|
NEO/POLY/BAC (NEOSPOR) OP OINT 3.5GM
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
NDC 574425035
|
| Hospital Charge Code |
2655934
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$160.20
|
|
|
NEO/POLY/BAC (NEOSPOR) OP OINT 3.5GM
|
Facility
|
OP
|
$178.00
|
|
|
Service Code
|
NDC 574425035
|
| Hospital Charge Code |
2655934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.08 |
| Max. Negotiated Rate |
$127.09 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$105.38
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$127.09
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$118.73
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$64.08
|
|
|
NEO/POLY/BAC (TRIP ANTIB) 28GM OINT
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
NDC 4.5802E+10
|
| Hospital Charge Code |
2696428
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$83.70
|
|
|
NEO/POLY/BAC (TRIP ANTIB) 28GM OINT
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
NDC 4.5802E+10
|
| Hospital Charge Code |
2696428
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.48 |
| Max. Negotiated Rate |
$66.40 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$55.06
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$66.40
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$62.03
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$33.48
|
|
|
NEO/POLY/BAC (TRPL ABX) OINT UD PKT
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 4.7682E+10
|
| Hospital Charge Code |
2696420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.84
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.20
|
|
|
NEO/POLY/BAC (TRPL ABX) OINT UD PKT
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 4.7682E+10
|
| Hospital Charge Code |
2696420
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
NEO/POLY/BAC (TRPL ABX) OINT UD PKT 0.9G
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 904880567
|
| Hospital Charge Code |
2620732
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
NEO/POLY/BAC (TRPL ABX) OINT UD PKT 0.9G
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 904880567
|
| Hospital Charge Code |
2620732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.84
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.20
|
|
|
NEO/POLY/DEX (MAXITROL)3.5GM OP OIN
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
NDC 6.1314E+10
|
| Hospital Charge Code |
2651647
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$60.30
|
|
|
NEO/POLY/DEX (MAXITROL)3.5GM OP OIN
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
NDC 6.1314E+10
|
| Hospital Charge Code |
2651647
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$39.66
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$47.84
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$44.69
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$24.12
|
|
|
NEO/POLY/DEX (MAXITROL)5ML OP SUSP
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
NDC 6.1314E+10
|
| Hospital Charge Code |
2651645
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$39.66
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$47.84
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$44.69
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$24.12
|
|
|
NEO/POLY/DEX (MAXITROL)5ML OP SUSP
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
NDC 6.1314E+10
|
| Hospital Charge Code |
2651645
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$60.30
|
|
|
NEO/POLY/DEX (MAXITROL)5ML OP SUSP EMP
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
NDC 6.1314E+10
|
| Hospital Charge Code |
2624606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$39.66
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$47.84
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$44.69
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$24.12
|
|
|
NEO/POLY/DEX (MAXITROL)5ML OP SUSP EMP
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
NDC 6.1314E+10
|
| Hospital Charge Code |
2624606
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$60.30
|
|
|
NEO/POLY/GRAM (NEOSPOR) OP SOL 10ML
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
NDC 182154963
|
| Hospital Charge Code |
2655945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.12 |
| Max. Negotiated Rate |
$137.09 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$113.66
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$137.09
|
| Rate for Payer: Cash Price |
$172.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$128.06
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$69.12
|
|
|
NEO/POLY/GRAM (NEOSPOR) OP SOL 10ML
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
NDC 182154963
|
| Hospital Charge Code |
2655945
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$172.80
|
|
|
NEO/POLY/HC (CORTISPOR) EAR SOL 10ML
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
NDC 6.1314E+10
|
| Hospital Charge Code |
2655752
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$264.60
|
|
|
NEO/POLY/HC (CORTISPOR) EAR SOL 10ML
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
NDC 6.1314E+10
|
| Hospital Charge Code |
2655752
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.84 |
| Max. Negotiated Rate |
$209.92 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$174.05
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$209.92
|
| Rate for Payer: Cash Price |
$264.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$196.10
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$105.84
|
|
|
NEO/POLY/HC (CORTISPOR) EAR SOL 10ML EMP
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
NDC 2.4208E+10
|
| Hospital Charge Code |
2625082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.84 |
| Max. Negotiated Rate |
$209.92 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$174.05
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$209.92
|
| Rate for Payer: Cash Price |
$264.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$196.10
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$105.84
|
|
|
NEO/POLY/HC (CORTISPOR) EAR SOL 10ML EMP
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
NDC 2.4208E+10
|
| Hospital Charge Code |
2625082
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$264.60
|
|
|
NEO/POLY/HC (CORTISPOR) EAR SUSP 10ML
|
Facility
|
IP
|
$294.00
|
|
|
Service Code
|
NDC 2.4208E+10
|
| Hospital Charge Code |
2655751
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$264.60
|
|
|
NEO/POLY/HC (CORTISPOR) EAR SUSP 10ML
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
NDC 2.4208E+10
|
| Hospital Charge Code |
2655751
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.84 |
| Max. Negotiated Rate |
$209.92 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$174.05
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$209.92
|
| Rate for Payer: Cash Price |
$264.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$196.10
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$105.84
|
|
|
NEOSTIGMINE 5MG/10ML VIAL
|
Facility
|
OP
|
$424.00
|
|
|
Service Code
|
NDC 8290305200
|
| Hospital Charge Code |
2619922
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$152.64 |
| Max. Negotiated Rate |
$302.74 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$251.01
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$302.74
|
| Rate for Payer: Cash Price |
$381.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$282.81
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$152.64
|
|
|
NEOSTIGMINE 5MG/10ML VIAL
|
Facility
|
IP
|
$424.00
|
|
|
Service Code
|
NDC 8290305200
|
| Hospital Charge Code |
2619922
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$381.60
|
|
|
NEOSTIGMINE 5MG VIAL 10ML
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
HCPCS J2710
|
| Hospital Charge Code |
2058046
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$137.52 |
| Max. Negotiated Rate |
$272.75 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$226.14
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$272.75
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$254.79
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$137.52
|
|
