88
|
| Rate for Payer: Cash Price |
$212.44
|
| Rate for Payer: Cofinity Commercial |
$249.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.44
|
| Rate for Payer: Healthscope Commercial |
$265.55
|
| Rate for Payer: Healthscope Whirlpool |
$257.58
|
| Rate for Payer: Mclaren Commercial |
$239.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.72
|
| Rate for Payer: Nomi Health Commercial |
$217.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$233.68
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
OP
|
$71.20
|
|
|
Service Code
|
NDC 43598016430
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.48 |
| Max. Negotiated Rate |
$71.20 |
| Rate for Payer: Aetna Commercial |
$64.08
|
| Rate for Payer: Aetna Medicare |
$35.60
|
| Rate for Payer: ASR ASR |
$69.06
|
| Rate for Payer: ASR Commercial |
$69.06
|
| Rate for Payer: BCBS Complete |
$28.48
|
| Rate for Payer: BCBS Trust/PPO |
$58.31
|
| Rate for Payer: BCN Commercial |
$55.20
|
| Rate for Payer: Cash Price |
$56.96
|
| Rate for Payer: Cofinity Commercial |
$66.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.96
|
| Rate for Payer: Healthscope Commercial |
$71.20
|
| Rate for Payer: Healthscope Whirlpool |
$69.06
|
| Rate for Payer: Mclaren Commercial |
$64.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.52
|
| Rate for Payer: Nomi Health Commercial |
$58.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$62.39
|
| Rate for Payer: Priority Health Narrow Network |
$49.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.66
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
OP
|
$1,625.93
|
|
|
Service Code
|
NDC 00002411530
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$650.37 |
| Max. Negotiated Rate |
$1,625.93 |
| Rate for Payer: Aetna Commercial |
$1,463.34
|
| Rate for Payer: Aetna Medicare |
$812.97
|
| Rate for Payer: ASR ASR |
$1,577.15
|
| Rate for Payer: ASR Commercial |
$1,577.15
|
| Rate for Payer: BCBS Complete |
$650.37
|
| Rate for Payer: BCBS Trust/PPO |
$1,331.47
|
| Rate for Payer: BCN Commercial |
$1,260.58
|
| Rate for Payer: Cash Price |
$1,300.74
|
| Rate for Payer: Cofinity Commercial |
$1,528.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,300.74
|
| Rate for Payer: Healthscope Commercial |
$1,625.93
|
| Rate for Payer: Healthscope Whirlpool |
$1,577.15
|
| Rate for Payer: Mclaren Commercial |
$1,463.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,382.04
|
| Rate for Payer: Nomi Health Commercial |
$1,333.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,056.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,424.64
|
| Rate for Payer: Priority Health Narrow Network |
$1,139.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,430.82
|
|
|
OLANZAPINE 5 MG TABLET
|
Facility
|
IP
|
$1,625.93
|
|
|
Service Code
|
NDC 00002411530
|
| Hospital Charge Code |
17936
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,056.85 |
| Max. Negotiated Rate |
$1,625.93 |
| Rate for Payer: Aetna Commercial |
$1,463.34
|
| Rate for Payer: ASR ASR |
$1,577.15
|
| Rate for Payer: ASR Commercial |
$1,577.15
|
| Rate for Payer: BCBS Trust/PPO |
$1,324.97
|
| Rate for Payer: BCN Commercial |
$1,260.58
|
| Rate for Payer: Cash Price |
$1,300.74
|
| Rate for Payer: Cofinity Commercial |
$1,528.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,300.74
|
| Rate for Payer: Healthscope Commercial |
$1,625.93
|
| Rate for Payer: Healthscope Whirlpool |
$1,577.15
|
| Rate for Payer: Mclaren Commercial |
$1,463.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,382.04
|
| Rate for Payer: Nomi Health Commercial |
$1,333.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,056.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,430.82
|
|
|
OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$2,265.79
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
188926
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.91 |
| Max. Negotiated Rate |
$2,265.79 |
| Rate for Payer: Aetna Commercial |
$2,039.21
|
| Rate for Payer: Aetna Medicare |
$44.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$55.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$55.75
|
| Rate for Payer: ASR ASR |
$2,197.82
|
| Rate for Payer: ASR Commercial |
$2,197.82
|
| Rate for Payer: BCBS Complete |
$25.10
|
| Rate for Payer: BCBS MAPPO |
$44.60
|
| Rate for Payer: BCBS Trust/PPO |
$1,855.46
|
| Rate for Payer: BCN Commercial |
$1,756.67
|
| Rate for Payer: BCN Medicare Advantage |
$44.60
|
| Rate for Payer: Cash Price |
$1,812.63
|
| Rate for Payer: Cash Price |
$1,812.63
|
| Rate for Payer: Cofinity Commercial |
$2,129.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,812.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$44.60
|
| Rate for Payer: Healthscope Commercial |
$2,265.79
|
| Rate for Payer: Healthscope Whirlpool |
$2,197.82
|
| Rate for Payer: Humana Choice PPO Medicare |
$44.60
|
| Rate for Payer: Mclaren Commercial |
$2,039.21
|
| Rate for Payer: Mclaren Medicaid |
$23.91
|
| Rate for Payer: Mclaren Medicare |
$44.60
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$46.83
|
| Rate for Payer: Meridian Medicaid |
$25.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$51.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,925.92
|
| Rate for Payer: Nomi Health Commercial |
$1,857.95
|
| Rate for Payer: PACE Medicare |
$42.37
|
| Rate for Payer: PACE SWMI |
$44.60
|
| Rate for Payer: PHP Commercial |
$49.06
|
| Rate for Payer: PHP Medicaid |
$23.91
|
| Rate for Payer: PHP Medicare Advantage |
$44.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$23.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,472.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,985.29
|
| Rate for Payer: Priority Health Medicare |
$44.60
|
| Rate for Payer: Priority Health Narrow Network |
$1,588.32
|
| Rate for Payer: Railroad Medicare Medicare |
$44.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,993.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$44.60
|
| Rate for Payer: UHC Exchange |
$69.13
|
| Rate for Payer: UHC Medicare Advantage |
$44.60
|
| Rate for Payer: UHCCP DNSP |
$44.60
|
| Rate for Payer: UHCCP Medicaid |
$23.91
|
| Rate for Payer: VA VA |
$44.60
|
|
|
OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$2,265.79
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
188926
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,472.76 |
| Max. Negotiated Rate |
$2,265.79 |
| Rate for Payer: Aetna Commercial |
$2,039.21
|
| Rate for Payer: ASR ASR |
$2,197.82
|
| Rate for Payer: ASR Commercial |
$2,197.82
|
| Rate for Payer: BCBS Trust/PPO |
$1,846.39
|
| Rate for Payer: BCN Commercial |
$1,756.67
|
| Rate for Payer: Cash Price |
$1,812.63
|
| Rate for Payer: Cofinity Commercial |
$2,129.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,812.63
|
| Rate for Payer: Healthscope Commercial |
$2,265.79
|
| Rate for Payer: Healthscope Whirlpool |
$2,197.82
|
| Rate for Payer: Mclaren Commercial |
$2,039.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,925.92
|
| Rate for Payer: Nomi Health Commercial |
$1,857.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,472.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,993.90
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
IP
|
$440.86
|
|
|
Service Code
|
NDC 00904670606
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.56 |
| Max. Negotiated Rate |
$440.86 |
| Rate for Payer: Aetna Commercial |
$396.77
|
| Rate for Payer: ASR ASR |
$427.63
|
| Rate for Payer: ASR Commercial |
$427.63
|
| Rate for Payer: BCBS Trust/PPO |
$359.26
|
| Rate for Payer: BCN Commercial |
$341.80
|
| Rate for Payer: Cash Price |
$352.68
|
| Rate for Payer: Cofinity Commercial |
$414.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.69
|
| Rate for Payer: Healthscope Commercial |
$440.86
|
| Rate for Payer: Healthscope Whirlpool |
$427.63
|
| Rate for Payer: Mclaren Commercial |
$396.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.73
|
| Rate for Payer: Nomi Health Commercial |
$361.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$387.96
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
OP
|
$485.07
|
|
|
Service Code
|
NDC 60687012765
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.03 |
| Max. Negotiated Rate |
$485.07 |
| Rate for Payer: Aetna Commercial |
$436.56
|
| Rate for Payer: Aetna Medicare |
$242.53
|
| Rate for Payer: ASR ASR |
$470.52
|
| Rate for Payer: ASR Commercial |
$470.52
|
| Rate for Payer: BCBS Complete |
$194.03
|
| Rate for Payer: BCBS Trust/PPO |
$397.22
|
| Rate for Payer: BCN Commercial |
$376.07
|
| Rate for Payer: Cash Price |
$388.06
|
| Rate for Payer: Cofinity Commercial |
$455.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$388.06
|
| Rate for Payer: Healthscope Commercial |
$485.07
|
| Rate for Payer: Healthscope Whirlpool |
$470.52
|
| Rate for Payer: Mclaren Commercial |
$436.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$412.31
|
| Rate for Payer: Nomi Health Commercial |
$397.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$315.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$425.02
|
| Rate for Payer: Priority Health Narrow Network |
$340.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$426.86
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
OP
|
$9.70
|
|
|
Service Code
|
NDC 60687012711
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Aetna Commercial |
$8.73
|
| Rate for Payer: Aetna Medicare |
$4.85
|
| Rate for Payer: ASR ASR |
$9.41
|
| Rate for Payer: ASR Commercial |
$9.41
|
| Rate for Payer: BCBS Complete |
$3.88
|
| Rate for Payer: BCBS Trust/PPO |
$7.94
|
| Rate for Payer: BCN Commercial |
$7.52
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cofinity Commercial |
$9.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.76
|
| Rate for Payer: Healthscope Commercial |
$9.70
|
| Rate for Payer: Healthscope Whirlpool |
$9.41
|
| Rate for Payer: Mclaren Commercial |
$8.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.24
|
| Rate for Payer: Nomi Health Commercial |
$7.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.50
|
| Rate for Payer: Priority Health Narrow Network |
$6.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.54
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
OP
|
$493.50
|
|
|
Service Code
|
NDC 60505317007
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.40 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: Aetna Commercial |
$444.15
|
| Rate for Payer: Aetna Medicare |
$246.75
|
| Rate for Payer: ASR ASR |
$478.69
|
| Rate for Payer: ASR Commercial |
$478.69
|
| Rate for Payer: BCBS Complete |
$197.40
|
| Rate for Payer: BCBS Trust/PPO |
$404.13
|
| Rate for Payer: BCN Commercial |
$382.61
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cofinity Commercial |
$463.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$394.80
|
| Rate for Payer: Healthscope Commercial |
$493.50
|
| Rate for Payer: Healthscope Whirlpool |
$478.69
|
| Rate for Payer: Mclaren Commercial |
$444.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$419.48
|
| Rate for Payer: Nomi Health Commercial |
$404.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$320.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$432.40
|
| Rate for Payer: Priority Health Narrow Network |
$345.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$434.28
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
IP
|
$493.50
|
|
|
Service Code
|
NDC 60505317007
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$320.77 |
| Max. Negotiated Rate |
$493.50 |
| Rate for Payer: Aetna Commercial |
$444.15
|
| Rate for Payer: ASR ASR |
$478.69
|
| Rate for Payer: ASR Commercial |
$478.69
|
| Rate for Payer: BCBS Trust/PPO |
$402.15
|
| Rate for Payer: BCN Commercial |
$382.61
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cofinity Commercial |
$463.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$394.80
|
| Rate for Payer: Healthscope Commercial |
$493.50
|
| Rate for Payer: Healthscope Whirlpool |
$478.69
|
| Rate for Payer: Mclaren Commercial |
$444.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$419.48
|
| Rate for Payer: Nomi Health Commercial |
$404.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$320.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$434.28
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
OP
|
$440.86
|
|
|
Service Code
|
NDC 00904670606
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.34 |
| Max. Negotiated Rate |
$440.86 |
| Rate for Payer: Aetna Commercial |
$396.77
|
| Rate for Payer: Aetna Medicare |
$220.43
|
| Rate for Payer: ASR ASR |
$427.63
|
| Rate for Payer: ASR Commercial |
$427.63
|
| Rate for Payer: BCBS Complete |
$176.34
|
| Rate for Payer: BCBS Trust/PPO |
$361.02
|
| Rate for Payer: BCN Commercial |
$341.80
|
| Rate for Payer: Cash Price |
$352.68
|
| Rate for Payer: Cofinity Commercial |
$414.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.69
|
| Rate for Payer: Healthscope Commercial |
$440.86
|
| Rate for Payer: Healthscope Whirlpool |
$427.63
|
| Rate for Payer: Mclaren Commercial |
$396.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.73
|
| Rate for Payer: Nomi Health Commercial |
$361.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$386.28
|
| Rate for Payer: Priority Health Narrow Network |
$309.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$387.96
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
IP
|
$485.07
|
|
|
Service Code
|
NDC 60687012765
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$315.30 |
| Max. Negotiated Rate |
$485.07 |
| Rate for Payer: Aetna Commercial |
$436.56
|
| Rate for Payer: ASR ASR |
$470.52
|
| Rate for Payer: ASR Commercial |
$470.52
|
| Rate for Payer: BCBS Trust/PPO |
$395.28
|
| Rate for Payer: BCN Commercial |
$376.07
|
| Rate for Payer: Cash Price |
$388.06
|
| Rate for Payer: Cofinity Commercial |
$455.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$388.06
|
| Rate for Payer: Healthscope Commercial |
$485.07
|
| Rate for Payer: Healthscope Whirlpool |
$470.52
|
| Rate for Payer: Mclaren Commercial |
$436.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$412.31
|
| Rate for Payer: Nomi Health Commercial |
$397.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$315.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$426.86
|
|
|
OMEGA-3 ACID ETHYL ESTERS 1 GRAM CAPSULE
|
Facility
|
IP
|
$9.70
|
|
|
Service Code
|
NDC 60687012711
|
| Hospital Charge Code |
41822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Aetna Commercial |
$8.73
|
| Rate for Payer: ASR ASR |
$9.41
|
| Rate for Payer: ASR Commercial |
$9.41
|
| Rate for Payer: BCBS Trust/PPO |
$7.90
|
| Rate for Payer: BCN Commercial |
$7.52
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cofinity Commercial |
$9.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.76
|
| Rate for Payer: Healthscope Commercial |
$9.70
|
| Rate for Payer: Healthscope Whirlpool |
$9.41
|
| Rate for Payer: Mclaren Commercial |
$8.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.24
|
| Rate for Payer: Nomi Health Commercial |
$7.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.54
|
|
|
ONDANSETRON 4 MG DISINTEGRATING TABLET
|
Facility
|
OP
|
$83.66
|
|
|
Service Code
|
NDC 65862039010
|
| Hospital Charge Code |
27697
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.46 |
| Max. Negotiated Rate |
$83.66 |
| Rate for Payer: Aetna Commercial |
$75.29
|
| Rate for Payer: Aetna Medicare |
$41.83
|
| Rate for Payer: ASR ASR |
$81.15
|
| Rate for Payer: ASR Commercial |
$81.15
|
| Rate for Payer: BCBS Complete |
$33.46
|
| Rate for Payer: BCBS Trust/PPO |
$68.51
|
| Rate for Payer: BCN Commercial |
$64.86
|
| Rate for Payer: Cash Price |
$66.93
|
| Rate for Payer: Cofinity Commercial |
$78.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.93
|
| Rate for Payer: Healthscope Commercial |
$83.66
|
| Rate for Payer: Healthscope Whirlpool |
$81.15
|
| Rate for Payer: Mclaren Commercial |
$75.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.11
|
| Rate for Payer: Nomi Health Commercial |
$68.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$73.30
|
| Rate for Payer: Priority Health Narrow Network |
$58.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$73.62
|
|
