|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$27.55
|
|
|
Service Code
|
NDC 00409488750
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.02 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Aetna Commercial |
$24.80
|
| Rate for Payer: Aetna Medicare |
$13.78
|
| Rate for Payer: ASR ASR |
$26.72
|
| Rate for Payer: ASR Commercial |
$26.72
|
| Rate for Payer: BCBS Complete |
$11.02
|
| Rate for Payer: BCBS Trust/PPO |
$22.56
|
| Rate for Payer: BCN Commercial |
$21.36
|
| Rate for Payer: Cash Price |
$22.04
|
| Rate for Payer: Cofinity Commercial |
$25.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.04
|
| Rate for Payer: Healthscope Commercial |
$27.55
|
| Rate for Payer: Healthscope Whirlpool |
$26.72
|
| Rate for Payer: Mclaren Commercial |
$24.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.42
|
| Rate for Payer: Nomi Health Commercial |
$22.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24.14
|
| Rate for Payer: Priority Health Narrow Network |
$19.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.24
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$20.24
|
|
|
Service Code
|
NDC 63323018505
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Medicare |
$10.12
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: ASR Commercial |
$19.63
|
| Rate for Payer: BCBS Complete |
$8.10
|
| Rate for Payer: BCBS Trust/PPO |
$16.57
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.20
|
| Rate for Payer: Nomi Health Commercial |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.73
|
| Rate for Payer: Priority Health Narrow Network |
$14.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$15.08
|
|
|
Service Code
|
NDC 00409488720
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna Commercial |
$13.57
|
| Rate for Payer: Aetna Medicare |
$7.54
|
| Rate for Payer: ASR ASR |
$14.63
|
| Rate for Payer: ASR Commercial |
$14.63
|
| Rate for Payer: BCBS Complete |
$6.03
|
| Rate for Payer: BCBS Trust/PPO |
$12.35
|
| Rate for Payer: BCN Commercial |
$11.69
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: Healthscope Whirlpool |
$14.63
|
| Rate for Payer: Mclaren Commercial |
$13.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.82
|
| Rate for Payer: Nomi Health Commercial |
$12.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.21
|
| Rate for Payer: Priority Health Narrow Network |
$10.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.27
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$20.24
|
|
|
Service Code
|
NDC 63323018504
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Medicare |
$10.12
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: ASR Commercial |
$19.63
|
| Rate for Payer: BCBS Complete |
$8.10
|
| Rate for Payer: BCBS Trust/PPO |
$16.57
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.20
|
| Rate for Payer: Nomi Health Commercial |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.73
|
| Rate for Payer: Priority Health Narrow Network |
$14.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$18.11
|
|
|
Service Code
|
NDC 63323018510
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.77 |
| Max. Negotiated Rate |
$18.11 |
| Rate for Payer: Aetna Commercial |
$16.30
|
| Rate for Payer: ASR ASR |
$17.57
|
| Rate for Payer: ASR Commercial |
$17.57
|
| Rate for Payer: BCBS Trust/PPO |
$14.76
|
| Rate for Payer: BCN Commercial |
$14.04
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.49
|
| Rate for Payer: Healthscope Commercial |
$18.11
|
| Rate for Payer: Healthscope Whirlpool |
$17.57
|
| Rate for Payer: Mclaren Commercial |
$16.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.39
|
| Rate for Payer: Nomi Health Commercial |
$14.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.94
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$18.11
|
|
|
Service Code
|
NDC 63323018510
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.24 |
| Max. Negotiated Rate |
$18.11 |
| Rate for Payer: Aetna Commercial |
$16.30
|
| Rate for Payer: Aetna Medicare |
$9.06
|
| Rate for Payer: ASR ASR |
$17.57
|
| Rate for Payer: ASR Commercial |
$17.57
|
| Rate for Payer: BCBS Complete |
$7.24
|
| Rate for Payer: BCBS Trust/PPO |
$14.83
|
| Rate for Payer: BCN Commercial |
$14.04
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.49
|
| Rate for Payer: Healthscope Commercial |
$18.11
|
| Rate for Payer: Healthscope Whirlpool |
$17.57
|
| Rate for Payer: Mclaren Commercial |
$16.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.39
|
| Rate for Payer: Nomi Health Commercial |
$14.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.87
|
| Rate for Payer: Priority Health Narrow Network |
$12.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.94
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$27.55
|
|
|
Service Code
|
NDC 00409488750
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.91 |
| Max. Negotiated Rate |
$27.55 |
| Rate for Payer: Aetna Commercial |
$24.80
|
| Rate for Payer: ASR ASR |
$26.72
|
| Rate for Payer: ASR Commercial |
$26.72
|
| Rate for Payer: BCBS Trust/PPO |
$22.45
|
| Rate for Payer: BCN Commercial |
$21.36
|
| Rate for Payer: Cash Price |
$22.04
|
| Rate for Payer: Cofinity Commercial |
$25.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.04
|
| Rate for Payer: Healthscope Commercial |
$27.55
|
| Rate for Payer: Healthscope Whirlpool |
$26.72
|
| Rate for Payer: Mclaren Commercial |
$24.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.42
|
| Rate for Payer: Nomi Health Commercial |
$22.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.24
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00409488710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.10 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$12.60
|
| Rate for Payer: ASR ASR |
$13.58
|
| Rate for Payer: ASR Commercial |
$13.58
|
| Rate for Payer: BCBS Trust/PPO |
$11.41
|
| Rate for Payer: BCN Commercial |
$10.85
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.20
|
| Rate for Payer: Healthscope Commercial |
$14.00
|
| Rate for Payer: Healthscope Whirlpool |
$13.58
|
| Rate for Payer: Mclaren Commercial |
$12.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.90
|
| Rate for Payer: Nomi Health Commercial |
$11.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.32
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$23.67
|
|
|
Service Code
|
NDC 63323018520
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.39 |
| Max. Negotiated Rate |
$23.67 |
| Rate for Payer: Aetna Commercial |
$21.30
|
| Rate for Payer: ASR ASR |
$22.96
|
| Rate for Payer: ASR Commercial |
$22.96
|
| Rate for Payer: BCBS Trust/PPO |
$19.29
|
| Rate for Payer: BCN Commercial |
$18.35
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cofinity Commercial |
$22.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Healthscope Commercial |
$23.67
|
| Rate for Payer: Healthscope Whirlpool |
$22.96
|
| Rate for Payer: Mclaren Commercial |
$21.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.12
|
| Rate for Payer: Nomi Health Commercial |
$19.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.83
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$15.08
|
|
|
Service Code
|
NDC 00409488723
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna Commercial |
$13.57
|
| Rate for Payer: Aetna Medicare |
$7.54
|
| Rate for Payer: ASR ASR |
$14.63
|
| Rate for Payer: ASR Commercial |
$14.63
|
| Rate for Payer: BCBS Complete |
$6.03
|
| Rate for Payer: BCBS Trust/PPO |
$12.35
|
| Rate for Payer: BCN Commercial |
$11.69
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: Healthscope Whirlpool |
$14.63
|
| Rate for Payer: Mclaren Commercial |
$13.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.82
|
| Rate for Payer: Nomi Health Commercial |
$12.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.21
|
| Rate for Payer: Priority Health Narrow Network |
$10.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.27
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$23.67
|
|
|
Service Code
|
NDC 63323018520
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.47 |
| Max. Negotiated Rate |
$23.67 |
| Rate for Payer: Aetna Commercial |
$21.30
|
| Rate for Payer: Aetna Medicare |
$11.84
|
| Rate for Payer: ASR ASR |
$22.96
|
| Rate for Payer: ASR Commercial |
$22.96
|
| Rate for Payer: BCBS Complete |
$9.47
|
| Rate for Payer: BCBS Trust/PPO |
$19.38
|
| Rate for Payer: BCN Commercial |
$18.35
|
| Rate for Payer: Cash Price |
$18.94
|
| Rate for Payer: Cofinity Commercial |
$22.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.94
|
| Rate for Payer: Healthscope Commercial |
$23.67
|
| Rate for Payer: Healthscope Whirlpool |
$22.96
|
| Rate for Payer: Mclaren Commercial |
$21.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.12
|
| Rate for Payer: Nomi Health Commercial |
$19.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.74
|
| Rate for Payer: Priority Health Narrow Network |
$16.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.83
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$20.24
|
|
|
Service Code
|
NDC 63323018504
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: ASR Commercial |
$19.63
|
| Rate for Payer: BCBS Trust/PPO |
$16.49
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.20
|
| Rate for Payer: Nomi Health Commercial |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$15.08
|
|
|
Service Code
|
NDC 00409488720
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna Commercial |
$13.57
|
| Rate for Payer: ASR ASR |
$14.63
|
| Rate for Payer: ASR Commercial |
$14.63
|
| Rate for Payer: BCBS Trust/PPO |
$12.29
|
| Rate for Payer: BCN Commercial |
$11.69
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: Healthscope Whirlpool |
$14.63
|
| Rate for Payer: Mclaren Commercial |
$13.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.82
|
| Rate for Payer: Nomi Health Commercial |
$12.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.27
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 00409488710
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: Aetna Commercial |
$12.60
|
| Rate for Payer: Aetna Medicare |
$7.00
|
| Rate for Payer: ASR ASR |
$13.58
|
| Rate for Payer: ASR Commercial |
$13.58
|
| Rate for Payer: BCBS Complete |
$5.60
|
| Rate for Payer: BCBS Trust/PPO |
$11.46
|
| Rate for Payer: BCN Commercial |
$10.85
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.20
|
| Rate for Payer: Healthscope Commercial |
$14.00
|
| Rate for Payer: Healthscope Whirlpool |
$13.58
|
| Rate for Payer: Mclaren Commercial |
$12.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.90
|
| Rate for Payer: Nomi Health Commercial |
$11.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.27
|
| Rate for Payer: Priority Health Narrow Network |
$9.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.32
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$20.24
|
|
|
Service Code
|
NDC 63323018505
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: ASR Commercial |
$19.63
|
| Rate for Payer: BCBS Trust/PPO |
$16.49
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.20
|
| Rate for Payer: Nomi Health Commercial |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION
|
Facility
|
IP
|
$15.08
|
|
|
Service Code
|
NDC 00409488723
|
| Hospital Charge Code |
11671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna Commercial |
$13.57
|
| Rate for Payer: ASR ASR |
$14.63
|
| Rate for Payer: ASR Commercial |
$14.63
|
| Rate for Payer: BCBS Trust/PPO |
$12.29
|
| Rate for Payer: BCN Commercial |
$11.69
|
| Rate for Payer: Cash Price |
$12.06
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.06
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: Healthscope Whirlpool |
$14.63
|
| Rate for Payer: Mclaren Commercial |
$13.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.82
|
| Rate for Payer: Nomi Health Commercial |
$12.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.27
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION FOR SOLID FORM MIXTURES
|
Facility
|
IP
|
$18.11
|
|
|
Service Code
|
NDC 63323018507
|
| Hospital Charge Code |
301772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.77 |
| Max. Negotiated Rate |
$18.11 |
| Rate for Payer: Aetna Commercial |
$16.30
|
| Rate for Payer: ASR ASR |
$17.57
|
| Rate for Payer: ASR Commercial |
$17.57
|
| Rate for Payer: BCBS Trust/PPO |
$14.76
|
| Rate for Payer: BCN Commercial |
$14.04
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.49
|
| Rate for Payer: Healthscope Commercial |
$18.11
|
| Rate for Payer: Healthscope Whirlpool |
$17.57
|
| Rate for Payer: Mclaren Commercial |
$16.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.39
|
| Rate for Payer: Nomi Health Commercial |
$14.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.94
|
|
|
WATER FOR INJECTION, STERILE INJECTION SOLUTION FOR SOLID FORM MIXTURES
|
Facility
|
OP
|
$18.11
|
|
|
Service Code
|
NDC 63323018507
|
| Hospital Charge Code |
301772
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.24 |
| Max. Negotiated Rate |
$18.11 |
| Rate for Payer: Aetna Commercial |
$16.30
|
| Rate for Payer: Aetna Medicare |
$9.06
|
| Rate for Payer: ASR ASR |
$17.57
|
| Rate for Payer: ASR Commercial |
$17.57
|
| Rate for Payer: BCBS Complete |
$7.24
|
| Rate for Payer: BCBS Trust/PPO |
$14.83
|
| Rate for Payer: BCN Commercial |
$14.04
|
| Rate for Payer: Cash Price |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$17.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.49
|
| Rate for Payer: Healthscope Commercial |
$18.11
|
| Rate for Payer: Healthscope Whirlpool |
$17.57
|
| Rate for Payer: Mclaren Commercial |
$16.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.39
|
| Rate for Payer: Nomi Health Commercial |
$14.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.87
|
| Rate for Payer: Priority Health Narrow Network |
$12.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.94
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$47.85
|
|
|
Service Code
|
NDC 00338001304
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.10 |
| Max. Negotiated Rate |
$47.85 |
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: ASR ASR |
$46.41
|
| Rate for Payer: ASR Commercial |
$46.41
|
| Rate for Payer: BCBS Trust/PPO |
$38.99
|
| Rate for Payer: BCN Commercial |
$37.10
|
| 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 |
$47.85
|
| Rate for Payer: Healthscope Whirlpool |
$46.41
|
| 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: Priority Health Cigna Priority Health |
$31.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$42.11
|
|
|
WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$47.85
|
|
|
Service Code
|
NDC 00338001304
|
| Hospital Charge Code |
28400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$47.85 |
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: Aetna Medicare |
$23.92
|
| Rate for Payer: ASR ASR |
$46.41
|
| Rate for Payer: ASR Commercial |
$46.41
|
| Rate for Payer: BCBS Complete |
$19.14
|
| Rate for Payer: BCBS Trust/PPO |
$39.18
|
| Rate for Payer: BCN Commercial |
$37.10
|
| 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 |
$47.85
|
| Rate for Payer: Healthscope Whirlpool |
$46.41
|
| 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: Priority Health Cigna Priority Health |
$31.10
|
| Rate for Payer: 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 |
$18.07 |
| Max. Negotiated Rate |
$27.80 |
| Rate for Payer: Aetna Commercial |
$25.02
|
| Rate for Payer: ASR ASR |
$26.97
|
| Rate for Payer: ASR Commercial |
$26.97
|
| Rate for Payer: BCBS Trust/PPO |
$22.65
|
| Rate for Payer: BCN Commercial |
$21.55
|
| 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 |
$27.80
|
| Rate for Payer: Healthscope Whirlpool |
$26.97
|
| Rate for Payer: Mclaren Commercial |
$25.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Nomi Health Commercial |
$22.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.07
|
| 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 |
$11.12 |
| Max. Negotiated Rate |
$27.80 |
| Rate for Payer: Aetna Commercial |
$25.02
|
| Rate for Payer: Aetna Medicare |
$13.90
|
| Rate for Payer: ASR ASR |
$26.97
|
| Rate for Payer: ASR Commercial |
$26.97
|
| Rate for Payer: BCBS Complete |
$11.12
|
| Rate for Payer: BCBS Trust/PPO |
$22.77
|
| Rate for Payer: BCN Commercial |
$21.55
|
| 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 |
$27.80
|
| Rate for Payer: Healthscope Whirlpool |
$26.97
|
| Rate for Payer: Mclaren Commercial |
$25.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.63
|
| Rate for Payer: Nomi Health Commercial |
$22.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24.36
|
| Rate for Payer: Priority Health Narrow Network |
$19.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.46
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT
|
Facility
|
IP
|
$31.81
|
|
|
Service Code
|
NDC 00023031204
|
| Hospital Charge Code |
117955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.68 |
| Max. Negotiated Rate |
$31.81 |
| Rate for Payer: Aetna Commercial |
$28.63
|
| Rate for Payer: ASR ASR |
$30.86
|
| Rate for Payer: ASR Commercial |
$30.86
|
| Rate for Payer: BCBS Trust/PPO |
$25.92
|
| Rate for Payer: BCN Commercial |
$24.66
|
| Rate for Payer: Cash Price |
$25.45
|
| Rate for Payer: Cofinity Commercial |
$29.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.45
|
| Rate for Payer: Healthscope Commercial |
$31.81
|
| Rate for Payer: Healthscope Whirlpool |
$30.86
|
| Rate for Payer: Mclaren Commercial |
$28.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.04
|
| Rate for Payer: Nomi Health Commercial |
$26.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.99
|
|
|
WHITE PETROLATUM-MINERAL OIL 56.8 %-42.5 % EYE OINTMENT
|
Facility
|
OP
|
$31.81
|
|
|
Service Code
|
NDC 00023031204
|
| Hospital Charge Code |
117955
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.72 |
| Max. Negotiated Rate |
$31.81 |
| Rate for Payer: Aetna Commercial |
$28.63
|
| Rate for Payer: Aetna Medicare |
$15.90
|
| Rate for Payer: ASR ASR |
$30.86
|
| Rate for Payer: ASR Commercial |
$30.86
|
| Rate for Payer: BCBS Complete |
$12.72
|
| Rate for Payer: BCBS Trust/PPO |
$26.05
|
| Rate for Payer: BCN Commercial |
$24.66
|
| Rate for Payer: Cash Price |
$25.45
|
| Rate for Payer: Cofinity Commercial |
$29.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.45
|
| Rate for Payer: Healthscope Commercial |
$31.81
|
| Rate for Payer: Healthscope Whirlpool |
$30.86
|
| Rate for Payer: Mclaren Commercial |
$28.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.04
|
| Rate for Payer: Nomi Health Commercial |
$26.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.87
|
| Rate for Payer: Priority Health Narrow Network |
$22.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.99
|
|
|
WHITE PETROLATUM-MINERAL OIL 83 %-15 % EYE OINTMENT
|
Facility
|
OP
|
$22.10
|
|
|
Service Code
|
NDC 00904648838
|
| Hospital Charge Code |
117765
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$22.10 |
| Rate for Payer: Aetna Commercial |
$19.89
|
| Rate for Payer: Aetna Medicare |
$11.05
|
| Rate for Payer: ASR ASR |
$21.44
|
| Rate for Payer: ASR Commercial |
$21.44
|
| Rate for Payer: BCBS Complete |
$8.84
|
| Rate for Payer: BCBS Trust/PPO |
$18.10
|
| Rate for Payer: BCN Commercial |
$17.13
|
| 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 |
$22.10
|
| Rate for Payer: Healthscope Whirlpool |
$21.44
|
| 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: Priority Health Cigna Priority Health |
$14.36
|
| Rate for Payer: 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
|
|
