|
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 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
|
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
|
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
|
$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
|
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
|
$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
|
|
|
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
|
|
|
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION
|
Facility
|
OP
|
$43.46
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
31270
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.77 |
| Max. Negotiated Rate |
$43.46 |
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$43.46
|
| Rate for Payer: Priority Health Narrow Network |
$34.77
|
|
|
PERFLUTREN LIPID MICROSPHERES (DILUTED) INTRAVENOUS SUSP
|
Facility
|
OP
|
$43.46
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
180013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.77 |
| Max. Negotiated Rate |
$43.46 |
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$43.46
|
| Rate for Payer: Priority Health Narrow Network |
$34.77
|
|
|
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
|
$322.35
|
|
|
Service Code
|
NDC 45802026937
|
| 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
|
$83.16
|
|
|
Service Code
|
NDC 21922002107
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.26 |
| Max. Negotiated Rate |
$83.16 |
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: Aetna Medicare |
$41.58
|
| Rate for Payer: ASR ASR |
$80.67
|
| Rate for Payer: ASR Commercial |
$80.67
|
| Rate for Payer: BCBS Complete |
$33.26
|
| Rate for Payer: BCBS Trust/PPO |
$68.10
|
| 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: Priority Health HMO/PPO/Tiered Network |
$72.86
|
| Rate for Payer: Priority Health Narrow Network |
$58.30
|
| 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
|
|
|
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
|
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
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
IP
|
$326.80
|
|
|
Service Code
|
NDC 75826011510
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$212.42 |
| Max. Negotiated Rate |
$326.80 |
| Rate for Payer: Aetna Commercial |
$294.12
|
| Rate for Payer: ASR ASR |
$317.00
|
| Rate for Payer: ASR Commercial |
$317.00
|
| Rate for Payer: BCBS Trust/PPO |
$266.31
|
| Rate for Payer: BCN Commercial |
$253.37
|
| Rate for Payer: Cash Price |
$261.44
|
| Rate for Payer: Cofinity Commercial |
$307.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.44
|
| Rate for Payer: Healthscope Commercial |
$326.80
|
| Rate for Payer: Healthscope Whirlpool |
$317.00
|
| Rate for Payer: Mclaren Commercial |
$294.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.78
|
| Rate for Payer: Nomi Health Commercial |
$267.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$287.58
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
OP
|
$326.80
|
|
|
Service Code
|
NDC 75826011510
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.72 |
| Max. Negotiated Rate |
$326.80 |
| Rate for Payer: Aetna Commercial |
$294.12
|
| Rate for Payer: Aetna Medicare |
$163.40
|
| Rate for Payer: ASR ASR |
$317.00
|
| Rate for Payer: ASR Commercial |
$317.00
|
| Rate for Payer: BCBS Complete |
$130.72
|
| Rate for Payer: BCBS Trust/PPO |
$267.62
|
| Rate for Payer: BCN Commercial |
$253.37
|
| Rate for Payer: Cash Price |
$261.44
|
| Rate for Payer: Cofinity Commercial |
$307.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.44
|
| Rate for Payer: Healthscope Commercial |
$326.80
|
| Rate for Payer: Healthscope Whirlpool |
$317.00
|
| Rate for Payer: Mclaren Commercial |
$294.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.78
|
| Rate for Payer: Nomi Health Commercial |
$267.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$286.34
|
| Rate for Payer: Priority Health Narrow Network |
$229.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$287.58
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
IP
|
$353.40
|
|
|
Service Code
|
NDC 65162068210
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$229.71 |
| Max. Negotiated Rate |
$353.40 |
| Rate for Payer: Aetna Commercial |
$318.06
|
| Rate for Payer: ASR ASR |
$342.80
|
| Rate for Payer: ASR Commercial |
$342.80
|
| Rate for Payer: BCBS Trust/PPO |
$287.99
|
| Rate for Payer: BCN Commercial |
$273.99
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Commercial |
$332.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$353.40
|
| Rate for Payer: Healthscope Whirlpool |
$342.80
|
| Rate for Payer: Mclaren Commercial |
$318.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.39
|
| Rate for Payer: Nomi Health Commercial |
$289.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$310.99
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
OP
|
$318.25
|
|
|
Service Code
|
NDC 42192080201
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.30 |
| Max. Negotiated Rate |
$318.25 |
| Rate for Payer: Aetna Commercial |
$286.42
|
| Rate for Payer: Aetna Medicare |
$159.12
|
| Rate for Payer: ASR ASR |
$308.70
|
| Rate for Payer: ASR Commercial |
$308.70
|
| Rate for Payer: BCBS Complete |
$127.30
|
| Rate for Payer: BCBS Trust/PPO |
$260.61
|
| Rate for Payer: BCN Commercial |
$246.74
|
| Rate for Payer: Cash Price |
$254.60
|
| Rate for Payer: Cofinity Commercial |
$299.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.60
|
| Rate for Payer: Healthscope Commercial |
$318.25
|
| Rate for Payer: Healthscope Whirlpool |
$308.70
|
| Rate for Payer: Mclaren Commercial |
$286.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.51
|
| Rate for Payer: Nomi Health Commercial |
$260.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$278.85
|
| Rate for Payer: Priority Health Narrow Network |
$223.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$280.06
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
IP
|
$318.25
|
|
|
Service Code
|
NDC 42192080201
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.86 |
| Max. Negotiated Rate |
$318.25 |
| Rate for Payer: Aetna Commercial |
$286.42
|
| Rate for Payer: ASR ASR |
$308.70
|
| Rate for Payer: ASR Commercial |
$308.70
|
| Rate for Payer: BCBS Trust/PPO |
$259.34
|
| Rate for Payer: BCN Commercial |
$246.74
|
| Rate for Payer: Cash Price |
$254.60
|
| Rate for Payer: Cofinity Commercial |
$299.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.60
|
| Rate for Payer: Healthscope Commercial |
$318.25
|
| Rate for Payer: Healthscope Whirlpool |
$308.70
|
| Rate for Payer: Mclaren Commercial |
$286.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.51
|
| Rate for Payer: Nomi Health Commercial |
$260.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$280.06
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
OP
|
$353.40
|
|
|
Service Code
|
NDC 65162068210
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.36 |
| Max. Negotiated Rate |
$353.40 |
| Rate for Payer: Aetna Commercial |
$318.06
|
| Rate for Payer: Aetna Medicare |
$176.70
|
| Rate for Payer: ASR ASR |
$342.80
|
| Rate for Payer: ASR Commercial |
$342.80
|
| Rate for Payer: BCBS Complete |
$141.36
|
| Rate for Payer: BCBS Trust/PPO |
$289.40
|
| Rate for Payer: BCN Commercial |
$273.99
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Commercial |
$332.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$353.40
|
| Rate for Payer: Healthscope Whirlpool |
$342.80
|
| Rate for Payer: Mclaren Commercial |
$318.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.39
|
| Rate for Payer: Nomi Health Commercial |
$289.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$309.65
|
| Rate for Payer: Priority Health Narrow Network |
$247.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$310.99
|
|
