|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$3.63
|
|
|
Service Code
|
NDC 68084075095
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Aetna Medicare |
$1.82
|
| Rate for Payer: ASR ASR |
$3.52
|
| Rate for Payer: ASR Commercial |
$3.52
|
| Rate for Payer: BCBS Complete |
$1.45
|
| Rate for Payer: BCBS Trust/PPO |
$2.97
|
| Rate for Payer: BCN Commercial |
$2.81
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: Cofinity Commercial |
$3.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.90
|
| Rate for Payer: Healthscope Commercial |
$3.63
|
| Rate for Payer: Healthscope Whirlpool |
$3.52
|
| Rate for Payer: Mclaren Commercial |
$3.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.09
|
| Rate for Payer: Nomi Health Commercial |
$2.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.18
|
| Rate for Payer: Priority Health Narrow Network |
$2.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.19
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET
|
Facility
|
IP
|
$223.25
|
|
|
Service Code
|
NDC 72888009501
|
| Hospital Charge Code |
8134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.11 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Aetna Commercial |
$200.92
|
| Rate for Payer: ASR ASR |
$216.55
|
| Rate for Payer: ASR Commercial |
$216.55
|
| Rate for Payer: BCBS Trust/PPO |
$181.93
|
| Rate for Payer: BCN Commercial |
$173.09
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$209.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$223.25
|
| Rate for Payer: Healthscope Whirlpool |
$216.55
|
| Rate for Payer: Mclaren Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: Nomi Health Commercial |
$183.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$196.46
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET
|
Facility
|
OP
|
$223.25
|
|
|
Service Code
|
NDC 72888009501
|
| Hospital Charge Code |
8134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.30 |
| Max. Negotiated Rate |
$223.25 |
| Rate for Payer: Aetna Commercial |
$200.92
|
| Rate for Payer: Aetna Medicare |
$111.62
|
| Rate for Payer: ASR ASR |
$216.55
|
| Rate for Payer: ASR Commercial |
$216.55
|
| Rate for Payer: BCBS Complete |
$89.30
|
| Rate for Payer: BCBS Trust/PPO |
$182.82
|
| Rate for Payer: BCN Commercial |
$173.09
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$209.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$223.25
|
| Rate for Payer: Healthscope Whirlpool |
$216.55
|
| Rate for Payer: Mclaren Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.76
|
| Rate for Payer: Nomi Health Commercial |
$183.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$195.61
|
| Rate for Payer: Priority Health Narrow Network |
$156.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$196.46
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET
|
Facility
|
OP
|
$248.90
|
|
|
Service Code
|
NDC 60505265701
|
| Hospital Charge Code |
8134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.56 |
| Max. Negotiated Rate |
$248.90 |
| Rate for Payer: Aetna Commercial |
$224.01
|
| Rate for Payer: Aetna Medicare |
$124.45
|
| Rate for Payer: ASR ASR |
$241.43
|
| Rate for Payer: ASR Commercial |
$241.43
|
| Rate for Payer: BCBS Complete |
$99.56
|
| Rate for Payer: BCBS Trust/PPO |
$203.82
|
| Rate for Payer: BCN Commercial |
$192.97
|
| Rate for Payer: Cash Price |
$199.12
|
| Rate for Payer: Cofinity Commercial |
$233.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.12
|
| Rate for Payer: Healthscope Commercial |
$248.90
|
| Rate for Payer: Healthscope Whirlpool |
$241.43
|
| Rate for Payer: Mclaren Commercial |
$224.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.56
|
| Rate for Payer: Nomi Health Commercial |
$204.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$218.09
|
| Rate for Payer: Priority Health Narrow Network |
$174.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$219.03
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET
|
Facility
|
IP
|
$248.90
|
|
|
Service Code
|
NDC 60505265701
|
| Hospital Charge Code |
8134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.78 |
| Max. Negotiated Rate |
$248.90 |
| Rate for Payer: Aetna Commercial |
$224.01
|
| Rate for Payer: ASR ASR |
$241.43
|
| Rate for Payer: ASR Commercial |
$241.43
|
| Rate for Payer: BCBS Trust/PPO |
$202.83
|
| Rate for Payer: BCN Commercial |
$192.97
|
| Rate for Payer: Cash Price |
$199.12
|
| Rate for Payer: Cofinity Commercial |
$233.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.12
|
| Rate for Payer: Healthscope Commercial |
$248.90
|
| Rate for Payer: Healthscope Whirlpool |
$241.43
|
| Rate for Payer: Mclaren Commercial |
$224.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.56
|
| Rate for Payer: Nomi Health Commercial |
$204.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$219.03
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
|
OP
|
$11.64
|
|
|
Service Code
|
NDC 09900000607
|
| Hospital Charge Code |
169208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Aetna Commercial |
$10.48
|
| Rate for Payer: Aetna Medicare |
$5.82
|
| Rate for Payer: ASR ASR |
$11.29
|
| Rate for Payer: ASR Commercial |
$11.29
|
| Rate for Payer: BCBS Complete |
$4.66
|
| Rate for Payer: BCBS Trust/PPO |
$9.53
|
| Rate for Payer: BCN Commercial |
$9.02
|
| Rate for Payer: Cash Price |
$9.31
|
| Rate for Payer: Cofinity Commercial |
$10.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.31
|
| Rate for Payer: Healthscope Commercial |
$11.64
|
| Rate for Payer: Healthscope Whirlpool |
$11.29
|
| Rate for Payer: Mclaren Commercial |
$10.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.89
|
| Rate for Payer: Nomi Health Commercial |
$9.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.20
|
| Rate for Payer: Priority Health Narrow Network |
$8.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.24
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
|
IP
|
$11.64
|
|
|
Service Code
|
NDC 09900000607
|
| Hospital Charge Code |
169208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Aetna Commercial |
$10.48
|
| Rate for Payer: ASR ASR |
$11.29
|
| Rate for Payer: ASR Commercial |
$11.29
|
| Rate for Payer: BCBS Trust/PPO |
$9.49
|
| Rate for Payer: BCN Commercial |
$9.02
|
| Rate for Payer: Cash Price |
$9.31
|
| Rate for Payer: Cofinity Commercial |
$10.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.31
|
| Rate for Payer: Healthscope Commercial |
$11.64
|
| Rate for Payer: Healthscope Whirlpool |
$11.29
|
| Rate for Payer: Mclaren Commercial |
$10.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.89
|
| Rate for Payer: Nomi Health Commercial |
$9.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.24
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
|
IP
|
$9.09
|
|
|
Service Code
|
NDC 72140085700
|
| Hospital Charge Code |
169208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: Aetna Commercial |
$8.18
|
| Rate for Payer: ASR ASR |
$8.82
|
| Rate for Payer: ASR Commercial |
$8.82
|
| Rate for Payer: BCBS Trust/PPO |
$7.41
|
| Rate for Payer: BCN Commercial |
$7.05
|
| Rate for Payer: Cash Price |
$7.27
|
| Rate for Payer: Cofinity Commercial |
$8.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.27
|
| Rate for Payer: Healthscope Commercial |
$9.09
|
| Rate for Payer: Healthscope Whirlpool |
$8.82
|
| Rate for Payer: Mclaren Commercial |
$8.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.73
|
| Rate for Payer: Nomi Health Commercial |
$7.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.00
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
|
OP
|
$9.09
|
|
|
Service Code
|
NDC 72140085700
|
| Hospital Charge Code |
169208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$9.09 |
| Rate for Payer: Aetna Commercial |
$8.18
|
| Rate for Payer: Aetna Medicare |
$4.54
|
| Rate for Payer: ASR ASR |
$8.82
|
| Rate for Payer: ASR Commercial |
$8.82
|
| Rate for Payer: BCBS Complete |
$3.64
|
| Rate for Payer: BCBS Trust/PPO |
$7.44
|
| Rate for Payer: BCN Commercial |
$7.05
|
| Rate for Payer: Cash Price |
$7.27
|
| Rate for Payer: Cofinity Commercial |
$8.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.27
|
| Rate for Payer: Healthscope Commercial |
$9.09
|
| Rate for Payer: Healthscope Whirlpool |
$8.82
|
| Rate for Payer: Mclaren Commercial |
$8.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.73
|
| Rate for Payer: Nomi Health Commercial |
$7.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.96
|
| Rate for Payer: Priority Health Narrow Network |
$6.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.00
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$23.13
|
|
|
Service Code
|
NDC 24208058559
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$23.13 |
| Rate for Payer: Aetna Commercial |
$20.82
|
| Rate for Payer: Aetna Medicare |
$11.56
|
| Rate for Payer: ASR ASR |
$22.44
|
| Rate for Payer: ASR Commercial |
$22.44
|
| Rate for Payer: BCBS Complete |
$9.25
|
| Rate for Payer: BCBS Trust/PPO |
$18.94
|
| Rate for Payer: BCN Commercial |
$17.93
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cofinity Commercial |
$21.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.50
|
| Rate for Payer: Healthscope Commercial |
$23.13
|
| Rate for Payer: Healthscope Whirlpool |
$22.44
|
| Rate for Payer: Mclaren Commercial |
$20.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.66
|
| Rate for Payer: Nomi Health Commercial |
$18.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.27
|
| Rate for Payer: Priority Health Narrow Network |
$16.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.35
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
IP
|
$33.18
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$33.18 |
| Rate for Payer: Aetna Commercial |
$29.86
|
| Rate for Payer: ASR ASR |
$32.18
|
| Rate for Payer: ASR Commercial |
$32.18
|
| Rate for Payer: BCBS Trust/PPO |
$27.04
|
| Rate for Payer: BCN Commercial |
$25.72
|
| Rate for Payer: Cash Price |
$26.54
|
| Rate for Payer: Cofinity Commercial |
$31.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.54
|
| Rate for Payer: Healthscope Commercial |
$33.18
|
| Rate for Payer: Healthscope Whirlpool |
$32.18
|
| Rate for Payer: Mclaren Commercial |
$29.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.20
|
| Rate for Payer: Nomi Health Commercial |
$27.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.20
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
IP
|
$312.80
|
|
|
Service Code
|
NDC 00998035515
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.32 |
| Max. Negotiated Rate |
$312.80 |
| Rate for Payer: Aetna Commercial |
$281.52
|
| Rate for Payer: ASR ASR |
$303.42
|
| Rate for Payer: ASR Commercial |
$303.42
|
| Rate for Payer: BCBS Trust/PPO |
$254.90
|
| Rate for Payer: BCN Commercial |
$242.51
|
| Rate for Payer: Cash Price |
$250.24
|
| Rate for Payer: Cofinity Commercial |
$294.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.24
|
| Rate for Payer: Healthscope Commercial |
$312.80
|
| Rate for Payer: Healthscope Whirlpool |
$303.42
|
| Rate for Payer: Mclaren Commercial |
$281.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.88
|
| Rate for Payer: Nomi Health Commercial |
$256.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$275.26
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
IP
|
$23.13
|
|
|
Service Code
|
NDC 24208058559
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.03 |
| Max. Negotiated Rate |
$23.13 |
| Rate for Payer: Aetna Commercial |
$20.82
|
| Rate for Payer: ASR ASR |
$22.44
|
| Rate for Payer: ASR Commercial |
$22.44
|
| Rate for Payer: BCBS Trust/PPO |
$18.85
|
| Rate for Payer: BCN Commercial |
$17.93
|
| Rate for Payer: Cash Price |
$18.50
|
| Rate for Payer: Cofinity Commercial |
$21.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.50
|
| Rate for Payer: Healthscope Commercial |
$23.13
|
| Rate for Payer: Healthscope Whirlpool |
$22.44
|
| Rate for Payer: Mclaren Commercial |
$20.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.66
|
| Rate for Payer: Nomi Health Commercial |
$18.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.35
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
IP
|
$26.20
|
|
|
Service Code
|
NDC 17478010212
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$26.20 |
| Rate for Payer: Aetna Commercial |
$23.58
|
| Rate for Payer: ASR ASR |
$25.41
|
| Rate for Payer: ASR Commercial |
$25.41
|
| Rate for Payer: BCBS Trust/PPO |
$21.35
|
| Rate for Payer: BCN Commercial |
$20.31
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Commercial |
$24.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$26.20
|
| Rate for Payer: Healthscope Whirlpool |
$25.41
|
| Rate for Payer: Mclaren Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: Nomi Health Commercial |
$21.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.06
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$16.88
|
|
|
Service Code
|
NDC 24208058564
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$8.44
|
| Rate for Payer: ASR ASR |
$16.37
|
| Rate for Payer: ASR Commercial |
$16.37
|
| Rate for Payer: BCBS Complete |
$6.75
|
| Rate for Payer: BCBS Trust/PPO |
$13.82
|
| Rate for Payer: BCN Commercial |
$13.09
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cofinity Commercial |
$15.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.50
|
| Rate for Payer: Healthscope Commercial |
$16.88
|
| Rate for Payer: Healthscope Whirlpool |
$16.37
|
| Rate for Payer: Mclaren Commercial |
$15.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.35
|
| Rate for Payer: Nomi Health Commercial |
$13.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.79
|
| Rate for Payer: Priority Health Narrow Network |
$11.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.85
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
IP
|
$16.88
|
|
|
Service Code
|
NDC 24208058564
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: ASR ASR |
$16.37
|
| Rate for Payer: ASR Commercial |
$16.37
|
| Rate for Payer: BCBS Trust/PPO |
$13.76
|
| Rate for Payer: BCN Commercial |
$13.09
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cofinity Commercial |
$15.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.50
|
| Rate for Payer: Healthscope Commercial |
$16.88
|
| Rate for Payer: Healthscope Whirlpool |
$16.37
|
| Rate for Payer: Mclaren Commercial |
$15.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.35
|
| Rate for Payer: Nomi Health Commercial |
$13.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.85
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$312.80
|
|
|
Service Code
|
NDC 00998035515
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.12 |
| Max. Negotiated Rate |
$312.80 |
| Rate for Payer: Aetna Commercial |
$281.52
|
| Rate for Payer: Aetna Medicare |
$156.40
|
| Rate for Payer: ASR ASR |
$303.42
|
| Rate for Payer: ASR Commercial |
$303.42
|
| Rate for Payer: BCBS Complete |
$125.12
|
| Rate for Payer: BCBS Trust/PPO |
$256.15
|
| Rate for Payer: BCN Commercial |
$242.51
|
| Rate for Payer: Cash Price |
$250.24
|
| Rate for Payer: Cofinity Commercial |
$294.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.24
|
| Rate for Payer: Healthscope Commercial |
$312.80
|
| Rate for Payer: Healthscope Whirlpool |
$303.42
|
| Rate for Payer: Mclaren Commercial |
$281.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.88
|
| Rate for Payer: Nomi Health Commercial |
$256.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$274.08
|
| Rate for Payer: Priority Health Narrow Network |
$219.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$275.26
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$33.18
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$33.18 |
| Rate for Payer: Aetna Commercial |
$29.86
|
| Rate for Payer: Aetna Medicare |
$16.59
|
| Rate for Payer: ASR ASR |
$32.18
|
| Rate for Payer: ASR Commercial |
$32.18
|
| Rate for Payer: BCBS Complete |
$13.27
|
| Rate for Payer: BCBS Trust/PPO |
$27.17
|
| Rate for Payer: BCN Commercial |
$25.72
|
| Rate for Payer: Cash Price |
$26.54
|
| Rate for Payer: Cofinity Commercial |
$31.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.54
|
| Rate for Payer: Healthscope Commercial |
$33.18
|
| Rate for Payer: Healthscope Whirlpool |
$32.18
|
| Rate for Payer: Mclaren Commercial |
$29.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.20
|
| Rate for Payer: Nomi Health Commercial |
$27.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$29.07
|
| Rate for Payer: Priority Health Narrow Network |
$23.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.20
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$26.20
|
|
|
Service Code
|
NDC 17478010212
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$26.20 |
| Rate for Payer: Aetna Commercial |
$23.58
|
| Rate for Payer: Aetna Medicare |
$13.10
|
| Rate for Payer: ASR ASR |
$25.41
|
| Rate for Payer: ASR Commercial |
$25.41
|
| Rate for Payer: BCBS Complete |
$10.48
|
| Rate for Payer: BCBS Trust/PPO |
$21.46
|
| Rate for Payer: BCN Commercial |
$20.31
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Commercial |
$24.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$26.20
|
| Rate for Payer: Healthscope Whirlpool |
$25.41
|
| Rate for Payer: Mclaren Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: Nomi Health Commercial |
$21.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.96
|
| Rate for Payer: Priority Health Narrow Network |
$18.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.06
|
|
|
TUBE THORACOSTOMY, INCLUDES CONNECTION TO DRAINAGE SYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$2,359.15
|
|
|
Service Code
|
CPT 32551
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$672.86 |
| Max. Negotiated Rate |
$2,359.15 |
| Rate for Payer: Aetna Medicare |
$1,522.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,902.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,902.54
|
| Rate for Payer: BCBS Complete |
$856.60
|
| Rate for Payer: BCBS MAPPO |
$1,522.03
|
| Rate for Payer: BCN Medicare Advantage |
$1,522.03
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,522.03
|
| Rate for Payer: Humana Choice PPO Medicare |
$1,522.03
|
| Rate for Payer: Mclaren Medicaid |
$815.81
|
| Rate for Payer: Mclaren Medicare |
$1,522.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,598.13
|
| Rate for Payer: Meridian Medicaid |
$856.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,750.33
|
| Rate for Payer: PACE Medicare |
$1,445.93
|
| Rate for Payer: PACE SWMI |
$1,522.03
|
| Rate for Payer: PHP Commercial |
$1,674.23
|
| Rate for Payer: PHP Medicaid |
$815.81
|
| Rate for Payer: PHP Medicare Advantage |
$1,522.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$815.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$841.07
|
| Rate for Payer: Priority Health Medicare |
$1,522.03
|
| Rate for Payer: Priority Health Narrow Network |
$672.86
|
| Rate for Payer: Railroad Medicare Medicare |
$1,522.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,522.03
|
| Rate for Payer: UHC Exchange |
$2,359.15
|
| Rate for Payer: UHC Medicare Advantage |
$1,522.03
|
| Rate for Payer: UHCCP DNSP |
$1,522.03
|
| Rate for Payer: UHCCP Medicaid |
$815.81
|
| Rate for Payer: VA VA |
$1,522.03
|
|
|
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
|
IP
|
$134.68
|
|
|
Service Code
|
NDC 00173087306
|
| Hospital Charge Code |
173272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.54 |
| Max. Negotiated Rate |
$134.68 |
| Rate for Payer: Aetna Commercial |
$121.21
|
| Rate for Payer: ASR ASR |
$130.64
|
| Rate for Payer: ASR Commercial |
$130.64
|
| Rate for Payer: BCBS Trust/PPO |
$109.75
|
| Rate for Payer: BCN Commercial |
$104.42
|
| Rate for Payer: Cash Price |
$107.74
|
| Rate for Payer: Cofinity Commercial |
$126.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.74
|
| Rate for Payer: Healthscope Commercial |
$134.68
|
| Rate for Payer: Healthscope Whirlpool |
$130.64
|
| Rate for Payer: Mclaren Commercial |
$121.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.48
|
| Rate for Payer: Nomi Health Commercial |
$110.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$118.52
|
|
|
UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION
|
Facility
|
OP
|
$134.68
|
|
|
Service Code
|
NDC 00173087306
|
| Hospital Charge Code |
173272
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.87 |
| Max. Negotiated Rate |
$134.68 |
| Rate for Payer: Aetna Commercial |
$121.21
|
| Rate for Payer: Aetna Medicare |
$67.34
|
| Rate for Payer: ASR ASR |
$130.64
|
| Rate for Payer: ASR Commercial |
$130.64
|
| Rate for Payer: BCBS Complete |
$53.87
|
| Rate for Payer: BCBS Trust/PPO |
$110.29
|
| Rate for Payer: BCN Commercial |
$104.42
|
| Rate for Payer: Cash Price |
$107.74
|
| Rate for Payer: Cofinity Commercial |
$126.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.74
|
| Rate for Payer: Healthscope Commercial |
$134.68
|
| Rate for Payer: Healthscope Whirlpool |
$130.64
|
| Rate for Payer: Mclaren Commercial |
$121.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$114.48
|
| Rate for Payer: Nomi Health Commercial |
$110.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$118.01
|
| Rate for Payer: Priority Health Narrow Network |
$94.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$118.52
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
OP
|
$365.75
|
|
|
Service Code
|
NDC 42806050301
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.30 |
| Max. Negotiated Rate |
$365.75 |
| Rate for Payer: Aetna Commercial |
$329.18
|
| Rate for Payer: Aetna Medicare |
$182.88
|
| Rate for Payer: ASR ASR |
$354.78
|
| Rate for Payer: ASR Commercial |
$354.78
|
| Rate for Payer: BCBS Complete |
$146.30
|
| Rate for Payer: BCBS Trust/PPO |
$299.51
|
| Rate for Payer: BCN Commercial |
$283.57
|
| Rate for Payer: Cash Price |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$343.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.60
|
| Rate for Payer: Healthscope Commercial |
$365.75
|
| Rate for Payer: Healthscope Whirlpool |
$354.78
|
| Rate for Payer: Mclaren Commercial |
$329.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.89
|
| Rate for Payer: Nomi Health Commercial |
$299.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$320.47
|
| Rate for Payer: Priority Health Narrow Network |
$256.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$321.86
|
|
|
URSODIOL 300 MG CAPSULE
|
Facility
|
IP
|
$365.75
|
|
|
Service Code
|
NDC 42806050301
|
| Hospital Charge Code |
11624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$237.74 |
| Max. Negotiated Rate |
$365.75 |
| Rate for Payer: Aetna Commercial |
$329.18
|
| Rate for Payer: ASR ASR |
$354.78
|
| Rate for Payer: ASR Commercial |
$354.78
|
| Rate for Payer: BCBS Trust/PPO |
$298.05
|
| Rate for Payer: BCN Commercial |
$283.57
|
| Rate for Payer: Cash Price |
$292.60
|
| Rate for Payer: Cofinity Commercial |
$343.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.60
|
| Rate for Payer: Healthscope Commercial |
$365.75
|
| Rate for Payer: Healthscope Whirlpool |
$354.78
|
| Rate for Payer: Mclaren Commercial |
$329.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.89
|
| Rate for Payer: Nomi Health Commercial |
$299.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$237.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$321.86
|
|
|
VALACYCLOVIR 500 MG TABLET
|
Facility
|
OP
|
$6.15
|
|
|
Service Code
|
NDC 50268078811
|
| Hospital Charge Code |
13133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$6.15 |
| Rate for Payer: Aetna Commercial |
$5.54
|
| Rate for Payer: Aetna Medicare |
$3.08
|
| Rate for Payer: ASR ASR |
$5.97
|
| Rate for Payer: ASR Commercial |
$5.97
|
| Rate for Payer: BCBS Complete |
$2.46
|
| Rate for Payer: BCBS Trust/PPO |
$5.04
|
| Rate for Payer: BCN Commercial |
$4.77
|
| Rate for Payer: Cash Price |
$4.92
|
| Rate for Payer: Cofinity Commercial |
$5.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.92
|
| Rate for Payer: Healthscope Commercial |
$6.15
|
| Rate for Payer: Healthscope Whirlpool |
$5.97
|
| Rate for Payer: Mclaren Commercial |
$5.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.23
|
| Rate for Payer: Nomi Health Commercial |
$5.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.39
|
| Rate for Payer: Priority Health Narrow Network |
$4.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.41
|
|
