|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER
|
Facility
IP
|
$185.64
|
|
|
Service Code
|
NDC 0186-0372-28
|
| Hospital Charge Code |
81453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.22 |
| Max. Negotiated Rate |
$167.08 |
| Rate for Payer: Aetna Commercial |
$157.79
|
| Rate for Payer: BCBS Trust/PPO |
$143.46
|
| Rate for Payer: BCN Commercial |
$143.46
|
| Rate for Payer: Cash Price |
$148.51
|
| Rate for Payer: Cofinity Commercial |
$159.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.51
|
| Rate for Payer: Healthscope Commercial |
$167.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$139.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$157.79
|
| Rate for Payer: PHP Commercial |
$157.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$161.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$113.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.36
|
| Rate for Payer: UHC Core |
$155.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$139.23
|
|
|
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION
|
Facility
IP
|
$25.52
|
|
|
Service Code
|
HCPCS J1939
|
| Hospital Charge Code |
9308
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$22.97 |
| Rate for Payer: Aetna Commercial |
$21.69
|
| Rate for Payer: Aetna Commercial |
$21.90
|
| Rate for Payer: Aetna Commercial |
$24.45
|
| Rate for Payer: BCBS Trust/PPO |
$22.23
|
| Rate for Payer: BCBS Trust/PPO |
$19.72
|
| Rate for Payer: BCBS Trust/PPO |
$19.91
|
| Rate for Payer: BCN Commercial |
$19.91
|
| Rate for Payer: BCN Commercial |
$19.72
|
| Rate for Payer: BCN Commercial |
$22.23
|
| Rate for Payer: Cash Price |
$20.42
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cash Price |
$20.61
|
| Rate for Payer: Cofinity Commercial |
$22.15
|
| Rate for Payer: Cofinity Commercial |
$24.74
|
| Rate for Payer: Cofinity Commercial |
$21.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.42
|
| Rate for Payer: Healthscope Commercial |
$25.89
|
| Rate for Payer: Healthscope Commercial |
$22.97
|
| Rate for Payer: Healthscope Commercial |
$23.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.90
|
| Rate for Payer: PHP Commercial |
$21.90
|
| Rate for Payer: PHP Commercial |
$21.69
|
| Rate for Payer: PHP Commercial |
$24.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.46
|
| Rate for Payer: UHC Core |
$24.02
|
| Rate for Payer: UHC Core |
$21.51
|
| Rate for Payer: UHC Core |
$21.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.58
|
|
|
BUMETANIDE 0.5 MG TABLET
|
Facility
IP
|
$213.12
|
|
|
Service Code
|
NDC 50268-130-15
|
| Hospital Charge Code |
9309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.98 |
| Max. Negotiated Rate |
$191.81 |
| Rate for Payer: Aetna Commercial |
$181.15
|
| Rate for Payer: BCBS Trust/PPO |
$164.70
|
| Rate for Payer: BCN Commercial |
$164.70
|
| Rate for Payer: Cash Price |
$170.50
|
| Rate for Payer: Cofinity Commercial |
$183.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.50
|
| Rate for Payer: Healthscope Commercial |
$191.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$181.15
|
| Rate for Payer: PHP Commercial |
$181.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$185.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$129.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$187.55
|
| Rate for Payer: UHC Core |
$177.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.84
|
|
|
BUMETANIDE 0.5 MG TABLET
|
Facility
IP
|
$300.20
|
|
|
Service Code
|
NDC 42799-119-01
|
| Hospital Charge Code |
9309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.09 |
| Max. Negotiated Rate |
$270.18 |
| Rate for Payer: Aetna Commercial |
$255.17
|
| Rate for Payer: BCBS Trust/PPO |
$231.99
|
| Rate for Payer: BCN Commercial |
$231.99
|
| Rate for Payer: Cash Price |
$240.16
|
| Rate for Payer: Cofinity Commercial |
$258.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.16
|
| Rate for Payer: Healthscope Commercial |
$270.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$255.17
|
| Rate for Payer: PHP Commercial |
$255.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$261.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$183.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$264.18
|
| Rate for Payer: UHC Core |
$250.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.15
|
|
|
BUMETANIDE 0.5 MG TABLET
|
Facility
IP
|
$4.27
|
|
|
Service Code
|
NDC 50268-130-11
|
| Hospital Charge Code |
9309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: BCBS Trust/PPO |
$3.30
|
| Rate for Payer: BCN Commercial |
$3.30
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cofinity Commercial |
$3.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.42
|
| Rate for Payer: Healthscope Commercial |
$3.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.63
|
| Rate for Payer: PHP Commercial |
$3.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.76
|
| Rate for Payer: UHC Core |
$3.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.20
|
|
|
BUMETANIDE 0.5 MG TABLET
|
Facility
IP
|
$398.05
|
|
|
Service Code
|
NDC 0185-0128-01
|
| Hospital Charge Code |
9309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.77 |
| Max. Negotiated Rate |
$358.24 |
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: BCBS Trust/PPO |
$307.61
|
| Rate for Payer: BCN Commercial |
$307.61
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Healthscope Commercial |
$358.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$298.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$338.34
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$346.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$242.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$350.28
|
| Rate for Payer: UHC Core |
$332.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$298.54
|
|
|
BUMETANIDE 0.5 MG TABLET
|
Facility
IP
|
$299.25
|
|
|
Service Code
|
NDC 69238-1489-1
|
| Hospital Charge Code |
9309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.51 |
| Max. Negotiated Rate |
$269.32 |
| Rate for Payer: Aetna Commercial |
$254.36
|
| Rate for Payer: BCBS Trust/PPO |
$231.26
|
| Rate for Payer: BCN Commercial |
$231.26
|
| Rate for Payer: Cash Price |
$239.40
|
| Rate for Payer: Cofinity Commercial |
$257.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.40
|
| Rate for Payer: Healthscope Commercial |
$269.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$224.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$254.36
|
| Rate for Payer: PHP Commercial |
$254.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$260.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$182.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$263.34
|
| Rate for Payer: UHC Core |
$249.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$224.44
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$387.36
|
|
|
Service Code
|
NDC 0904-7016-61
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$236.25 |
| Max. Negotiated Rate |
$348.62 |
| Rate for Payer: Aetna Commercial |
$329.26
|
| Rate for Payer: BCBS Trust/PPO |
$299.35
|
| Rate for Payer: BCN Commercial |
$299.35
|
| Rate for Payer: Cash Price |
$309.89
|
| Rate for Payer: Cofinity Commercial |
$333.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.89
|
| Rate for Payer: Healthscope Commercial |
$348.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$329.26
|
| Rate for Payer: PHP Commercial |
$329.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$337.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$236.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.88
|
| Rate for Payer: UHC Core |
$323.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.52
|
|
|
BUMETANIDE 1 MG TABLET
|
Facility
IP
|
$400.90
|
|
|
Service Code
|
NDC 0185-0129-01
|
| Hospital Charge Code |
9310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$244.51 |
| Max. Negotiated Rate |
$360.81 |
| Rate for Payer: Aetna Commercial |
$340.76
|
| Rate for Payer: BCBS Trust/PPO |
$309.82
|
| Rate for Payer: BCN Commercial |
$309.82
|
| Rate for Payer: Cash Price |
$320.72
|
| Rate for Payer: Cofinity Commercial |
$344.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.72
|
| Rate for Payer: Healthscope Commercial |
$360.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$340.76
|
| Rate for Payer: PHP Commercial |
$340.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$280.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$348.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$244.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$352.79
|
| Rate for Payer: UHC Core |
$334.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.68
|
|
|
BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE
|
Facility
IP
|
$16.24
|
|
|
Service Code
|
NDC 0362-0557-05
|
| Hospital Charge Code |
116394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Aetna Commercial |
$13.80
|
| Rate for Payer: BCBS Trust/PPO |
$12.55
|
| Rate for Payer: BCN Commercial |
$12.55
|
| Rate for Payer: Cash Price |
$12.99
|
| Rate for Payer: Cofinity Commercial |
$13.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.99
|
| Rate for Payer: Healthscope Commercial |
$14.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.80
|
| Rate for Payer: PHP Commercial |
$13.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.29
|
| Rate for Payer: UHC Core |
$13.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.18
|
|
|
BUPIVACAINE 0.5 %-EPINEPHRINE BITARTRATE 1:200,000 INJECTION,CARTRIDGE
|
Facility
IP
|
$16.24
|
|
|
Service Code
|
NDC 0362-9011-50
|
| Hospital Charge Code |
116394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.90 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Aetna Commercial |
$13.80
|
| Rate for Payer: BCBS Trust/PPO |
$12.55
|
| Rate for Payer: BCN Commercial |
$12.55
|
| Rate for Payer: Cash Price |
$12.99
|
| Rate for Payer: Cofinity Commercial |
$13.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.99
|
| Rate for Payer: Healthscope Commercial |
$14.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.80
|
| Rate for Payer: PHP Commercial |
$13.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.29
|
| Rate for Payer: UHC Core |
$13.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.18
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$40.32
|
|
|
Service Code
|
NDC 63323-468-37
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.59 |
| Max. Negotiated Rate |
$36.29 |
| Rate for Payer: Aetna Commercial |
$34.27
|
| Rate for Payer: BCBS Trust/PPO |
$31.16
|
| Rate for Payer: BCN Commercial |
$31.16
|
| Rate for Payer: Cash Price |
$32.26
|
| Rate for Payer: Cofinity Commercial |
$34.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.26
|
| Rate for Payer: Healthscope Commercial |
$36.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.27
|
| Rate for Payer: PHP Commercial |
$34.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$35.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$24.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.48
|
| Rate for Payer: UHC Core |
$33.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.24
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$25.50
|
|
|
Service Code
|
NDC 63323-468-01
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.55 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$21.68
|
| Rate for Payer: BCBS Trust/PPO |
$19.71
|
| Rate for Payer: BCN Commercial |
$19.71
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$21.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$22.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: PHP Commercial |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.44
|
| Rate for Payer: UHC Core |
$21.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.12
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$25.76
|
|
|
Service Code
|
NDC 0409-9042-11
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.71 |
| Max. Negotiated Rate |
$23.18 |
| Rate for Payer: Aetna Commercial |
$21.90
|
| Rate for Payer: BCBS Trust/PPO |
$19.91
|
| Rate for Payer: BCN Commercial |
$19.91
|
| Rate for Payer: Cash Price |
$20.61
|
| Rate for Payer: Cofinity Commercial |
$22.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.61
|
| Rate for Payer: Healthscope Commercial |
$23.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.90
|
| Rate for Payer: PHP Commercial |
$21.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.67
|
| Rate for Payer: UHC Core |
$21.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.32
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$23.39
|
|
|
Service Code
|
NDC 0409-1746-10
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$19.88
|
| Rate for Payer: BCBS Trust/PPO |
$18.08
|
| Rate for Payer: BCN Commercial |
$18.08
|
| Rate for Payer: Cash Price |
$18.71
|
| Rate for Payer: Cofinity Commercial |
$20.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.71
|
| Rate for Payer: Healthscope Commercial |
$21.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.88
|
| Rate for Payer: PHP Commercial |
$19.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.58
|
| Rate for Payer: UHC Core |
$19.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.54
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$40.32
|
|
|
Service Code
|
NDC 63323-468-02
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.59 |
| Max. Negotiated Rate |
$36.29 |
| Rate for Payer: Aetna Commercial |
$34.27
|
| Rate for Payer: BCBS Trust/PPO |
$31.16
|
| Rate for Payer: BCN Commercial |
$31.16
|
| Rate for Payer: Cash Price |
$32.26
|
| Rate for Payer: Cofinity Commercial |
$34.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.26
|
| Rate for Payer: Healthscope Commercial |
$36.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.27
|
| Rate for Payer: PHP Commercial |
$34.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$35.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$24.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.48
|
| Rate for Payer: UHC Core |
$33.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.24
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$25.76
|
|
|
Service Code
|
NDC 0409-9042-01
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.71 |
| Max. Negotiated Rate |
$23.18 |
| Rate for Payer: Aetna Commercial |
$21.90
|
| Rate for Payer: BCBS Trust/PPO |
$19.91
|
| Rate for Payer: BCN Commercial |
$19.91
|
| Rate for Payer: Cash Price |
$20.61
|
| Rate for Payer: Cofinity Commercial |
$22.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.61
|
| Rate for Payer: Healthscope Commercial |
$23.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.90
|
| Rate for Payer: PHP Commercial |
$21.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.67
|
| Rate for Payer: UHC Core |
$21.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.32
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$23.39
|
|
|
Service Code
|
NDC 0409-1746-70
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$21.05 |
| Rate for Payer: Aetna Commercial |
$19.88
|
| Rate for Payer: BCBS Trust/PPO |
$18.08
|
| Rate for Payer: BCN Commercial |
$18.08
|
| Rate for Payer: Cash Price |
$18.71
|
| Rate for Payer: Cofinity Commercial |
$20.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.71
|
| Rate for Payer: Healthscope Commercial |
$21.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.88
|
| Rate for Payer: PHP Commercial |
$19.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.58
|
| Rate for Payer: UHC Core |
$19.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.54
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$25.50
|
|
|
Service Code
|
NDC 63323-468-17
|
| Hospital Charge Code |
105633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.55 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$21.68
|
| Rate for Payer: BCBS Trust/PPO |
$19.71
|
| Rate for Payer: BCN Commercial |
$19.71
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cofinity Commercial |
$21.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.40
|
| Rate for Payer: Healthscope Commercial |
$22.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: PHP Commercial |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.44
|
| Rate for Payer: UHC Core |
$21.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.12
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$26.17
|
|
|
Service Code
|
NDC 63323-462-17
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$23.55 |
| Rate for Payer: Aetna Commercial |
$22.24
|
| Rate for Payer: BCBS Trust/PPO |
$20.22
|
| Rate for Payer: BCN Commercial |
$20.22
|
| Rate for Payer: Cash Price |
$20.94
|
| Rate for Payer: Cofinity Commercial |
$22.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.94
|
| Rate for Payer: Healthscope Commercial |
$23.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.24
|
| Rate for Payer: PHP Commercial |
$22.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.03
|
| Rate for Payer: UHC Core |
$21.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.63
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$19.10
|
|
|
Service Code
|
NDC 0409-1749-29
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$17.19 |
| Rate for Payer: Aetna Commercial |
$16.24
|
| Rate for Payer: BCBS Trust/PPO |
$14.76
|
| Rate for Payer: BCN Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$15.28
|
| Rate for Payer: Cofinity Commercial |
$16.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.28
|
| Rate for Payer: Healthscope Commercial |
$17.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.24
|
| Rate for Payer: PHP Commercial |
$16.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.81
|
| Rate for Payer: UHC Core |
$15.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.32
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$43.39
|
|
|
Service Code
|
NDC 63323-462-37
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$39.05 |
| Rate for Payer: Aetna Commercial |
$36.88
|
| Rate for Payer: BCBS Trust/PPO |
$33.53
|
| Rate for Payer: BCN Commercial |
$33.53
|
| Rate for Payer: Cash Price |
$34.71
|
| Rate for Payer: Cofinity Commercial |
$37.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.71
|
| Rate for Payer: Healthscope Commercial |
$39.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$36.88
|
| Rate for Payer: PHP Commercial |
$36.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.18
|
| Rate for Payer: UHC Core |
$36.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.54
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$21.17
|
|
|
Service Code
|
NDC 0409-1749-70
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.91 |
| Max. Negotiated Rate |
$19.05 |
| Rate for Payer: Aetna Commercial |
$17.99
|
| Rate for Payer: BCBS Trust/PPO |
$16.36
|
| Rate for Payer: BCN Commercial |
$16.36
|
| Rate for Payer: Cash Price |
$16.94
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.94
|
| Rate for Payer: Healthscope Commercial |
$19.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.99
|
| Rate for Payer: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.63
|
| Rate for Payer: UHC Core |
$17.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.88
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$26.17
|
|
|
Service Code
|
NDC 63323-462-04
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.96 |
| Max. Negotiated Rate |
$23.55 |
| Rate for Payer: Aetna Commercial |
$22.24
|
| Rate for Payer: BCBS Trust/PPO |
$20.22
|
| Rate for Payer: BCN Commercial |
$20.22
|
| Rate for Payer: Cash Price |
$20.94
|
| Rate for Payer: Cofinity Commercial |
$22.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.94
|
| Rate for Payer: Healthscope Commercial |
$23.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.24
|
| Rate for Payer: PHP Commercial |
$22.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.03
|
| Rate for Payer: UHC Core |
$21.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.63
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
IP
|
$16.65
|
|
|
Service Code
|
NDC 0409-9045-17
|
| Hospital Charge Code |
105634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$14.98 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| Rate for Payer: BCN Commercial |
$12.87
|
| Rate for Payer: Cash Price |
$13.32
|
| Rate for Payer: Cofinity Commercial |
$14.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.32
|
| Rate for Payer: Healthscope Commercial |
$14.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.15
|
| Rate for Payer: PHP Commercial |
$14.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.65
|
| Rate for Payer: UHC Core |
$13.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.49
|
|
