|
VILAZODONE 20 MG TABLET
|
Facility
|
OP
|
$527.03
|
|
|
Service Code
|
NDC 60505477303
|
| Hospital Charge Code |
152700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.81 |
| Max. Negotiated Rate |
$527.03 |
| Rate for Payer: Aetna Commercial |
$474.33
|
| Rate for Payer: Aetna Medicare |
$263.51
|
| Rate for Payer: ASR ASR |
$511.22
|
| Rate for Payer: ASR Commercial |
$511.22
|
| Rate for Payer: BCBS Complete |
$210.81
|
| Rate for Payer: BCBS Trust/PPO |
$431.58
|
| Rate for Payer: BCN Commercial |
$408.61
|
| Rate for Payer: Cash Price |
$421.62
|
| Rate for Payer: Cofinity Commercial |
$495.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$421.62
|
| Rate for Payer: Healthscope Commercial |
$527.03
|
| Rate for Payer: Healthscope Whirlpool |
$511.22
|
| Rate for Payer: Mclaren Commercial |
$474.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$447.98
|
| Rate for Payer: Nomi Health Commercial |
$432.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$342.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$461.78
|
| Rate for Payer: Priority Health Narrow Network |
$369.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$463.79
|
|
|
VILAZODONE 40 MG TABLET
|
Facility
|
OP
|
$542.24
|
|
|
Service Code
|
NDC 62332023430
|
| Hospital Charge Code |
152701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$216.90 |
| Max. Negotiated Rate |
$542.24 |
| Rate for Payer: Aetna Commercial |
$488.02
|
| Rate for Payer: Aetna Medicare |
$271.12
|
| Rate for Payer: ASR ASR |
$525.97
|
| Rate for Payer: ASR Commercial |
$525.97
|
| Rate for Payer: BCBS Complete |
$216.90
|
| Rate for Payer: BCBS Trust/PPO |
$444.04
|
| Rate for Payer: BCN Commercial |
$420.40
|
| Rate for Payer: Cash Price |
$433.79
|
| Rate for Payer: Cofinity Commercial |
$509.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$433.79
|
| Rate for Payer: Healthscope Commercial |
$542.24
|
| Rate for Payer: Healthscope Whirlpool |
$525.97
|
| Rate for Payer: Mclaren Commercial |
$488.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$460.90
|
| Rate for Payer: Nomi Health Commercial |
$444.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$352.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$475.11
|
| Rate for Payer: Priority Health Narrow Network |
$380.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$477.17
|
|
|
VILAZODONE 40 MG TABLET
|
Facility
|
IP
|
$542.24
|
|
|
Service Code
|
NDC 62332023430
|
| Hospital Charge Code |
152701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$352.46 |
| Max. Negotiated Rate |
$542.24 |
| Rate for Payer: Aetna Commercial |
$488.02
|
| Rate for Payer: ASR ASR |
$525.97
|
| Rate for Payer: ASR Commercial |
$525.97
|
| Rate for Payer: BCBS Trust/PPO |
$441.87
|
| Rate for Payer: BCN Commercial |
$420.40
|
| Rate for Payer: Cash Price |
$433.79
|
| Rate for Payer: Cofinity Commercial |
$509.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$433.79
|
| Rate for Payer: Healthscope Commercial |
$542.24
|
| Rate for Payer: Healthscope Whirlpool |
$525.97
|
| Rate for Payer: Mclaren Commercial |
$488.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$460.90
|
| Rate for Payer: Nomi Health Commercial |
$444.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$352.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$477.17
|
|
|
VIT A-D3-E-ALOE VERA-ZINC TOPICAL OINTMENT
|
Facility
|
OP
|
$15.30
|
|
|
Service Code
|
NDC 61924020404
|
| Hospital Charge Code |
115852
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: Aetna Medicare |
$7.65
|
| Rate for Payer: ASR ASR |
$14.84
|
| Rate for Payer: ASR Commercial |
$14.84
|
| Rate for Payer: BCBS Complete |
$6.12
|
| Rate for Payer: BCBS Trust/PPO |
$12.53
|
| Rate for Payer: BCN Commercial |
$11.86
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Healthscope Commercial |
$15.30
|
| Rate for Payer: Healthscope Whirlpool |
$14.84
|
| Rate for Payer: Mclaren Commercial |
$13.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: Nomi Health Commercial |
$12.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.41
|
| Rate for Payer: Priority Health Narrow Network |
$10.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.46
|
|
|
VIT A-D3-E-ALOE VERA-ZINC TOPICAL OINTMENT
|
Facility
|
IP
|
$15.30
|
|
|
Service Code
|
NDC 61924020404
|
| Hospital Charge Code |
115852
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: ASR ASR |
$14.84
|
| Rate for Payer: ASR Commercial |
$14.84
|
| Rate for Payer: BCBS Trust/PPO |
$12.47
|
| Rate for Payer: BCN Commercial |
$11.86
|
| Rate for Payer: Cash Price |
$12.24
|
| Rate for Payer: Cofinity Commercial |
$14.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.24
|
| Rate for Payer: Healthscope Commercial |
$15.30
|
| Rate for Payer: Healthscope Whirlpool |
$14.84
|
| Rate for Payer: Mclaren Commercial |
$13.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: Nomi Health Commercial |
$12.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.46
|
|
|
VITAMIN B COMPLEX CAPSULE
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
NDC 00536478701
|
| Hospital Charge Code |
804
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.65 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: ASR ASR |
$136.77
|
| Rate for Payer: ASR Commercial |
$136.77
|
| Rate for Payer: BCBS Trust/PPO |
$114.90
|
| Rate for Payer: BCN Commercial |
$109.32
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$132.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$141.00
|
| Rate for Payer: Healthscope Whirlpool |
$136.77
|
| Rate for Payer: Mclaren Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: Nomi Health Commercial |
$115.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.08
|
|
|
VITAMIN B COMPLEX CAPSULE
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
NDC 00536478701
|
| Hospital Charge Code |
804
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.40 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Aetna Medicare |
$70.50
|
| Rate for Payer: ASR ASR |
$136.77
|
| Rate for Payer: ASR Commercial |
$136.77
|
| Rate for Payer: BCBS Complete |
$56.40
|
| Rate for Payer: BCBS Trust/PPO |
$115.46
|
| Rate for Payer: BCN Commercial |
$109.32
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$132.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$141.00
|
| Rate for Payer: Healthscope Whirlpool |
$136.77
|
| Rate for Payer: Mclaren Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: Nomi Health Commercial |
$115.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$123.54
|
| Rate for Payer: Priority Health Narrow Network |
$98.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.08
|
|
|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT
|
Facility
|
IP
|
$12.62
|
|
|
Service Code
|
NDC 41100081163
|
| Hospital Charge Code |
118725
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$12.62 |
| Rate for Payer: Aetna Commercial |
$11.36
|
| Rate for Payer: ASR ASR |
$12.24
|
| Rate for Payer: ASR Commercial |
$12.24
|
| Rate for Payer: BCBS Trust/PPO |
$10.28
|
| Rate for Payer: BCN Commercial |
$9.78
|
| Rate for Payer: Cash Price |
$10.10
|
| Rate for Payer: Cofinity Commercial |
$11.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.10
|
| Rate for Payer: Healthscope Commercial |
$12.62
|
| Rate for Payer: Healthscope Whirlpool |
$12.24
|
| Rate for Payer: Mclaren Commercial |
$11.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.73
|
| Rate for Payer: Nomi Health Commercial |
$10.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.11
|
|
|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT
|
Facility
|
OP
|
$12.62
|
|
|
Service Code
|
NDC 41100081163
|
| Hospital Charge Code |
118725
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.05 |
| Max. Negotiated Rate |
$12.62 |
| Rate for Payer: Aetna Commercial |
$11.36
|
| Rate for Payer: Aetna Medicare |
$6.31
|
| Rate for Payer: ASR ASR |
$12.24
|
| Rate for Payer: ASR Commercial |
$12.24
|
| Rate for Payer: BCBS Complete |
$5.05
|
| Rate for Payer: BCBS Trust/PPO |
$10.33
|
| Rate for Payer: BCN Commercial |
$9.78
|
| Rate for Payer: Cash Price |
$10.10
|
| Rate for Payer: Cofinity Commercial |
$11.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.10
|
| Rate for Payer: Healthscope Commercial |
$12.62
|
| Rate for Payer: Healthscope Whirlpool |
$12.24
|
| Rate for Payer: Mclaren Commercial |
$11.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.73
|
| Rate for Payer: Nomi Health Commercial |
$10.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.06
|
| Rate for Payer: Priority Health Narrow Network |
$8.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.11
|
|
|
VIVONEX RTF BOLUS FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 43900036250
|
| Hospital Charge Code |
150771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF BOLUS FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 43900036250
|
| Hospital Charge Code |
150771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF CONTINUOUS FEED
|
Facility
|
IP
|
$6,408.40
|
|
|
Service Code
|
NDC 09900000576
|
| Hospital Charge Code |
168947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,165.46 |
| Max. Negotiated Rate |
$6,408.40 |
| Rate for Payer: Aetna Commercial |
$5,767.56
|
| Rate for Payer: ASR ASR |
$6,216.15
|
| Rate for Payer: ASR Commercial |
$6,216.15
|
| Rate for Payer: BCBS Trust/PPO |
$5,222.21
|
| Rate for Payer: BCN Commercial |
$4,968.43
|
| Rate for Payer: Cash Price |
$5,126.72
|
| Rate for Payer: Cofinity Commercial |
$6,023.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,126.72
|
| Rate for Payer: Healthscope Commercial |
$6,408.40
|
| Rate for Payer: Healthscope Whirlpool |
$6,216.15
|
| Rate for Payer: Mclaren Commercial |
$5,767.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,447.14
|
| Rate for Payer: Nomi Health Commercial |
$5,254.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,165.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,639.39
|
|
|
VIVONEX RTF CONTINUOUS FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 43900036250
|
| Hospital Charge Code |
168947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF CONTINUOUS FEED
|
Facility
|
OP
|
$6,408.40
|
|
|
Service Code
|
NDC 09900000576
|
| Hospital Charge Code |
168947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,563.36 |
| Max. Negotiated Rate |
$6,408.40 |
| Rate for Payer: Aetna Commercial |
$5,767.56
|
| Rate for Payer: Aetna Medicare |
$3,204.20
|
| Rate for Payer: ASR ASR |
$6,216.15
|
| Rate for Payer: ASR Commercial |
$6,216.15
|
| Rate for Payer: BCBS Complete |
$2,563.36
|
| Rate for Payer: BCBS Trust/PPO |
$5,247.84
|
| Rate for Payer: BCN Commercial |
$4,968.43
|
| Rate for Payer: Cash Price |
$5,126.72
|
| Rate for Payer: Cofinity Commercial |
$6,023.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,126.72
|
| Rate for Payer: Healthscope Commercial |
$6,408.40
|
| Rate for Payer: Healthscope Whirlpool |
$6,216.15
|
| Rate for Payer: Mclaren Commercial |
$5,767.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,447.14
|
| Rate for Payer: Nomi Health Commercial |
$5,254.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,165.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,615.04
|
| Rate for Payer: Priority Health Narrow Network |
$4,492.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,639.39
|
|
|
VIVONEX RTF CONTINUOUS FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 43900036250
|
| Hospital Charge Code |
168947
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF CYCLIC FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 43900036250
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF CYCLIC FEED
|
Facility
|
OP
|
$6,408.40
|
|
|
Service Code
|
NDC 09900000576
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,563.36 |
| Max. Negotiated Rate |
$6,408.40 |
| Rate for Payer: Aetna Commercial |
$5,767.56
|
| Rate for Payer: Aetna Medicare |
$3,204.20
|
| Rate for Payer: ASR ASR |
$6,216.15
|
| Rate for Payer: ASR Commercial |
$6,216.15
|
| Rate for Payer: BCBS Complete |
$2,563.36
|
| Rate for Payer: BCBS Trust/PPO |
$5,247.84
|
| Rate for Payer: BCN Commercial |
$4,968.43
|
| Rate for Payer: Cash Price |
$5,126.72
|
| Rate for Payer: Cofinity Commercial |
$6,023.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,126.72
|
| Rate for Payer: Healthscope Commercial |
$6,408.40
|
| Rate for Payer: Healthscope Whirlpool |
$6,216.15
|
| Rate for Payer: Mclaren Commercial |
$5,767.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,447.14
|
| Rate for Payer: Nomi Health Commercial |
$5,254.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,165.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,615.04
|
| Rate for Payer: Priority Health Narrow Network |
$4,492.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,639.39
|
|
|
VIVONEX RTF CYCLIC FEED
|
Facility
|
IP
|
$6,408.40
|
|
|
Service Code
|
NDC 09900000576
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,165.46 |
| Max. Negotiated Rate |
$6,408.40 |
| Rate for Payer: Aetna Commercial |
$5,767.56
|
| Rate for Payer: ASR ASR |
$6,216.15
|
| Rate for Payer: ASR Commercial |
$6,216.15
|
| Rate for Payer: BCBS Trust/PPO |
$5,222.21
|
| Rate for Payer: BCN Commercial |
$4,968.43
|
| Rate for Payer: Cash Price |
$5,126.72
|
| Rate for Payer: Cofinity Commercial |
$6,023.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,126.72
|
| Rate for Payer: Healthscope Commercial |
$6,408.40
|
| Rate for Payer: Healthscope Whirlpool |
$6,216.15
|
| Rate for Payer: Mclaren Commercial |
$5,767.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,447.14
|
| Rate for Payer: Nomi Health Commercial |
$5,254.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,165.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,639.39
|
|
|
VIVONEX RTF CYCLIC FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 43900036250
|
| Hospital Charge Code |
200089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 43900036250
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
|
IP
|
$6,408.40
|
|
|
Service Code
|
NDC 09900000576
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,165.46 |
| Max. Negotiated Rate |
$6,408.40 |
| Rate for Payer: Aetna Commercial |
$5,767.56
|
| Rate for Payer: ASR ASR |
$6,216.15
|
| Rate for Payer: ASR Commercial |
$6,216.15
|
| Rate for Payer: BCBS Trust/PPO |
$5,222.21
|
| Rate for Payer: BCN Commercial |
$4,968.43
|
| Rate for Payer: Cash Price |
$5,126.72
|
| Rate for Payer: Cofinity Commercial |
$6,023.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,126.72
|
| Rate for Payer: Healthscope Commercial |
$6,408.40
|
| Rate for Payer: Healthscope Whirlpool |
$6,216.15
|
| Rate for Payer: Mclaren Commercial |
$5,767.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,447.14
|
| Rate for Payer: Nomi Health Commercial |
$5,254.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,165.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,639.39
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
|
OP
|
$6,408.40
|
|
|
Service Code
|
NDC 09900000576
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,563.36 |
| Max. Negotiated Rate |
$6,408.40 |
| Rate for Payer: Aetna Commercial |
$5,767.56
|
| Rate for Payer: Aetna Medicare |
$3,204.20
|
| Rate for Payer: ASR ASR |
$6,216.15
|
| Rate for Payer: ASR Commercial |
$6,216.15
|
| Rate for Payer: BCBS Complete |
$2,563.36
|
| Rate for Payer: BCBS Trust/PPO |
$5,247.84
|
| Rate for Payer: BCN Commercial |
$4,968.43
|
| Rate for Payer: Cash Price |
$5,126.72
|
| Rate for Payer: Cofinity Commercial |
$6,023.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,126.72
|
| Rate for Payer: Healthscope Commercial |
$6,408.40
|
| Rate for Payer: Healthscope Whirlpool |
$6,216.15
|
| Rate for Payer: Mclaren Commercial |
$5,767.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,447.14
|
| Rate for Payer: Nomi Health Commercial |
$5,254.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,165.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,615.04
|
| Rate for Payer: Priority Health Narrow Network |
$4,492.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5,639.39
|
|
|
VIVONEX RTF INTERMITTENT FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 43900036250
|
| Hospital Charge Code |
200088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
WARFARIN 1 MG TABLET
|
Facility
|
OP
|
$371.30
|
|
|
Service Code
|
NDC 00832121101
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.52 |
| Max. Negotiated Rate |
$371.30 |
| Rate for Payer: Aetna Commercial |
$334.17
|
| Rate for Payer: Aetna Medicare |
$185.65
|
| Rate for Payer: ASR ASR |
$360.16
|
| Rate for Payer: ASR Commercial |
$360.16
|
| Rate for Payer: BCBS Complete |
$148.52
|
| Rate for Payer: BCBS Trust/PPO |
$304.06
|
| Rate for Payer: BCN Commercial |
$287.87
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Commercial |
$349.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$371.30
|
| Rate for Payer: Healthscope Whirlpool |
$360.16
|
| Rate for Payer: Mclaren Commercial |
$334.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.61
|
| Rate for Payer: Nomi Health Commercial |
$304.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$325.33
|
| Rate for Payer: Priority Health Narrow Network |
$260.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$326.74
|
|
|
WARFARIN 1 MG TABLET
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 00832121189
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: ASR ASR |
$3.60
|
| Rate for Payer: ASR Commercial |
$3.60
|
| Rate for Payer: BCBS Trust/PPO |
$3.02
|
| Rate for Payer: BCN Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$2.97
|
| Rate for Payer: Cofinity Commercial |
$3.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.97
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Healthscope Whirlpool |
$3.60
|
| Rate for Payer: Mclaren Commercial |
$3.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.15
|
| Rate for Payer: Nomi Health Commercial |
$3.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.26
|
|
