|
PEPTAMEN AF CONTINUOUS FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
168955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CONTINUOUS FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
168955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CONTINUOUS FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
168955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CYCLIC FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
200079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CYCLIC FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
200079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CYCLIC FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
200079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF CYCLIC FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
200079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF INTERMITTENT FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
200078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF INTERMITTENT FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
200078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF INTERMITTENT FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 98716066370
|
| Hospital Charge Code |
200078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN AF INTERMITTENT FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 98716066360
|
| Hospital Charge Code |
200078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
PEPTAMEN INTENSE VHP BOLUS FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 43900043271
|
| Hospital Charge Code |
300293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.81
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
PEPTAMEN INTENSE VHP BOLUS FEED
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 43900043271
|
| Hospital Charge Code |
300293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.77
|
| Rate for Payer: Priority Health Narrow Network |
$11.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
PEPTAMEN INTENSE VHP CONTINUOUS FEED
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 43900073049
|
| Hospital Charge Code |
181406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.77
|
| Rate for Payer: Priority Health Narrow Network |
$11.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
PEPTAMEN INTENSE VHP CONTINUOUS FEED
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 43900043271
|
| Hospital Charge Code |
181406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.77
|
| Rate for Payer: Priority Health Narrow Network |
$11.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
PEPTAMEN INTENSE VHP CONTINUOUS FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 43900043271
|
| Hospital Charge Code |
181406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.81
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
PEPTAMEN INTENSE VHP CONTINUOUS FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 43900073049
|
| Hospital Charge Code |
181406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.81
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
PEPTAMEN INTENSE VHP CYCLIC FEED
|
Facility
|
IP
|
$70.30
|
|
|
Service Code
|
NDC 43900072395
|
| Hospital Charge Code |
300422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.70 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Aetna Commercial |
$63.27
|
| Rate for Payer: ASR ASR |
$68.19
|
| Rate for Payer: ASR Commercial |
$68.19
|
| Rate for Payer: BCBS Trust/PPO |
$57.29
|
| Rate for Payer: BCN Commercial |
$54.50
|
| Rate for Payer: Cash Price |
$56.24
|
| Rate for Payer: Cofinity Commercial |
$66.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.24
|
| Rate for Payer: Healthscope Commercial |
$70.30
|
| Rate for Payer: Healthscope Whirlpool |
$68.19
|
| Rate for Payer: Mclaren Commercial |
$63.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.76
|
| Rate for Payer: Nomi Health Commercial |
$57.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.86
|
|
|
PEPTAMEN INTENSE VHP CYCLIC FEED
|
Facility
|
OP
|
$70.30
|
|
|
Service Code
|
NDC 43900072395
|
| Hospital Charge Code |
300422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.12 |
| Max. Negotiated Rate |
$70.30 |
| Rate for Payer: Aetna Commercial |
$63.27
|
| Rate for Payer: Aetna Medicare |
$35.15
|
| Rate for Payer: ASR ASR |
$68.19
|
| Rate for Payer: ASR Commercial |
$68.19
|
| Rate for Payer: BCBS Complete |
$28.12
|
| Rate for Payer: BCBS Trust/PPO |
$57.57
|
| Rate for Payer: BCN Commercial |
$54.50
|
| Rate for Payer: Cash Price |
$56.24
|
| Rate for Payer: Cofinity Commercial |
$66.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.24
|
| Rate for Payer: Healthscope Commercial |
$70.30
|
| Rate for Payer: Healthscope Whirlpool |
$68.19
|
| Rate for Payer: Mclaren Commercial |
$63.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.76
|
| Rate for Payer: Nomi Health Commercial |
$57.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.60
|
| Rate for Payer: Priority Health Narrow Network |
$49.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.86
|
|
|
PEPTAMEN INTENSE VHP CYCLIC FEED
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 43900073049
|
| Hospital Charge Code |
300422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Trust/PPO |
$12.81
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
PEPTAMEN INTENSE VHP CYCLIC FEED
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 43900073049
|
| Hospital Charge Code |
300422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Medicare |
$7.86
|
| Rate for Payer: ASR ASR |
$15.25
|
| Rate for Payer: ASR Commercial |
$15.25
|
| Rate for Payer: BCBS Complete |
$6.29
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| Rate for Payer: BCN Commercial |
$12.19
|
| Rate for Payer: Cash Price |
$12.58
|
| Rate for Payer: Cofinity Commercial |
$14.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Whirlpool |
$15.25
|
| Rate for Payer: Mclaren Commercial |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.36
|
| Rate for Payer: Nomi Health Commercial |
$12.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.77
|
| Rate for Payer: Priority Health Narrow Network |
$11.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.83
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
IP
|
$322.35
|
|
|
Service Code
|
NDC 00472024260
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$209.53 |
| Max. Negotiated Rate |
$322.35 |
| Rate for Payer: Aetna Commercial |
$290.12
|
| Rate for Payer: ASR ASR |
$312.68
|
| Rate for Payer: ASR Commercial |
$312.68
|
| Rate for Payer: BCBS Trust/PPO |
$262.68
|
| Rate for Payer: BCN Commercial |
$249.92
|
| Rate for Payer: Cash Price |
$257.88
|
| Rate for Payer: Cofinity Commercial |
$303.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.88
|
| Rate for Payer: Healthscope Commercial |
$322.35
|
| Rate for Payer: Healthscope Whirlpool |
$312.68
|
| Rate for Payer: Mclaren Commercial |
$290.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.00
|
| Rate for Payer: Nomi Health Commercial |
$264.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.67
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
OP
|
$322.35
|
|
|
Service Code
|
NDC 00472024260
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.94 |
| Max. Negotiated Rate |
$322.35 |
| Rate for Payer: Aetna Commercial |
$290.12
|
| Rate for Payer: Aetna Medicare |
$161.18
|
| Rate for Payer: ASR ASR |
$312.68
|
| Rate for Payer: ASR Commercial |
$312.68
|
| Rate for Payer: BCBS Complete |
$128.94
|
| Rate for Payer: BCBS Trust/PPO |
$263.97
|
| Rate for Payer: BCN Commercial |
$249.92
|
| Rate for Payer: Cash Price |
$257.88
|
| Rate for Payer: Cofinity Commercial |
$303.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.88
|
| Rate for Payer: Healthscope Commercial |
$322.35
|
| Rate for Payer: Healthscope Whirlpool |
$312.68
|
| Rate for Payer: Mclaren Commercial |
$290.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.00
|
| Rate for Payer: Nomi Health Commercial |
$264.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$282.44
|
| Rate for Payer: Priority Health Narrow Network |
$225.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.67
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
IP
|
$83.16
|
|
|
Service Code
|
NDC 21922002107
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.05 |
| Max. Negotiated Rate |
$83.16 |
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: ASR ASR |
$80.67
|
| Rate for Payer: ASR Commercial |
$80.67
|
| Rate for Payer: BCBS Trust/PPO |
$67.77
|
| Rate for Payer: BCN Commercial |
$64.47
|
| Rate for Payer: Cash Price |
$66.53
|
| Rate for Payer: Cofinity Commercial |
$78.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.53
|
| Rate for Payer: Healthscope Commercial |
$83.16
|
| Rate for Payer: Healthscope Whirlpool |
$80.67
|
| Rate for Payer: Mclaren Commercial |
$74.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.69
|
| Rate for Payer: Nomi Health Commercial |
$68.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$73.18
|
|
|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
OP
|
$322.35
|
|
|
Service Code
|
NDC 45802026937
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.94 |
| Max. Negotiated Rate |
$322.35 |
| Rate for Payer: Aetna Commercial |
$290.12
|
| Rate for Payer: Aetna Medicare |
$161.18
|
| Rate for Payer: ASR ASR |
$312.68
|
| Rate for Payer: ASR Commercial |
$312.68
|
| Rate for Payer: BCBS Complete |
$128.94
|
| Rate for Payer: BCBS Trust/PPO |
$263.97
|
| Rate for Payer: BCN Commercial |
$249.92
|
| Rate for Payer: Cash Price |
$257.88
|
| Rate for Payer: Cofinity Commercial |
$303.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.88
|
| Rate for Payer: Healthscope Commercial |
$322.35
|
| Rate for Payer: Healthscope Whirlpool |
$312.68
|
| Rate for Payer: Mclaren Commercial |
$290.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.00
|
| Rate for Payer: Nomi Health Commercial |
$264.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$282.44
|
| Rate for Payer: Priority Health Narrow Network |
$225.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$283.67
|
|
