|
SENNOSIDES 8.6 MG TABLET
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
NDC 00904725261
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Medicare |
$70.00
|
| Rate for Payer: ASR ASR |
$135.80
|
| Rate for Payer: ASR Commercial |
$135.80
|
| Rate for Payer: BCBS Complete |
$56.00
|
| Rate for Payer: BCBS Trust/PPO |
$114.65
|
| Rate for Payer: BCN Commercial |
$108.54
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.00
|
| Rate for Payer: Healthscope Commercial |
$140.00
|
| Rate for Payer: Healthscope Whirlpool |
$135.80
|
| Rate for Payer: Mclaren Commercial |
$126.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.00
|
| Rate for Payer: Nomi Health Commercial |
$114.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$122.67
|
| Rate for Payer: Priority Health Narrow Network |
$98.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$123.20
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
|
OP
|
$163.80
|
|
|
Service Code
|
NDC 51645085101
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.52 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna Commercial |
$147.42
|
| Rate for Payer: Aetna Medicare |
$81.90
|
| Rate for Payer: ASR ASR |
$158.89
|
| Rate for Payer: ASR Commercial |
$158.89
|
| Rate for Payer: BCBS Complete |
$65.52
|
| Rate for Payer: BCBS Trust/PPO |
$134.14
|
| Rate for Payer: BCN Commercial |
$126.99
|
| Rate for Payer: Cash Price |
$131.04
|
| Rate for Payer: Cofinity Commercial |
$153.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.04
|
| Rate for Payer: Healthscope Commercial |
$163.80
|
| Rate for Payer: Healthscope Whirlpool |
$158.89
|
| Rate for Payer: Mclaren Commercial |
$147.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.23
|
| Rate for Payer: Nomi Health Commercial |
$134.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$143.52
|
| Rate for Payer: Priority Health Narrow Network |
$114.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$144.14
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
|
IP
|
$113.40
|
|
|
Service Code
|
NDC 49483008001
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.71 |
| Max. Negotiated Rate |
$113.40 |
| Rate for Payer: Aetna Commercial |
$102.06
|
| Rate for Payer: ASR ASR |
$110.00
|
| Rate for Payer: ASR Commercial |
$110.00
|
| Rate for Payer: BCBS Trust/PPO |
$92.41
|
| Rate for Payer: BCN Commercial |
$87.92
|
| Rate for Payer: Cash Price |
$90.72
|
| Rate for Payer: Cofinity Commercial |
$106.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.72
|
| Rate for Payer: Healthscope Commercial |
$113.40
|
| Rate for Payer: Healthscope Whirlpool |
$110.00
|
| Rate for Payer: Mclaren Commercial |
$102.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$96.39
|
| Rate for Payer: Nomi Health Commercial |
$92.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$73.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$99.79
|
|
|
SENNOSIDES 8.6 MG TABLET
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
NDC 00904652261
|
| Hospital Charge Code |
11349
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Aetna Commercial |
$118.80
|
| Rate for Payer: ASR ASR |
$128.04
|
| Rate for Payer: ASR Commercial |
$128.04
|
| Rate for Payer: BCBS Trust/PPO |
$107.57
|
| Rate for Payer: BCN Commercial |
$102.34
|
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Cofinity Commercial |
$124.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.60
|
| Rate for Payer: Healthscope Commercial |
$132.00
|
| Rate for Payer: Healthscope Whirlpool |
$128.04
|
| Rate for Payer: Mclaren Commercial |
$118.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.20
|
| Rate for Payer: Nomi Health Commercial |
$108.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$116.16
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$31.73
|
|
|
Service Code
|
NDC 68180035206
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.62 |
| Max. Negotiated Rate |
$31.73 |
| Rate for Payer: Aetna Commercial |
$28.56
|
| Rate for Payer: ASR ASR |
$30.78
|
| Rate for Payer: ASR Commercial |
$30.78
|
| Rate for Payer: BCBS Trust/PPO |
$25.86
|
| Rate for Payer: BCN Commercial |
$24.60
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Cofinity Commercial |
$29.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.38
|
| Rate for Payer: Healthscope Commercial |
$31.73
|
| Rate for Payer: Healthscope Whirlpool |
$30.78
|
| Rate for Payer: Mclaren Commercial |
$28.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.97
|
| Rate for Payer: Nomi Health Commercial |
$26.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.92
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$304.95
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.98 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$274.45
|
| Rate for Payer: Aetna Medicare |
$152.47
|
| Rate for Payer: ASR ASR |
$295.80
|
| Rate for Payer: ASR Commercial |
$295.80
|
| Rate for Payer: BCBS Complete |
$121.98
|
| Rate for Payer: BCBS Trust/PPO |
$249.72
|
| Rate for Payer: BCN Commercial |
$236.43
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$286.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$304.95
|
| Rate for Payer: Healthscope Whirlpool |
$295.80
|
| Rate for Payer: Mclaren Commercial |
$274.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.21
|
| Rate for Payer: Nomi Health Commercial |
$250.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$267.20
|
| Rate for Payer: Priority Health Narrow Network |
$213.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$268.36
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$4,976.87
|
|
|
Service Code
|
NDC 00049490041
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,990.75 |
| Max. Negotiated Rate |
$4,976.87 |
| Rate for Payer: Aetna Commercial |
$4,479.18
|
| Rate for Payer: Aetna Medicare |
$2,488.43
|
| Rate for Payer: ASR ASR |
$4,827.56
|
| Rate for Payer: ASR Commercial |
$4,827.56
|
| Rate for Payer: BCBS Complete |
$1,990.75
|
| Rate for Payer: BCBS Trust/PPO |
$4,075.56
|
| Rate for Payer: BCN Commercial |
$3,858.57
|
| Rate for Payer: Cash Price |
$3,981.50
|
| Rate for Payer: Cofinity Commercial |
$4,678.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,981.50
|
| Rate for Payer: Healthscope Commercial |
$4,976.87
|
| Rate for Payer: Healthscope Whirlpool |
$4,827.56
|
| Rate for Payer: Mclaren Commercial |
$4,479.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,230.34
|
| Rate for Payer: Nomi Health Commercial |
$4,081.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,234.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,360.73
|
| Rate for Payer: Priority Health Narrow Network |
$3,488.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,379.65
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$3.05
|
|
|
Service Code
|
NDC 60687024211
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: Aetna Medicare |
$1.52
|
| Rate for Payer: ASR ASR |
$2.96
|
| Rate for Payer: ASR Commercial |
$2.96
|
| Rate for Payer: BCBS Complete |
$1.22
|
| Rate for Payer: BCBS Trust/PPO |
$2.50
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$3.05
|
| Rate for Payer: Healthscope Whirlpool |
$2.96
|
| Rate for Payer: Mclaren Commercial |
$2.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.59
|
| Rate for Payer: Nomi Health Commercial |
$2.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.67
|
| Rate for Payer: Priority Health Narrow Network |
$2.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.68
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$277.40
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.31 |
| Max. Negotiated Rate |
$277.40 |
| Rate for Payer: Aetna Commercial |
$249.66
|
| Rate for Payer: ASR ASR |
$269.08
|
| Rate for Payer: ASR Commercial |
$269.08
|
| Rate for Payer: BCBS Trust/PPO |
$226.05
|
| Rate for Payer: BCN Commercial |
$215.07
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$260.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$277.40
|
| Rate for Payer: Healthscope Whirlpool |
$269.08
|
| Rate for Payer: Mclaren Commercial |
$249.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Nomi Health Commercial |
$227.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.11
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$31.73
|
|
|
Service Code
|
NDC 68180035206
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.69 |
| Max. Negotiated Rate |
$31.73 |
| Rate for Payer: Aetna Commercial |
$28.56
|
| Rate for Payer: Aetna Medicare |
$15.87
|
| Rate for Payer: ASR ASR |
$30.78
|
| Rate for Payer: ASR Commercial |
$30.78
|
| Rate for Payer: BCBS Complete |
$12.69
|
| Rate for Payer: BCBS Trust/PPO |
$25.98
|
| Rate for Payer: BCN Commercial |
$24.60
|
| Rate for Payer: Cash Price |
$25.38
|
| Rate for Payer: Cofinity Commercial |
$29.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.38
|
| Rate for Payer: Healthscope Commercial |
$31.73
|
| Rate for Payer: Healthscope Whirlpool |
$30.78
|
| Rate for Payer: Mclaren Commercial |
$28.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.97
|
| Rate for Payer: Nomi Health Commercial |
$26.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.80
|
| Rate for Payer: Priority Health Narrow Network |
$22.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.92
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 60687024211
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: ASR ASR |
$2.96
|
| Rate for Payer: ASR Commercial |
$2.96
|
| Rate for Payer: BCBS Trust/PPO |
$2.49
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$3.05
|
| Rate for Payer: Healthscope Whirlpool |
$2.96
|
| Rate for Payer: Mclaren Commercial |
$2.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.59
|
| Rate for Payer: Nomi Health Commercial |
$2.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.68
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$277.40
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.96 |
| Max. Negotiated Rate |
$277.40 |
| Rate for Payer: Aetna Commercial |
$249.66
|
| Rate for Payer: Aetna Medicare |
$138.70
|
| Rate for Payer: ASR ASR |
$269.08
|
| Rate for Payer: ASR Commercial |
$269.08
|
| Rate for Payer: BCBS Complete |
$110.96
|
| Rate for Payer: BCBS Trust/PPO |
$227.16
|
| Rate for Payer: BCN Commercial |
$215.07
|
| Rate for Payer: Cash Price |
$221.92
|
| Rate for Payer: Cofinity Commercial |
$260.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.92
|
| Rate for Payer: Healthscope Commercial |
$277.40
|
| Rate for Payer: Healthscope Whirlpool |
$269.08
|
| Rate for Payer: Mclaren Commercial |
$249.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.79
|
| Rate for Payer: Nomi Health Commercial |
$227.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$243.06
|
| Rate for Payer: Priority Health Narrow Network |
$194.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.11
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.64 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: ASR Commercial |
$218.83
|
| Rate for Payer: BCBS Trust/PPO |
$183.84
|
| Rate for Payer: BCN Commercial |
$174.91
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$225.60
|
| Rate for Payer: Healthscope Whirlpool |
$218.83
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.24 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$203.04
|
| Rate for Payer: Aetna Medicare |
$112.80
|
| Rate for Payer: ASR ASR |
$218.83
|
| Rate for Payer: ASR Commercial |
$218.83
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: BCBS Trust/PPO |
$184.74
|
| Rate for Payer: BCN Commercial |
$174.91
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Commercial |
$212.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$225.60
|
| Rate for Payer: Healthscope Whirlpool |
$218.83
|
| Rate for Payer: Mclaren Commercial |
$203.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Nomi Health Commercial |
$184.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$197.67
|
| Rate for Payer: Priority Health Narrow Network |
$158.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.53
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$304.95
|
|
|
Service Code
|
NDC 60687024201
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.22 |
| Max. Negotiated Rate |
$304.95 |
| Rate for Payer: Aetna Commercial |
$274.45
|
| Rate for Payer: ASR ASR |
$295.80
|
| Rate for Payer: ASR Commercial |
$295.80
|
| Rate for Payer: BCBS Trust/PPO |
$248.50
|
| Rate for Payer: BCN Commercial |
$236.43
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$286.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$304.95
|
| Rate for Payer: Healthscope Whirlpool |
$295.80
|
| Rate for Payer: Mclaren Commercial |
$274.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.21
|
| Rate for Payer: Nomi Health Commercial |
$250.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$268.36
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
IP
|
$4,976.87
|
|
|
Service Code
|
NDC 00049490041
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,234.97 |
| Max. Negotiated Rate |
$4,976.87 |
| Rate for Payer: Aetna Commercial |
$4,479.18
|
| Rate for Payer: ASR ASR |
$4,827.56
|
| Rate for Payer: ASR Commercial |
$4,827.56
|
| Rate for Payer: BCBS Trust/PPO |
$4,055.65
|
| Rate for Payer: BCN Commercial |
$3,858.57
|
| Rate for Payer: Cash Price |
$3,981.50
|
| Rate for Payer: Cofinity Commercial |
$4,678.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,981.50
|
| Rate for Payer: Healthscope Commercial |
$4,976.87
|
| Rate for Payer: Healthscope Whirlpool |
$4,827.56
|
| Rate for Payer: Mclaren Commercial |
$4,479.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,230.34
|
| Rate for Payer: Nomi Health Commercial |
$4,081.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,234.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4,379.65
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: ASR ASR |
$5.01
|
| Rate for Payer: ASR Commercial |
$5.01
|
| Rate for Payer: BCBS Trust/PPO |
$4.20
|
| Rate for Payer: BCN Commercial |
$4.00
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$4.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$5.16
|
| Rate for Payer: Healthscope Whirlpool |
$5.01
|
| Rate for Payer: Mclaren Commercial |
$4.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Nomi Health Commercial |
$4.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.54
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
IP
|
$81.90
|
|
|
Service Code
|
NDC 12165010003
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.23 |
| Max. Negotiated Rate |
$81.90 |
| Rate for Payer: Aetna Commercial |
$73.71
|
| Rate for Payer: ASR ASR |
$79.44
|
| Rate for Payer: ASR Commercial |
$79.44
|
| Rate for Payer: BCBS Trust/PPO |
$66.74
|
| Rate for Payer: BCN Commercial |
$63.50
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$76.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$81.90
|
| Rate for Payer: Healthscope Whirlpool |
$79.44
|
| Rate for Payer: Mclaren Commercial |
$73.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.61
|
| Rate for Payer: Nomi Health Commercial |
$67.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.07
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$5.16
|
|
|
Service Code
|
NDC 09900000976
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$5.16 |
| Rate for Payer: Aetna Commercial |
$4.64
|
| Rate for Payer: Aetna Medicare |
$2.58
|
| Rate for Payer: ASR ASR |
$5.01
|
| Rate for Payer: ASR Commercial |
$5.01
|
| Rate for Payer: BCBS Complete |
$2.06
|
| Rate for Payer: BCBS Trust/PPO |
$4.23
|
| Rate for Payer: BCN Commercial |
$4.00
|
| Rate for Payer: Cash Price |
$4.13
|
| Rate for Payer: Cofinity Commercial |
$4.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.13
|
| Rate for Payer: Healthscope Commercial |
$5.16
|
| Rate for Payer: Healthscope Whirlpool |
$5.01
|
| Rate for Payer: Mclaren Commercial |
$4.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Nomi Health Commercial |
$4.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.52
|
| Rate for Payer: Priority Health Narrow Network |
$3.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.54
|
|
|
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK
|
Facility
|
OP
|
$81.90
|
|
|
Service Code
|
NDC 12165010003
|
| Hospital Charge Code |
11359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$81.90 |
| Rate for Payer: Aetna Commercial |
$73.71
|
| Rate for Payer: Aetna Medicare |
$40.95
|
| Rate for Payer: ASR ASR |
$79.44
|
| Rate for Payer: ASR Commercial |
$79.44
|
| Rate for Payer: BCBS Complete |
$32.76
|
| Rate for Payer: BCBS Trust/PPO |
$67.07
|
| Rate for Payer: BCN Commercial |
$63.50
|
| Rate for Payer: Cash Price |
$65.52
|
| Rate for Payer: Cofinity Commercial |
$76.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.52
|
| Rate for Payer: Healthscope Commercial |
$81.90
|
| Rate for Payer: Healthscope Whirlpool |
$79.44
|
| Rate for Payer: Mclaren Commercial |
$73.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.61
|
| Rate for Payer: Nomi Health Commercial |
$67.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$71.76
|
| Rate for Payer: Priority Health Narrow Network |
$57.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.07
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$30.94
|
|
|
Service Code
|
NDC 61570013120
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: Aetna Medicare |
$15.47
|
| Rate for Payer: ASR ASR |
$30.01
|
| Rate for Payer: ASR Commercial |
$30.01
|
| Rate for Payer: BCBS Complete |
$12.38
|
| Rate for Payer: BCBS Trust/PPO |
$25.34
|
| Rate for Payer: BCN Commercial |
$23.99
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$29.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.75
|
| Rate for Payer: Healthscope Commercial |
$30.94
|
| Rate for Payer: Healthscope Whirlpool |
$30.01
|
| Rate for Payer: Mclaren Commercial |
$27.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.30
|
| Rate for Payer: Nomi Health Commercial |
$25.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.11
|
| Rate for Payer: Priority Health Narrow Network |
$21.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.23
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$26.32
|
|
|
Service Code
|
NDC 43598021025
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$26.32 |
| Rate for Payer: Aetna Commercial |
$23.69
|
| Rate for Payer: Aetna Medicare |
$13.16
|
| Rate for Payer: ASR ASR |
$25.53
|
| Rate for Payer: ASR Commercial |
$25.53
|
| Rate for Payer: BCBS Complete |
$10.53
|
| Rate for Payer: BCBS Trust/PPO |
$21.55
|
| Rate for Payer: BCN Commercial |
$20.41
|
| Rate for Payer: Cash Price |
$21.06
|
| Rate for Payer: Cofinity Commercial |
$24.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.06
|
| Rate for Payer: Healthscope Commercial |
$26.32
|
| Rate for Payer: Healthscope Whirlpool |
$25.53
|
| Rate for Payer: Mclaren Commercial |
$23.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.37
|
| Rate for Payer: Nomi Health Commercial |
$21.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.06
|
| Rate for Payer: Priority Health Narrow Network |
$18.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.16
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
OP
|
$15.07
|
|
|
Service Code
|
NDC 67877012425
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$15.07 |
| Rate for Payer: Aetna Commercial |
$13.56
|
| Rate for Payer: Aetna Medicare |
$7.54
|
| Rate for Payer: ASR ASR |
$14.62
|
| Rate for Payer: ASR Commercial |
$14.62
|
| Rate for Payer: BCBS Complete |
$6.03
|
| Rate for Payer: BCBS Trust/PPO |
$12.34
|
| Rate for Payer: BCN Commercial |
$11.68
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.07
|
| Rate for Payer: Healthscope Whirlpool |
$14.62
|
| Rate for Payer: Mclaren Commercial |
$13.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.81
|
| Rate for Payer: Nomi Health Commercial |
$12.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.20
|
| Rate for Payer: Priority Health Narrow Network |
$10.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.26
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$26.32
|
|
|
Service Code
|
NDC 43598021025
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.11 |
| Max. Negotiated Rate |
$26.32 |
| Rate for Payer: Aetna Commercial |
$23.69
|
| Rate for Payer: ASR ASR |
$25.53
|
| Rate for Payer: ASR Commercial |
$25.53
|
| Rate for Payer: BCBS Trust/PPO |
$21.45
|
| Rate for Payer: BCN Commercial |
$20.41
|
| Rate for Payer: Cash Price |
$21.06
|
| Rate for Payer: Cofinity Commercial |
$24.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.06
|
| Rate for Payer: Healthscope Commercial |
$26.32
|
| Rate for Payer: Healthscope Whirlpool |
$25.53
|
| Rate for Payer: Mclaren Commercial |
$23.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.37
|
| Rate for Payer: Nomi Health Commercial |
$21.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.16
|
|
|
SILVER SULFADIAZINE 1 % TOPICAL CREAM
|
Facility
|
IP
|
$30.94
|
|
|
Service Code
|
NDC 61570013120
|
| Hospital Charge Code |
7224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.11 |
| Max. Negotiated Rate |
$30.94 |
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: ASR ASR |
$30.01
|
| Rate for Payer: ASR Commercial |
$30.01
|
| Rate for Payer: BCBS Trust/PPO |
$25.21
|
| Rate for Payer: BCN Commercial |
$23.99
|
| Rate for Payer: Cash Price |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$29.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.75
|
| Rate for Payer: Healthscope Commercial |
$30.94
|
| Rate for Payer: Healthscope Whirlpool |
$30.01
|
| Rate for Payer: Mclaren Commercial |
$27.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.30
|
| Rate for Payer: Nomi Health Commercial |
$25.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.23
|
|
