|
FLUTICASONE (FLOVENT) 44MCG IHNALER
|
Facility
|
IP
|
$504.00
|
|
|
Service Code
|
NDC 173071820
|
| Hospital Charge Code |
2626378
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$453.60
|
|
|
FLUTICASONE (FLOVENT)HFA 110MCG INH
|
Facility
|
IP
|
$621.00
|
|
|
Service Code
|
NDC 173071920
|
| Hospital Charge Code |
2624267
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$558.90
|
|
|
FLUTICASONE (FLOVENT)HFA 110MCG INH
|
Facility
|
IP
|
$621.00
|
|
|
Service Code
|
NDC 173071920
|
| Hospital Charge Code |
2626264
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$558.90
|
|
|
FLUTICASONE (FLOVENT)HFA 110MCG INH
|
Facility
|
IP
|
$621.00
|
|
|
Service Code
|
NDC 173071920
|
| Hospital Charge Code |
2624266
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$558.90
|
|
|
FLUTICASONE (FLOVENT)HFA 110MCG INH
|
Facility
|
OP
|
$621.00
|
|
|
Service Code
|
NDC 173071920
|
| Hospital Charge Code |
2626264
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$223.56 |
| Max. Negotiated Rate |
$443.39 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$367.63
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$443.39
|
| Rate for Payer: Cash Price |
$558.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$414.21
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$223.56
|
|
|
FLUTICASONE (FLOVENT)HFA 110MCG INH
|
Facility
|
OP
|
$621.00
|
|
|
Service Code
|
NDC 173071920
|
| Hospital Charge Code |
2624267
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$223.56 |
| Max. Negotiated Rate |
$443.39 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$367.63
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$443.39
|
| Rate for Payer: Cash Price |
$558.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$414.21
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$223.56
|
|
|
FLUTICASONE (FLOVENT)HFA 110MCG INH
|
Facility
|
OP
|
$621.00
|
|
|
Service Code
|
NDC 173071920
|
| Hospital Charge Code |
2624266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$223.56 |
| Max. Negotiated Rate |
$443.39 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$367.63
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$443.39
|
| Rate for Payer: Cash Price |
$558.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$414.21
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$223.56
|
|
|
FLUTICASONE (FLOVENT)HFA 110MCG INH EMP
|
Facility
|
IP
|
$664.00
|
|
|
Service Code
|
NDC 173071920
|
| Hospital Charge Code |
2622558
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$597.60
|
|
|
FLUTICASONE (FLOVENT)HFA 110MCG INH EMP
|
Facility
|
OP
|
$664.00
|
|
|
Service Code
|
NDC 173071920
|
| Hospital Charge Code |
2622558
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$239.04 |
| Max. Negotiated Rate |
$474.10 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$393.09
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$474.10
|
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$442.89
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$239.04
|
|
|
FLUTICASONE (FLOVENT)HFA 44MCG INH EMP
|
Facility
|
OP
|
$664.00
|
|
|
Service Code
|
NDC 173071820
|
| Hospital Charge Code |
2624268
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$239.04 |
| Max. Negotiated Rate |
$474.10 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$393.09
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$474.10
|
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$442.89
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$239.04
|
|
|
FLUTICASONE (FLOVENT)HFA 44MCG INH EMP
|
Facility
|
IP
|
$664.00
|
|
|
Service Code
|
NDC 173071820
|
| Hospital Charge Code |
2624268
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$597.60
|
|
|
FLUTICASONE HFA 220MCG INH 120 DOSES
|
Facility
|
IP
|
$950.00
|
|
|
Service Code
|
NDC 173072020
|
| Hospital Charge Code |
2626536
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$855.00
|
|
|
FLUTICASONE HFA 220MCG INH 120 DOSES
|
Facility
|
OP
|
$950.00
|
|
|
Service Code
|
NDC 173072020
|
| Hospital Charge Code |
2626536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$678.30 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$562.40
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$678.30
|
| Rate for Payer: Cash Price |
$855.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$633.65
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$342.00
|
|
|
FLUTICASONE/SALMET(ADVAIR)250/50INH
|
Facility
|
IP
|
$414.00
|
|
|
Service Code
|
NDC 173069604
|
| Hospital Charge Code |
2626374
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$372.60
|
|
|
FLUTICASONE/SALMET(ADVAIR)250/50INH
|
Facility
|
OP
|
$414.00
|
|
|
Service Code
|
NDC 173069604
|
| Hospital Charge Code |
2626374
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$149.04 |
| Max. Negotiated Rate |
$295.60 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$245.09
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$295.60
|
| Rate for Payer: Cash Price |
$372.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$276.14
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$149.04
|
|
|
FLUTIC/SALMET 100/50 INH 60-DS EMP
|
Facility
|
IP
|
$592.00
|
|
|
Service Code
|
NDC 6.6993E+10
|
| Hospital Charge Code |
2627320
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$532.80
|
|
|
FLUTIC/SALMET 100/50 INH 60-DS EMP
|
Facility
|
OP
|
$592.00
|
|
|
Service Code
|
NDC 6.6993E+10
|
| Hospital Charge Code |
2627320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$213.12 |
| Max. Negotiated Rate |
$422.69 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$350.46
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$422.69
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$394.86
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$213.12
|
|
|
FLUTIC/SALMET (ADVAIR) 100/50 INH 14-DS
|
Facility
|
IP
|
$367.00
|
|
|
Service Code
|
NDC 173069504
|
| Hospital Charge Code |
2626469
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$330.30
|
|
|
FLUTIC/SALMET (ADVAIR) 100/50 INH 14-DS
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
NDC 173069504
|
| Hospital Charge Code |
2626469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.12 |
| Max. Negotiated Rate |
$262.04 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$217.26
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$262.04
|
| Rate for Payer: Cash Price |
$330.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$244.79
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$132.12
|
|
|
FLUTIC/SALMET (ADVAIR) 100/50 INH 60-DS
|
Facility
|
OP
|
$592.00
|
|
|
Service Code
|
NDC 173069504
|
| Hospital Charge Code |
2626659
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$213.12 |
| Max. Negotiated Rate |
$422.69 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$350.46
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$422.69
|
| Rate for Payer: Cash Price |
$532.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$394.86
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$213.12
|
|
|
FLUTIC/SALMET (ADVAIR) 100/50 INH 60-DS
|
Facility
|
IP
|
$592.00
|
|
|
Service Code
|
NDC 173069504
|
| Hospital Charge Code |
2626659
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$532.80
|
|
|
FLUTIC/SALMET (ADVAIR) 500/50 INH
|
Facility
|
IP
|
$508.00
|
|
|
Service Code
|
NDC 173069704
|
| Hospital Charge Code |
2626468
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$457.20
|
|
|
FLUTIC/SALMET (ADVAIR) 500/50 INH
|
Facility
|
OP
|
$508.00
|
|
|
Service Code
|
NDC 173069704
|
| Hospital Charge Code |
2626468
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$182.88 |
| Max. Negotiated Rate |
$362.71 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$300.74
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$362.71
|
| Rate for Payer: Cash Price |
$457.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$338.84
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$182.88
|
|
|
FOAM PACK VITOSS BA2X 5CC
|
Facility
|
OP
|
$4,521.00
|
|
| Hospital Charge Code |
123410
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,627.56 |
| Max. Negotiated Rate |
$3,227.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$2,676.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$3,227.99
|
| Rate for Payer: Cash Price |
$4,068.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$3,015.51
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$1,627.56
|
|
|
FOAM PACK VITOSS BA2X 5CC
|
Facility
|
IP
|
$4,521.00
|
|
| Hospital Charge Code |
123410
|
|
Hospital Revenue Code
|
271
|
| Rate for Payer: Cash Price |
$4,068.90
|
|
