|
PR EEG COMPLETE STD PHYS/QHP>84 HR W/VEEG
|
Professional
|
Both
|
$839.00
|
|
|
Service Code
|
HCPCS 95726
|
| Min. Negotiated Rate |
$335.60 |
| Max. Negotiated Rate |
$700.15 |
| Rate for Payer: Aetna Commercial |
$507.14
|
| Rate for Payer: Aetna Medicare |
$393.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$544.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$507.14
|
| Rate for Payer: BCBS Complete |
$335.60
|
| Rate for Payer: BCBS MAPPO |
$378.46
|
| Rate for Payer: BCN Medicare Advantage |
$378.46
|
| Rate for Payer: Cash Price |
$671.20
|
| Rate for Payer: Cash Price |
$671.20
|
| Rate for Payer: Cofinity Commercial |
$544.98
|
| Rate for Payer: Cofinity Commercial |
$507.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$378.46
|
| Rate for Payer: Healthscope Commercial |
$700.15
|
| Rate for Payer: Healthscope Commercial |
$605.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$397.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$545.35
|
| Rate for Payer: Nomi Health Commercial |
$454.15
|
| Rate for Payer: PACE SWMI |
$378.46
|
| Rate for Payer: PHP Medicare Advantage |
$378.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$545.35
|
| Rate for Payer: Priority Health Medicare |
$378.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$378.46
|
| Rate for Payer: UHC Medicare Advantage |
$378.46
|
|
|
PR EEG EXTENDED MONITORING 61-119 MINUTES
|
Professional
|
Both
|
$868.00
|
|
|
Service Code
|
HCPCS 95813
|
| Min. Negotiated Rate |
$347.20 |
| Max. Negotiated Rate |
$734.76 |
| Rate for Payer: Aetna Commercial |
$532.21
|
| Rate for Payer: Aetna Medicare |
$413.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$571.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$532.21
|
| Rate for Payer: BCBS Complete |
$347.20
|
| Rate for Payer: BCBS MAPPO |
$397.17
|
| Rate for Payer: BCN Medicare Advantage |
$397.17
|
| Rate for Payer: Cash Price |
$694.40
|
| Rate for Payer: Cash Price |
$694.40
|
| Rate for Payer: Cofinity Commercial |
$571.92
|
| Rate for Payer: Cofinity Commercial |
$532.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$397.17
|
| Rate for Payer: Healthscope Commercial |
$635.47
|
| Rate for Payer: Healthscope Commercial |
$734.76
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$417.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$564.20
|
| Rate for Payer: Nomi Health Commercial |
$476.60
|
| Rate for Payer: PACE SWMI |
$397.17
|
| Rate for Payer: PHP Medicare Advantage |
$397.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$564.20
|
| Rate for Payer: Priority Health Medicare |
$397.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$397.17
|
| Rate for Payer: UHC Medicare Advantage |
$397.17
|
|
|
PR EEG MONITORING/COMPUTER, EA 24 HOURS, ATTENDED BY TECH/NURSE
|
Professional
|
Both
|
$2,889.00
|
|
|
Service Code
|
HCPCS 95956
|
| Min. Negotiated Rate |
$1,155.60 |
| Max. Negotiated Rate |
$1,877.85 |
| Rate for Payer: Aetna Medicare |
$1,444.50
|
| Rate for Payer: BCBS Complete |
$1,155.60
|
| Rate for Payer: Cash Price |
$2,311.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,877.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,877.85
|
|
|
PR EEG MONITORING/COMPUTER, EA 24 HOURS, UNATTENDED
|
Professional
|
Both
|
$747.00
|
|
|
Service Code
|
HCPCS 95953
|
| Min. Negotiated Rate |
$298.80 |
| Max. Negotiated Rate |
$485.55 |
| Rate for Payer: Aetna Medicare |
$373.50
|
| Rate for Payer: BCBS Complete |
$298.80
|
| Rate for Payer: Cash Price |
$597.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$485.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$485.55
|
|
|
PR EEG MONITORING/VIDEORECORD
|
Professional
|
Both
|
$1,556.00
|
|
|
Service Code
|
HCPCS 95951
|
| Min. Negotiated Rate |
$622.40 |
| Max. Negotiated Rate |
$1,011.40 |
| Rate for Payer: Aetna Medicare |
$778.00
|
| Rate for Payer: Aetna Medicare |
$1,551.00
|
| Rate for Payer: BCBS Complete |
$622.40
|
| Rate for Payer: BCBS Complete |
$1,240.80
|
| Rate for Payer: Cash Price |
$2,481.60
|
| Rate for Payer: Cash Price |
$1,244.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,011.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,016.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,011.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,016.30
|
|
|
PR EEG PHYS/QHP 2-12 HR WITHOUT VIDEO
|
Professional
|
Both
|
$209.00
|
|
|
Service Code
|
HCPCS 95717
|
| Min. Negotiated Rate |
$83.60 |
| Max. Negotiated Rate |
$185.43 |
| Rate for Payer: Aetna Commercial |
$134.31
|
| Rate for Payer: Aetna Medicare |
$104.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.33
|
| Rate for Payer: BCBS Complete |
$83.60
|
| Rate for Payer: BCBS MAPPO |
$100.23
|
| Rate for Payer: BCN Medicare Advantage |
$100.23
|
| Rate for Payer: Cash Price |
$167.20
|
| Rate for Payer: Cash Price |
$167.20
|
| Rate for Payer: Cofinity Commercial |
$144.33
|
| Rate for Payer: Cofinity Commercial |
$134.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$100.23
|
| Rate for Payer: Healthscope Commercial |
$160.37
|
| Rate for Payer: Healthscope Commercial |
$185.43
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$105.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.85
|
| Rate for Payer: Nomi Health Commercial |
$120.28
|
| Rate for Payer: PACE SWMI |
$100.23
|
| Rate for Payer: PHP Medicare Advantage |
$100.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.85
|
| Rate for Payer: Priority Health Medicare |
$100.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$100.23
|
| Rate for Payer: UHC Medicare Advantage |
$100.23
|
|
|
PR EEG PHYS/QHP 2-12 HR WITH VEEG
|
Professional
|
Both
|
$274.00
|
|
|
Service Code
|
HCPCS 95718
|
| Min. Negotiated Rate |
$109.60 |
| Max. Negotiated Rate |
$233.03 |
| Rate for Payer: Aetna Commercial |
$168.79
|
| Rate for Payer: Aetna Medicare |
$131.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.79
|
| Rate for Payer: BCBS Complete |
$109.60
|
| Rate for Payer: BCBS MAPPO |
$125.96
|
| Rate for Payer: BCN Medicare Advantage |
$125.96
|
| Rate for Payer: Cash Price |
$219.20
|
| Rate for Payer: Cash Price |
$219.20
|
| Rate for Payer: Cofinity Commercial |
$181.38
|
| Rate for Payer: Cofinity Commercial |
$168.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.96
|
| Rate for Payer: Healthscope Commercial |
$233.03
|
| Rate for Payer: Healthscope Commercial |
$201.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$178.10
|
| Rate for Payer: Nomi Health Commercial |
$151.15
|
| Rate for Payer: PACE SWMI |
$125.96
|
| Rate for Payer: PHP Medicare Advantage |
$125.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.10
|
| Rate for Payer: Priority Health Medicare |
$125.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.96
|
| Rate for Payer: UHC Medicare Advantage |
$125.96
|
|
|
PR EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR WO VID
|
Professional
|
Both
|
$323.00
|
|
|
Service Code
|
HCPCS 95719
|
| Min. Negotiated Rate |
$129.20 |
| Max. Negotiated Rate |
$278.68 |
| Rate for Payer: Aetna Commercial |
$201.86
|
| Rate for Payer: Aetna Medicare |
$156.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.86
|
| Rate for Payer: BCBS Complete |
$129.20
|
| Rate for Payer: BCBS MAPPO |
$150.64
|
| Rate for Payer: BCN Medicare Advantage |
$150.64
|
| Rate for Payer: Cash Price |
$258.40
|
| Rate for Payer: Cash Price |
$258.40
|
| Rate for Payer: Cofinity Commercial |
$216.92
|
| Rate for Payer: Cofinity Commercial |
$201.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$150.64
|
| Rate for Payer: Healthscope Commercial |
$241.02
|
| Rate for Payer: Healthscope Commercial |
$278.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$158.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.95
|
| Rate for Payer: Nomi Health Commercial |
$180.77
|
| Rate for Payer: PACE SWMI |
$150.64
|
| Rate for Payer: PHP Medicare Advantage |
$150.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.95
|
| Rate for Payer: Priority Health Medicare |
$150.64
|
| Rate for Payer: UHC Dual Complete DSNP |
$150.64
|
| Rate for Payer: UHC Medicare Advantage |
$150.64
|
|
|
PR EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 95720
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$357.81 |
| Rate for Payer: Aetna Commercial |
$259.17
|
| Rate for Payer: Aetna Medicare |
$201.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.17
|
| Rate for Payer: BCBS Complete |
$170.00
|
| Rate for Payer: BCBS MAPPO |
$193.41
|
| Rate for Payer: BCN Medicare Advantage |
$193.41
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cofinity Commercial |
$278.51
|
| Rate for Payer: Cofinity Commercial |
$259.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$193.41
|
| Rate for Payer: Healthscope Commercial |
$357.81
|
| Rate for Payer: Healthscope Commercial |
$309.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$203.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.25
|
| Rate for Payer: Nomi Health Commercial |
$232.09
|
| Rate for Payer: PACE SWMI |
$193.41
|
| Rate for Payer: PHP Medicare Advantage |
$193.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.25
|
| Rate for Payer: Priority Health Medicare |
$193.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$193.41
|
| Rate for Payer: UHC Medicare Advantage |
$193.41
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
OP
|
$3,133.87
|
|
|
Service Code
|
NDC 00071101568
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,253.55 |
| Max. Negotiated Rate |
$2,820.48 |
| Rate for Payer: Aetna Commercial |
$2,663.79
|
| Rate for Payer: Aetna Medicare |
$1,566.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,037.02
|
| Rate for Payer: BCBS Complete |
$1,253.55
|
| Rate for Payer: Cash Price |
$2,507.10
|
| Rate for Payer: Cofinity Commercial |
$2,193.71
|
| Rate for Payer: Cofinity Commercial |
$2,695.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,193.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,507.10
|
| Rate for Payer: Healthscope Commercial |
$2,820.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,663.79
|
| Rate for Payer: PHP Commercial |
$2,663.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,037.02
|
| Rate for Payer: Priority Health SBD |
$1,974.34
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
IP
|
$3,647.83
|
|
|
Service Code
|
NDC 00071101541
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,298.13 |
| Max. Negotiated Rate |
$3,283.05 |
| Rate for Payer: Aetna Commercial |
$3,100.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,371.09
|
| Rate for Payer: Cash Price |
$2,918.26
|
| Rate for Payer: Cofinity Commercial |
$2,553.48
|
| Rate for Payer: Cofinity Commercial |
$3,137.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,553.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,918.26
|
| Rate for Payer: Healthscope Commercial |
$3,283.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,100.66
|
| Rate for Payer: PHP Commercial |
$3,100.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,371.09
|
| Rate for Payer: Priority Health SBD |
$2,298.13
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
OP
|
$3,647.83
|
|
|
Service Code
|
NDC 00071101541
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,459.13 |
| Max. Negotiated Rate |
$3,283.05 |
| Rate for Payer: Aetna Commercial |
$3,100.66
|
| Rate for Payer: Aetna Medicare |
$1,823.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,371.09
|
| Rate for Payer: BCBS Complete |
$1,459.13
|
| Rate for Payer: Cash Price |
$2,918.26
|
| Rate for Payer: Cofinity Commercial |
$2,553.48
|
| Rate for Payer: Cofinity Commercial |
$3,137.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,553.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,918.26
|
| Rate for Payer: Healthscope Commercial |
$3,283.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,100.66
|
| Rate for Payer: PHP Commercial |
$3,100.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,371.09
|
| Rate for Payer: Priority Health SBD |
$2,298.13
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
OP
|
$428.45
|
|
|
Service Code
|
NDC 00904700161
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.38 |
| Max. Negotiated Rate |
$385.61 |
| Rate for Payer: Aetna Commercial |
$364.18
|
| Rate for Payer: Aetna Medicare |
$214.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.49
|
| Rate for Payer: BCBS Complete |
$171.38
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$299.92
|
| Rate for Payer: Cofinity Commercial |
$368.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$385.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.18
|
| Rate for Payer: PHP Commercial |
$364.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.49
|
| Rate for Payer: Priority Health SBD |
$269.92
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
IP
|
$428.45
|
|
|
Service Code
|
NDC 00904700161
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$269.92 |
| Max. Negotiated Rate |
$385.61 |
| Rate for Payer: Aetna Commercial |
$364.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.49
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$299.92
|
| Rate for Payer: Cofinity Commercial |
$368.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$385.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.18
|
| Rate for Payer: PHP Commercial |
$364.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.49
|
| Rate for Payer: Priority Health SBD |
$269.92
|
|
|
PREGABALIN 100 MG CAPSULE
|
Facility
|
IP
|
$3,133.87
|
|
|
Service Code
|
NDC 00071101568
|
| Hospital Charge Code |
42165
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,974.34 |
| Max. Negotiated Rate |
$2,820.48 |
| Rate for Payer: Aetna Commercial |
$2,663.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,037.02
|
| Rate for Payer: Cash Price |
$2,507.10
|
| Rate for Payer: Cofinity Commercial |
$2,193.71
|
| Rate for Payer: Cofinity Commercial |
$2,695.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,193.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,507.10
|
| Rate for Payer: Healthscope Commercial |
$2,820.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,663.79
|
| Rate for Payer: PHP Commercial |
$2,663.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,037.02
|
| Rate for Payer: Priority Health SBD |
$1,974.34
|
|
|
PREGABALIN 20 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$1,934.10
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
161926
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,218.48 |
| Max. Negotiated Rate |
$1,740.69 |
| Rate for Payer: Aetna Commercial |
$1,643.98
|
| Rate for Payer: Aetna Commercial |
$1,294.41
|
| Rate for Payer: Aetna Commercial |
$3,552.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,716.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$989.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,257.16
|
| Rate for Payer: Cash Price |
$1,547.28
|
| Rate for Payer: Cash Price |
$1,218.26
|
| Rate for Payer: Cash Price |
$3,343.39
|
| Rate for Payer: Cofinity Commercial |
$2,925.47
|
| Rate for Payer: Cofinity Commercial |
$3,594.15
|
| Rate for Payer: Cofinity Commercial |
$1,663.33
|
| Rate for Payer: Cofinity Commercial |
$1,309.63
|
| Rate for Payer: Cofinity Commercial |
$1,065.98
|
| Rate for Payer: Cofinity Commercial |
$1,353.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,065.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,353.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,925.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,218.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,547.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,343.39
|
| Rate for Payer: Healthscope Commercial |
$1,370.55
|
| Rate for Payer: Healthscope Commercial |
$1,740.69
|
| Rate for Payer: Healthscope Commercial |
$3,761.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,643.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,294.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,552.35
|
| Rate for Payer: PHP Commercial |
$1,294.41
|
| Rate for Payer: PHP Commercial |
$1,643.98
|
| Rate for Payer: PHP Commercial |
$3,552.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$989.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,257.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,716.51
|
| Rate for Payer: Priority Health SBD |
$2,632.92
|
| Rate for Payer: Priority Health SBD |
$959.38
|
| Rate for Payer: Priority Health SBD |
$1,218.48
|
|
|
PREGABALIN 20 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$1,522.83
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
161926
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$609.13 |
| Max. Negotiated Rate |
$1,370.55 |
| Rate for Payer: Aetna Commercial |
$1,294.41
|
| Rate for Payer: Aetna Commercial |
$3,552.35
|
| Rate for Payer: Aetna Commercial |
$1,643.98
|
| Rate for Payer: Aetna Medicare |
$2,089.62
|
| Rate for Payer: Aetna Medicare |
$761.41
|
| Rate for Payer: Aetna Medicare |
$967.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,716.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$989.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,257.16
|
| Rate for Payer: BCBS Complete |
$773.64
|
| Rate for Payer: BCBS Complete |
$609.13
|
| Rate for Payer: BCBS Complete |
$1,671.70
|
| Rate for Payer: Cash Price |
$3,343.39
|
| Rate for Payer: Cash Price |
$1,218.26
|
| Rate for Payer: Cash Price |
$1,547.28
|
| Rate for Payer: Cofinity Commercial |
$3,594.15
|
| Rate for Payer: Cofinity Commercial |
$1,309.63
|
| Rate for Payer: Cofinity Commercial |
$1,065.98
|
| Rate for Payer: Cofinity Commercial |
$1,663.33
|
| Rate for Payer: Cofinity Commercial |
$1,353.87
|
| Rate for Payer: Cofinity Commercial |
$2,925.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,353.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,065.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,925.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,547.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,343.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,218.26
|
| Rate for Payer: Healthscope Commercial |
$1,740.69
|
| Rate for Payer: Healthscope Commercial |
$1,370.55
|
| Rate for Payer: Healthscope Commercial |
$3,761.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,643.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,552.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,294.41
|
| Rate for Payer: PHP Commercial |
$1,643.98
|
| Rate for Payer: PHP Commercial |
$1,294.41
|
| Rate for Payer: PHP Commercial |
$3,552.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$989.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,716.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,257.16
|
| Rate for Payer: Priority Health SBD |
$2,632.92
|
| Rate for Payer: Priority Health SBD |
$1,218.48
|
| Rate for Payer: Priority Health SBD |
$959.38
|
|
|
PREGABALIN 25 MG CAPSULE
|
Facility
|
IP
|
$131.13
|
|
|
Service Code
|
NDC 72205001190
|
| Hospital Charge Code |
42162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.61 |
| Max. Negotiated Rate |
$118.02 |
| Rate for Payer: Aetna Commercial |
$111.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.23
|
| Rate for Payer: Cash Price |
$104.90
|
| Rate for Payer: Cofinity Commercial |
$112.77
|
| Rate for Payer: Cofinity Commercial |
$91.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.90
|
| Rate for Payer: Healthscope Commercial |
$118.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.46
|
| Rate for Payer: PHP Commercial |
$111.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.23
|
| Rate for Payer: Priority Health SBD |
$82.61
|
|
|
PREGABALIN 25 MG CAPSULE
|
Facility
|
IP
|
$3,140.19
|
|
|
Service Code
|
NDC 00071101268
|
| Hospital Charge Code |
42162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,978.32 |
| Max. Negotiated Rate |
$2,826.17 |
| Rate for Payer: Aetna Commercial |
$2,669.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,041.12
|
| Rate for Payer: Cash Price |
$2,512.15
|
| Rate for Payer: Cofinity Commercial |
$2,198.13
|
| Rate for Payer: Cofinity Commercial |
$2,700.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,198.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,512.15
|
| Rate for Payer: Healthscope Commercial |
$2,826.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,669.16
|
| Rate for Payer: PHP Commercial |
$2,669.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,041.12
|
| Rate for Payer: Priority Health SBD |
$1,978.32
|
|
|
PREGABALIN 25 MG CAPSULE
|
Facility
|
OP
|
$131.13
|
|
|
Service Code
|
NDC 72205001190
|
| Hospital Charge Code |
42162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.45 |
| Max. Negotiated Rate |
$118.02 |
| Rate for Payer: Aetna Commercial |
$111.46
|
| Rate for Payer: Aetna Medicare |
$65.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$85.23
|
| Rate for Payer: BCBS Complete |
$52.45
|
| Rate for Payer: Cash Price |
$104.90
|
| Rate for Payer: Cofinity Commercial |
$112.77
|
| Rate for Payer: Cofinity Commercial |
$91.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.90
|
| Rate for Payer: Healthscope Commercial |
$118.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.46
|
| Rate for Payer: PHP Commercial |
$111.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.23
|
| Rate for Payer: Priority Health SBD |
$82.61
|
|
|
PREGABALIN 25 MG CAPSULE
|
Facility
|
OP
|
$3,140.19
|
|
|
Service Code
|
NDC 00071101268
|
| Hospital Charge Code |
42162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,256.08 |
| Max. Negotiated Rate |
$2,826.17 |
| Rate for Payer: Aetna Commercial |
$2,669.16
|
| Rate for Payer: Aetna Medicare |
$1,570.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,041.12
|
| Rate for Payer: BCBS Complete |
$1,256.08
|
| Rate for Payer: Cash Price |
$2,512.15
|
| Rate for Payer: Cofinity Commercial |
$2,198.13
|
| Rate for Payer: Cofinity Commercial |
$2,700.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,198.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,512.15
|
| Rate for Payer: Healthscope Commercial |
$2,826.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,669.16
|
| Rate for Payer: PHP Commercial |
$2,669.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,041.12
|
| Rate for Payer: Priority Health SBD |
$1,978.32
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
OP
|
$384.75
|
|
|
Service Code
|
NDC 00904699261
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.90 |
| Max. Negotiated Rate |
$346.27 |
| Rate for Payer: Aetna Commercial |
$327.04
|
| Rate for Payer: Aetna Medicare |
$192.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.09
|
| Rate for Payer: BCBS Complete |
$153.90
|
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Cofinity Commercial |
$269.32
|
| Rate for Payer: Cofinity Commercial |
$330.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.80
|
| Rate for Payer: Healthscope Commercial |
$346.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.04
|
| Rate for Payer: PHP Commercial |
$327.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.09
|
| Rate for Payer: Priority Health SBD |
$242.39
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$384.75
|
|
|
Service Code
|
NDC 00904699261
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.39 |
| Max. Negotiated Rate |
$346.27 |
| Rate for Payer: Aetna Commercial |
$327.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.09
|
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Cofinity Commercial |
$269.32
|
| Rate for Payer: Cofinity Commercial |
$330.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$269.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.80
|
| Rate for Payer: Healthscope Commercial |
$346.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.04
|
| Rate for Payer: PHP Commercial |
$327.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.09
|
| Rate for Payer: Priority Health SBD |
$242.39
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
IP
|
$3,258.59
|
|
|
Service Code
|
NDC 00071101341
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,052.91 |
| Max. Negotiated Rate |
$2,932.73 |
| Rate for Payer: Aetna Commercial |
$2,769.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,118.08
|
| Rate for Payer: Cash Price |
$2,606.87
|
| Rate for Payer: Cofinity Commercial |
$2,281.01
|
| Rate for Payer: Cofinity Commercial |
$2,802.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,281.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,606.87
|
| Rate for Payer: Healthscope Commercial |
$2,932.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,769.80
|
| Rate for Payer: PHP Commercial |
$2,769.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,118.08
|
| Rate for Payer: Priority Health SBD |
$2,052.91
|
|
|
PREGABALIN 50 MG CAPSULE
|
Facility
|
OP
|
$2.66
|
|
|
Service Code
|
NDC 60687048411
|
| Hospital Charge Code |
42163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$2.39 |
| Rate for Payer: Aetna Commercial |
$2.26
|
| Rate for Payer: Aetna Medicare |
$1.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.73
|
| Rate for Payer: BCBS Complete |
$1.06
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cofinity Commercial |
$1.86
|
| Rate for Payer: Cofinity Commercial |
$2.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.13
|
| Rate for Payer: Healthscope Commercial |
$2.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.26
|
| Rate for Payer: PHP Commercial |
$2.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.73
|
| Rate for Payer: Priority Health SBD |
$1.68
|
|
