|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$21.58
|
|
|
Service Code
|
NDC 409488750
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$21.58 |
| Rate for Payer: Aetna Commercial |
$19.42
|
| Rate for Payer: Aetna Medicare |
$7.99
|
| Rate for Payer: ASR ASR |
$20.94
|
| Rate for Payer: BCBS Complete |
$8.63
|
| Rate for Payer: BCBS Trust/PPO |
$17.80
|
| Rate for Payer: BCN Commercial |
$17.80
|
| Rate for Payer: Cash Price |
$17.27
|
| Rate for Payer: Cofinity Commercial |
$20.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.27
|
| Rate for Payer: Healthscope Commercial |
$20.94
|
| Rate for Payer: Healthscope Whirlpool |
$21.58
|
| Rate for Payer: Mclaren Commercial |
$19.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.35
|
| Rate for Payer: Nomi Health Commercial |
$17.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.19
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18.91
|
| Rate for Payer: Priority Health Narrow Network |
$15.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.99
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$23.05
|
|
|
Service Code
|
NDC 63323018505
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.29 |
| Max. Negotiated Rate |
$23.05 |
| Rate for Payer: Aetna Commercial |
$20.75
|
| Rate for Payer: ASR ASR |
$22.36
|
| Rate for Payer: BCBS Trust/PPO |
$18.93
|
| Rate for Payer: BCN Commercial |
$18.93
|
| Rate for Payer: Cash Price |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$21.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.44
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Whirlpool |
$23.05
|
| Rate for Payer: Mclaren Commercial |
$20.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.59
|
| Rate for Payer: Nomi Health Commercial |
$18.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.28
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 409488710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.55 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$13.50
|
| Rate for Payer: Aetna Medicare |
$5.55
|
| Rate for Payer: ASR ASR |
$14.55
|
| Rate for Payer: BCBS Complete |
$6.00
|
| Rate for Payer: BCBS Trust/PPO |
$12.37
|
| Rate for Payer: BCN Commercial |
$12.37
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$14.55
|
| Rate for Payer: Healthscope Whirlpool |
$15.00
|
| Rate for Payer: Mclaren Commercial |
$13.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.75
|
| Rate for Payer: Nomi Health Commercial |
$12.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.25
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$13.14
|
| Rate for Payer: Priority Health Narrow Network |
$10.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.20
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$26.97
|
|
|
Service Code
|
NDC 63323018520
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$26.97 |
| Rate for Payer: Aetna Commercial |
$24.27
|
| Rate for Payer: Aetna Medicare |
$9.98
|
| Rate for Payer: ASR ASR |
$26.16
|
| Rate for Payer: BCBS Complete |
$10.79
|
| Rate for Payer: BCBS Trust/PPO |
$22.23
|
| Rate for Payer: BCN Commercial |
$22.23
|
| Rate for Payer: Cash Price |
$21.57
|
| Rate for Payer: Cofinity Commercial |
$25.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.57
|
| Rate for Payer: Healthscope Commercial |
$26.16
|
| Rate for Payer: Healthscope Whirlpool |
$26.97
|
| Rate for Payer: Mclaren Commercial |
$24.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.92
|
| Rate for Payer: Nomi Health Commercial |
$22.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.23
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23.63
|
| Rate for Payer: Priority Health Narrow Network |
$18.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.73
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$20.65
|
|
|
Service Code
|
NDC 63323018510
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$20.65 |
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: BCBS Trust/PPO |
$16.96
|
| Rate for Payer: BCN Commercial |
$16.96
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$20.65
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$20.65
|
|
|
Service Code
|
NDC 63323018510
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$20.65 |
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: Aetna Medicare |
$7.64
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Trust/PPO |
$17.02
|
| Rate for Payer: BCN Commercial |
$17.02
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$20.65
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18.09
|
| Rate for Payer: Priority Health Narrow Network |
$14.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 409488710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna Commercial |
$13.50
|
| Rate for Payer: ASR ASR |
$14.55
|
| Rate for Payer: BCBS Trust/PPO |
$12.32
|
| Rate for Payer: BCN Commercial |
$12.32
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cofinity Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Healthscope Commercial |
$14.55
|
| Rate for Payer: Healthscope Whirlpool |
$15.00
|
| Rate for Payer: Mclaren Commercial |
$13.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.75
|
| Rate for Payer: Nomi Health Commercial |
$12.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.20
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$19.14
|
|
|
Service Code
|
NDC 409488723
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.36 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Aetna Commercial |
$17.23
|
| Rate for Payer: ASR ASR |
$18.57
|
| Rate for Payer: BCBS Trust/PPO |
$15.72
|
| Rate for Payer: BCN Commercial |
$15.72
|
| Rate for Payer: Cash Price |
$15.31
|
| Rate for Payer: Cofinity Commercial |
$17.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.31
|
| Rate for Payer: Healthscope Commercial |
$18.57
|
| Rate for Payer: Healthscope Whirlpool |
$19.14
|
| Rate for Payer: Mclaren Commercial |
$17.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.27
|
| Rate for Payer: Nomi Health Commercial |
$15.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.84
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$19.14
|
|
|
Service Code
|
NDC 409488720
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.36 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Aetna Commercial |
$17.23
|
| Rate for Payer: ASR ASR |
$18.57
|
| Rate for Payer: BCBS Trust/PPO |
$15.72
|
| Rate for Payer: BCN Commercial |
$15.72
|
| Rate for Payer: Cash Price |
$15.31
|
| Rate for Payer: Cofinity Commercial |
$17.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.31
|
| Rate for Payer: Healthscope Commercial |
$18.57
|
| Rate for Payer: Healthscope Whirlpool |
$19.14
|
| Rate for Payer: Mclaren Commercial |
$17.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.27
|
| Rate for Payer: Nomi Health Commercial |
$15.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.84
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$21.58
|
|
|
Service Code
|
NDC 409488750
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.19 |
| Max. Negotiated Rate |
$21.58 |
| Rate for Payer: Aetna Commercial |
$19.42
|
| Rate for Payer: ASR ASR |
$20.94
|
| Rate for Payer: BCBS Trust/PPO |
$17.72
|
| Rate for Payer: BCN Commercial |
$17.72
|
| Rate for Payer: Cash Price |
$17.27
|
| Rate for Payer: Cofinity Commercial |
$20.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.27
|
| Rate for Payer: Healthscope Commercial |
$20.94
|
| Rate for Payer: Healthscope Whirlpool |
$21.58
|
| Rate for Payer: Mclaren Commercial |
$19.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.35
|
| Rate for Payer: Nomi Health Commercial |
$17.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.99
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$23.05
|
|
|
Service Code
|
NDC 63323018505
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.53 |
| Max. Negotiated Rate |
$23.05 |
| Rate for Payer: Aetna Commercial |
$20.75
|
| Rate for Payer: Aetna Medicare |
$8.53
|
| Rate for Payer: ASR ASR |
$22.36
|
| Rate for Payer: BCBS Complete |
$9.22
|
| Rate for Payer: BCBS Trust/PPO |
$19.01
|
| Rate for Payer: BCN Commercial |
$19.01
|
| Rate for Payer: Cash Price |
$18.44
|
| Rate for Payer: Cofinity Commercial |
$21.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.44
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Whirlpool |
$23.05
|
| Rate for Payer: Mclaren Commercial |
$20.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.59
|
| Rate for Payer: Nomi Health Commercial |
$18.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.29
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$20.20
|
| Rate for Payer: Priority Health Narrow Network |
$16.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.28
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION FOR SOLID FORM MIXTURES
|
Facility
|
OP
|
$20.65
|
|
|
Service Code
|
NDC 63323018507
|
| Hospital Charge Code |
301772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$20.65 |
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: Aetna Medicare |
$7.64
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Trust/PPO |
$17.02
|
| Rate for Payer: BCN Commercial |
$17.02
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$20.65
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$18.09
|
| Rate for Payer: Priority Health Narrow Network |
$14.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION FOR SOLID FORM MIXTURES
|
Facility
|
IP
|
$20.65
|
|
|
Service Code
|
NDC 63323018507
|
| Hospital Charge Code |
301772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$20.65 |
| Rate for Payer: Aetna Commercial |
$18.58
|
| Rate for Payer: ASR ASR |
$20.03
|
| Rate for Payer: BCBS Trust/PPO |
$16.96
|
| Rate for Payer: BCN Commercial |
$16.96
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$19.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Healthscope Whirlpool |
$20.65
|
| Rate for Payer: Mclaren Commercial |
$18.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.17
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$47.85
|
|
|
Service Code
|
NDC 338001304
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.89 |
| Max. Negotiated Rate |
$47.85 |
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: ASR ASR |
$46.41
|
| Rate for Payer: BCBS Trust/PPO |
$39.29
|
| Rate for Payer: BCN Commercial |
$39.29
|
| Rate for Payer: Cash Price |
$38.28
|
| Rate for Payer: Cofinity Commercial |
$44.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.28
|
| Rate for Payer: Healthscope Commercial |
$46.41
|
| Rate for Payer: Healthscope Whirlpool |
$47.85
|
| Rate for Payer: Mclaren Commercial |
$43.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.67
|
| Rate for Payer: Nomi Health Commercial |
$39.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.11
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$47.85
|
|
|
Service Code
|
NDC 338001304
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$47.85 |
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: Aetna Medicare |
$17.70
|
| Rate for Payer: ASR ASR |
$46.41
|
| Rate for Payer: BCBS Complete |
$19.14
|
| Rate for Payer: BCBS Trust/PPO |
$39.45
|
| Rate for Payer: BCN Commercial |
$39.45
|
| Rate for Payer: Cash Price |
$38.28
|
| Rate for Payer: Cofinity Commercial |
$44.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.28
|
| Rate for Payer: Healthscope Commercial |
$46.41
|
| Rate for Payer: Healthscope Whirlpool |
$47.85
|
| Rate for Payer: Mclaren Commercial |
$43.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$38.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.67
|
| Rate for Payer: Nomi Health Commercial |
$39.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$41.93
|
| Rate for Payer: Priority Health Narrow Network |
$33.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.11
|
|
|
WHITE PETROLATUM 57.7 %-MINERAL OIL 31.9 % EYE OINTMENT
|
Facility
|
IP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
175688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.85 |
| Max. Negotiated Rate |
$27.80 |
| Rate for Payer: Aetna Commercial |
$25.02
|
| Rate for Payer: ASR ASR |
$26.96
|
| Rate for Payer: BCBS Trust/PPO |
$22.83
|
| Rate for Payer: BCN Commercial |
$22.83
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Commercial |
$26.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Healthscope Commercial |
$26.96
|
| Rate for Payer: Healthscope Whirlpool |
$27.80
|
| Rate for Payer: Mclaren Commercial |
$25.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Nomi Health Commercial |
$22.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.46
|
|
|
WHITE PETROLATUM 57.7 %-MINERAL OIL 31.9 % EYE OINTMENT
|
Facility
|
OP
|
$27.80
|
|
|
Service Code
|
NDC 63736014308
|
| Hospital Charge Code |
175688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.28 |
| Max. Negotiated Rate |
$27.80 |
| Rate for Payer: Aetna Commercial |
$25.02
|
| Rate for Payer: Aetna Medicare |
$10.28
|
| Rate for Payer: ASR ASR |
$26.96
|
| Rate for Payer: BCBS Complete |
$11.12
|
| Rate for Payer: BCBS Trust/PPO |
$22.92
|
| Rate for Payer: BCN Commercial |
$22.92
|
| Rate for Payer: Cash Price |
$22.24
|
| Rate for Payer: Cofinity Commercial |
$26.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.24
|
| Rate for Payer: Healthscope Commercial |
$26.96
|
| Rate for Payer: Healthscope Whirlpool |
$27.80
|
| Rate for Payer: Mclaren Commercial |
$25.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Nomi Health Commercial |
$22.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$24.35
|
| Rate for Payer: Priority Health Narrow Network |
$19.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.46
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT
|
Facility
|
OP
|
$31.81
|
|
|
Service Code
|
NDC 23031204
|
| Hospital Charge Code |
117955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.77 |
| Max. Negotiated Rate |
$31.81 |
| Rate for Payer: Aetna Commercial |
$28.63
|
| Rate for Payer: Aetna Medicare |
$11.77
|
| Rate for Payer: ASR ASR |
$30.86
|
| Rate for Payer: BCBS Complete |
$12.73
|
| Rate for Payer: BCBS Trust/PPO |
$26.23
|
| Rate for Payer: BCN Commercial |
$26.23
|
| Rate for Payer: Cash Price |
$25.45
|
| Rate for Payer: Cofinity Commercial |
$29.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.45
|
| Rate for Payer: Healthscope Commercial |
$30.86
|
| Rate for Payer: Healthscope Whirlpool |
$31.81
|
| Rate for Payer: Mclaren Commercial |
$28.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.04
|
| Rate for Payer: Nomi Health Commercial |
$26.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$27.88
|
| Rate for Payer: Priority Health Narrow Network |
$22.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.00
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT
|
Facility
|
IP
|
$31.81
|
|
|
Service Code
|
NDC 23031204
|
| Hospital Charge Code |
117955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.86 |
| Max. Negotiated Rate |
$31.81 |
| Rate for Payer: Aetna Commercial |
$28.63
|
| Rate for Payer: ASR ASR |
$30.86
|
| Rate for Payer: BCBS Trust/PPO |
$26.13
|
| Rate for Payer: BCN Commercial |
$26.13
|
| Rate for Payer: Cash Price |
$25.45
|
| Rate for Payer: Cofinity Commercial |
$29.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.45
|
| Rate for Payer: Healthscope Commercial |
$30.86
|
| Rate for Payer: Healthscope Whirlpool |
$31.81
|
| Rate for Payer: Mclaren Commercial |
$28.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.04
|
| Rate for Payer: Nomi Health Commercial |
$26.09
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.00
|
|
|
WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT
|
Facility
|
OP
|
$22.10
|
|
|
Service Code
|
NDC 904648838
|
| Hospital Charge Code |
117765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$22.10 |
| Rate for Payer: Aetna Commercial |
$19.89
|
| Rate for Payer: Aetna Medicare |
$8.18
|
| Rate for Payer: ASR ASR |
$21.44
|
| Rate for Payer: BCBS Complete |
$8.84
|
| Rate for Payer: BCBS Trust/PPO |
$18.22
|
| Rate for Payer: BCN Commercial |
$18.22
|
| Rate for Payer: Cash Price |
$17.68
|
| Rate for Payer: Cofinity Commercial |
$20.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.68
|
| Rate for Payer: Healthscope Commercial |
$21.44
|
| Rate for Payer: Healthscope Whirlpool |
$22.10
|
| Rate for Payer: Mclaren Commercial |
$19.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.78
|
| Rate for Payer: Nomi Health Commercial |
$18.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.57
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$19.36
|
| Rate for Payer: Priority Health Narrow Network |
$15.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.45
|
|
|
WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT
|
Facility
|
IP
|
$22.10
|
|
|
Service Code
|
NDC 904648838
|
| Hospital Charge Code |
117765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$22.10 |
| Rate for Payer: Aetna Commercial |
$19.89
|
| Rate for Payer: ASR ASR |
$21.44
|
| Rate for Payer: BCBS Trust/PPO |
$18.15
|
| Rate for Payer: BCN Commercial |
$18.15
|
| Rate for Payer: Cash Price |
$17.68
|
| Rate for Payer: Cofinity Commercial |
$20.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.68
|
| Rate for Payer: Healthscope Commercial |
$21.44
|
| Rate for Payer: Healthscope Whirlpool |
$22.10
|
| Rate for Payer: Mclaren Commercial |
$19.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.78
|
| Rate for Payer: Nomi Health Commercial |
$18.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.45
|
|
|
WHITE PETROLATUM TOPICAL JELLY
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 53329006801
|
| Hospital Charge Code |
28809
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$5.11 |
| Rate for Payer: Aetna Commercial |
$4.60
|
| Rate for Payer: Aetna Medicare |
$1.89
|
| Rate for Payer: ASR ASR |
$4.96
|
| Rate for Payer: BCBS Complete |
$2.04
|
| Rate for Payer: BCBS Trust/PPO |
$4.21
|
| Rate for Payer: BCN Commercial |
$4.21
|
| Rate for Payer: Cash Price |
$4.09
|
| Rate for Payer: Cofinity Commercial |
$4.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.09
|
| Rate for Payer: Healthscope Commercial |
$4.96
|
| Rate for Payer: Healthscope Whirlpool |
$5.11
|
| Rate for Payer: Mclaren Commercial |
$4.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.35
|
| Rate for Payer: Nomi Health Commercial |
$4.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.83
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.48
|
| Rate for Payer: Priority Health Narrow Network |
$3.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.50
|
|
|
WHITE PETROLATUM TOPICAL JELLY
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 53329006801
|
| Hospital Charge Code |
28809
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$5.11 |
| Rate for Payer: Aetna Commercial |
$4.60
|
| Rate for Payer: ASR ASR |
$4.96
|
| Rate for Payer: BCBS Trust/PPO |
$4.20
|
| Rate for Payer: BCN Commercial |
$4.20
|
| Rate for Payer: Cash Price |
$4.09
|
| Rate for Payer: Cofinity Commercial |
$4.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.09
|
| Rate for Payer: Healthscope Commercial |
$4.96
|
| Rate for Payer: Healthscope Whirlpool |
$5.11
|
| Rate for Payer: Mclaren Commercial |
$4.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.35
|
| Rate for Payer: Nomi Health Commercial |
$4.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.50
|
|
|
WHITE PETROLATUM TOPICAL JELLY
|
Facility
|
IP
|
$5.11
|
|
|
Service Code
|
NDC 84389011138
|
| Hospital Charge Code |
28809
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$5.11 |
| Rate for Payer: Aetna Commercial |
$4.60
|
| Rate for Payer: ASR ASR |
$4.96
|
| Rate for Payer: BCBS Trust/PPO |
$4.20
|
| Rate for Payer: BCN Commercial |
$4.20
|
| Rate for Payer: Cash Price |
$4.09
|
| Rate for Payer: Cofinity Commercial |
$4.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.09
|
| Rate for Payer: Healthscope Commercial |
$4.96
|
| Rate for Payer: Healthscope Whirlpool |
$5.11
|
| Rate for Payer: Mclaren Commercial |
$4.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.35
|
| Rate for Payer: Nomi Health Commercial |
$4.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.50
|
|
|
WHITE PETROLATUM TOPICAL JELLY
|
Facility
|
OP
|
$5.11
|
|
|
Service Code
|
NDC 84389011138
|
| Hospital Charge Code |
28809
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$5.11 |
| Rate for Payer: Aetna Commercial |
$4.60
|
| Rate for Payer: Aetna Medicare |
$1.89
|
| Rate for Payer: ASR ASR |
$4.96
|
| Rate for Payer: BCBS Complete |
$2.04
|
| Rate for Payer: BCBS Trust/PPO |
$4.21
|
| Rate for Payer: BCN Commercial |
$4.21
|
| Rate for Payer: Cash Price |
$4.09
|
| Rate for Payer: Cofinity Commercial |
$4.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.09
|
| Rate for Payer: Healthscope Commercial |
$4.96
|
| Rate for Payer: Healthscope Whirlpool |
$5.11
|
| Rate for Payer: Mclaren Commercial |
$4.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.35
|
| Rate for Payer: Nomi Health Commercial |
$4.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.83
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.48
|
| Rate for Payer: Priority Health Narrow Network |
$3.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.50
|
|
