|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$54.19
|
|
|
Service Code
|
NDC 41100080676
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.68 |
| Max. Negotiated Rate |
$54.19 |
| Rate for Payer: Aetna Commercial |
$48.77
|
| Rate for Payer: Aetna Medicare |
$27.10
|
| Rate for Payer: ASR ASR |
$52.56
|
| Rate for Payer: ASR Commercial |
$52.56
|
| Rate for Payer: BCBS Complete |
$21.68
|
| Rate for Payer: BCBS Trust/PPO |
$44.38
|
| Rate for Payer: BCN Commercial |
$42.01
|
| Rate for Payer: Cash Price |
$43.35
|
| Rate for Payer: Cofinity Commercial |
$50.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.35
|
| Rate for Payer: Healthscope Commercial |
$54.19
|
| Rate for Payer: Healthscope Whirlpool |
$52.56
|
| Rate for Payer: Mclaren Commercial |
$48.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.06
|
| Rate for Payer: Nomi Health Commercial |
$44.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$47.48
|
| Rate for Payer: Priority Health Narrow Network |
$37.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.69
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$520.80
|
|
|
Service Code
|
NDC 00904693181
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.32 |
| Max. Negotiated Rate |
$520.80 |
| Rate for Payer: Aetna Commercial |
$468.72
|
| Rate for Payer: Aetna Medicare |
$260.40
|
| Rate for Payer: ASR ASR |
$505.18
|
| Rate for Payer: ASR Commercial |
$505.18
|
| Rate for Payer: BCBS Complete |
$208.32
|
| Rate for Payer: BCBS Trust/PPO |
$426.48
|
| Rate for Payer: BCN Commercial |
$403.78
|
| Rate for Payer: Cash Price |
$416.64
|
| Rate for Payer: Cofinity Commercial |
$489.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$416.64
|
| Rate for Payer: Healthscope Commercial |
$520.80
|
| Rate for Payer: Healthscope Whirlpool |
$505.18
|
| Rate for Payer: Mclaren Commercial |
$468.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$442.68
|
| Rate for Payer: Nomi Health Commercial |
$427.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$338.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$456.32
|
| Rate for Payer: Priority Health Narrow Network |
$365.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$458.30
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$69.89
|
|
|
Service Code
|
NDC 68084043098
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$69.89 |
| Rate for Payer: Aetna Commercial |
$62.90
|
| Rate for Payer: ASR ASR |
$67.79
|
| Rate for Payer: ASR Commercial |
$67.79
|
| Rate for Payer: BCBS Trust/PPO |
$56.95
|
| Rate for Payer: BCN Commercial |
$54.19
|
| Rate for Payer: Cash Price |
$55.91
|
| Rate for Payer: Cofinity Commercial |
$65.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.91
|
| Rate for Payer: Healthscope Commercial |
$69.89
|
| Rate for Payer: Healthscope Whirlpool |
$67.79
|
| Rate for Payer: Mclaren Commercial |
$62.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.41
|
| Rate for Payer: Nomi Health Commercial |
$57.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.50
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$54.19
|
|
|
Service Code
|
NDC 41100080676
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.22 |
| Max. Negotiated Rate |
$54.19 |
| Rate for Payer: Aetna Commercial |
$48.77
|
| Rate for Payer: ASR ASR |
$52.56
|
| Rate for Payer: ASR Commercial |
$52.56
|
| Rate for Payer: BCBS Trust/PPO |
$44.16
|
| Rate for Payer: BCN Commercial |
$42.01
|
| Rate for Payer: Cash Price |
$43.35
|
| Rate for Payer: Cofinity Commercial |
$50.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.35
|
| Rate for Payer: Healthscope Commercial |
$54.19
|
| Rate for Payer: Healthscope Whirlpool |
$52.56
|
| Rate for Payer: Mclaren Commercial |
$48.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.06
|
| Rate for Payer: Nomi Health Commercial |
$44.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.69
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$103.22
|
|
|
Service Code
|
NDC 45802086866
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.29 |
| Max. Negotiated Rate |
$103.22 |
| Rate for Payer: Aetna Commercial |
$92.90
|
| Rate for Payer: Aetna Medicare |
$51.61
|
| Rate for Payer: ASR ASR |
$100.12
|
| Rate for Payer: ASR Commercial |
$100.12
|
| Rate for Payer: BCBS Complete |
$41.29
|
| Rate for Payer: BCBS Trust/PPO |
$84.53
|
| Rate for Payer: BCN Commercial |
$80.03
|
| Rate for Payer: Cash Price |
$82.58
|
| Rate for Payer: Cofinity Commercial |
$97.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.58
|
| Rate for Payer: Healthscope Commercial |
$103.22
|
| Rate for Payer: Healthscope Whirlpool |
$100.12
|
| Rate for Payer: Mclaren Commercial |
$92.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.74
|
| Rate for Payer: Nomi Health Commercial |
$84.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$90.44
|
| Rate for Payer: Priority Health Narrow Network |
$72.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$90.83
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$6.84
|
|
|
Service Code
|
NDC 51079030601
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: ASR ASR |
$6.63
|
| Rate for Payer: ASR Commercial |
$6.63
|
| Rate for Payer: BCBS Trust/PPO |
$5.57
|
| Rate for Payer: BCN Commercial |
$5.30
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Cofinity Commercial |
$6.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.47
|
| Rate for Payer: Healthscope Commercial |
$6.84
|
| Rate for Payer: Healthscope Whirlpool |
$6.63
|
| Rate for Payer: Mclaren Commercial |
$6.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Nomi Health Commercial |
$5.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.02
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$691.20
|
|
|
Service Code
|
NDC 17856031201
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$449.28 |
| Max. Negotiated Rate |
$691.20 |
| Rate for Payer: Aetna Commercial |
$622.08
|
| Rate for Payer: ASR ASR |
$670.46
|
| Rate for Payer: ASR Commercial |
$670.46
|
| Rate for Payer: BCBS Trust/PPO |
$563.26
|
| Rate for Payer: BCN Commercial |
$535.89
|
| Rate for Payer: Cash Price |
$552.96
|
| Rate for Payer: Cofinity Commercial |
$649.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$552.96
|
| Rate for Payer: Healthscope Commercial |
$691.20
|
| Rate for Payer: Healthscope Whirlpool |
$670.46
|
| Rate for Payer: Mclaren Commercial |
$622.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$587.52
|
| Rate for Payer: Nomi Health Commercial |
$566.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$449.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$608.26
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$6.70
|
|
|
Service Code
|
NDC 00904693186
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.03
|
| Rate for Payer: ASR ASR |
$6.50
|
| Rate for Payer: ASR Commercial |
$6.50
|
| Rate for Payer: BCBS Trust/PPO |
$5.46
|
| Rate for Payer: BCN Commercial |
$5.19
|
| Rate for Payer: Cash Price |
$5.36
|
| Rate for Payer: Cofinity Commercial |
$6.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.36
|
| Rate for Payer: Healthscope Commercial |
$6.70
|
| Rate for Payer: Healthscope Whirlpool |
$6.50
|
| Rate for Payer: Mclaren Commercial |
$6.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.70
|
| Rate for Payer: Nomi Health Commercial |
$5.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.90
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$7.37
|
|
|
Service Code
|
NDC 45802086800
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$7.37 |
| Rate for Payer: Aetna Commercial |
$6.63
|
| Rate for Payer: Aetna Medicare |
$3.68
|
| Rate for Payer: ASR ASR |
$7.15
|
| Rate for Payer: ASR Commercial |
$7.15
|
| Rate for Payer: BCBS Complete |
$2.95
|
| Rate for Payer: BCBS Trust/PPO |
$6.04
|
| Rate for Payer: BCN Commercial |
$5.71
|
| Rate for Payer: Cash Price |
$5.90
|
| Rate for Payer: Cofinity Commercial |
$6.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.90
|
| Rate for Payer: Healthscope Commercial |
$7.37
|
| Rate for Payer: Healthscope Whirlpool |
$7.15
|
| Rate for Payer: Mclaren Commercial |
$6.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.26
|
| Rate for Payer: Nomi Health Commercial |
$6.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.46
|
| Rate for Payer: Priority Health Narrow Network |
$5.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.49
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$691.20
|
|
|
Service Code
|
NDC 17856031201
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$276.48 |
| Max. Negotiated Rate |
$691.20 |
| Rate for Payer: Aetna Commercial |
$622.08
|
| Rate for Payer: Aetna Medicare |
$345.60
|
| Rate for Payer: ASR ASR |
$670.46
|
| Rate for Payer: ASR Commercial |
$670.46
|
| Rate for Payer: BCBS Complete |
$276.48
|
| Rate for Payer: BCBS Trust/PPO |
$566.02
|
| Rate for Payer: BCN Commercial |
$535.89
|
| Rate for Payer: Cash Price |
$552.96
|
| Rate for Payer: Cofinity Commercial |
$649.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$552.96
|
| Rate for Payer: Healthscope Commercial |
$691.20
|
| Rate for Payer: Healthscope Whirlpool |
$670.46
|
| Rate for Payer: Mclaren Commercial |
$622.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$587.52
|
| Rate for Payer: Nomi Health Commercial |
$566.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$449.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$605.63
|
| Rate for Payer: Priority Health Narrow Network |
$484.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$608.26
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$69.89
|
|
|
Service Code
|
NDC 68084043098
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$69.89 |
| Rate for Payer: Aetna Commercial |
$62.90
|
| Rate for Payer: Aetna Medicare |
$34.94
|
| Rate for Payer: ASR ASR |
$67.79
|
| Rate for Payer: ASR Commercial |
$67.79
|
| Rate for Payer: BCBS Complete |
$27.96
|
| Rate for Payer: BCBS Trust/PPO |
$57.23
|
| Rate for Payer: BCN Commercial |
$54.19
|
| Rate for Payer: Cash Price |
$55.91
|
| Rate for Payer: Cofinity Commercial |
$65.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.91
|
| Rate for Payer: Healthscope Commercial |
$69.89
|
| Rate for Payer: Healthscope Whirlpool |
$67.79
|
| Rate for Payer: Mclaren Commercial |
$62.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.41
|
| Rate for Payer: Nomi Health Commercial |
$57.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.24
|
| Rate for Payer: Priority Health Narrow Network |
$48.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.50
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$69.89
|
|
|
Service Code
|
NDC 68084043099
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.43 |
| Max. Negotiated Rate |
$69.89 |
| Rate for Payer: Aetna Commercial |
$62.90
|
| Rate for Payer: ASR ASR |
$67.79
|
| Rate for Payer: ASR Commercial |
$67.79
|
| Rate for Payer: BCBS Trust/PPO |
$56.95
|
| Rate for Payer: BCN Commercial |
$54.19
|
| Rate for Payer: Cash Price |
$55.91
|
| Rate for Payer: Cofinity Commercial |
$65.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.91
|
| Rate for Payer: Healthscope Commercial |
$69.89
|
| Rate for Payer: Healthscope Whirlpool |
$67.79
|
| Rate for Payer: Mclaren Commercial |
$62.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.41
|
| Rate for Payer: Nomi Health Commercial |
$57.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$61.50
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$7.37
|
|
|
Service Code
|
NDC 45802086800
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$7.37 |
| Rate for Payer: Aetna Commercial |
$6.63
|
| Rate for Payer: ASR ASR |
$7.15
|
| Rate for Payer: ASR Commercial |
$7.15
|
| Rate for Payer: BCBS Trust/PPO |
$6.01
|
| Rate for Payer: BCN Commercial |
$5.71
|
| Rate for Payer: Cash Price |
$5.90
|
| Rate for Payer: Cofinity Commercial |
$6.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.90
|
| Rate for Payer: Healthscope Commercial |
$7.37
|
| Rate for Payer: Healthscope Whirlpool |
$7.15
|
| Rate for Payer: Mclaren Commercial |
$6.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.26
|
| Rate for Payer: Nomi Health Commercial |
$6.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.49
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$6.70
|
|
|
Service Code
|
NDC 00904693186
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.03
|
| Rate for Payer: Aetna Medicare |
$3.35
|
| Rate for Payer: ASR ASR |
$6.50
|
| Rate for Payer: ASR Commercial |
$6.50
|
| Rate for Payer: BCBS Complete |
$2.68
|
| Rate for Payer: BCBS Trust/PPO |
$5.49
|
| Rate for Payer: BCN Commercial |
$5.19
|
| Rate for Payer: Cash Price |
$5.36
|
| Rate for Payer: Cofinity Commercial |
$6.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.36
|
| Rate for Payer: Healthscope Commercial |
$6.70
|
| Rate for Payer: Healthscope Whirlpool |
$6.50
|
| Rate for Payer: Mclaren Commercial |
$6.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.70
|
| Rate for Payer: Nomi Health Commercial |
$5.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.87
|
| Rate for Payer: Priority Health Narrow Network |
$4.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.90
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$103.22
|
|
|
Service Code
|
NDC 45802086866
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.09 |
| Max. Negotiated Rate |
$103.22 |
| Rate for Payer: Aetna Commercial |
$92.90
|
| Rate for Payer: ASR ASR |
$100.12
|
| Rate for Payer: ASR Commercial |
$100.12
|
| Rate for Payer: BCBS Trust/PPO |
$84.11
|
| Rate for Payer: BCN Commercial |
$80.03
|
| Rate for Payer: Cash Price |
$82.58
|
| Rate for Payer: Cofinity Commercial |
$97.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.58
|
| Rate for Payer: Healthscope Commercial |
$103.22
|
| Rate for Payer: Healthscope Whirlpool |
$100.12
|
| Rate for Payer: Mclaren Commercial |
$92.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.74
|
| Rate for Payer: Nomi Health Commercial |
$84.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$90.83
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$205.20
|
|
|
Service Code
|
NDC 51079030630
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.38 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna Commercial |
$184.68
|
| Rate for Payer: ASR ASR |
$199.04
|
| Rate for Payer: ASR Commercial |
$199.04
|
| Rate for Payer: BCBS Trust/PPO |
$167.22
|
| Rate for Payer: BCN Commercial |
$159.09
|
| Rate for Payer: Cash Price |
$164.16
|
| Rate for Payer: Cofinity Commercial |
$192.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.16
|
| Rate for Payer: Healthscope Commercial |
$205.20
|
| Rate for Payer: Healthscope Whirlpool |
$199.04
|
| Rate for Payer: Mclaren Commercial |
$184.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.42
|
| Rate for Payer: Nomi Health Commercial |
$168.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$180.58
|
|
|
POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$6.84
|
|
|
Service Code
|
NDC 51079030601
|
| Hospital Charge Code |
25424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: Aetna Medicare |
$3.42
|
| Rate for Payer: ASR ASR |
$6.63
|
| Rate for Payer: ASR Commercial |
$6.63
|
| Rate for Payer: BCBS Complete |
$2.74
|
| Rate for Payer: BCBS Trust/PPO |
$5.60
|
| Rate for Payer: BCN Commercial |
$5.30
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Cofinity Commercial |
$6.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.47
|
| Rate for Payer: Healthscope Commercial |
$6.84
|
| Rate for Payer: Healthscope Whirlpool |
$6.63
|
| Rate for Payer: Mclaren Commercial |
$6.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.81
|
| Rate for Payer: Nomi Health Commercial |
$5.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.99
|
| Rate for Payer: Priority Health Narrow Network |
$4.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.02
|
|
|
POTASSIUM CHLORIDE 10 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$15.17
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Aetna Commercial |
$13.65
|
| Rate for Payer: Aetna Medicare |
$7.58
|
| Rate for Payer: ASR ASR |
$14.71
|
| Rate for Payer: ASR Commercial |
$14.71
|
| Rate for Payer: BCBS Complete |
$6.07
|
| Rate for Payer: BCBS Trust/PPO |
$12.42
|
| Rate for Payer: BCN Commercial |
$11.76
|
| Rate for Payer: Cash Price |
$12.14
|
| Rate for Payer: Cash Price |
$12.14
|
| Rate for Payer: Cofinity Commercial |
$14.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$15.17
|
| Rate for Payer: Healthscope Whirlpool |
$14.71
|
| Rate for Payer: Mclaren Commercial |
$13.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.89
|
| Rate for Payer: Nomi Health Commercial |
$12.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.21
|
| Rate for Payer: Priority Health Narrow Network |
$0.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.35
|
|
|
POTASSIUM CHLORIDE 10 MEQ/50 ML IN STERILE WATER INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$15.17
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.86 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Aetna Commercial |
$13.65
|
| Rate for Payer: ASR ASR |
$14.71
|
| Rate for Payer: ASR Commercial |
$14.71
|
| Rate for Payer: BCBS Trust/PPO |
$12.36
|
| Rate for Payer: BCN Commercial |
$11.76
|
| Rate for Payer: Cash Price |
$12.14
|
| Rate for Payer: Cofinity Commercial |
$14.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$15.17
|
| Rate for Payer: Healthscope Whirlpool |
$14.71
|
| Rate for Payer: Mclaren Commercial |
$13.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.89
|
| Rate for Payer: Nomi Health Commercial |
$12.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.35
|
|
|
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$80.41
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.27 |
| Max. Negotiated Rate |
$80.41 |
| Rate for Payer: Aetna Commercial |
$72.37
|
| Rate for Payer: Aetna Commercial |
$67.47
|
| Rate for Payer: ASR ASR |
$78.00
|
| Rate for Payer: ASR ASR |
$72.72
|
| Rate for Payer: ASR Commercial |
$72.72
|
| Rate for Payer: ASR Commercial |
$78.00
|
| Rate for Payer: BCBS Trust/PPO |
$61.09
|
| Rate for Payer: BCBS Trust/PPO |
$65.53
|
| Rate for Payer: BCN Commercial |
$62.34
|
| Rate for Payer: BCN Commercial |
$58.12
|
| Rate for Payer: Cash Price |
$64.33
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cofinity Commercial |
$70.47
|
| Rate for Payer: Cofinity Commercial |
$75.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.33
|
| Rate for Payer: Healthscope Commercial |
$74.97
|
| Rate for Payer: Healthscope Commercial |
$80.41
|
| Rate for Payer: Healthscope Whirlpool |
$72.72
|
| Rate for Payer: Healthscope Whirlpool |
$78.00
|
| Rate for Payer: Mclaren Commercial |
$67.47
|
| Rate for Payer: Mclaren Commercial |
$72.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.35
|
| Rate for Payer: Nomi Health Commercial |
$61.48
|
| Rate for Payer: Nomi Health Commercial |
$65.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.76
|
|
|
POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$80.41
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
11076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$80.41 |
| Rate for Payer: Aetna Commercial |
$72.37
|
| Rate for Payer: Aetna Commercial |
$67.47
|
| Rate for Payer: Aetna Medicare |
$37.48
|
| Rate for Payer: Aetna Medicare |
$40.20
|
| Rate for Payer: ASR ASR |
$78.00
|
| Rate for Payer: ASR ASR |
$72.72
|
| Rate for Payer: ASR Commercial |
$72.72
|
| Rate for Payer: ASR Commercial |
$78.00
|
| Rate for Payer: BCBS Complete |
$32.16
|
| Rate for Payer: BCBS Complete |
$29.99
|
| Rate for Payer: BCBS Trust/PPO |
$65.85
|
| Rate for Payer: BCBS Trust/PPO |
$61.39
|
| Rate for Payer: BCN Commercial |
$58.12
|
| Rate for Payer: BCN Commercial |
$62.34
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cash Price |
$59.97
|
| Rate for Payer: Cash Price |
$64.33
|
| Rate for Payer: Cash Price |
$64.33
|
| Rate for Payer: Cofinity Commercial |
$70.47
|
| Rate for Payer: Cofinity Commercial |
$75.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.98
|
| Rate for Payer: Healthscope Commercial |
$80.41
|
| Rate for Payer: Healthscope Commercial |
$74.97
|
| Rate for Payer: Healthscope Whirlpool |
$78.00
|
| Rate for Payer: Healthscope Whirlpool |
$72.72
|
| Rate for Payer: Mclaren Commercial |
$67.47
|
| Rate for Payer: Mclaren Commercial |
$72.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: Nomi Health Commercial |
$65.94
|
| Rate for Payer: Nomi Health Commercial |
$61.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.21
|
| Rate for Payer: Priority Health Narrow Network |
$0.17
|
| Rate for Payer: Priority Health Narrow Network |
$0.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.76
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID
|
Facility
|
IP
|
$20.54
|
|
|
Service Code
|
NDC 66689004701
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$20.54 |
| Rate for Payer: Aetna Commercial |
$18.49
|
| Rate for Payer: ASR ASR |
$19.92
|
| Rate for Payer: ASR Commercial |
$19.92
|
| Rate for Payer: BCBS Trust/PPO |
$16.74
|
| Rate for Payer: BCN Commercial |
$15.92
|
| Rate for Payer: Cash Price |
$16.43
|
| Rate for Payer: Cofinity Commercial |
$19.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.43
|
| Rate for Payer: Healthscope Commercial |
$20.54
|
| Rate for Payer: Healthscope Whirlpool |
$19.92
|
| Rate for Payer: Mclaren Commercial |
$18.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.46
|
| Rate for Payer: Nomi Health Commercial |
$16.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.08
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID
|
Facility
|
OP
|
$24.14
|
|
|
Service Code
|
NDC 00904706187
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$24.14 |
| Rate for Payer: Aetna Commercial |
$21.73
|
| Rate for Payer: Aetna Medicare |
$12.07
|
| Rate for Payer: ASR ASR |
$23.42
|
| Rate for Payer: ASR Commercial |
$23.42
|
| Rate for Payer: BCBS Complete |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$19.77
|
| Rate for Payer: BCN Commercial |
$18.72
|
| Rate for Payer: Cash Price |
$19.31
|
| Rate for Payer: Cofinity Commercial |
$22.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.31
|
| Rate for Payer: Healthscope Commercial |
$24.14
|
| Rate for Payer: Healthscope Whirlpool |
$23.42
|
| Rate for Payer: Mclaren Commercial |
$21.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.52
|
| Rate for Payer: Nomi Health Commercial |
$19.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.15
|
| Rate for Payer: Priority Health Narrow Network |
$16.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.24
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID
|
Facility
|
IP
|
$20.54
|
|
|
Service Code
|
NDC 66689004730
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$20.54 |
| Rate for Payer: Aetna Commercial |
$18.49
|
| Rate for Payer: ASR ASR |
$19.92
|
| Rate for Payer: ASR Commercial |
$19.92
|
| Rate for Payer: BCBS Trust/PPO |
$16.74
|
| Rate for Payer: BCN Commercial |
$15.92
|
| Rate for Payer: Cash Price |
$16.43
|
| Rate for Payer: Cofinity Commercial |
$19.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.43
|
| Rate for Payer: Healthscope Commercial |
$20.54
|
| Rate for Payer: Healthscope Whirlpool |
$19.92
|
| Rate for Payer: Mclaren Commercial |
$18.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.46
|
| Rate for Payer: Nomi Health Commercial |
$16.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.08
|
|
|
POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID
|
Facility
|
IP
|
$16.04
|
|
|
Service Code
|
NDC 00121494800
|
| Hospital Charge Code |
6432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna Commercial |
$14.44
|
| Rate for Payer: ASR ASR |
$15.56
|
| Rate for Payer: ASR Commercial |
$15.56
|
| Rate for Payer: BCBS Trust/PPO |
$13.07
|
| Rate for Payer: BCN Commercial |
$12.44
|
| Rate for Payer: Cash Price |
$12.83
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.83
|
| Rate for Payer: Healthscope Commercial |
$16.04
|
| Rate for Payer: Healthscope Whirlpool |
$15.56
|
| Rate for Payer: Mclaren Commercial |
$14.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.63
|
| Rate for Payer: Nomi Health Commercial |
$13.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.12
|
|
