|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$222.30
|
|
|
Service Code
|
NDC 63739056410
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.50 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$200.07
|
| Rate for Payer: ASR ASR |
$215.63
|
| Rate for Payer: ASR Commercial |
$215.63
|
| Rate for Payer: BCBS Trust/PPO |
$181.15
|
| Rate for Payer: BCN Commercial |
$172.35
|
| Rate for Payer: Cash Price |
$177.84
|
| Rate for Payer: Cofinity Commercial |
$208.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.84
|
| Rate for Payer: Healthscope Commercial |
$222.30
|
| Rate for Payer: Healthscope Whirlpool |
$215.63
|
| Rate for Payer: Mclaren Commercial |
$200.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.96
|
| Rate for Payer: Nomi Health Commercial |
$182.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$195.62
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4,482.85
|
|
|
Service Code
|
NDC 00008084181
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,913.85 |
| Max. Negotiated Rate |
$4,482.85 |
| Rate for Payer: Aetna Commercial |
$4,034.57
|
| Rate for Payer: ASR ASR |
$4,348.36
|
| Rate for Payer: ASR Commercial |
$4,348.36
|
| Rate for Payer: BCBS Trust/PPO |
$3,653.07
|
| Rate for Payer: BCN Commercial |
$3,475.55
|
| Rate for Payer: Cash Price |
$3,586.28
|
| Rate for Payer: Cofinity Commercial |
$4,213.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,586.28
|
| Rate for Payer: Healthscope Commercial |
$4,482.85
|
| Rate for Payer: Healthscope Whirlpool |
$4,348.36
|
| Rate for Payer: Mclaren Commercial |
$4,034.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,810.42
|
| Rate for Payer: Nomi Health Commercial |
$3,675.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,913.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,944.91
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$4,482.85
|
|
|
Service Code
|
NDC 00008084181
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,793.14 |
| Max. Negotiated Rate |
$4,482.85 |
| Rate for Payer: Aetna Commercial |
$4,034.57
|
| Rate for Payer: Aetna Medicare |
$2,241.43
|
| Rate for Payer: ASR ASR |
$4,348.36
|
| Rate for Payer: ASR Commercial |
$4,348.36
|
| Rate for Payer: BCBS Complete |
$1,793.14
|
| Rate for Payer: BCBS Trust/PPO |
$3,671.01
|
| Rate for Payer: BCN Commercial |
$3,475.55
|
| Rate for Payer: Cash Price |
$3,586.28
|
| Rate for Payer: Cofinity Commercial |
$4,213.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,586.28
|
| Rate for Payer: Healthscope Commercial |
$4,482.85
|
| Rate for Payer: Healthscope Whirlpool |
$4,348.36
|
| Rate for Payer: Mclaren Commercial |
$4,034.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,810.42
|
| Rate for Payer: Nomi Health Commercial |
$3,675.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,913.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,927.87
|
| Rate for Payer: Priority Health Narrow Network |
$3,142.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,944.91
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 51079005101
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna Commercial |
$1.99
|
| Rate for Payer: ASR ASR |
$2.14
|
| Rate for Payer: ASR Commercial |
$2.14
|
| Rate for Payer: BCBS Trust/PPO |
$1.80
|
| Rate for Payer: BCN Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$2.21
|
| Rate for Payer: Healthscope Whirlpool |
$2.14
|
| Rate for Payer: Mclaren Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.88
|
| Rate for Payer: Nomi Health Commercial |
$1.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.94
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$446.50
|
|
|
Service Code
|
NDC 66993006880
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$290.23 |
| Max. Negotiated Rate |
$446.50 |
| Rate for Payer: Aetna Commercial |
$401.85
|
| Rate for Payer: ASR ASR |
$433.11
|
| Rate for Payer: ASR Commercial |
$433.11
|
| Rate for Payer: BCBS Trust/PPO |
$363.85
|
| Rate for Payer: BCN Commercial |
$346.17
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$419.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$446.50
|
| Rate for Payer: Healthscope Whirlpool |
$433.11
|
| Rate for Payer: Mclaren Commercial |
$401.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$379.52
|
| Rate for Payer: Nomi Health Commercial |
$366.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$290.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$392.92
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$2.21
|
|
|
Service Code
|
NDC 51079005101
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna Commercial |
$1.99
|
| Rate for Payer: Aetna Medicare |
$1.10
|
| Rate for Payer: ASR ASR |
$2.14
|
| Rate for Payer: ASR Commercial |
$2.14
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: BCBS Trust/PPO |
$1.81
|
| Rate for Payer: BCN Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$2.21
|
| Rate for Payer: Healthscope Whirlpool |
$2.14
|
| Rate for Payer: Mclaren Commercial |
$1.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.88
|
| Rate for Payer: Nomi Health Commercial |
$1.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.94
|
| Rate for Payer: Priority Health Narrow Network |
$1.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.94
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$153.93
|
|
|
Service Code
|
NDC 50268063915
|
| Hospital Charge Code |
26225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.57 |
| Max. Negotiated Rate |
$153.93 |
| Rate for Payer: Aetna Commercial |
$138.54
|
| Rate for Payer: Aetna Medicare |
$76.97
|
| Rate for Payer: ASR ASR |
$149.31
|
| Rate for Payer: ASR Commercial |
$149.31
|
| Rate for Payer: BCBS Complete |
$61.57
|
| Rate for Payer: BCBS Trust/PPO |
$126.05
|
| Rate for Payer: BCN Commercial |
$119.34
|
| Rate for Payer: Cash Price |
$123.14
|
| Rate for Payer: Cofinity Commercial |
$144.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.14
|
| Rate for Payer: Healthscope Commercial |
$153.93
|
| Rate for Payer: Healthscope Whirlpool |
$149.31
|
| Rate for Payer: Mclaren Commercial |
$138.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$130.84
|
| Rate for Payer: Nomi Health Commercial |
$126.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$134.87
|
| Rate for Payer: Priority Health Narrow Network |
$107.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$135.46
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
IP
|
$470.25
|
|
|
Service Code
|
NDC 68084004411
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$305.66 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$423.23
|
| Rate for Payer: ASR ASR |
$456.14
|
| Rate for Payer: ASR Commercial |
$456.14
|
| Rate for Payer: BCBS Trust/PPO |
$383.21
|
| Rate for Payer: BCN Commercial |
$364.58
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$442.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$470.25
|
| Rate for Payer: Healthscope Whirlpool |
$456.14
|
| Rate for Payer: Mclaren Commercial |
$423.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.71
|
| Rate for Payer: Nomi Health Commercial |
$385.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$413.82
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
IP
|
$74.73
|
|
|
Service Code
|
NDC 00378700193
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.57 |
| Max. Negotiated Rate |
$74.73 |
| Rate for Payer: Aetna Commercial |
$67.26
|
| Rate for Payer: ASR ASR |
$72.49
|
| Rate for Payer: ASR Commercial |
$72.49
|
| Rate for Payer: BCBS Trust/PPO |
$60.90
|
| Rate for Payer: BCN Commercial |
$57.94
|
| Rate for Payer: Cash Price |
$59.78
|
| Rate for Payer: Cofinity Commercial |
$70.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.78
|
| Rate for Payer: Healthscope Commercial |
$74.73
|
| Rate for Payer: Healthscope Whirlpool |
$72.49
|
| Rate for Payer: Mclaren Commercial |
$67.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.52
|
| Rate for Payer: Nomi Health Commercial |
$61.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.76
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
OP
|
$470.25
|
|
|
Service Code
|
NDC 68084004411
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.10 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$423.23
|
| Rate for Payer: Aetna Medicare |
$235.12
|
| Rate for Payer: ASR ASR |
$456.14
|
| Rate for Payer: ASR Commercial |
$456.14
|
| Rate for Payer: BCBS Complete |
$188.10
|
| Rate for Payer: BCBS Trust/PPO |
$385.09
|
| Rate for Payer: BCN Commercial |
$364.58
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$442.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$470.25
|
| Rate for Payer: Healthscope Whirlpool |
$456.14
|
| Rate for Payer: Mclaren Commercial |
$423.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.71
|
| Rate for Payer: Nomi Health Commercial |
$385.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$412.03
|
| Rate for Payer: Priority Health Narrow Network |
$329.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$413.82
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
OP
|
$74.73
|
|
|
Service Code
|
NDC 00378700193
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$74.73 |
| Rate for Payer: Aetna Commercial |
$67.26
|
| Rate for Payer: Aetna Medicare |
$37.37
|
| Rate for Payer: ASR ASR |
$72.49
|
| Rate for Payer: ASR Commercial |
$72.49
|
| Rate for Payer: BCBS Complete |
$29.89
|
| Rate for Payer: BCBS Trust/PPO |
$61.20
|
| Rate for Payer: BCN Commercial |
$57.94
|
| Rate for Payer: Cash Price |
$59.78
|
| Rate for Payer: Cofinity Commercial |
$70.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.78
|
| Rate for Payer: Healthscope Commercial |
$74.73
|
| Rate for Payer: Healthscope Whirlpool |
$72.49
|
| Rate for Payer: Mclaren Commercial |
$67.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.52
|
| Rate for Payer: Nomi Health Commercial |
$61.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$65.48
|
| Rate for Payer: Priority Health Narrow Network |
$52.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.76
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
IP
|
$470.25
|
|
|
Service Code
|
NDC 68084004401
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$305.66 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$423.23
|
| Rate for Payer: ASR ASR |
$456.14
|
| Rate for Payer: ASR Commercial |
$456.14
|
| Rate for Payer: BCBS Trust/PPO |
$383.21
|
| Rate for Payer: BCN Commercial |
$364.58
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$442.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$470.25
|
| Rate for Payer: Healthscope Whirlpool |
$456.14
|
| Rate for Payer: Mclaren Commercial |
$423.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.71
|
| Rate for Payer: Nomi Health Commercial |
$385.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$413.82
|
|
|
PAROXETINE 10 MG TABLET
|
Facility
|
OP
|
$470.25
|
|
|
Service Code
|
NDC 68084004401
|
| Hospital Charge Code |
16632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.10 |
| Max. Negotiated Rate |
$470.25 |
| Rate for Payer: Aetna Commercial |
$423.23
|
| Rate for Payer: Aetna Medicare |
$235.12
|
| Rate for Payer: ASR ASR |
$456.14
|
| Rate for Payer: ASR Commercial |
$456.14
|
| Rate for Payer: BCBS Complete |
$188.10
|
| Rate for Payer: BCBS Trust/PPO |
$385.09
|
| Rate for Payer: BCN Commercial |
$364.58
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$442.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$470.25
|
| Rate for Payer: Healthscope Whirlpool |
$456.14
|
| Rate for Payer: Mclaren Commercial |
$423.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.71
|
| Rate for Payer: Nomi Health Commercial |
$385.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$412.03
|
| Rate for Payer: Priority Health Narrow Network |
$329.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$413.82
|
|
|
PAROXETINE 20 MG TABLET
|
Facility
|
IP
|
$397.15
|
|
|
Service Code
|
NDC 00904567761
|
| Hospital Charge Code |
10855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.15 |
| Max. Negotiated Rate |
$397.15 |
| Rate for Payer: Aetna Commercial |
$357.44
|
| Rate for Payer: ASR ASR |
$385.24
|
| Rate for Payer: ASR Commercial |
$385.24
|
| Rate for Payer: BCBS Trust/PPO |
$323.64
|
| Rate for Payer: BCN Commercial |
$307.91
|
| Rate for Payer: Cash Price |
$317.72
|
| Rate for Payer: Cofinity Commercial |
$373.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$317.72
|
| Rate for Payer: Healthscope Commercial |
$397.15
|
| Rate for Payer: Healthscope Whirlpool |
$385.24
|
| Rate for Payer: Mclaren Commercial |
$357.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$337.58
|
| Rate for Payer: Nomi Health Commercial |
$325.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$349.49
|
|
|
PAROXETINE 20 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 63739096310
|
| Hospital Charge Code |
10855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$209.27 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: ASR Commercial |
$312.29
|
| Rate for Payer: BCBS Trust/PPO |
$262.36
|
| Rate for Payer: BCN Commercial |
$249.61
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$302.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$321.95
|
| Rate for Payer: Healthscope Whirlpool |
$312.29
|
| Rate for Payer: Mclaren Commercial |
$289.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: Nomi Health Commercial |
$264.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.32
|
|
|
PAROXETINE 20 MG TABLET
|
Facility
|
OP
|
$321.95
|
|
|
Service Code
|
NDC 63739096310
|
| Hospital Charge Code |
10855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.78 |
| Max. Negotiated Rate |
$321.95 |
| Rate for Payer: Aetna Commercial |
$289.75
|
| Rate for Payer: Aetna Medicare |
$160.97
|
| Rate for Payer: ASR ASR |
$312.29
|
| Rate for Payer: ASR Commercial |
$312.29
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: BCBS Trust/PPO |
$263.64
|
| Rate for Payer: BCN Commercial |
$249.61
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$302.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$321.95
|
| Rate for Payer: Healthscope Whirlpool |
$312.29
|
| Rate for Payer: Mclaren Commercial |
$289.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: Nomi Health Commercial |
$264.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$282.09
|
| Rate for Payer: Priority Health Narrow Network |
$225.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.32
|
|
|
PAROXETINE 20 MG TABLET
|
Facility
|
OP
|
$397.15
|
|
|
Service Code
|
NDC 00904567761
|
| Hospital Charge Code |
10855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.86 |
| Max. Negotiated Rate |
$397.15 |
| Rate for Payer: Aetna Commercial |
$357.44
|
| Rate for Payer: Aetna Medicare |
$198.57
|
| Rate for Payer: ASR ASR |
$385.24
|
| Rate for Payer: ASR Commercial |
$385.24
|
| Rate for Payer: BCBS Complete |
$158.86
|
| Rate for Payer: BCBS Trust/PPO |
$325.23
|
| Rate for Payer: BCN Commercial |
$307.91
|
| Rate for Payer: Cash Price |
$317.72
|
| Rate for Payer: Cofinity Commercial |
$373.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$317.72
|
| Rate for Payer: Healthscope Commercial |
$397.15
|
| Rate for Payer: Healthscope Whirlpool |
$385.24
|
| Rate for Payer: Mclaren Commercial |
$357.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$337.58
|
| Rate for Payer: Nomi Health Commercial |
$325.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$347.98
|
| Rate for Payer: Priority Health Narrow Network |
$278.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$349.49
|
|
|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
OP
|
$1,384.11
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$413.00 |
| Max. Negotiated Rate |
$1,384.11 |
| Rate for Payer: Aetna Commercial |
$1,245.70
|
| Rate for Payer: Aetna Medicare |
$770.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$963.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$963.16
|
| Rate for Payer: ASR ASR |
$1,342.59
|
| Rate for Payer: ASR Commercial |
$1,342.59
|
| Rate for Payer: BCBS Complete |
$433.65
|
| Rate for Payer: BCBS MAPPO |
$770.53
|
| Rate for Payer: BCBS Trust/PPO |
$1,133.45
|
| Rate for Payer: BCN Commercial |
$1,073.10
|
| Rate for Payer: BCN Medicare Advantage |
$770.53
|
| Rate for Payer: Cash Price |
$1,107.29
|
| Rate for Payer: Cash Price |
$1,107.29
|
| Rate for Payer: Cofinity Commercial |
$1,301.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,107.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$770.53
|
| Rate for Payer: Healthscope Commercial |
$1,384.11
|
| Rate for Payer: Healthscope Whirlpool |
$1,342.59
|
| Rate for Payer: Humana Choice PPO Medicare |
$770.53
|
| Rate for Payer: Mclaren Commercial |
$1,245.70
|
| Rate for Payer: Mclaren Medicaid |
$413.00
|
| Rate for Payer: Mclaren Medicare |
$770.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$809.06
|
| Rate for Payer: Meridian Medicaid |
$433.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$886.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,176.49
|
| Rate for Payer: Nomi Health Commercial |
$1,134.97
|
| Rate for Payer: PACE Medicare |
$732.00
|
| Rate for Payer: PACE SWMI |
$770.53
|
| Rate for Payer: PHP Commercial |
$847.58
|
| Rate for Payer: PHP Medicaid |
$413.00
|
| Rate for Payer: PHP Medicare Advantage |
$770.53
|
| Rate for Payer: Priority Health Choice Medicaid |
$413.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$899.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,212.76
|
| Rate for Payer: Priority Health Medicare |
$770.53
|
| Rate for Payer: Priority Health Narrow Network |
$970.26
|
| Rate for Payer: Railroad Medicare Medicare |
$770.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,218.02
|
| Rate for Payer: UHC Dual Complete DSNP |
$770.53
|
| Rate for Payer: UHC Exchange |
$1,194.32
|
| Rate for Payer: UHC Medicare Advantage |
$770.53
|
| Rate for Payer: UHCCP DNSP |
$770.53
|
| Rate for Payer: UHCCP Medicaid |
$413.00
|
| Rate for Payer: VA VA |
$770.53
|
|
|
PEDS ECHO LIMITED W/DEFINITY
|
Facility
|
IP
|
$1,384.11
|
|
|
Service Code
|
HCPCS C8922
|
| Hospital Charge Code |
48000029
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$899.67 |
| Max. Negotiated Rate |
$1,384.11 |
| Rate for Payer: Aetna Commercial |
$1,245.70
|
| Rate for Payer: ASR ASR |
$1,342.59
|
| Rate for Payer: ASR Commercial |
$1,342.59
|
| Rate for Payer: BCBS Trust/PPO |
$1,127.91
|
| Rate for Payer: BCN Commercial |
$1,073.10
|
| Rate for Payer: Cash Price |
$1,107.29
|
| Rate for Payer: Cofinity Commercial |
$1,301.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,107.29
|
| Rate for Payer: Healthscope Commercial |
$1,384.11
|
| Rate for Payer: Healthscope Whirlpool |
$1,342.59
|
| Rate for Payer: Mclaren Commercial |
$1,245.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,176.49
|
| Rate for Payer: Nomi Health Commercial |
$1,134.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$899.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,218.02
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 43386009019
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: ASR ASR |
$54.32
|
| Rate for Payer: ASR Commercial |
$54.32
|
| Rate for Payer: BCBS Trust/PPO |
$45.63
|
| Rate for Payer: BCN Commercial |
$43.42
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$52.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Healthscope Commercial |
$56.00
|
| Rate for Payer: Healthscope Whirlpool |
$54.32
|
| Rate for Payer: Mclaren Commercial |
$50.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: Nomi Health Commercial |
$45.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.28
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Medicare |
$35.00
|
| Rate for Payer: ASR ASR |
$67.90
|
| Rate for Payer: ASR Commercial |
$67.90
|
| Rate for Payer: BCBS Complete |
$28.00
|
| Rate for Payer: BCBS Trust/PPO |
$57.32
|
| Rate for Payer: BCN Commercial |
$54.27
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Commercial |
$65.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.00
|
| Rate for Payer: Healthscope Commercial |
$70.00
|
| Rate for Payer: Healthscope Whirlpool |
$67.90
|
| Rate for Payer: Mclaren Commercial |
$63.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.50
|
| Rate for Payer: Nomi Health Commercial |
$57.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.33
|
| Rate for Payer: Priority Health Narrow Network |
$49.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.60
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 43386009019
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Medicare |
$28.00
|
| Rate for Payer: ASR ASR |
$54.32
|
| Rate for Payer: ASR Commercial |
$54.32
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: BCBS Trust/PPO |
$45.86
|
| Rate for Payer: BCN Commercial |
$43.42
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$52.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Healthscope Commercial |
$56.00
|
| Rate for Payer: Healthscope Whirlpool |
$54.32
|
| Rate for Payer: Mclaren Commercial |
$50.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: Nomi Health Commercial |
$45.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49.07
|
| Rate for Payer: Priority Health Narrow Network |
$39.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$49.28
|
|
|
PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
10839
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: ASR ASR |
$67.90
|
| Rate for Payer: ASR Commercial |
$67.90
|
| Rate for Payer: BCBS Trust/PPO |
$57.04
|
| Rate for Payer: BCN Commercial |
$54.27
|
| Rate for Payer: Cash Price |
$56.00
|
| Rate for Payer: Cofinity Commercial |
$65.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.00
|
| Rate for Payer: Healthscope Commercial |
$70.00
|
| Rate for Payer: Healthscope Whirlpool |
$67.90
|
| Rate for Payer: Mclaren Commercial |
$63.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.50
|
| Rate for Payer: Nomi Health Commercial |
$57.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.60
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS
|
Facility
|
IP
|
$11.07
|
|
|
Service Code
|
NDC 96295013764
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$11.07 |
| Rate for Payer: Aetna Commercial |
$9.96
|
| Rate for Payer: ASR ASR |
$10.74
|
| Rate for Payer: ASR Commercial |
$10.74
|
| Rate for Payer: BCBS Trust/PPO |
$9.02
|
| Rate for Payer: BCN Commercial |
$8.58
|
| Rate for Payer: Cash Price |
$8.86
|
| Rate for Payer: Cofinity Commercial |
$10.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.86
|
| Rate for Payer: Healthscope Commercial |
$11.07
|
| Rate for Payer: Healthscope Whirlpool |
$10.74
|
| Rate for Payer: Mclaren Commercial |
$9.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.41
|
| Rate for Payer: Nomi Health Commercial |
$9.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.74
|
|
|
PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS
|
Facility
|
OP
|
$9.52
|
|
|
Service Code
|
NDC 57896018105
|
| Hospital Charge Code |
41412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.81 |
| Max. Negotiated Rate |
$9.52 |
| Rate for Payer: Aetna Commercial |
$8.57
|
| Rate for Payer: Aetna Medicare |
$4.76
|
| Rate for Payer: ASR ASR |
$9.23
|
| Rate for Payer: ASR Commercial |
$9.23
|
| Rate for Payer: BCBS Complete |
$3.81
|
| Rate for Payer: BCBS Trust/PPO |
$7.80
|
| Rate for Payer: BCN Commercial |
$7.38
|
| Rate for Payer: Cash Price |
$7.61
|
| Rate for Payer: Cofinity Commercial |
$8.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.62
|
| Rate for Payer: Healthscope Commercial |
$9.52
|
| Rate for Payer: Healthscope Whirlpool |
$9.23
|
| Rate for Payer: Mclaren Commercial |
$8.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.09
|
| Rate for Payer: Nomi Health Commercial |
$7.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.34
|
| Rate for Payer: Priority Health Narrow Network |
$6.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.38
|
|
