|
BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION
|
Facility
|
OP
|
$5.38
|
|
|
Service Code
|
NDC 32909076401
|
| Hospital Charge Code |
19436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$5.38 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Aetna Medicare |
$2.69
|
| Rate for Payer: ASR ASR |
$5.22
|
| Rate for Payer: ASR Commercial |
$5.22
|
| Rate for Payer: BCBS Complete |
$2.15
|
| Rate for Payer: BCBS Trust/PPO |
$4.41
|
| Rate for Payer: BCN Commercial |
$4.17
|
| Rate for Payer: Cash Price |
$4.30
|
| Rate for Payer: Cofinity Commercial |
$5.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.30
|
| Rate for Payer: Healthscope Commercial |
$5.38
|
| Rate for Payer: Healthscope Whirlpool |
$5.22
|
| Rate for Payer: Mclaren Commercial |
$4.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.57
|
| Rate for Payer: Nomi Health Commercial |
$4.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.71
|
| Rate for Payer: Priority Health Narrow Network |
$3.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.73
|
|
|
BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION
|
Facility
|
IP
|
$5.38
|
|
|
Service Code
|
NDC 32909076401
|
| Hospital Charge Code |
19436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.38 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: ASR ASR |
$5.22
|
| Rate for Payer: ASR Commercial |
$5.22
|
| Rate for Payer: BCBS Trust/PPO |
$4.38
|
| Rate for Payer: BCN Commercial |
$4.17
|
| Rate for Payer: Cash Price |
$4.30
|
| Rate for Payer: Cofinity Commercial |
$5.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.30
|
| Rate for Payer: Healthscope Commercial |
$5.38
|
| Rate for Payer: Healthscope Whirlpool |
$5.22
|
| Rate for Payer: Mclaren Commercial |
$4.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.57
|
| Rate for Payer: Nomi Health Commercial |
$4.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.73
|
|
|
BENAZEPRIL 5 MG TABLET
|
Facility
|
OP
|
$4.63
|
|
|
Service Code
|
NDC 50268010911
|
| Hospital Charge Code |
9223
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$4.17
|
| Rate for Payer: Aetna Medicare |
$2.32
|
| Rate for Payer: ASR ASR |
$4.49
|
| Rate for Payer: ASR Commercial |
$4.49
|
| Rate for Payer: BCBS Complete |
$1.85
|
| Rate for Payer: BCBS Trust/PPO |
$3.79
|
| Rate for Payer: BCN Commercial |
$3.59
|
| Rate for Payer: Cash Price |
$3.70
|
| Rate for Payer: Cofinity Commercial |
$4.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.70
|
| Rate for Payer: Healthscope Commercial |
$4.63
|
| Rate for Payer: Healthscope Whirlpool |
$4.49
|
| Rate for Payer: Mclaren Commercial |
$4.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.94
|
| Rate for Payer: Nomi Health Commercial |
$3.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.06
|
| Rate for Payer: Priority Health Narrow Network |
$3.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.07
|
|
|
BENAZEPRIL 5 MG TABLET
|
Facility
|
OP
|
$152.75
|
|
|
Service Code
|
NDC 65162075110
|
| Hospital Charge Code |
9223
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.10 |
| Max. Negotiated Rate |
$152.75 |
| Rate for Payer: Aetna Commercial |
$137.48
|
| Rate for Payer: Aetna Medicare |
$76.38
|
| Rate for Payer: ASR ASR |
$148.17
|
| Rate for Payer: ASR Commercial |
$148.17
|
| Rate for Payer: BCBS Complete |
$61.10
|
| Rate for Payer: BCBS Trust/PPO |
$125.09
|
| Rate for Payer: BCN Commercial |
$118.43
|
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Cofinity Commercial |
$143.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.20
|
| Rate for Payer: Healthscope Commercial |
$152.75
|
| Rate for Payer: Healthscope Whirlpool |
$148.17
|
| Rate for Payer: Mclaren Commercial |
$137.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.84
|
| Rate for Payer: Nomi Health Commercial |
$125.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$133.84
|
| Rate for Payer: Priority Health Narrow Network |
$107.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.42
|
|
|
BENAZEPRIL 5 MG TABLET
|
Facility
|
IP
|
$231.32
|
|
|
Service Code
|
NDC 50268010915
|
| Hospital Charge Code |
9223
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.36 |
| Max. Negotiated Rate |
$231.32 |
| Rate for Payer: Aetna Commercial |
$208.19
|
| Rate for Payer: ASR ASR |
$224.38
|
| Rate for Payer: ASR Commercial |
$224.38
|
| Rate for Payer: BCBS Trust/PPO |
$188.50
|
| Rate for Payer: BCN Commercial |
$179.34
|
| Rate for Payer: Cash Price |
$185.06
|
| Rate for Payer: Cofinity Commercial |
$217.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.06
|
| Rate for Payer: Healthscope Commercial |
$231.32
|
| Rate for Payer: Healthscope Whirlpool |
$224.38
|
| Rate for Payer: Mclaren Commercial |
$208.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.62
|
| Rate for Payer: Nomi Health Commercial |
$189.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$203.56
|
|
|
BENAZEPRIL 5 MG TABLET
|
Facility
|
OP
|
$231.32
|
|
|
Service Code
|
NDC 50268010915
|
| Hospital Charge Code |
9223
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.53 |
| Max. Negotiated Rate |
$231.32 |
| Rate for Payer: Aetna Commercial |
$208.19
|
| Rate for Payer: Aetna Medicare |
$115.66
|
| Rate for Payer: ASR ASR |
$224.38
|
| Rate for Payer: ASR Commercial |
$224.38
|
| Rate for Payer: BCBS Complete |
$92.53
|
| Rate for Payer: BCBS Trust/PPO |
$189.43
|
| Rate for Payer: BCN Commercial |
$179.34
|
| Rate for Payer: Cash Price |
$185.06
|
| Rate for Payer: Cofinity Commercial |
$217.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.06
|
| Rate for Payer: Healthscope Commercial |
$231.32
|
| Rate for Payer: Healthscope Whirlpool |
$224.38
|
| Rate for Payer: Mclaren Commercial |
$208.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.62
|
| Rate for Payer: Nomi Health Commercial |
$189.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$202.68
|
| Rate for Payer: Priority Health Narrow Network |
$162.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$203.56
|
|
|
BENAZEPRIL 5 MG TABLET
|
Facility
|
IP
|
$4.63
|
|
|
Service Code
|
NDC 50268010911
|
| Hospital Charge Code |
9223
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$4.17
|
| Rate for Payer: ASR ASR |
$4.49
|
| Rate for Payer: ASR Commercial |
$4.49
|
| Rate for Payer: BCBS Trust/PPO |
$3.77
|
| Rate for Payer: BCN Commercial |
$3.59
|
| Rate for Payer: Cash Price |
$3.70
|
| Rate for Payer: Cofinity Commercial |
$4.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.70
|
| Rate for Payer: Healthscope Commercial |
$4.63
|
| Rate for Payer: Healthscope Whirlpool |
$4.49
|
| Rate for Payer: Mclaren Commercial |
$4.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.94
|
| Rate for Payer: Nomi Health Commercial |
$3.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.07
|
|
|
BENAZEPRIL 5 MG TABLET
|
Facility
|
IP
|
$152.75
|
|
|
Service Code
|
NDC 65162075110
|
| Hospital Charge Code |
9223
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.29 |
| Max. Negotiated Rate |
$152.75 |
| Rate for Payer: Aetna Commercial |
$137.48
|
| Rate for Payer: ASR ASR |
$148.17
|
| Rate for Payer: ASR Commercial |
$148.17
|
| Rate for Payer: BCBS Trust/PPO |
$124.48
|
| Rate for Payer: BCN Commercial |
$118.43
|
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Cofinity Commercial |
$143.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.20
|
| Rate for Payer: Healthscope Commercial |
$152.75
|
| Rate for Payer: Healthscope Whirlpool |
$148.17
|
| Rate for Payer: Mclaren Commercial |
$137.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.84
|
| Rate for Payer: Nomi Health Commercial |
$125.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$134.42
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS AUTO-INJECTOR
|
Facility
|
IP
|
$21,634.08
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
191757
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,062.15 |
| Max. Negotiated Rate |
$21,634.08 |
| Rate for Payer: Aetna Commercial |
$19,470.67
|
| Rate for Payer: ASR ASR |
$20,985.06
|
| Rate for Payer: ASR Commercial |
$20,985.06
|
| Rate for Payer: BCBS Trust/PPO |
$17,629.61
|
| Rate for Payer: BCN Commercial |
$16,772.90
|
| Rate for Payer: Cash Price |
$17,307.27
|
| Rate for Payer: Cofinity Commercial |
$20,336.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17,307.26
|
| Rate for Payer: Healthscope Commercial |
$21,634.08
|
| Rate for Payer: Healthscope Whirlpool |
$20,985.06
|
| Rate for Payer: Mclaren Commercial |
$19,470.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18,388.97
|
| Rate for Payer: Nomi Health Commercial |
$17,739.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14,062.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19,037.99
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS AUTO-INJECTOR
|
Facility
|
OP
|
$21,634.08
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
191757
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.92 |
| Max. Negotiated Rate |
$21,634.08 |
| Rate for Payer: Aetna Commercial |
$19,470.67
|
| Rate for Payer: Aetna Medicare |
$165.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$207.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$207.36
|
| Rate for Payer: ASR ASR |
$20,985.06
|
| Rate for Payer: ASR Commercial |
$20,985.06
|
| Rate for Payer: BCBS Complete |
$93.36
|
| Rate for Payer: BCBS MAPPO |
$165.89
|
| Rate for Payer: BCBS Trust/PPO |
$17,716.15
|
| Rate for Payer: BCN Commercial |
$16,772.90
|
| Rate for Payer: BCN Medicare Advantage |
$165.89
|
| Rate for Payer: Cash Price |
$17,307.27
|
| Rate for Payer: Cash Price |
$17,307.27
|
| Rate for Payer: Cofinity Commercial |
$20,336.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17,307.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$165.89
|
| Rate for Payer: Healthscope Commercial |
$21,634.08
|
| Rate for Payer: Healthscope Whirlpool |
$20,985.06
|
| Rate for Payer: Humana Choice PPO Medicare |
$165.89
|
| Rate for Payer: Mclaren Commercial |
$19,470.67
|
| Rate for Payer: Mclaren Medicaid |
$88.92
|
| Rate for Payer: Mclaren Medicare |
$165.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$174.18
|
| Rate for Payer: Meridian Medicaid |
$93.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18,388.97
|
| Rate for Payer: Nomi Health Commercial |
$17,739.95
|
| Rate for Payer: PACE Medicare |
$157.60
|
| Rate for Payer: PACE SWMI |
$165.89
|
| Rate for Payer: PHP Commercial |
$182.48
|
| Rate for Payer: PHP Medicaid |
$88.92
|
| Rate for Payer: PHP Medicare Advantage |
$165.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$88.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14,062.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$169.46
|
| Rate for Payer: Priority Health Medicare |
$165.89
|
| Rate for Payer: Priority Health Narrow Network |
$135.57
|
| Rate for Payer: Railroad Medicare Medicare |
$165.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19,037.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$165.89
|
| Rate for Payer: UHC Exchange |
$257.13
|
| Rate for Payer: UHC Medicare Advantage |
$165.89
|
| Rate for Payer: UHCCP DNSP |
$165.89
|
| Rate for Payer: UHCCP Medicaid |
$88.92
|
| Rate for Payer: VA VA |
$165.89
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$19,146.17
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
185161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,445.01 |
| Max. Negotiated Rate |
$19,146.17 |
| Rate for Payer: Aetna Commercial |
$17,231.55
|
| Rate for Payer: ASR ASR |
$18,571.78
|
| Rate for Payer: ASR Commercial |
$18,571.78
|
| Rate for Payer: BCBS Trust/PPO |
$15,602.21
|
| Rate for Payer: BCN Commercial |
$14,844.03
|
| Rate for Payer: Cash Price |
$15,316.93
|
| Rate for Payer: Cofinity Commercial |
$17,997.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,316.94
|
| Rate for Payer: Healthscope Commercial |
$19,146.17
|
| Rate for Payer: Healthscope Whirlpool |
$18,571.78
|
| Rate for Payer: Mclaren Commercial |
$17,231.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,274.24
|
| Rate for Payer: Nomi Health Commercial |
$15,699.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,445.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16,848.63
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$19,146.17
|
|
|
Service Code
|
HCPCS J0517
|
| Hospital Charge Code |
185161
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.92 |
| Max. Negotiated Rate |
$19,146.17 |
| Rate for Payer: Aetna Commercial |
$17,231.55
|
| Rate for Payer: Aetna Medicare |
$165.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$207.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$207.36
|
| Rate for Payer: ASR ASR |
$18,571.78
|
| Rate for Payer: ASR Commercial |
$18,571.78
|
| Rate for Payer: BCBS Complete |
$93.36
|
| Rate for Payer: BCBS MAPPO |
$165.89
|
| Rate for Payer: BCBS Trust/PPO |
$15,678.80
|
| Rate for Payer: BCN Commercial |
$14,844.03
|
| Rate for Payer: BCN Medicare Advantage |
$165.89
|
| Rate for Payer: Cash Price |
$15,316.93
|
| Rate for Payer: Cash Price |
$15,316.93
|
| Rate for Payer: Cofinity Commercial |
$17,997.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,316.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$165.89
|
| Rate for Payer: Healthscope Commercial |
$19,146.17
|
| Rate for Payer: Healthscope Whirlpool |
$18,571.78
|
| Rate for Payer: Humana Choice PPO Medicare |
$165.89
|
| Rate for Payer: Mclaren Commercial |
$17,231.55
|
| Rate for Payer: Mclaren Medicaid |
$88.92
|
| Rate for Payer: Mclaren Medicare |
$165.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$174.18
|
| Rate for Payer: Meridian Medicaid |
$93.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,274.24
|
| Rate for Payer: Nomi Health Commercial |
$15,699.86
|
| Rate for Payer: PACE Medicare |
$157.60
|
| Rate for Payer: PACE SWMI |
$165.89
|
| Rate for Payer: PHP Commercial |
$182.48
|
| Rate for Payer: PHP Medicaid |
$88.92
|
| Rate for Payer: PHP Medicare Advantage |
$165.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$88.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,445.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$169.46
|
| Rate for Payer: Priority Health Medicare |
$165.89
|
| Rate for Payer: Priority Health Narrow Network |
$135.57
|
| Rate for Payer: Railroad Medicare Medicare |
$165.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16,848.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$165.89
|
| Rate for Payer: UHC Exchange |
$257.13
|
| Rate for Payer: UHC Medicare Advantage |
$165.89
|
| Rate for Payer: UHCCP DNSP |
$165.89
|
| Rate for Payer: UHCCP Medicaid |
$88.92
|
| Rate for Payer: VA VA |
$165.89
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES
|
Facility
|
OP
|
$43.99
|
|
|
Service Code
|
NDC 63824071316
|
| Hospital Charge Code |
153363
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$43.99 |
| Rate for Payer: Aetna Commercial |
$39.59
|
| Rate for Payer: Aetna Medicare |
$22.00
|
| Rate for Payer: ASR ASR |
$42.67
|
| Rate for Payer: ASR Commercial |
$42.67
|
| Rate for Payer: BCBS Complete |
$17.60
|
| Rate for Payer: BCBS Trust/PPO |
$36.02
|
| Rate for Payer: BCN Commercial |
$34.11
|
| Rate for Payer: Cash Price |
$35.19
|
| Rate for Payer: Cofinity Commercial |
$41.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.19
|
| Rate for Payer: Healthscope Commercial |
$43.99
|
| Rate for Payer: Healthscope Whirlpool |
$42.67
|
| Rate for Payer: Mclaren Commercial |
$39.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.39
|
| Rate for Payer: Nomi Health Commercial |
$36.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38.54
|
| Rate for Payer: Priority Health Narrow Network |
$30.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$38.71
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES
|
Facility
|
IP
|
$62.60
|
|
|
Service Code
|
NDC 00904625549
|
| Hospital Charge Code |
153363
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.69 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna Commercial |
$56.34
|
| Rate for Payer: ASR ASR |
$60.72
|
| Rate for Payer: ASR Commercial |
$60.72
|
| Rate for Payer: BCBS Trust/PPO |
$51.01
|
| Rate for Payer: BCN Commercial |
$48.53
|
| Rate for Payer: Cash Price |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$58.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.08
|
| Rate for Payer: Healthscope Commercial |
$62.60
|
| Rate for Payer: Healthscope Whirlpool |
$60.72
|
| Rate for Payer: Mclaren Commercial |
$56.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.21
|
| Rate for Payer: Nomi Health Commercial |
$51.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$55.09
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES
|
Facility
|
OP
|
$62.60
|
|
|
Service Code
|
NDC 00904625549
|
| Hospital Charge Code |
153363
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna Commercial |
$56.34
|
| Rate for Payer: Aetna Medicare |
$31.30
|
| Rate for Payer: ASR ASR |
$60.72
|
| Rate for Payer: ASR Commercial |
$60.72
|
| Rate for Payer: BCBS Complete |
$25.04
|
| Rate for Payer: BCBS Trust/PPO |
$51.26
|
| Rate for Payer: BCN Commercial |
$48.53
|
| Rate for Payer: Cash Price |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$58.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.08
|
| Rate for Payer: Healthscope Commercial |
$62.60
|
| Rate for Payer: Healthscope Whirlpool |
$60.72
|
| Rate for Payer: Mclaren Commercial |
$56.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.21
|
| Rate for Payer: Nomi Health Commercial |
$51.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$54.85
|
| Rate for Payer: Priority Health Narrow Network |
$43.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$55.09
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES
|
Facility
|
IP
|
$43.99
|
|
|
Service Code
|
NDC 63824071316
|
| Hospital Charge Code |
153363
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.59 |
| Max. Negotiated Rate |
$43.99 |
| Rate for Payer: Aetna Commercial |
$39.59
|
| Rate for Payer: ASR ASR |
$42.67
|
| Rate for Payer: ASR Commercial |
$42.67
|
| Rate for Payer: BCBS Trust/PPO |
$35.85
|
| Rate for Payer: BCN Commercial |
$34.11
|
| Rate for Payer: Cash Price |
$35.19
|
| Rate for Payer: Cofinity Commercial |
$41.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.19
|
| Rate for Payer: Healthscope Commercial |
$43.99
|
| Rate for Payer: Healthscope Whirlpool |
$42.67
|
| Rate for Payer: Mclaren Commercial |
$39.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.39
|
| Rate for Payer: Nomi Health Commercial |
$36.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$38.71
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
OP
|
$34.85
|
|
|
Service Code
|
NDC 00283061026
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.94 |
| Max. Negotiated Rate |
$34.85 |
| Rate for Payer: Aetna Commercial |
$31.36
|
| Rate for Payer: Aetna Medicare |
$17.42
|
| Rate for Payer: ASR ASR |
$33.80
|
| Rate for Payer: ASR Commercial |
$33.80
|
| Rate for Payer: BCBS Complete |
$13.94
|
| Rate for Payer: BCBS Trust/PPO |
$28.54
|
| Rate for Payer: BCN Commercial |
$27.02
|
| Rate for Payer: Cash Price |
$27.88
|
| Rate for Payer: Cofinity Commercial |
$32.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.88
|
| Rate for Payer: Healthscope Commercial |
$34.85
|
| Rate for Payer: Healthscope Whirlpool |
$33.80
|
| Rate for Payer: Mclaren Commercial |
$31.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.62
|
| Rate for Payer: Nomi Health Commercial |
$28.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$30.54
|
| Rate for Payer: Priority Health Narrow Network |
$24.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.67
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
OP
|
$37.17
|
|
|
Service Code
|
NDC 00283061043
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.87 |
| Max. Negotiated Rate |
$37.17 |
| Rate for Payer: Aetna Commercial |
$33.45
|
| Rate for Payer: Aetna Medicare |
$18.58
|
| Rate for Payer: ASR ASR |
$36.05
|
| Rate for Payer: ASR Commercial |
$36.05
|
| Rate for Payer: BCBS Complete |
$14.87
|
| Rate for Payer: BCBS Trust/PPO |
$30.44
|
| Rate for Payer: BCN Commercial |
$28.82
|
| Rate for Payer: Cash Price |
$29.73
|
| Rate for Payer: Cofinity Commercial |
$34.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.74
|
| Rate for Payer: Healthscope Commercial |
$37.17
|
| Rate for Payer: Healthscope Whirlpool |
$36.05
|
| Rate for Payer: Mclaren Commercial |
$33.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.59
|
| Rate for Payer: Nomi Health Commercial |
$30.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.57
|
| Rate for Payer: Priority Health Narrow Network |
$26.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.71
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
IP
|
$34.85
|
|
|
Service Code
|
NDC 00283061026
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.65 |
| Max. Negotiated Rate |
$34.85 |
| Rate for Payer: Aetna Commercial |
$31.36
|
| Rate for Payer: ASR ASR |
$33.80
|
| Rate for Payer: ASR Commercial |
$33.80
|
| Rate for Payer: BCBS Trust/PPO |
$28.40
|
| Rate for Payer: BCN Commercial |
$27.02
|
| Rate for Payer: Cash Price |
$27.88
|
| Rate for Payer: Cofinity Commercial |
$32.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.88
|
| Rate for Payer: Healthscope Commercial |
$34.85
|
| Rate for Payer: Healthscope Whirlpool |
$33.80
|
| Rate for Payer: Mclaren Commercial |
$31.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.62
|
| Rate for Payer: Nomi Health Commercial |
$28.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.67
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
|
IP
|
$37.17
|
|
|
Service Code
|
NDC 00283061043
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.16 |
| Max. Negotiated Rate |
$37.17 |
| Rate for Payer: Aetna Commercial |
$33.45
|
| Rate for Payer: ASR ASR |
$36.05
|
| Rate for Payer: ASR Commercial |
$36.05
|
| Rate for Payer: BCBS Trust/PPO |
$30.29
|
| Rate for Payer: BCN Commercial |
$28.82
|
| Rate for Payer: Cash Price |
$29.73
|
| Rate for Payer: Cofinity Commercial |
$34.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.74
|
| Rate for Payer: Healthscope Commercial |
$37.17
|
| Rate for Payer: Healthscope Whirlpool |
$36.05
|
| Rate for Payer: Mclaren Commercial |
$33.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.59
|
| Rate for Payer: Nomi Health Commercial |
$30.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.71
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$364.80
|
|
|
Service Code
|
NDC 68084021401
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$237.12 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$328.32
|
| Rate for Payer: ASR ASR |
$353.86
|
| Rate for Payer: ASR Commercial |
$353.86
|
| Rate for Payer: BCBS Trust/PPO |
$297.28
|
| Rate for Payer: BCN Commercial |
$282.83
|
| Rate for Payer: Cash Price |
$291.84
|
| Rate for Payer: Cofinity Commercial |
$342.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.84
|
| Rate for Payer: Healthscope Commercial |
$364.80
|
| Rate for Payer: Healthscope Whirlpool |
$353.86
|
| Rate for Payer: Mclaren Commercial |
$328.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.08
|
| Rate for Payer: Nomi Health Commercial |
$299.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$321.02
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$302.10
|
|
|
Service Code
|
NDC 00904656461
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.84 |
| Max. Negotiated Rate |
$302.10 |
| Rate for Payer: Aetna Commercial |
$271.89
|
| Rate for Payer: Aetna Medicare |
$151.05
|
| Rate for Payer: ASR ASR |
$293.04
|
| Rate for Payer: ASR Commercial |
$293.04
|
| Rate for Payer: BCBS Complete |
$120.84
|
| Rate for Payer: BCBS Trust/PPO |
$247.39
|
| Rate for Payer: BCN Commercial |
$234.22
|
| Rate for Payer: Cash Price |
$241.68
|
| Rate for Payer: Cofinity Commercial |
$283.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.68
|
| Rate for Payer: Healthscope Commercial |
$302.10
|
| Rate for Payer: Healthscope Whirlpool |
$293.04
|
| Rate for Payer: Mclaren Commercial |
$271.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$256.78
|
| Rate for Payer: Nomi Health Commercial |
$247.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$264.70
|
| Rate for Payer: Priority Health Narrow Network |
$211.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$265.85
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$309.70
|
|
|
Service Code
|
NDC 00904715361
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$201.30 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$278.73
|
| Rate for Payer: ASR ASR |
$300.41
|
| Rate for Payer: ASR Commercial |
$300.41
|
| Rate for Payer: BCBS Trust/PPO |
$252.37
|
| Rate for Payer: BCN Commercial |
$240.11
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$291.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$309.70
|
| Rate for Payer: Healthscope Whirlpool |
$300.41
|
| Rate for Payer: Mclaren Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.24
|
| Rate for Payer: Nomi Health Commercial |
$253.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$272.54
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
OP
|
$309.70
|
|
|
Service Code
|
NDC 00904715361
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.88 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$278.73
|
| Rate for Payer: Aetna Medicare |
$154.85
|
| Rate for Payer: ASR ASR |
$300.41
|
| Rate for Payer: ASR Commercial |
$300.41
|
| Rate for Payer: BCBS Complete |
$123.88
|
| Rate for Payer: BCBS Trust/PPO |
$253.61
|
| Rate for Payer: BCN Commercial |
$240.11
|
| Rate for Payer: Cash Price |
$247.76
|
| Rate for Payer: Cofinity Commercial |
$291.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.76
|
| Rate for Payer: Healthscope Commercial |
$309.70
|
| Rate for Payer: Healthscope Whirlpool |
$300.41
|
| Rate for Payer: Mclaren Commercial |
$278.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.24
|
| Rate for Payer: Nomi Health Commercial |
$253.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$271.36
|
| Rate for Payer: Priority Health Narrow Network |
$217.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$272.54
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
|
IP
|
$3.65
|
|
|
Service Code
|
NDC 68084021411
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$3.65 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: ASR ASR |
$3.54
|
| Rate for Payer: ASR Commercial |
$3.54
|
| Rate for Payer: BCBS Trust/PPO |
$2.97
|
| Rate for Payer: BCN Commercial |
$2.83
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cofinity Commercial |
$3.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.92
|
| Rate for Payer: Healthscope Commercial |
$3.65
|
| Rate for Payer: Healthscope Whirlpool |
$3.54
|
| Rate for Payer: Mclaren Commercial |
$3.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.10
|
| Rate for Payer: Nomi Health Commercial |
$2.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.21
|
|
