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hospital_name Fairview Regional Medical Center Authority
last_updated_on 7/1/2024
version 2.0.0
hospital_location Fairview Regional Medical Center
hospital_address 523 E State Road Fairview, OK 73737
license_number| OK 2248
**To the best of its knowledge and belief, Fairview Regional Medical Center has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.
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| PROC_NAME | HCPCS_CODE | TOT_QUANTITY | TOT_TX_AMOUNT | Charge | BCBS ALLOWED AMOUNT | HEALTHCHOICE ALLOWED AMOUNT | MEDICAID ALLOWED AMOUNT | MEDICARE ALLOWED AMOUNT | AETNA ALLOWED AMOUNT | HIGHEST ALLOWED | LOWEST ALLOWED |
|---|---|---|---|---|---|---|---|---|---|---|---|
| IOHEXOL 350 MG/ML SOLN | Q9967 | 5,400 | $21,529.80 | $3.99 | $0.00 | $0.11 | $0.11 | 1.8753 | $0.11 | 1.8753 | 1.8753 |
| IOHEXOL 240 MG/ML SOLN | Q9966 | 3,000 | $8,971.90 | $2.99 | $0.00 | $0.39 | $0.31 | 1.4053 | $0.28 | 0 | 0 |
| HEPARIN LOCK FLUSH 100 UNIT/ML SOLN | J1642 | 2,900 | $1,131.00 | $0.39 | $0.00 | $0.02 | $0.00 | 0.1833 | $0.02 | 0 | 0 |
| PREDNISONE 20 MG TABS | J7512 | 2,280 | $220.40 | $0.10 | $0.00 | $0.00 | $0.01 | 0.047 | $0.01 | 0 | 0 |
| CEFTRIAXONE 1 G SOLR 1 EACH VIAL | J0696 | 1,229 | $5,440.50 | $4.43 | $0.00 | $0.72 | $0.53 | 2.0821 | $0.68 | 0 | 0 |
| PIPERACILLIN - TAZOBACTAM 3.375 (3-0.375) G SOLR 1 EACH VIAL | J2543 | 893 | $17,317.90 | $19.39 | $0.00 | $1.88 | $1.68 | 9.1133 | $1.79 | 0 | 0 |
| PROPOFOL 200 MG/20ML EMUL | J2704 | 756 | $945.40 | $1.25 | $0.00 | $0.13 | $0.00 | 0.5875 | $0.11 | 0 | 0 |
| LEVETIRACETAM 500 MG/5ML SOLN 5 ML VIAL | J1953 | 700 | $318.60 | $0.46 | $0.00 | $0.14 | $0.14 | 0.2162 | $0.11 | 0 | 0 |
| 0.9% NACL 0.9 % SOLN 100 ML FLEX CONT | J7050 | 656 | $73,472.00 | $112.00 | $0.00 | $0.72 | $0.64 | 52.64 | $0.68 | 0 | 0 |
| ONDANSETRON 2 MG/ML SOLN | J2405 | 644 | $2,905.50 | $4.51 | $0.00 | $0.10 | $0.10 | 2.1197 | $0.10 | 0 | 0 |
| KETOROLAC 30 MG/ML SOLN | J1885 | 575 | $3,637.50 | $6.33 | $0.00 | $0.76 | $0.58 | 2.9751 | $0.72 | 0 | 0 |
| 0.9% NACL 0.9 % SOLN | J7030 | 447 | $50,064.00 | $112.00 | $0.00 | $2.90 | $2.55 | 52.64 | $2.74 | 0 | 0 |
| FUROSEMIDE 10 MG/ML SOLN | J1940 | 430 | $9,197.30 | $21.39 | $0.00 | $0.90 | $0.60 | 10.0533 | $0.85 | 0 | 0 |
| BUDESONIDE 0.5 MG/2ML SUSP | J7626 | 425 | $15,372.00 | $36.17 | $0.00 | $1.95 | $1.78 | 16.9999 | $1.84 | 0 | 0 |
| INSULIN GLARGINE 100 UNIT/ML SOLN | J1815 | 415 | $2,598.40 | $6.26 | $0.00 | $0.99 | $0.83 | 2.9422 | $0.67 | 0 | 0 |
| MORPHINE 4 MG/ML SOLN | J2270 | 410 | $7,995.00 | $19.50 | $0.00 | $2.13 | $3.72 | 9.165 | $2.02 | 0 | 0 |
| DEXAMETHASONE 4 MG TABS | J8540 | 400 | $98.50 | $0.25 | $0.00 | $0.00 | $0.10 | 0.1175 | $0.07 | 0 | 0 |
| ALBUTEROL (2.5 MG/3ML) 0.083% NEBU | J7613 | 318 | $361.90 | $1.14 | $0.00 | $0.05 | $0.04 | 0.5358 | $0.05 | 0 | 0 |
| VANCOMYCIN 1 G SOLR 1 EACH VIAL | J3370 | 301 | $3,157.10 | $10.49 | $0.00 | $3.16 | $2.77 | 4.9303 | $2.99 | 0 | 0 |
| ATROPINE 0.1 MG/ML SOLN | J0461 | 300 | $60.00 | $0.20 | $0.00 | $0.10 | $0.06 | 0.094 | $0.09 | 0 | 0 |
| EPOETIN 40000 UNIT/ML SOLN | J0885 | 280 | $29,633.10 | $105.83 | $0.00 | $10.39 | $9.70 | 49.7401 | $9.84 | 0 | 0 |
| HEPARIN 5000 UNIT/ML SOLN | J1644 | 270 | $1,053.00 | $3.90 | $0.00 | $0.29 | $0.25 | 1.833 | $0.31 | 0 | 0 |
| ALTEPLASE 100 MG SOLR | J2997 | 264 | $91,166.40 | $345.33 | $0.00 | $99.35 | $87.89 | 162.3051 | $74.39 | 0 | 0 |
| FAMOTIDINE 10 MG/ML SOLN | J3490 | 251 | $2,457.00 | $9.79 | $0.00 | $0.00 | $0.00 | 4.6013 | $0.17 | 0 | 0 |
| ENOXAPARIN 40 MG/0.4ML SOLN | J1650 | 240 | $5,501.60 | $22.92 | $0.00 | $0.78 | $0.69 | 10.7724 | $0.74 | 0 | 0 |
| LACTATED RINGERS SOLN | J7120 | 221 | $14,672.00 | $66.39 | $0.00 | $2.67 | $2.34 | 31.2033 | $2.53 | 0 | 0 |
| DEXAMETHASONE 4 MG/ML SOLN | J1100 | 219 | $1,053.00 | $4.81 | $0.00 | $0.16 | $0.12 | 2.2607 | $0.14 | 0 | 0 |
| MEROPENEM 1 G SOLR 1 EACH VIAL | J2185 | 210 | $999.60 | $4.76 | $0.00 | $0.98 | $0.79 | 2.2372 | $0.92 | 0 | 0 |
| LIDOCAINE (PF) 4 % SOLN | J2001 | 204 | $994.50 | $4.88 | $0.00 | $0.03 | $0.02 | 2.2936 | $0.02 | 0 | 0 |
| LORAZEPAM 2 MG/ML SOLN | J2060 | 193 | $3,763.50 | $19.50 | $0.00 | $0.86 | $0.69 | 9.165 | $0.81 | 0 | 0 |
| EPINEPHRINE PF 1 MG/10ML | J0171 | 180 | $354.00 | $1.97 | $0.00 | $1.00 | $0.91 | 0.9259 | $0.66 | 0 | 0 |
| MIDAZOLAM 1 MG/ML SOLN | J2250 | 163 | $1,257.70 | $7.72 | $0.00 | $0.15 | $0.11 | 3.6284 | $0.14 | 0 | 0 |
| METHYLPREDNISOLONE SOD SUCC 40 MG SOLR | J2920 | 141 | $3,254.00 | $23.08 | $0.00 | $4.75 | $4.52 | 10.8476 | $4.50 | 0 | 0 |
| MILRINONE 20-5 MG/100ML-% SOLN | J2260 | 136 | $3,808.00 | $28.00 | $0.00 | $1.72 | $1.43 | 13.16 | $1.63 | 0 | 0 |
| ARFORMOTEROL 15 MCG/2ML NEBU | J7605 | 118 | $8,151.60 | $69.08 | $0.00 | $12.73 | $11.00 | 32.4676 | $12.06 | 0 | 0 |
| POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL | J3480 | 90 | $97.50 | $1.08 | $0.00 | $0.17 | $0.18 | 0.5076 | $0.17 | 0 | 0 |
| PROMETHAZINE 25 MG/ML SOLN | J2550 | 76 | $1,482.00 | $19.50 | $0.00 | $2.63 | $2.23 | 9.165 | $2.50 | 0 | 0 |
| CIPROFLOXACIN 400 MG/200ML SOLN | J0744 | 70 | $682.50 | $9.75 | $0.00 | $1.14 | $1.13 | 4.5825 | $1.08 | 0 | 0 |
| TDAP (TETANUS-DIPHTHERIA-ACELL PERTUSSIS) 5-2-15.5 LF-MCG/0.5 SUSP | 90715 | 68 | $12,318.60 | $181.16 | $0.00 | $46.28 | $33.44 | 85.1452 | $37.02 | 0 | 0 |
| HYDROMORPHONE 1 MG/ML SOLN | J1170 | 66 | $1,294.20 | $19.61 | $0.00 | $2.26 | $3.11 | 9.2167 | $2.13 | 0 | 0 |
| AZITHROMYCIN 500 MG SOLR 1 EACH VIAL | J0456 | 65 | $2,269.10 | $34.91 | $0.00 | $4.59 | $3.42 | 16.4077 | $4.36 | 0 | 0 |
| GADOBENATE DIMEGLUMINE 529 MG/ML SOLN | A9577 | 54 | $1,213.50 | $22.47 | $0.00 | $2.06 | $0.00 | 10.5609 | $1.96 | 0 | 0 |
| MAGNESIUM SULFATE 50 % SOLN 10 ML VIAL | J3475 | 52 | $253.50 | $4.88 | $0.00 | $0.48 | $0.64 | 2.2936 | $0.36 | 0 | 0 |
| METHYLPREDNISOLONE ACETATE 80 MG/ML SUSP | J1040 | 51 | $3,111.40 | $61.01 | $0.00 | $12.76 | $11.70 | 28.6747 | $12.09 | 0 | 0 |
| LEVALBUTEROL 1.25 MG/0.5ML NEBU | J7612 | 51 | $479.40 | $9.40 | $0.00 | $0.43 | $0.29 | 4.418 | $0.41 | 0 | 0 |
