|
OXYCODONE 10 MG TABLET
|
Facility
|
IP
|
$422.80
|
|
|
Service Code
|
NDC 00406851062
|
| Hospital Charge Code |
87795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$274.82 |
| Max. Negotiated Rate |
$422.80 |
| Rate for Payer: Aetna Commercial |
$380.52
|
| Rate for Payer: ASR ASR |
$410.12
|
| Rate for Payer: ASR Commercial |
$410.12
|
| Rate for Payer: BCBS Trust/PPO |
$344.54
|
| Rate for Payer: BCN Commercial |
$327.80
|
| Rate for Payer: Cash Price |
$338.24
|
| Rate for Payer: Cofinity Commercial |
$397.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.24
|
| Rate for Payer: Healthscope Commercial |
$422.80
|
| Rate for Payer: Healthscope Whirlpool |
$410.12
|
| Rate for Payer: Mclaren Commercial |
$380.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.38
|
| Rate for Payer: Nomi Health Commercial |
$346.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$372.06
|
|
|
OXYCODONE 10 MG TABLET
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 00406851023
|
| Hospital Charge Code |
87795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: ASR ASR |
$4.10
|
| Rate for Payer: ASR Commercial |
$4.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.45
|
| Rate for Payer: BCN Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$3.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$4.23
|
| Rate for Payer: Healthscope Whirlpool |
$4.10
|
| Rate for Payer: Mclaren Commercial |
$3.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: Nomi Health Commercial |
$3.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.72
|
|
|
OXYCODONE 10 MG TABLET
|
Facility
|
OP
|
$422.80
|
|
|
Service Code
|
NDC 00406851062
|
| Hospital Charge Code |
87795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.12 |
| Max. Negotiated Rate |
$422.80 |
| Rate for Payer: Aetna Commercial |
$380.52
|
| Rate for Payer: Aetna Medicare |
$211.40
|
| Rate for Payer: ASR ASR |
$410.12
|
| Rate for Payer: ASR Commercial |
$410.12
|
| Rate for Payer: BCBS Complete |
$169.12
|
| Rate for Payer: BCBS Trust/PPO |
$346.23
|
| Rate for Payer: BCN Commercial |
$327.80
|
| Rate for Payer: Cash Price |
$338.24
|
| Rate for Payer: Cofinity Commercial |
$397.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.24
|
| Rate for Payer: Healthscope Commercial |
$422.80
|
| Rate for Payer: Healthscope Whirlpool |
$410.12
|
| Rate for Payer: Mclaren Commercial |
$380.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.38
|
| Rate for Payer: Nomi Health Commercial |
$346.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$370.46
|
| Rate for Payer: Priority Health Narrow Network |
$296.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$372.06
|
|
|
OXYCODONE 10 MG TABLET
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 00406851023
|
| Hospital Charge Code |
87795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Aetna Medicare |
$2.12
|
| Rate for Payer: ASR ASR |
$4.10
|
| Rate for Payer: ASR Commercial |
$4.10
|
| Rate for Payer: BCBS Complete |
$1.69
|
| Rate for Payer: BCBS Trust/PPO |
$3.46
|
| Rate for Payer: BCN Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$3.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$4.23
|
| Rate for Payer: Healthscope Whirlpool |
$4.10
|
| Rate for Payer: Mclaren Commercial |
$3.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: Nomi Health Commercial |
$3.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.71
|
| Rate for Payer: Priority Health Narrow Network |
$2.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.72
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$204.75
|
|
|
Service Code
|
NDC 42858000101
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.09 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Aetna Commercial |
$184.28
|
| Rate for Payer: ASR ASR |
$198.61
|
| Rate for Payer: ASR Commercial |
$198.61
|
| Rate for Payer: BCBS Trust/PPO |
$166.85
|
| Rate for Payer: BCN Commercial |
$158.74
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cofinity Commercial |
$192.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.80
|
| Rate for Payer: Healthscope Commercial |
$204.75
|
| Rate for Payer: Healthscope Whirlpool |
$198.61
|
| Rate for Payer: Mclaren Commercial |
$184.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.04
|
| Rate for Payer: Nomi Health Commercial |
$167.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$180.18
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
IP
|
$325.50
|
|
|
Service Code
|
NDC 00406055201
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$211.57 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$292.95
|
| Rate for Payer: ASR ASR |
$315.74
|
| Rate for Payer: ASR Commercial |
$315.74
|
| Rate for Payer: BCBS Trust/PPO |
$265.25
|
| Rate for Payer: BCN Commercial |
$252.36
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.40
|
| Rate for Payer: Healthscope Commercial |
$325.50
|
| Rate for Payer: Healthscope Whirlpool |
$315.74
|
| Rate for Payer: Mclaren Commercial |
$292.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.68
|
| Rate for Payer: Nomi Health Commercial |
$266.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$286.44
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$204.75
|
|
|
Service Code
|
NDC 42858000101
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Aetna Commercial |
$184.28
|
| Rate for Payer: Aetna Medicare |
$102.38
|
| Rate for Payer: ASR ASR |
$198.61
|
| Rate for Payer: ASR Commercial |
$198.61
|
| Rate for Payer: BCBS Complete |
$81.90
|
| Rate for Payer: BCBS Trust/PPO |
$167.67
|
| Rate for Payer: BCN Commercial |
$158.74
|
| Rate for Payer: Cash Price |
$163.80
|
| Rate for Payer: Cofinity Commercial |
$192.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.80
|
| Rate for Payer: Healthscope Commercial |
$204.75
|
| Rate for Payer: Healthscope Whirlpool |
$198.61
|
| Rate for Payer: Mclaren Commercial |
$184.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.04
|
| Rate for Payer: Nomi Health Commercial |
$167.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$179.40
|
| Rate for Payer: Priority Health Narrow Network |
$143.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$180.18
|
|
|
OXYCODONE 5 MG TABLET
|
Facility
|
OP
|
$325.50
|
|
|
Service Code
|
NDC 00406055201
|
| Hospital Charge Code |
10814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.20 |
| Max. Negotiated Rate |
$325.50 |
| Rate for Payer: Aetna Commercial |
$292.95
|
| Rate for Payer: Aetna Medicare |
$162.75
|
| Rate for Payer: ASR ASR |
$315.74
|
| Rate for Payer: ASR Commercial |
$315.74
|
| Rate for Payer: BCBS Complete |
$130.20
|
| Rate for Payer: BCBS Trust/PPO |
$266.55
|
| Rate for Payer: BCN Commercial |
$252.36
|
| Rate for Payer: Cash Price |
$260.40
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.40
|
| Rate for Payer: Healthscope Commercial |
$325.50
|
| Rate for Payer: Healthscope Whirlpool |
$315.74
|
| Rate for Payer: Mclaren Commercial |
$292.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.68
|
| Rate for Payer: Nomi Health Commercial |
$266.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$285.20
|
| Rate for Payer: Priority Health Narrow Network |
$228.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$286.44
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$277.55
|
|
|
Service Code
|
NDC 50268064615
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.41 |
| Max. Negotiated Rate |
$277.55 |
| Rate for Payer: Aetna Commercial |
$249.79
|
| Rate for Payer: ASR ASR |
$269.22
|
| Rate for Payer: ASR Commercial |
$269.22
|
| Rate for Payer: BCBS Trust/PPO |
$226.18
|
| Rate for Payer: BCN Commercial |
$215.18
|
| Rate for Payer: Cash Price |
$222.04
|
| Rate for Payer: Cofinity Commercial |
$260.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.04
|
| Rate for Payer: Healthscope Commercial |
$277.55
|
| Rate for Payer: Healthscope Whirlpool |
$269.22
|
| Rate for Payer: Mclaren Commercial |
$249.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.92
|
| Rate for Payer: Nomi Health Commercial |
$227.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.24
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
OP
|
$963.20
|
|
|
Service Code
|
NDC 68084071001
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$385.28 |
| Max. Negotiated Rate |
$963.20 |
| Rate for Payer: Aetna Commercial |
$866.88
|
| Rate for Payer: Aetna Medicare |
$481.60
|
| Rate for Payer: ASR ASR |
$934.30
|
| Rate for Payer: ASR Commercial |
$934.30
|
| Rate for Payer: BCBS Complete |
$385.28
|
| Rate for Payer: BCBS Trust/PPO |
$788.76
|
| Rate for Payer: BCN Commercial |
$746.77
|
| Rate for Payer: Cash Price |
$770.56
|
| Rate for Payer: Cofinity Commercial |
$905.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$770.56
|
| Rate for Payer: Healthscope Commercial |
$963.20
|
| Rate for Payer: Healthscope Whirlpool |
$934.30
|
| Rate for Payer: Mclaren Commercial |
$866.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$818.72
|
| Rate for Payer: Nomi Health Commercial |
$789.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$626.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$843.96
|
| Rate for Payer: Priority Health Narrow Network |
$675.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$847.62
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$963.20
|
|
|
Service Code
|
NDC 68084071001
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$626.08 |
| Max. Negotiated Rate |
$963.20 |
| Rate for Payer: Aetna Commercial |
$866.88
|
| Rate for Payer: ASR ASR |
$934.30
|
| Rate for Payer: ASR Commercial |
$934.30
|
| Rate for Payer: BCBS Trust/PPO |
$784.91
|
| Rate for Payer: BCN Commercial |
$746.77
|
| Rate for Payer: Cash Price |
$770.56
|
| Rate for Payer: Cofinity Commercial |
$905.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$770.56
|
| Rate for Payer: Healthscope Commercial |
$963.20
|
| Rate for Payer: Healthscope Whirlpool |
$934.30
|
| Rate for Payer: Mclaren Commercial |
$866.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$818.72
|
| Rate for Payer: Nomi Health Commercial |
$789.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$626.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$847.62
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$9.63
|
|
|
Service Code
|
NDC 68084071011
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.26 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Aetna Commercial |
$8.67
|
| Rate for Payer: ASR ASR |
$9.34
|
| Rate for Payer: ASR Commercial |
$9.34
|
| Rate for Payer: BCBS Trust/PPO |
$7.85
|
| Rate for Payer: BCN Commercial |
$7.47
|
| Rate for Payer: Cash Price |
$7.71
|
| Rate for Payer: Cofinity Commercial |
$9.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.70
|
| Rate for Payer: Healthscope Commercial |
$9.63
|
| Rate for Payer: Healthscope Whirlpool |
$9.34
|
| Rate for Payer: Mclaren Commercial |
$8.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.19
|
| Rate for Payer: Nomi Health Commercial |
$7.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.47
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
OP
|
$5.55
|
|
|
Service Code
|
NDC 50268064611
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: Aetna Medicare |
$2.77
|
| Rate for Payer: ASR ASR |
$5.38
|
| Rate for Payer: ASR Commercial |
$5.38
|
| Rate for Payer: BCBS Complete |
$2.22
|
| Rate for Payer: BCBS Trust/PPO |
$4.54
|
| Rate for Payer: BCN Commercial |
$4.30
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: Cofinity Commercial |
$5.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.44
|
| Rate for Payer: Healthscope Commercial |
$5.55
|
| Rate for Payer: Healthscope Whirlpool |
$5.38
|
| Rate for Payer: Mclaren Commercial |
$5.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.72
|
| Rate for Payer: Nomi Health Commercial |
$4.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.86
|
| Rate for Payer: Priority Health Narrow Network |
$3.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.88
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
OP
|
$9.63
|
|
|
Service Code
|
NDC 68084071011
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Aetna Commercial |
$8.67
|
| Rate for Payer: Aetna Medicare |
$4.82
|
| Rate for Payer: ASR ASR |
$9.34
|
| Rate for Payer: ASR Commercial |
$9.34
|
| Rate for Payer: BCBS Complete |
$3.85
|
| Rate for Payer: BCBS Trust/PPO |
$7.89
|
| Rate for Payer: BCN Commercial |
$7.47
|
| Rate for Payer: Cash Price |
$7.71
|
| Rate for Payer: Cofinity Commercial |
$9.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.70
|
| Rate for Payer: Healthscope Commercial |
$9.63
|
| Rate for Payer: Healthscope Whirlpool |
$9.34
|
| Rate for Payer: Mclaren Commercial |
$8.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.19
|
| Rate for Payer: Nomi Health Commercial |
$7.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.44
|
| Rate for Payer: Priority Health Narrow Network |
$6.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.47
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
IP
|
$5.55
|
|
|
Service Code
|
NDC 50268064611
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$5.55 |
| Rate for Payer: Aetna Commercial |
$5.00
|
| Rate for Payer: ASR ASR |
$5.38
|
| Rate for Payer: ASR Commercial |
$5.38
|
| Rate for Payer: BCBS Trust/PPO |
$4.52
|
| Rate for Payer: BCN Commercial |
$4.30
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: Cofinity Commercial |
$5.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.44
|
| Rate for Payer: Healthscope Commercial |
$5.55
|
| Rate for Payer: Healthscope Whirlpool |
$5.38
|
| Rate for Payer: Mclaren Commercial |
$5.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.72
|
| Rate for Payer: Nomi Health Commercial |
$4.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.88
|
|
|
OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET
|
Facility
|
OP
|
$277.55
|
|
|
Service Code
|
NDC 50268064615
|
| Hospital Charge Code |
31864
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.02 |
| Max. Negotiated Rate |
$277.55 |
| Rate for Payer: Aetna Commercial |
$249.79
|
| Rate for Payer: Aetna Medicare |
$138.78
|
| Rate for Payer: ASR ASR |
$269.22
|
| Rate for Payer: ASR Commercial |
$269.22
|
| Rate for Payer: BCBS Complete |
$111.02
|
| Rate for Payer: BCBS Trust/PPO |
$227.29
|
| Rate for Payer: BCN Commercial |
$215.18
|
| Rate for Payer: Cash Price |
$222.04
|
| Rate for Payer: Cofinity Commercial |
$260.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.04
|
| Rate for Payer: Healthscope Commercial |
$277.55
|
| Rate for Payer: Healthscope Whirlpool |
$269.22
|
| Rate for Payer: Mclaren Commercial |
$249.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.92
|
| Rate for Payer: Nomi Health Commercial |
$227.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$243.19
|
| Rate for Payer: Priority Health Narrow Network |
$194.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.24
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
IP
|
$449.75
|
|
|
Service Code
|
NDC 00904709361
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$292.34 |
| Max. Negotiated Rate |
$449.75 |
| Rate for Payer: Aetna Commercial |
$404.77
|
| Rate for Payer: ASR ASR |
$436.26
|
| Rate for Payer: ASR Commercial |
$436.26
|
| Rate for Payer: BCBS Trust/PPO |
$366.50
|
| Rate for Payer: BCN Commercial |
$348.69
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: Cofinity Commercial |
$422.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.80
|
| Rate for Payer: Healthscope Commercial |
$449.75
|
| Rate for Payer: Healthscope Whirlpool |
$436.26
|
| Rate for Payer: Mclaren Commercial |
$404.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.29
|
| Rate for Payer: Nomi Health Commercial |
$368.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$395.78
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$637.00
|
|
|
Service Code
|
NDC 68084035501
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.80 |
| Max. Negotiated Rate |
$637.00 |
| Rate for Payer: Aetna Commercial |
$573.30
|
| Rate for Payer: Aetna Medicare |
$318.50
|
| Rate for Payer: ASR ASR |
$617.89
|
| Rate for Payer: ASR Commercial |
$617.89
|
| Rate for Payer: BCBS Complete |
$254.80
|
| Rate for Payer: BCBS Trust/PPO |
$521.64
|
| Rate for Payer: BCN Commercial |
$493.87
|
| Rate for Payer: Cash Price |
$509.60
|
| Rate for Payer: Cofinity Commercial |
$598.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$509.60
|
| Rate for Payer: Healthscope Commercial |
$637.00
|
| Rate for Payer: Healthscope Whirlpool |
$617.89
|
| Rate for Payer: Mclaren Commercial |
$573.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$541.45
|
| Rate for Payer: Nomi Health Commercial |
$522.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$414.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$558.14
|
| Rate for Payer: Priority Health Narrow Network |
$446.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$560.56
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
IP
|
$65.28
|
|
|
Service Code
|
NDC 00406051262
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.43 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$58.75
|
| Rate for Payer: ASR ASR |
$63.32
|
| Rate for Payer: ASR Commercial |
$63.32
|
| Rate for Payer: BCBS Trust/PPO |
$53.20
|
| Rate for Payer: BCN Commercial |
$50.61
|
| Rate for Payer: Cash Price |
$52.22
|
| Rate for Payer: Cofinity Commercial |
$61.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.22
|
| Rate for Payer: Healthscope Commercial |
$65.28
|
| Rate for Payer: Healthscope Whirlpool |
$63.32
|
| Rate for Payer: Mclaren Commercial |
$58.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.49
|
| Rate for Payer: Nomi Health Commercial |
$53.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.45
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$4.13
|
|
|
Service Code
|
NDC 09900000890
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Aetna Medicare |
$2.06
|
| Rate for Payer: ASR ASR |
$4.01
|
| Rate for Payer: ASR Commercial |
$4.01
|
| Rate for Payer: BCBS Complete |
$1.65
|
| Rate for Payer: BCBS Trust/PPO |
$3.38
|
| Rate for Payer: BCN Commercial |
$3.20
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Commercial |
$3.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$4.13
|
| Rate for Payer: Healthscope Whirlpool |
$4.01
|
| Rate for Payer: Mclaren Commercial |
$3.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.51
|
| Rate for Payer: Nomi Health Commercial |
$3.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.62
|
| Rate for Payer: Priority Health Narrow Network |
$2.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.63
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$637.00
|
|
|
Service Code
|
NDC 68084035511
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.80 |
| Max. Negotiated Rate |
$637.00 |
| Rate for Payer: Aetna Commercial |
$573.30
|
| Rate for Payer: Aetna Medicare |
$318.50
|
| Rate for Payer: ASR ASR |
$617.89
|
| Rate for Payer: ASR Commercial |
$617.89
|
| Rate for Payer: BCBS Complete |
$254.80
|
| Rate for Payer: BCBS Trust/PPO |
$521.64
|
| Rate for Payer: BCN Commercial |
$493.87
|
| Rate for Payer: Cash Price |
$509.60
|
| Rate for Payer: Cofinity Commercial |
$598.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$509.60
|
| Rate for Payer: Healthscope Commercial |
$637.00
|
| Rate for Payer: Healthscope Whirlpool |
$617.89
|
| Rate for Payer: Mclaren Commercial |
$573.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$541.45
|
| Rate for Payer: Nomi Health Commercial |
$522.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$414.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$558.14
|
| Rate for Payer: Priority Health Narrow Network |
$446.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$560.56
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$290.50
|
|
|
Service Code
|
NDC 00406051201
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.20 |
| Max. Negotiated Rate |
$290.50 |
| Rate for Payer: Aetna Commercial |
$261.45
|
| Rate for Payer: Aetna Medicare |
$145.25
|
| Rate for Payer: ASR ASR |
$281.79
|
| Rate for Payer: ASR Commercial |
$281.79
|
| Rate for Payer: BCBS Complete |
$116.20
|
| Rate for Payer: BCBS Trust/PPO |
$237.89
|
| Rate for Payer: BCN Commercial |
$225.22
|
| Rate for Payer: Cash Price |
$232.40
|
| Rate for Payer: Cofinity Commercial |
$273.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.40
|
| Rate for Payer: Healthscope Commercial |
$290.50
|
| Rate for Payer: Healthscope Whirlpool |
$281.79
|
| Rate for Payer: Mclaren Commercial |
$261.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$246.93
|
| Rate for Payer: Nomi Health Commercial |
$238.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$254.54
|
| Rate for Payer: Priority Health Narrow Network |
$203.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$255.64
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
IP
|
$290.50
|
|
|
Service Code
|
NDC 00406051201
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.82 |
| Max. Negotiated Rate |
$290.50 |
| Rate for Payer: Aetna Commercial |
$261.45
|
| Rate for Payer: ASR ASR |
$281.79
|
| Rate for Payer: ASR Commercial |
$281.79
|
| Rate for Payer: BCBS Trust/PPO |
$236.73
|
| Rate for Payer: BCN Commercial |
$225.22
|
| Rate for Payer: Cash Price |
$232.40
|
| Rate for Payer: Cofinity Commercial |
$273.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.40
|
| Rate for Payer: Healthscope Commercial |
$290.50
|
| Rate for Payer: Healthscope Whirlpool |
$281.79
|
| Rate for Payer: Mclaren Commercial |
$261.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$246.93
|
| Rate for Payer: Nomi Health Commercial |
$238.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$255.64
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$65.28
|
|
|
Service Code
|
NDC 00406051262
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.11 |
| Max. Negotiated Rate |
$65.28 |
| Rate for Payer: Aetna Commercial |
$58.75
|
| Rate for Payer: Aetna Medicare |
$32.64
|
| Rate for Payer: ASR ASR |
$63.32
|
| Rate for Payer: ASR Commercial |
$63.32
|
| Rate for Payer: BCBS Complete |
$26.11
|
| Rate for Payer: BCBS Trust/PPO |
$53.46
|
| Rate for Payer: BCN Commercial |
$50.61
|
| Rate for Payer: Cash Price |
$52.22
|
| Rate for Payer: Cofinity Commercial |
$61.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.22
|
| Rate for Payer: Healthscope Commercial |
$65.28
|
| Rate for Payer: Healthscope Whirlpool |
$63.32
|
| Rate for Payer: Mclaren Commercial |
$58.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.49
|
| Rate for Payer: Nomi Health Commercial |
$53.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$57.20
|
| Rate for Payer: Priority Health Narrow Network |
$45.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$57.45
|
|
|
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET
|
Facility
|
OP
|
$449.75
|
|
|
Service Code
|
NDC 00904709361
|
| Hospital Charge Code |
5940
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.90 |
| Max. Negotiated Rate |
$449.75 |
| Rate for Payer: Aetna Commercial |
$404.77
|
| Rate for Payer: Aetna Medicare |
$224.88
|
| Rate for Payer: ASR ASR |
$436.26
|
| Rate for Payer: ASR Commercial |
$436.26
|
| Rate for Payer: BCBS Complete |
$179.90
|
| Rate for Payer: BCBS Trust/PPO |
$368.30
|
| Rate for Payer: BCN Commercial |
$348.69
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: Cofinity Commercial |
$422.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.80
|
| Rate for Payer: Healthscope Commercial |
$449.75
|
| Rate for Payer: Healthscope Whirlpool |
$436.26
|
| Rate for Payer: Mclaren Commercial |
$404.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.29
|
| Rate for Payer: Nomi Health Commercial |
$368.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$394.07
|
| Rate for Payer: Priority Health Narrow Network |
$315.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$395.78
|
|
