|
WARFARIN 1 MG TABLET
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
NDC 00832121189
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Aetna Medicare |
$1.85
|
| Rate for Payer: ASR ASR |
$3.60
|
| Rate for Payer: ASR Commercial |
$3.60
|
| Rate for Payer: BCBS Complete |
$1.48
|
| Rate for Payer: BCBS Trust/PPO |
$3.04
|
| 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: Priority Health HMO/PPO/Tiered Network |
$3.25
|
| Rate for Payer: Priority Health Narrow Network |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.26
|
|
|
WARFARIN 1 MG TABLET
|
Facility
|
IP
|
$371.30
|
|
|
Service Code
|
NDC 00832121101
|
| Hospital Charge Code |
11664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.34 |
| Max. Negotiated Rate |
$371.30 |
| Rate for Payer: Aetna Commercial |
$334.17
|
| Rate for Payer: ASR ASR |
$360.16
|
| Rate for Payer: ASR Commercial |
$360.16
|
| Rate for Payer: BCBS Trust/PPO |
$302.57
|
| 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: UHC All Payor (Choice/PPO) + Core |
$326.74
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
|
IP
|
$368.95
|
|
|
Service Code
|
NDC 00832121301
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$239.82 |
| Max. Negotiated Rate |
$368.95 |
| Rate for Payer: Aetna Commercial |
$332.06
|
| Rate for Payer: ASR ASR |
$357.88
|
| Rate for Payer: ASR Commercial |
$357.88
|
| Rate for Payer: BCBS Trust/PPO |
$300.66
|
| Rate for Payer: BCN Commercial |
$286.05
|
| Rate for Payer: Cash Price |
$295.16
|
| Rate for Payer: Cofinity Commercial |
$346.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$295.16
|
| Rate for Payer: Healthscope Commercial |
$368.95
|
| Rate for Payer: Healthscope Whirlpool |
$357.88
|
| Rate for Payer: Mclaren Commercial |
$332.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$313.61
|
| Rate for Payer: Nomi Health Commercial |
$302.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$239.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$324.68
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
|
OP
|
$368.95
|
|
|
Service Code
|
NDC 00832121301
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.58 |
| Max. Negotiated Rate |
$368.95 |
| Rate for Payer: Aetna Commercial |
$332.06
|
| Rate for Payer: Aetna Medicare |
$184.47
|
| Rate for Payer: ASR ASR |
$357.88
|
| Rate for Payer: ASR Commercial |
$357.88
|
| Rate for Payer: BCBS Complete |
$147.58
|
| Rate for Payer: BCBS Trust/PPO |
$302.13
|
| Rate for Payer: BCN Commercial |
$286.05
|
| Rate for Payer: Cash Price |
$295.16
|
| Rate for Payer: Cofinity Commercial |
$346.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$295.16
|
| Rate for Payer: Healthscope Commercial |
$368.95
|
| Rate for Payer: Healthscope Whirlpool |
$357.88
|
| Rate for Payer: Mclaren Commercial |
$332.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$313.61
|
| Rate for Payer: Nomi Health Commercial |
$302.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$239.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$323.27
|
| Rate for Payer: Priority Health Narrow Network |
$258.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$324.68
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
|
IP
|
$3.69
|
|
|
Service Code
|
NDC 00832121389
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: ASR ASR |
$3.58
|
| Rate for Payer: ASR Commercial |
$3.58
|
| Rate for Payer: BCBS Trust/PPO |
$3.01
|
| Rate for Payer: BCN Commercial |
$2.86
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cofinity Commercial |
$3.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.95
|
| Rate for Payer: Healthscope Commercial |
$3.69
|
| Rate for Payer: Healthscope Whirlpool |
$3.58
|
| Rate for Payer: Mclaren Commercial |
$3.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.14
|
| Rate for Payer: Nomi Health Commercial |
$3.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.25
|
|
|
WARFARIN 2.5 MG TABLET
|
Facility
|
OP
|
$3.69
|
|
|
Service Code
|
NDC 00832121389
|
| Hospital Charge Code |
8750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$3.69 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Aetna Medicare |
$1.84
|
| Rate for Payer: ASR ASR |
$3.58
|
| Rate for Payer: ASR Commercial |
$3.58
|
| Rate for Payer: BCBS Complete |
$1.48
|
| Rate for Payer: BCBS Trust/PPO |
$3.02
|
| Rate for Payer: BCN Commercial |
$2.86
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cofinity Commercial |
$3.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.95
|
| Rate for Payer: Healthscope Commercial |
$3.69
|
| Rate for Payer: Healthscope Whirlpool |
$3.58
|
| Rate for Payer: Mclaren Commercial |
$3.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.14
|
| Rate for Payer: Nomi Health Commercial |
$3.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.23
|
| Rate for Payer: Priority Health Narrow Network |
$2.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.25
|
|
|
WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION
|
Facility
|
OP
|
$46.50
|
|
|
Service Code
|
NDC 00409397703
|
| Hospital Charge Code |
864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$46.50 |
| Rate for Payer: Aetna Commercial |
$41.85
|
| Rate for Payer: Aetna Medicare |
$23.25
|
| Rate for Payer: ASR ASR |
$45.10
|
| Rate for Payer: ASR Commercial |
$45.10
|
| Rate for Payer: BCBS Complete |
$18.60
|
| Rate for Payer: BCBS Trust/PPO |
$38.08
|
| Rate for Payer: BCN Commercial |
$36.05
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cofinity Commercial |
$43.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.20
|
| Rate for Payer: Healthscope Commercial |
$46.50
|
| Rate for Payer: Healthscope Whirlpool |
$45.10
|
| Rate for Payer: Mclaren Commercial |
$41.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.52
|
| Rate for Payer: Nomi Health Commercial |
$38.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.74
|
| Rate for Payer: Priority Health Narrow Network |
$32.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.92
|
|
|
WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION
|
Facility
|
IP
|
$46.50
|
|
|
Service Code
|
NDC 00409397703
|
| Hospital Charge Code |
864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.23 |
| Max. Negotiated Rate |
$46.50 |
| Rate for Payer: Aetna Commercial |
$41.85
|
| Rate for Payer: ASR ASR |
$45.10
|
| Rate for Payer: ASR Commercial |
$45.10
|
| Rate for Payer: BCBS Trust/PPO |
$37.89
|
| Rate for Payer: BCN Commercial |
$36.05
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cofinity Commercial |
$43.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.20
|
| Rate for Payer: Healthscope Commercial |
$46.50
|
| Rate for Payer: Healthscope Whirlpool |
$45.10
|
| Rate for Payer: Mclaren Commercial |
$41.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.52
|
| Rate for Payer: Nomi Health Commercial |
$38.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$40.92
|
|
|
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 |
$9.05
|
| 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
|
$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
|
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
|
$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
|
$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
|
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
|
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
|
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
|
$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
|
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
|
$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
|
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
|
$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 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 |
$9.05
|
| 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
|
|
