|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$402.49
|
|
|
Service Code
|
NDC 45802075830
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.00 |
| Max. Negotiated Rate |
$402.49 |
| Rate for Payer: Aetna Commercial |
$362.24
|
| Rate for Payer: Aetna Medicare |
$201.25
|
| Rate for Payer: ASR ASR |
$390.42
|
| Rate for Payer: ASR Commercial |
$390.42
|
| Rate for Payer: BCBS Complete |
$161.00
|
| Rate for Payer: BCBS Trust/PPO |
$329.60
|
| Rate for Payer: BCN Commercial |
$312.05
|
| Rate for Payer: Cash Price |
$321.99
|
| Rate for Payer: Cofinity Commercial |
$378.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.99
|
| Rate for Payer: Healthscope Commercial |
$402.49
|
| Rate for Payer: Healthscope Whirlpool |
$390.42
|
| Rate for Payer: Mclaren Commercial |
$362.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.12
|
| Rate for Payer: Nomi Health Commercial |
$330.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$352.66
|
| Rate for Payer: Priority Health Narrow Network |
$282.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$354.19
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$183.02
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.96 |
| Max. Negotiated Rate |
$183.02 |
| Rate for Payer: Aetna Commercial |
$164.72
|
| Rate for Payer: ASR ASR |
$177.53
|
| Rate for Payer: ASR Commercial |
$177.53
|
| Rate for Payer: BCBS Trust/PPO |
$149.14
|
| Rate for Payer: BCN Commercial |
$141.90
|
| Rate for Payer: Cash Price |
$146.41
|
| Rate for Payer: Cofinity Commercial |
$172.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.42
|
| Rate for Payer: Healthscope Commercial |
$183.02
|
| Rate for Payer: Healthscope Whirlpool |
$177.53
|
| Rate for Payer: Mclaren Commercial |
$164.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.57
|
| Rate for Payer: Nomi Health Commercial |
$150.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$161.06
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$402.49
|
|
|
Service Code
|
NDC 45802075830
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.62 |
| Max. Negotiated Rate |
$402.49 |
| Rate for Payer: Aetna Commercial |
$362.24
|
| Rate for Payer: ASR ASR |
$390.42
|
| Rate for Payer: ASR Commercial |
$390.42
|
| Rate for Payer: BCBS Trust/PPO |
$327.99
|
| Rate for Payer: BCN Commercial |
$312.05
|
| Rate for Payer: Cash Price |
$321.99
|
| Rate for Payer: Cofinity Commercial |
$378.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.99
|
| Rate for Payer: Healthscope Commercial |
$402.49
|
| Rate for Payer: Healthscope Whirlpool |
$390.42
|
| Rate for Payer: Mclaren Commercial |
$362.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.12
|
| Rate for Payer: Nomi Health Commercial |
$330.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$354.19
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$33.54
|
|
|
Service Code
|
NDC 45802075800
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.80 |
| Max. Negotiated Rate |
$33.54 |
| Rate for Payer: Aetna Commercial |
$30.19
|
| Rate for Payer: ASR ASR |
$32.53
|
| Rate for Payer: ASR Commercial |
$32.53
|
| Rate for Payer: BCBS Trust/PPO |
$27.33
|
| Rate for Payer: BCN Commercial |
$26.00
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cofinity Commercial |
$31.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.83
|
| Rate for Payer: Healthscope Commercial |
$33.54
|
| Rate for Payer: Healthscope Whirlpool |
$32.53
|
| Rate for Payer: Mclaren Commercial |
$30.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.51
|
| Rate for Payer: Nomi Health Commercial |
$27.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.52
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$183.02
|
|
|
Service Code
|
NDC 00713053612
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.21 |
| Max. Negotiated Rate |
$183.02 |
| Rate for Payer: Aetna Commercial |
$164.72
|
| Rate for Payer: Aetna Medicare |
$91.51
|
| Rate for Payer: ASR ASR |
$177.53
|
| Rate for Payer: ASR Commercial |
$177.53
|
| Rate for Payer: BCBS Complete |
$73.21
|
| Rate for Payer: BCBS Trust/PPO |
$149.88
|
| Rate for Payer: BCN Commercial |
$141.90
|
| Rate for Payer: Cash Price |
$146.41
|
| Rate for Payer: Cofinity Commercial |
$172.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.42
|
| Rate for Payer: Healthscope Commercial |
$183.02
|
| Rate for Payer: Healthscope Whirlpool |
$177.53
|
| Rate for Payer: Mclaren Commercial |
$164.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.57
|
| Rate for Payer: Nomi Health Commercial |
$150.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$160.36
|
| Rate for Payer: Priority Health Narrow Network |
$128.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$161.06
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$15.25
|
|
|
Service Code
|
NDC 00713053606
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$15.25 |
| Rate for Payer: Aetna Commercial |
$13.72
|
| Rate for Payer: ASR ASR |
$14.79
|
| Rate for Payer: ASR Commercial |
$14.79
|
| Rate for Payer: BCBS Trust/PPO |
$12.43
|
| Rate for Payer: BCN Commercial |
$11.82
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Cofinity Commercial |
$14.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.20
|
| Rate for Payer: Healthscope Commercial |
$15.25
|
| Rate for Payer: Healthscope Whirlpool |
$14.79
|
| Rate for Payer: Mclaren Commercial |
$13.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.96
|
| Rate for Payer: Nomi Health Commercial |
$12.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.42
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$33.54
|
|
|
Service Code
|
NDC 45802075800
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.42 |
| Max. Negotiated Rate |
$33.54 |
| Rate for Payer: Aetna Commercial |
$30.19
|
| Rate for Payer: Aetna Medicare |
$16.77
|
| Rate for Payer: ASR ASR |
$32.53
|
| Rate for Payer: ASR Commercial |
$32.53
|
| Rate for Payer: BCBS Complete |
$13.42
|
| Rate for Payer: BCBS Trust/PPO |
$27.47
|
| Rate for Payer: BCN Commercial |
$26.00
|
| Rate for Payer: Cash Price |
$26.83
|
| Rate for Payer: Cofinity Commercial |
$31.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.83
|
| Rate for Payer: Healthscope Commercial |
$33.54
|
| Rate for Payer: Healthscope Whirlpool |
$32.53
|
| Rate for Payer: Mclaren Commercial |
$30.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.51
|
| Rate for Payer: Nomi Health Commercial |
$27.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$29.39
|
| Rate for Payer: Priority Health Narrow Network |
$23.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.52
|
|
|
PROMETHAZINE 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$22.05
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.33 |
| Max. Negotiated Rate |
$22.05 |
| Rate for Payer: Aetna Commercial |
$19.84
|
| Rate for Payer: Aetna Commercial |
$14.68
|
| Rate for Payer: Aetna Commercial |
$20.15
|
| Rate for Payer: ASR ASR |
$15.82
|
| Rate for Payer: ASR ASR |
$21.39
|
| Rate for Payer: ASR ASR |
$21.72
|
| Rate for Payer: ASR Commercial |
$21.39
|
| Rate for Payer: ASR Commercial |
$15.82
|
| Rate for Payer: ASR Commercial |
$21.72
|
| Rate for Payer: BCBS Trust/PPO |
$18.25
|
| Rate for Payer: BCBS Trust/PPO |
$13.29
|
| Rate for Payer: BCBS Trust/PPO |
$17.97
|
| Rate for Payer: BCN Commercial |
$12.65
|
| Rate for Payer: BCN Commercial |
$17.36
|
| Rate for Payer: BCN Commercial |
$17.10
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cash Price |
$17.91
|
| Rate for Payer: Cofinity Commercial |
$21.05
|
| Rate for Payer: Cofinity Commercial |
$15.33
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.91
|
| Rate for Payer: Healthscope Commercial |
$16.31
|
| Rate for Payer: Healthscope Commercial |
$22.05
|
| Rate for Payer: Healthscope Commercial |
$22.39
|
| Rate for Payer: Healthscope Whirlpool |
$21.39
|
| Rate for Payer: Healthscope Whirlpool |
$15.82
|
| Rate for Payer: Healthscope Whirlpool |
$21.72
|
| Rate for Payer: Mclaren Commercial |
$19.84
|
| Rate for Payer: Mclaren Commercial |
$14.68
|
| Rate for Payer: Mclaren Commercial |
$20.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.86
|
| Rate for Payer: Nomi Health Commercial |
$18.08
|
| Rate for Payer: Nomi Health Commercial |
$13.37
|
| Rate for Payer: Nomi Health Commercial |
$18.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.35
|
|
|
PROMETHAZINE 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$16.31
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.52 |
| Max. Negotiated Rate |
$16.31 |
| Rate for Payer: Aetna Commercial |
$14.68
|
| Rate for Payer: Aetna Commercial |
$19.84
|
| Rate for Payer: Aetna Commercial |
$20.15
|
| Rate for Payer: Aetna Medicare |
$11.03
|
| Rate for Payer: Aetna Medicare |
$11.20
|
| Rate for Payer: Aetna Medicare |
$8.15
|
| Rate for Payer: ASR ASR |
$21.39
|
| Rate for Payer: ASR ASR |
$15.82
|
| Rate for Payer: ASR ASR |
$21.72
|
| Rate for Payer: ASR Commercial |
$21.72
|
| Rate for Payer: ASR Commercial |
$21.39
|
| Rate for Payer: ASR Commercial |
$15.82
|
| Rate for Payer: BCBS Complete |
$6.52
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: BCBS Complete |
$8.96
|
| Rate for Payer: BCBS Trust/PPO |
$13.36
|
| Rate for Payer: BCBS Trust/PPO |
$18.06
|
| Rate for Payer: BCBS Trust/PPO |
$18.34
|
| Rate for Payer: BCN Commercial |
$17.36
|
| Rate for Payer: BCN Commercial |
$12.65
|
| Rate for Payer: BCN Commercial |
$17.10
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$13.05
|
| Rate for Payer: Cash Price |
$17.91
|
| Rate for Payer: Cofinity Commercial |
$21.05
|
| Rate for Payer: Cofinity Commercial |
$15.33
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.91
|
| Rate for Payer: Healthscope Commercial |
$16.31
|
| Rate for Payer: Healthscope Commercial |
$22.05
|
| Rate for Payer: Healthscope Commercial |
$22.39
|
| Rate for Payer: Healthscope Whirlpool |
$21.39
|
| Rate for Payer: Healthscope Whirlpool |
$15.82
|
| Rate for Payer: Healthscope Whirlpool |
$21.72
|
| Rate for Payer: Mclaren Commercial |
$14.68
|
| Rate for Payer: Mclaren Commercial |
$19.84
|
| Rate for Payer: Mclaren Commercial |
$20.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.03
|
| Rate for Payer: Nomi Health Commercial |
$13.37
|
| Rate for Payer: Nomi Health Commercial |
$18.08
|
| Rate for Payer: Nomi Health Commercial |
$18.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.62
|
| Rate for Payer: Priority Health Narrow Network |
$15.70
|
| Rate for Payer: Priority Health Narrow Network |
$11.43
|
| Rate for Payer: Priority Health Narrow Network |
$15.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.70
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
NDC 00713052612
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.35 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: ASR ASR |
$154.23
|
| Rate for Payer: ASR Commercial |
$154.23
|
| Rate for Payer: BCBS Trust/PPO |
$129.57
|
| Rate for Payer: BCN Commercial |
$123.27
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cofinity Commercial |
$149.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.20
|
| Rate for Payer: Healthscope Commercial |
$159.00
|
| Rate for Payer: Healthscope Whirlpool |
$154.23
|
| Rate for Payer: Mclaren Commercial |
$143.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.15
|
| Rate for Payer: Nomi Health Commercial |
$130.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$139.92
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
NDC 00713052612
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.60 |
| Max. Negotiated Rate |
$159.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Medicare |
$79.50
|
| Rate for Payer: ASR ASR |
$154.23
|
| Rate for Payer: ASR Commercial |
$154.23
|
| Rate for Payer: BCBS Complete |
$63.60
|
| Rate for Payer: BCBS Trust/PPO |
$130.21
|
| Rate for Payer: BCN Commercial |
$123.27
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cofinity Commercial |
$149.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.20
|
| Rate for Payer: Healthscope Commercial |
$159.00
|
| Rate for Payer: Healthscope Whirlpool |
$154.23
|
| Rate for Payer: Mclaren Commercial |
$143.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.15
|
| Rate for Payer: Nomi Health Commercial |
$130.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$139.32
|
| Rate for Payer: Priority Health Narrow Network |
$111.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$139.92
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 00904646161
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$251.45 |
| Rate for Payer: Aetna Commercial |
$226.31
|
| Rate for Payer: ASR ASR |
$243.91
|
| Rate for Payer: ASR Commercial |
$243.91
|
| Rate for Payer: BCBS Trust/PPO |
$204.91
|
| Rate for Payer: BCN Commercial |
$194.95
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$236.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$251.45
|
| Rate for Payer: Healthscope Whirlpool |
$243.91
|
| Rate for Payer: Mclaren Commercial |
$226.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: Nomi Health Commercial |
$206.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$221.28
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$336.05
|
|
|
Service Code
|
NDC 00904730461
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.42 |
| Max. Negotiated Rate |
$336.05 |
| Rate for Payer: Aetna Commercial |
$302.44
|
| Rate for Payer: Aetna Medicare |
$168.03
|
| Rate for Payer: ASR ASR |
$325.97
|
| Rate for Payer: ASR Commercial |
$325.97
|
| Rate for Payer: BCBS Complete |
$134.42
|
| Rate for Payer: BCBS Trust/PPO |
$275.19
|
| Rate for Payer: BCN Commercial |
$260.54
|
| Rate for Payer: Cash Price |
$268.84
|
| Rate for Payer: Cofinity Commercial |
$315.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.84
|
| Rate for Payer: Healthscope Commercial |
$336.05
|
| Rate for Payer: Healthscope Whirlpool |
$325.97
|
| Rate for Payer: Mclaren Commercial |
$302.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.64
|
| Rate for Payer: Nomi Health Commercial |
$275.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$294.45
|
| Rate for Payer: Priority Health Narrow Network |
$235.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$295.72
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$251.45
|
|
|
Service Code
|
NDC 00904646161
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.58 |
| Max. Negotiated Rate |
$251.45 |
| Rate for Payer: Aetna Commercial |
$226.31
|
| Rate for Payer: Aetna Medicare |
$125.72
|
| Rate for Payer: ASR ASR |
$243.91
|
| Rate for Payer: ASR Commercial |
$243.91
|
| Rate for Payer: BCBS Complete |
$100.58
|
| Rate for Payer: BCBS Trust/PPO |
$205.91
|
| Rate for Payer: BCN Commercial |
$194.95
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$236.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$251.45
|
| Rate for Payer: Healthscope Whirlpool |
$243.91
|
| Rate for Payer: Mclaren Commercial |
$226.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: Nomi Health Commercial |
$206.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$220.32
|
| Rate for Payer: Priority Health Narrow Network |
$176.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$221.28
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
NDC 68084015511
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna Commercial |
$1.74
|
| Rate for Payer: Aetna Medicare |
$0.97
|
| Rate for Payer: ASR ASR |
$1.87
|
| Rate for Payer: ASR Commercial |
$1.87
|
| Rate for Payer: BCBS Complete |
$0.77
|
| Rate for Payer: BCBS Trust/PPO |
$1.58
|
| Rate for Payer: BCN Commercial |
$1.50
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Cofinity Commercial |
$1.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.54
|
| Rate for Payer: Healthscope Commercial |
$1.93
|
| Rate for Payer: Healthscope Whirlpool |
$1.87
|
| Rate for Payer: Mclaren Commercial |
$1.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.64
|
| Rate for Payer: Nomi Health Commercial |
$1.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.69
|
| Rate for Payer: Priority Health Narrow Network |
$1.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.70
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
NDC 68084015511
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Aetna Commercial |
$1.74
|
| Rate for Payer: ASR ASR |
$1.87
|
| Rate for Payer: ASR Commercial |
$1.87
|
| Rate for Payer: BCBS Trust/PPO |
$1.57
|
| Rate for Payer: BCN Commercial |
$1.50
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Cofinity Commercial |
$1.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.54
|
| Rate for Payer: Healthscope Commercial |
$1.93
|
| Rate for Payer: Healthscope Whirlpool |
$1.87
|
| Rate for Payer: Mclaren Commercial |
$1.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.64
|
| Rate for Payer: Nomi Health Commercial |
$1.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.70
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$336.05
|
|
|
Service Code
|
NDC 00904730461
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$218.43 |
| Max. Negotiated Rate |
$336.05 |
| Rate for Payer: Aetna Commercial |
$302.44
|
| Rate for Payer: ASR ASR |
$325.97
|
| Rate for Payer: ASR Commercial |
$325.97
|
| Rate for Payer: BCBS Trust/PPO |
$273.85
|
| Rate for Payer: BCN Commercial |
$260.54
|
| Rate for Payer: Cash Price |
$268.84
|
| Rate for Payer: Cofinity Commercial |
$315.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.84
|
| Rate for Payer: Healthscope Commercial |
$336.05
|
| Rate for Payer: Healthscope Whirlpool |
$325.97
|
| Rate for Payer: Mclaren Commercial |
$302.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.64
|
| Rate for Payer: Nomi Health Commercial |
$275.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$295.72
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
OP
|
$1.57
|
|
|
Service Code
|
NDC 09900000413
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna Commercial |
$1.41
|
| Rate for Payer: Aetna Medicare |
$0.79
|
| Rate for Payer: ASR ASR |
$1.52
|
| Rate for Payer: ASR Commercial |
$1.52
|
| Rate for Payer: BCBS Complete |
$0.63
|
| Rate for Payer: BCBS Trust/PPO |
$1.29
|
| Rate for Payer: BCN Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Commercial |
$1.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.57
|
| Rate for Payer: Healthscope Whirlpool |
$1.52
|
| Rate for Payer: Mclaren Commercial |
$1.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.33
|
| Rate for Payer: Nomi Health Commercial |
$1.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.38
|
| Rate for Payer: Priority Health Narrow Network |
$1.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.38
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
NDC 09900000413
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna Commercial |
$1.41
|
| Rate for Payer: ASR ASR |
$1.52
|
| Rate for Payer: ASR Commercial |
$1.52
|
| Rate for Payer: BCBS Trust/PPO |
$1.28
|
| Rate for Payer: BCN Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Commercial |
$1.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.57
|
| Rate for Payer: Healthscope Whirlpool |
$1.52
|
| Rate for Payer: Mclaren Commercial |
$1.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.33
|
| Rate for Payer: Nomi Health Commercial |
$1.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.38
|
|
|
PR OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX
|
Professional
|
Both
|
$2,127.00
|
|
|
Service Code
|
HCPCS 49255
|
| Min. Negotiated Rate |
$767.78 |
| Max. Negotiated Rate |
$1,382.55 |
| Rate for Payer: Aetna Commercial |
$1,028.83
|
| Rate for Payer: Aetna Medicare |
$767.78
|
| Rate for Payer: BCBS Complete |
$850.80
|
| Rate for Payer: BCBS MAPPO |
$767.78
|
| Rate for Payer: BCN Medicare Advantage |
$767.78
|
| Rate for Payer: Cash Price |
$1,701.60
|
| Rate for Payer: Cash Price |
$1,701.60
|
| Rate for Payer: Cofinity Commercial |
$1,105.60
|
| Rate for Payer: Cofinity Commercial |
$1,028.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$767.78
|
| Rate for Payer: Healthscope Commercial |
$921.34
|
| Rate for Payer: Healthscope Whirlpool |
$921.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$806.17
|
| Rate for Payer: Nomi Health Commercial |
$921.34
|
| Rate for Payer: PACE SWMI |
$767.78
|
| Rate for Payer: PHP Medicare Advantage |
$767.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,382.55
|
| Rate for Payer: Priority Health Medicare |
$767.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$767.78
|
| Rate for Payer: UHC Medicare Advantage |
$767.78
|
| Rate for Payer: UHCCP DNSP |
$767.78
|
|
|
PR ONDANSETRON HCL INJECTION
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS J2405
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$20.15 |
| Rate for Payer: Aetna Commercial |
$0.12
|
| Rate for Payer: Aetna Medicare |
$0.09
|
| Rate for Payer: BCBS Complete |
$12.40
|
| Rate for Payer: BCBS MAPPO |
$0.09
|
| Rate for Payer: BCN Medicare Advantage |
$0.09
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cash Price |
$24.80
|
| Rate for Payer: Cofinity Commercial |
$0.13
|
| Rate for Payer: Cofinity Commercial |
$0.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.09
|
| Rate for Payer: Healthscope Commercial |
$0.11
|
| Rate for Payer: Healthscope Whirlpool |
$0.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.09
|
| Rate for Payer: Nomi Health Commercial |
$0.11
|
| Rate for Payer: PACE SWMI |
$0.09
|
| Rate for Payer: PHP Medicare Advantage |
$0.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.15
|
| Rate for Payer: Priority Health Medicare |
$0.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.09
|
| Rate for Payer: UHC Medicare Advantage |
$0.09
|
| Rate for Payer: UHCCP DNSP |
$0.09
|
|
|
PR ONE AREA LIPOSUCTION - 1 AREA 1.0 HR
|
Professional
|
Both
|
$2,040.00
|
|
|
Service Code
|
HCPCS 00527
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$816.00 |
| Max. Negotiated Rate |
$1,326.00 |
| Rate for Payer: Aetna Medicare |
$1,020.00
|
| Rate for Payer: BCBS Complete |
$816.00
|
| Rate for Payer: Cash Price |
$1,632.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,326.00
|
|
|
PR ONLINE DIGITAL E/M SVC EST PT <7 D 11-20 MINUTES
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS 99422
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$34.80 |
| Rate for Payer: Aetna Commercial |
$32.39
|
| Rate for Payer: Aetna Medicare |
$24.17
|
| Rate for Payer: BCBS Complete |
$14.40
|
| Rate for Payer: BCBS MAPPO |
$24.17
|
| Rate for Payer: BCN Medicare Advantage |
$24.17
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cofinity Commercial |
$34.80
|
| Rate for Payer: Cofinity Commercial |
$32.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24.17
|
| Rate for Payer: Healthscope Commercial |
$26.59
|
| Rate for Payer: Healthscope Whirlpool |
$26.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.38
|
| Rate for Payer: Nomi Health Commercial |
$29.00
|
| Rate for Payer: PACE SWMI |
$24.17
|
| Rate for Payer: PHP Medicare Advantage |
$24.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.40
|
| Rate for Payer: Priority Health Medicare |
$24.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$24.17
|
| Rate for Payer: UHC Medicare Advantage |
$24.17
|
| Rate for Payer: UHCCP DNSP |
$24.17
|
|
|
PR ONLINE DIGITAL E/M SVC EST PT <7 D 21+ MINUTES
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS 99423
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$53.87 |
| Rate for Payer: Aetna Commercial |
$50.13
|
| Rate for Payer: Aetna Medicare |
$37.41
|
| Rate for Payer: BCBS Complete |
$14.40
|
| Rate for Payer: BCBS MAPPO |
$37.41
|
| Rate for Payer: BCN Medicare Advantage |
$37.41
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cofinity Commercial |
$53.87
|
| Rate for Payer: Cofinity Commercial |
$50.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.41
|
| Rate for Payer: Healthscope Commercial |
$41.15
|
| Rate for Payer: Healthscope Whirlpool |
$41.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.28
|
| Rate for Payer: Nomi Health Commercial |
$44.89
|
| Rate for Payer: PACE SWMI |
$37.41
|
| Rate for Payer: PHP Medicare Advantage |
$37.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.40
|
| Rate for Payer: Priority Health Medicare |
$37.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$37.41
|
| Rate for Payer: UHC Medicare Advantage |
$37.41
|
| Rate for Payer: UHCCP DNSP |
$37.41
|
|
|
PR ONLINE DIGITAL E/M SVC EST PT <7 D 5-10 MINUTES
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS 99421
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$23.40 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Medicare |
$12.09
|
| Rate for Payer: BCBS Complete |
$14.40
|
| Rate for Payer: BCBS MAPPO |
$12.09
|
| Rate for Payer: BCN Medicare Advantage |
$12.09
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cofinity Commercial |
$17.41
|
| Rate for Payer: Cofinity Commercial |
$16.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.09
|
| Rate for Payer: Healthscope Commercial |
$13.30
|
| Rate for Payer: Healthscope Whirlpool |
$13.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.69
|
| Rate for Payer: Nomi Health Commercial |
$14.51
|
| Rate for Payer: PACE SWMI |
$12.09
|
| Rate for Payer: PHP Medicare Advantage |
$12.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.40
|
| Rate for Payer: Priority Health Medicare |
$12.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.09
|
| Rate for Payer: UHC Medicare Advantage |
$12.09
|
| Rate for Payer: UHCCP DNSP |
$12.09
|
|
