|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$173.90
|
|
|
Service Code
|
NDC 0172-4096-60
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.06 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: BCBS Trust/PPO |
$134.39
|
| Rate for Payer: BCN Commercial |
$134.39
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$130.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$151.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$106.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$153.03
|
| Rate for Payer: UHC Core |
$145.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.42
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$131.60
|
|
|
Service Code
|
NDC 52817-320-10
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.26 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: BCBS Trust/PPO |
$101.70
|
| Rate for Payer: BCN Commercial |
$101.70
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$114.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$80.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$115.81
|
| Rate for Payer: UHC Core |
$109.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
BACLOFEN 10 MG TABLET
|
Facility
IP
|
$331.55
|
|
|
Service Code
|
NDC 0904-6475-61
|
| Hospital Charge Code |
860
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.21 |
| Max. Negotiated Rate |
$298.40 |
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: BCBS Trust/PPO |
$256.22
|
| Rate for Payer: BCN Commercial |
$256.22
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$288.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$202.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$291.76
|
| Rate for Payer: UHC Core |
$276.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
IP
|
$385.40
|
|
|
Service Code
|
NDC 72888-009-01
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$235.06 |
| Max. Negotiated Rate |
$346.86 |
| Rate for Payer: Aetna Commercial |
$327.59
|
| Rate for Payer: BCBS Trust/PPO |
$297.84
|
| Rate for Payer: BCN Commercial |
$297.84
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$331.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$346.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$327.59
|
| Rate for Payer: PHP Commercial |
$327.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$335.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$235.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$339.15
|
| Rate for Payer: UHC Core |
$321.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.05
|
|
|
BACLOFEN 5 MG TABLET
|
Facility
IP
|
$329.00
|
|
|
Service Code
|
NDC 52817-319-10
|
| Hospital Charge Code |
186653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.66 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: BCBS Trust/PPO |
$254.25
|
| Rate for Payer: BCN Commercial |
$254.25
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$279.65
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$286.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$200.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$289.52
|
| Rate for Payer: UHC Core |
$274.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
B-COMPLEX WITH VITAMIN C TABLET
|
Facility
IP
|
$188.37
|
|
|
Service Code
|
NDC 8068112600
|
| Hospital Charge Code |
807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.89 |
| Max. Negotiated Rate |
$169.53 |
| Rate for Payer: Aetna Commercial |
$160.11
|
| Rate for Payer: BCBS Trust/PPO |
$145.57
|
| Rate for Payer: BCN Commercial |
$145.57
|
| Rate for Payer: Cash Price |
$150.70
|
| Rate for Payer: Cofinity Commercial |
$162.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.70
|
| Rate for Payer: Healthscope Commercial |
$169.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$160.11
|
| Rate for Payer: PHP Commercial |
$160.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$163.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$114.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$165.77
|
| Rate for Payer: UHC Core |
$157.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.28
|
|
|
B-COMPLEX WITH VITAMIN C TABLET
|
Facility
IP
|
$148.00
|
|
|
Service Code
|
NDC 8068115400
|
| Hospital Charge Code |
807
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.27 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna Commercial |
$125.80
|
| Rate for Payer: BCBS Trust/PPO |
$114.37
|
| Rate for Payer: BCN Commercial |
$114.37
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cofinity Commercial |
$127.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.40
|
| Rate for Payer: Healthscope Commercial |
$133.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.80
|
| Rate for Payer: PHP Commercial |
$125.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$128.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$90.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.24
|
| Rate for Payer: UHC Core |
$123.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.00
|
|
|
BECLOMETHASONE DIPROP 40 MCG/ACTUATION HFA BREATH ACTIVATED AEROSOL
|
Facility
IP
|
$695.41
|
|
|
Service Code
|
NDC 59310-302-40
|
| Hospital Charge Code |
184684
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$424.13 |
| Max. Negotiated Rate |
$625.87 |
| Rate for Payer: Aetna Commercial |
$591.10
|
| Rate for Payer: BCBS Trust/PPO |
$537.41
|
| Rate for Payer: BCN Commercial |
$537.41
|
| Rate for Payer: Cash Price |
$556.33
|
| Rate for Payer: Cofinity Commercial |
$598.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$556.33
|
| Rate for Payer: Healthscope Commercial |
$625.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$521.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$591.10
|
| Rate for Payer: PHP Commercial |
$591.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$486.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$605.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$424.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$611.96
|
| Rate for Payer: UHC Core |
$580.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$521.56
|
|
|
BENZOCAINE 20 %-MENTHOL 0.26 % MOUTH MUCOSAL GEL
|
Facility
IP
|
$22.24
|
|
|
Service Code
|
NDC 10310-430-28
|
| Hospital Charge Code |
190719
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.56 |
| Max. Negotiated Rate |
$20.02 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: BCBS Trust/PPO |
$17.19
|
| Rate for Payer: BCN Commercial |
$17.19
|
| Rate for Payer: Cash Price |
$17.79
|
| Rate for Payer: Cofinity Commercial |
$19.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.79
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.90
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.57
|
| Rate for Payer: UHC Core |
$18.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.68
|
|
|
BENZOCAINE 20 % MUCOSAL GEL
|
Facility
IP
|
$10.38
|
|
|
Service Code
|
NDC 10310-0283-40
|
| Hospital Charge Code |
19691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$9.34 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: BCBS Trust/PPO |
$8.02
|
| Rate for Payer: BCN Commercial |
$8.02
|
| Rate for Payer: Cash Price |
$8.30
|
| Rate for Payer: Cofinity Commercial |
$8.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.30
|
| Rate for Payer: Healthscope Commercial |
$9.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.82
|
| Rate for Payer: PHP Commercial |
$8.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.13
|
| Rate for Payer: UHC Core |
$8.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.78
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
IP
|
$34.86
|
|
|
Service Code
|
NDC 0283-0610-26
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.26 |
| Max. Negotiated Rate |
$31.37 |
| Rate for Payer: Aetna Commercial |
$29.63
|
| Rate for Payer: BCBS Trust/PPO |
$26.94
|
| Rate for Payer: BCN Commercial |
$26.94
|
| Rate for Payer: Cash Price |
$27.89
|
| Rate for Payer: Cofinity Commercial |
$29.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.89
|
| Rate for Payer: Healthscope Commercial |
$31.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.63
|
| Rate for Payer: PHP Commercial |
$29.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$30.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$30.68
|
| Rate for Payer: UHC Core |
$29.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.14
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY
|
Facility
IP
|
$37.17
|
|
|
Service Code
|
NDC 0283-0610-43
|
| Hospital Charge Code |
27666
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.67 |
| Max. Negotiated Rate |
$33.45 |
| Rate for Payer: Aetna Commercial |
$31.59
|
| Rate for Payer: BCBS Trust/PPO |
$28.72
|
| Rate for Payer: BCN Commercial |
$28.72
|
| Rate for Payer: Cash Price |
$29.74
|
| Rate for Payer: Cofinity Commercial |
$31.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.74
|
| Rate for Payer: Healthscope Commercial |
$33.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.59
|
| Rate for Payer: PHP Commercial |
$31.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.71
|
| Rate for Payer: UHC Core |
$31.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.88
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
IP
|
$131.60
|
|
|
Service Code
|
NDC 42806-714-01
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.26 |
| Max. Negotiated Rate |
$118.44 |
| Rate for Payer: Aetna Commercial |
$111.86
|
| Rate for Payer: BCBS Trust/PPO |
$101.70
|
| Rate for Payer: BCN Commercial |
$101.70
|
| Rate for Payer: Cash Price |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$113.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.28
|
| Rate for Payer: Healthscope Commercial |
$118.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$98.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$111.86
|
| Rate for Payer: PHP Commercial |
$111.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$114.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$80.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$115.81
|
| Rate for Payer: UHC Core |
$109.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$98.70
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
IP
|
$302.10
|
|
|
Service Code
|
NDC 0904-7153-61
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.25 |
| Max. Negotiated Rate |
$271.89 |
| Rate for Payer: Aetna Commercial |
$256.78
|
| Rate for Payer: BCBS Trust/PPO |
$233.46
|
| Rate for Payer: BCN Commercial |
$233.46
|
| Rate for Payer: Cash Price |
$241.68
|
| Rate for Payer: Cofinity Commercial |
$259.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.68
|
| Rate for Payer: Healthscope Commercial |
$271.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$226.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$256.78
|
| Rate for Payer: PHP Commercial |
$256.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$262.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$184.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.85
|
| Rate for Payer: UHC Core |
$252.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$226.58
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
IP
|
$371.30
|
|
|
Service Code
|
NDC 67877-573-01
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$226.46 |
| Max. Negotiated Rate |
$334.17 |
| Rate for Payer: Aetna Commercial |
$315.60
|
| Rate for Payer: BCBS Trust/PPO |
$286.94
|
| Rate for Payer: BCN Commercial |
$286.94
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Commercial |
$319.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$334.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$315.60
|
| Rate for Payer: PHP Commercial |
$315.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$259.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$323.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$226.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$326.74
|
| Rate for Payer: UHC Core |
$310.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.48
|
|
|
BENZONATATE 100 MG CAPSULE
|
Facility
IP
|
$302.10
|
|
|
Service Code
|
NDC 0904-6564-61
|
| Hospital Charge Code |
988
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.25 |
| Max. Negotiated Rate |
$271.89 |
| Rate for Payer: Aetna Commercial |
$256.78
|
| Rate for Payer: BCBS Trust/PPO |
$233.46
|
| Rate for Payer: BCN Commercial |
$233.46
|
| Rate for Payer: Cash Price |
$241.68
|
| Rate for Payer: Cofinity Commercial |
$259.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.68
|
| Rate for Payer: Healthscope Commercial |
$271.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$226.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$256.78
|
| Rate for Payer: PHP Commercial |
$256.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$262.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$184.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.85
|
| Rate for Payer: UHC Core |
$252.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$226.58
|
|
|
BENZOYL PEROXIDE 5 % TOPICAL CLEANSER
|
Facility
IP
|
$26.55
|
|
|
Service Code
|
NDC 0536-1259-19
|
| Hospital Charge Code |
993
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.19 |
| Max. Negotiated Rate |
$23.90 |
| Rate for Payer: Aetna Commercial |
$22.57
|
| Rate for Payer: BCBS Trust/PPO |
$20.52
|
| Rate for Payer: BCN Commercial |
$20.52
|
| Rate for Payer: Cash Price |
$21.24
|
| Rate for Payer: Cofinity Commercial |
$22.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.24
|
| Rate for Payer: Healthscope Commercial |
$23.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.57
|
| Rate for Payer: PHP Commercial |
$22.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.36
|
| Rate for Payer: UHC Core |
$22.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.91
|
|
|
BENZTROPINE 0.5 MG TABLET
|
Facility
IP
|
$284.35
|
|
|
Service Code
|
NDC 69097-826-07
|
| Hospital Charge Code |
998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.43 |
| Max. Negotiated Rate |
$255.92 |
| Rate for Payer: Aetna Commercial |
$241.70
|
| Rate for Payer: BCBS Trust/PPO |
$219.75
|
| Rate for Payer: BCN Commercial |
$219.75
|
| Rate for Payer: Cash Price |
$227.48
|
| Rate for Payer: Cofinity Commercial |
$244.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.48
|
| Rate for Payer: Healthscope Commercial |
$255.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.70
|
| Rate for Payer: PHP Commercial |
$241.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$247.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$173.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.23
|
| Rate for Payer: UHC Core |
$237.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.26
|
|
|
BENZTROPINE 0.5 MG TABLET
|
Facility
IP
|
$178.60
|
|
|
Service Code
|
NDC 69315-136-01
|
| Hospital Charge Code |
998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.93 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: BCBS Trust/PPO |
$138.02
|
| Rate for Payer: BCN Commercial |
$138.02
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$155.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$108.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.17
|
| Rate for Payer: UHC Core |
$149.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
BENZTROPINE 0.5 MG TABLET
|
Facility
IP
|
$216.20
|
|
|
Service Code
|
NDC 76385-103-01
|
| Hospital Charge Code |
998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.86 |
| Max. Negotiated Rate |
$194.58 |
| Rate for Payer: Aetna Commercial |
$183.77
|
| Rate for Payer: BCBS Trust/PPO |
$167.08
|
| Rate for Payer: BCN Commercial |
$167.08
|
| Rate for Payer: Cash Price |
$172.96
|
| Rate for Payer: Cofinity Commercial |
$185.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.96
|
| Rate for Payer: Healthscope Commercial |
$194.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.77
|
| Rate for Payer: PHP Commercial |
$183.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$188.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$131.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$190.26
|
| Rate for Payer: UHC Core |
$180.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.15
|
|
|
BENZTROPINE 0.5 MG TABLET
|
Facility
IP
|
$304.00
|
|
|
Service Code
|
NDC 0904-7288-61
|
| Hospital Charge Code |
998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.41 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: BCBS Trust/PPO |
$234.93
|
| Rate for Payer: BCN Commercial |
$234.93
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cofinity Commercial |
$261.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.20
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$258.40
|
| Rate for Payer: PHP Commercial |
$258.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$264.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$267.52
|
| Rate for Payer: UHC Core |
$253.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.00
|
|
|
BENZTROPINE 0.5 MG TABLET
|
Facility
IP
|
$285.00
|
|
|
Service Code
|
NDC 0904-6788-61
|
| Hospital Charge Code |
998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.82 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna Commercial |
$242.25
|
| Rate for Payer: BCBS Trust/PPO |
$220.25
|
| Rate for Payer: BCN Commercial |
$220.25
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.00
|
| Rate for Payer: Healthscope Commercial |
$256.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$242.25
|
| Rate for Payer: PHP Commercial |
$242.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$247.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$173.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.80
|
| Rate for Payer: UHC Core |
$237.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.75
|
|
|
BENZTROPINE 1 MG/ML INJECTION SOLUTION
|
Facility
IP
|
$189.80
|
|
|
Service Code
|
HCPCS J0515
|
| Hospital Charge Code |
9259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.76 |
| Max. Negotiated Rate |
$170.82 |
| Rate for Payer: Aetna Commercial |
$161.33
|
| Rate for Payer: BCBS Trust/PPO |
$146.68
|
| Rate for Payer: BCN Commercial |
$146.68
|
| Rate for Payer: Cash Price |
$151.84
|
| Rate for Payer: Cofinity Commercial |
$163.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.84
|
| Rate for Payer: Healthscope Commercial |
$170.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.33
|
| Rate for Payer: PHP Commercial |
$161.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$165.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$115.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$167.02
|
| Rate for Payer: UHC Core |
$158.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.35
|
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION
|
Facility
IP
|
$153.53
|
|
|
Service Code
|
HCPCS J0702
|
| Hospital Charge Code |
9266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.64 |
| Max. Negotiated Rate |
$138.18 |
| Rate for Payer: Aetna Commercial |
$130.50
|
| Rate for Payer: BCBS Trust/PPO |
$118.65
|
| Rate for Payer: BCN Commercial |
$118.65
|
| Rate for Payer: Cash Price |
$122.82
|
| Rate for Payer: Cofinity Commercial |
$132.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.82
|
| Rate for Payer: Healthscope Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$115.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.50
|
| Rate for Payer: PHP Commercial |
$130.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$133.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$93.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$135.11
|
| Rate for Payer: UHC Core |
$128.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$115.15
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL CREAM
|
Facility
IP
|
$137.55
|
|
|
Service Code
|
NDC 0168-0055-15
|
| Hospital Charge Code |
1027
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.89 |
| Max. Negotiated Rate |
$123.80 |
| Rate for Payer: Aetna Commercial |
$116.92
|
| Rate for Payer: BCBS Trust/PPO |
$106.30
|
| Rate for Payer: BCN Commercial |
$106.30
|
| Rate for Payer: Cash Price |
$110.04
|
| Rate for Payer: Cofinity Commercial |
$118.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.04
|
| Rate for Payer: Healthscope Commercial |
$123.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$116.92
|
| Rate for Payer: PHP Commercial |
$116.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$119.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$83.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$121.04
|
| Rate for Payer: UHC Core |
$114.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.16
|
|
