|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$277.30
|
|
|
Service Code
|
NDC 63739090310
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.25 |
| Max. Negotiated Rate |
$249.57 |
| Rate for Payer: Aetna Commercial |
$235.71
|
| Rate for Payer: BCBS Trust/PPO |
$226.36
|
| Rate for Payer: BCN Commercial |
$214.30
|
| Rate for Payer: Cash Price |
$221.84
|
| Rate for Payer: Cofinity Commercial |
$238.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.84
|
| Rate for Payer: Healthscope Commercial |
$249.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.71
|
| Rate for Payer: Nomi Health Commercial |
$227.39
|
| Rate for Payer: PHP Commercial |
$235.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.25
|
| Rate for Payer: Priority Health HMO/PPO |
$241.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$244.02
|
| Rate for Payer: UHC Core |
$231.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.97
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
OP
|
$103.40
|
|
|
Service Code
|
NDC 67877022301
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.56 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna Commercial |
$87.89
|
| Rate for Payer: Aetna Medicare |
$26.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$32.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$32.31
|
| Rate for Payer: BCBS Complete |
$41.36
|
| Rate for Payer: BCBS MAPPO |
$25.85
|
| Rate for Payer: BCBS Trust/PPO |
$85.01
|
| Rate for Payer: BCN Commercial |
$80.39
|
| Rate for Payer: BCN Medicare Advantage |
$25.85
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25.85
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$27.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.89
|
| Rate for Payer: Nomi Health Commercial |
$84.79
|
| Rate for Payer: PACE Senior Care Partners |
$24.56
|
| Rate for Payer: PACE SWMI |
$25.85
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: PHP Medicare Advantage |
$25.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.21
|
| Rate for Payer: Priority Health HMO/PPO |
$89.96
|
| Rate for Payer: Priority Health Medicare |
$26.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$69.28
|
| Rate for Payer: Railroad Medicare Medicare |
$25.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.99
|
| Rate for Payer: UHC Core |
$86.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$25.85
|
| Rate for Payer: UHC Exchange |
$25.85
|
| Rate for Payer: UHC Medicare Advantage |
$25.85
|
| Rate for Payer: VA VA |
$25.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
OP
|
$230.30
|
|
|
Service Code
|
NDC 63739023610
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.70 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna Commercial |
$195.75
|
| Rate for Payer: Aetna Medicare |
$59.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$71.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$71.97
|
| Rate for Payer: BCBS Complete |
$92.12
|
| Rate for Payer: BCBS MAPPO |
$57.58
|
| Rate for Payer: BCBS Trust/PPO |
$189.33
|
| Rate for Payer: BCN Commercial |
$179.06
|
| Rate for Payer: BCN Medicare Advantage |
$57.58
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$57.58
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$60.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.75
|
| Rate for Payer: Nomi Health Commercial |
$188.85
|
| Rate for Payer: PACE Senior Care Partners |
$54.70
|
| Rate for Payer: PACE SWMI |
$57.58
|
| Rate for Payer: PHP Commercial |
$195.75
|
| Rate for Payer: PHP Medicare Advantage |
$57.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.69
|
| Rate for Payer: Priority Health HMO/PPO |
$200.36
|
| Rate for Payer: Priority Health Medicare |
$58.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.30
|
| Rate for Payer: Railroad Medicare Medicare |
$57.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$202.66
|
| Rate for Payer: UHC Core |
$192.30
|
| Rate for Payer: UHC Dual Complete DSNP |
$57.58
|
| Rate for Payer: UHC Exchange |
$57.58
|
| Rate for Payer: UHC Medicare Advantage |
$57.58
|
| Rate for Payer: VA VA |
$57.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$103.40
|
|
|
Service Code
|
NDC 67877022301
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.21 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna Commercial |
$87.89
|
| Rate for Payer: BCBS Trust/PPO |
$84.41
|
| Rate for Payer: BCN Commercial |
$79.91
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.89
|
| Rate for Payer: Nomi Health Commercial |
$84.79
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.21
|
| Rate for Payer: Priority Health HMO/PPO |
$89.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$69.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.99
|
| Rate for Payer: UHC Core |
$86.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
OP
|
$251.45
|
|
|
Service Code
|
NDC 00904666661
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.72 |
| Max. Negotiated Rate |
$226.31 |
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna Medicare |
$65.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$78.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$78.58
|
| Rate for Payer: BCBS Complete |
$100.58
|
| Rate for Payer: BCBS MAPPO |
$62.86
|
| Rate for Payer: BCBS Trust/PPO |
$206.72
|
| Rate for Payer: BCN Commercial |
$195.50
|
| Rate for Payer: BCN Medicare Advantage |
$62.86
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.86
|
| Rate for Payer: Healthscope Commercial |
$226.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$66.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$72.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: Nomi Health Commercial |
$206.19
|
| Rate for Payer: PACE Senior Care Partners |
$59.72
|
| Rate for Payer: PACE SWMI |
$62.86
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: PHP Medicare Advantage |
$62.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: Priority Health HMO/PPO |
$218.76
|
| Rate for Payer: Priority Health Medicare |
$63.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$168.47
|
| Rate for Payer: Railroad Medicare Medicare |
$62.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$221.28
|
| Rate for Payer: UHC Core |
$209.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$62.86
|
| Rate for Payer: UHC Exchange |
$62.86
|
| Rate for Payer: UHC Medicare Advantage |
$62.86
|
| Rate for Payer: VA VA |
$62.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
OP
|
$277.30
|
|
|
Service Code
|
NDC 63739090310
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.86 |
| Max. Negotiated Rate |
$249.57 |
| Rate for Payer: Aetna Commercial |
$235.71
|
| Rate for Payer: Aetna Medicare |
$72.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$86.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$86.66
|
| Rate for Payer: BCBS Complete |
$110.92
|
| Rate for Payer: BCBS MAPPO |
$69.33
|
| Rate for Payer: BCBS Trust/PPO |
$227.97
|
| Rate for Payer: BCN Commercial |
$215.60
|
| Rate for Payer: BCN Medicare Advantage |
$69.33
|
| Rate for Payer: Cash Price |
$221.84
|
| Rate for Payer: Cofinity Commercial |
$238.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$69.33
|
| Rate for Payer: Healthscope Commercial |
$249.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$72.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$79.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.71
|
| Rate for Payer: Nomi Health Commercial |
$227.39
|
| Rate for Payer: PACE Senior Care Partners |
$65.86
|
| Rate for Payer: PACE SWMI |
$69.33
|
| Rate for Payer: PHP Commercial |
$235.71
|
| Rate for Payer: PHP Medicare Advantage |
$69.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.25
|
| Rate for Payer: Priority Health HMO/PPO |
$241.25
|
| Rate for Payer: Priority Health Medicare |
$70.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.79
|
| Rate for Payer: Railroad Medicare Medicare |
$69.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$244.02
|
| Rate for Payer: UHC Core |
$231.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$69.33
|
| Rate for Payer: UHC Exchange |
$69.33
|
| Rate for Payer: UHC Medicare Advantage |
$69.33
|
| Rate for Payer: VA VA |
$69.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.97
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$298.45
|
|
|
Service Code
|
NDC 63739090410
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.99 |
| Max. Negotiated Rate |
$268.61 |
| Rate for Payer: Aetna Commercial |
$253.68
|
| Rate for Payer: BCBS Trust/PPO |
$243.62
|
| Rate for Payer: BCN Commercial |
$230.64
|
| Rate for Payer: Cash Price |
$238.76
|
| Rate for Payer: Cofinity Commercial |
$256.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$238.76
|
| Rate for Payer: Healthscope Commercial |
$268.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$223.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$253.68
|
| Rate for Payer: Nomi Health Commercial |
$244.73
|
| Rate for Payer: PHP Commercial |
$253.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.99
|
| Rate for Payer: Priority Health HMO/PPO |
$259.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$262.64
|
| Rate for Payer: UHC Core |
$249.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$223.84
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 67877022401
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.23 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: BCBS Trust/PPO |
$120.85
|
| Rate for Payer: BCN Commercial |
$114.41
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health HMO/PPO |
$128.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.28
|
| Rate for Payer: UHC Core |
$123.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 67877022401
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna Medicare |
$38.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.27
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: BCBS MAPPO |
$37.01
|
| Rate for Payer: BCBS Trust/PPO |
$121.71
|
| Rate for Payer: BCN Commercial |
$115.11
|
| Rate for Payer: BCN Medicare Advantage |
$37.01
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.01
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$38.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: PACE Senior Care Partners |
$35.16
|
| Rate for Payer: PACE SWMI |
$37.01
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: PHP Medicare Advantage |
$37.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health HMO/PPO |
$128.80
|
| Rate for Payer: Priority Health Medicare |
$37.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.19
|
| Rate for Payer: Railroad Medicare Medicare |
$37.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.28
|
| Rate for Payer: UHC Core |
$123.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$37.01
|
| Rate for Payer: UHC Exchange |
$37.01
|
| Rate for Payer: UHC Medicare Advantage |
$37.01
|
| Rate for Payer: VA VA |
$37.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
OP
|
$272.60
|
|
|
Service Code
|
NDC 00904666761
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.74 |
| Max. Negotiated Rate |
$245.34 |
| Rate for Payer: Aetna Commercial |
$231.71
|
| Rate for Payer: Aetna Medicare |
$70.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$85.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$85.19
|
| Rate for Payer: BCBS Complete |
$109.04
|
| Rate for Payer: BCBS MAPPO |
$68.15
|
| Rate for Payer: BCBS Trust/PPO |
$224.10
|
| Rate for Payer: BCN Commercial |
$211.95
|
| Rate for Payer: BCN Medicare Advantage |
$68.15
|
| Rate for Payer: Cash Price |
$218.08
|
| Rate for Payer: Cofinity Commercial |
$234.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$68.15
|
| Rate for Payer: Healthscope Commercial |
$245.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$71.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$231.71
|
| Rate for Payer: Nomi Health Commercial |
$223.53
|
| Rate for Payer: PACE Senior Care Partners |
$64.74
|
| Rate for Payer: PACE SWMI |
$68.15
|
| Rate for Payer: PHP Commercial |
$231.71
|
| Rate for Payer: PHP Medicare Advantage |
$68.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.19
|
| Rate for Payer: Priority Health HMO/PPO |
$237.16
|
| Rate for Payer: Priority Health Medicare |
$68.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$182.64
|
| Rate for Payer: Railroad Medicare Medicare |
$68.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$239.89
|
| Rate for Payer: UHC Core |
$227.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$68.15
|
| Rate for Payer: UHC Exchange |
$68.15
|
| Rate for Payer: UHC Medicare Advantage |
$68.15
|
| Rate for Payer: VA VA |
$68.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.45
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$239.70
|
|
|
Service Code
|
NDC 63739098410
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.81 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna Commercial |
$203.75
|
| Rate for Payer: BCBS Trust/PPO |
$195.67
|
| Rate for Payer: BCN Commercial |
$185.24
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$206.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$215.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.75
|
| Rate for Payer: Nomi Health Commercial |
$196.55
|
| Rate for Payer: PHP Commercial |
$203.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.81
|
| Rate for Payer: Priority Health HMO/PPO |
$208.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$160.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.94
|
| Rate for Payer: UHC Core |
$200.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
OP
|
$239.70
|
|
|
Service Code
|
NDC 63739098410
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.93 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna Commercial |
$203.75
|
| Rate for Payer: Aetna Medicare |
$62.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$74.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$74.91
|
| Rate for Payer: BCBS Complete |
$95.88
|
| Rate for Payer: BCBS MAPPO |
$59.92
|
| Rate for Payer: BCBS Trust/PPO |
$197.06
|
| Rate for Payer: BCN Commercial |
$186.37
|
| Rate for Payer: BCN Medicare Advantage |
$59.92
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$206.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$59.92
|
| Rate for Payer: Healthscope Commercial |
$215.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$62.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.75
|
| Rate for Payer: Nomi Health Commercial |
$196.55
|
| Rate for Payer: PACE Senior Care Partners |
$56.93
|
| Rate for Payer: PACE SWMI |
$59.92
|
| Rate for Payer: PHP Commercial |
$203.75
|
| Rate for Payer: PHP Medicare Advantage |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.81
|
| Rate for Payer: Priority Health HMO/PPO |
$208.54
|
| Rate for Payer: Priority Health Medicare |
$60.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$160.60
|
| Rate for Payer: Railroad Medicare Medicare |
$59.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.94
|
| Rate for Payer: UHC Core |
$200.15
|
| Rate for Payer: UHC Dual Complete DSNP |
$59.92
|
| Rate for Payer: UHC Exchange |
$59.92
|
| Rate for Payer: UHC Medicare Advantage |
$59.92
|
| Rate for Payer: VA VA |
$59.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$272.60
|
|
|
Service Code
|
NDC 00904666761
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.19 |
| Max. Negotiated Rate |
$245.34 |
| Rate for Payer: Aetna Commercial |
$231.71
|
| Rate for Payer: BCBS Trust/PPO |
$222.52
|
| Rate for Payer: BCN Commercial |
$210.67
|
| Rate for Payer: Cash Price |
$218.08
|
| Rate for Payer: Cofinity Commercial |
$234.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.08
|
| Rate for Payer: Healthscope Commercial |
$245.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$231.71
|
| Rate for Payer: Nomi Health Commercial |
$223.53
|
| Rate for Payer: PHP Commercial |
$231.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.19
|
| Rate for Payer: Priority Health HMO/PPO |
$237.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$182.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$239.89
|
| Rate for Payer: UHC Core |
$227.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.45
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
OP
|
$298.45
|
|
|
Service Code
|
NDC 63739090410
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.88 |
| Max. Negotiated Rate |
$268.61 |
| Rate for Payer: Aetna Commercial |
$253.68
|
| Rate for Payer: Aetna Medicare |
$77.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$93.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$93.27
|
| Rate for Payer: BCBS Complete |
$119.38
|
| Rate for Payer: BCBS MAPPO |
$74.61
|
| Rate for Payer: BCBS Trust/PPO |
$245.36
|
| Rate for Payer: BCN Commercial |
$232.04
|
| Rate for Payer: BCN Medicare Advantage |
$74.61
|
| Rate for Payer: Cash Price |
$238.76
|
| Rate for Payer: Cofinity Commercial |
$256.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$238.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$74.61
|
| Rate for Payer: Healthscope Commercial |
$268.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$223.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$78.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$85.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$253.68
|
| Rate for Payer: Nomi Health Commercial |
$244.73
|
| Rate for Payer: PACE Senior Care Partners |
$70.88
|
| Rate for Payer: PACE SWMI |
$74.61
|
| Rate for Payer: PHP Commercial |
$253.68
|
| Rate for Payer: PHP Medicare Advantage |
$74.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.99
|
| Rate for Payer: Priority Health HMO/PPO |
$259.65
|
| Rate for Payer: Priority Health Medicare |
$75.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.96
|
| Rate for Payer: Railroad Medicare Medicare |
$74.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$262.64
|
| Rate for Payer: UHC Core |
$249.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$74.61
|
| Rate for Payer: UHC Exchange |
$74.61
|
| Rate for Payer: UHC Medicare Advantage |
$74.61
|
| Rate for Payer: VA VA |
$74.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$223.84
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$128.40
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.50 |
| Max. Negotiated Rate |
$115.56 |
| Rate for Payer: Aetna Commercial |
$109.14
|
| Rate for Payer: Aetna Commercial |
$81.86
|
| Rate for Payer: Aetna Commercial |
$27.29
|
| Rate for Payer: Aetna Medicare |
$25.04
|
| Rate for Payer: Aetna Medicare |
$33.38
|
| Rate for Payer: Aetna Medicare |
$8.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$40.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.03
|
| Rate for Payer: Amish Plain Church Group Commercial |
$40.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.03
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30.09
|
| Rate for Payer: BCBS Complete |
$12.84
|
| Rate for Payer: BCBS Complete |
$51.36
|
| Rate for Payer: BCBS Complete |
$38.52
|
| Rate for Payer: BCBS MAPPO |
$24.07
|
| Rate for Payer: BCBS MAPPO |
$32.10
|
| Rate for Payer: BCBS MAPPO |
$8.03
|
| Rate for Payer: BCBS Trust/PPO |
$26.39
|
| Rate for Payer: BCBS Trust/PPO |
$105.56
|
| Rate for Payer: BCBS Trust/PPO |
$79.17
|
| Rate for Payer: BCN Commercial |
$24.96
|
| Rate for Payer: BCN Commercial |
$74.87
|
| Rate for Payer: BCN Commercial |
$99.83
|
| Rate for Payer: BCN Medicare Advantage |
$32.10
|
| Rate for Payer: BCN Medicare Advantage |
$8.03
|
| Rate for Payer: BCN Medicare Advantage |
$24.07
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cofinity Commercial |
$82.82
|
| Rate for Payer: Cofinity Commercial |
$110.42
|
| Rate for Payer: Cofinity Commercial |
$27.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.03
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$32.10
|
| Rate for Payer: Healthscope Commercial |
$28.89
|
| Rate for Payer: Healthscope Commercial |
$115.56
|
| Rate for Payer: Healthscope Commercial |
$86.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$33.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.43
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$36.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.14
|
| Rate for Payer: Nomi Health Commercial |
$78.97
|
| Rate for Payer: Nomi Health Commercial |
$105.29
|
| Rate for Payer: Nomi Health Commercial |
$26.32
|
| Rate for Payer: PACE Senior Care Partners |
$22.87
|
| Rate for Payer: PACE Senior Care Partners |
$30.50
|
| Rate for Payer: PACE Senior Care Partners |
$7.62
|
| Rate for Payer: PACE SWMI |
$8.03
|
| Rate for Payer: PACE SWMI |
$32.10
|
| Rate for Payer: PACE SWMI |
$24.07
|
| Rate for Payer: PHP Commercial |
$81.86
|
| Rate for Payer: PHP Commercial |
$27.29
|
| Rate for Payer: PHP Commercial |
$109.14
|
| Rate for Payer: PHP Medicare Advantage |
$8.03
|
| Rate for Payer: PHP Medicare Advantage |
$24.07
|
| Rate for Payer: PHP Medicare Advantage |
$32.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.86
|
| Rate for Payer: Priority Health HMO/PPO |
$83.78
|
| Rate for Payer: Priority Health HMO/PPO |
$111.71
|
| Rate for Payer: Priority Health HMO/PPO |
$27.93
|
| Rate for Payer: Priority Health Medicare |
$32.42
|
| Rate for Payer: Priority Health Medicare |
$24.32
|
| Rate for Payer: Priority Health Medicare |
$8.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$64.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$86.03
|
| Rate for Payer: Railroad Medicare Medicare |
$8.03
|
| Rate for Payer: Railroad Medicare Medicare |
$24.07
|
| Rate for Payer: Railroad Medicare Medicare |
$32.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$112.99
|
| Rate for Payer: UHC Core |
$80.41
|
| Rate for Payer: UHC Core |
$26.80
|
| Rate for Payer: UHC Core |
$107.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$32.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$24.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$8.03
|
| Rate for Payer: UHC Exchange |
$8.03
|
| Rate for Payer: UHC Exchange |
$32.10
|
| Rate for Payer: UHC Exchange |
$24.07
|
| Rate for Payer: UHC Medicare Advantage |
$32.10
|
| Rate for Payer: UHC Medicare Advantage |
$8.03
|
| Rate for Payer: UHC Medicare Advantage |
$24.07
|
| Rate for Payer: VA VA |
$8.03
|
| Rate for Payer: VA VA |
$24.07
|
| Rate for Payer: VA VA |
$32.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.07
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$128.40
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.46 |
| Max. Negotiated Rate |
$115.56 |
| Rate for Payer: Aetna Commercial |
$109.14
|
| Rate for Payer: Aetna Commercial |
$27.29
|
| Rate for Payer: Aetna Commercial |
$81.86
|
| Rate for Payer: BCBS Trust/PPO |
$26.20
|
| Rate for Payer: BCBS Trust/PPO |
$104.81
|
| Rate for Payer: BCBS Trust/PPO |
$78.61
|
| Rate for Payer: BCN Commercial |
$24.81
|
| Rate for Payer: BCN Commercial |
$99.23
|
| Rate for Payer: BCN Commercial |
$74.42
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cofinity Commercial |
$82.82
|
| Rate for Payer: Cofinity Commercial |
$27.61
|
| Rate for Payer: Cofinity Commercial |
$110.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.04
|
| Rate for Payer: Healthscope Commercial |
$28.89
|
| Rate for Payer: Healthscope Commercial |
$115.56
|
| Rate for Payer: Healthscope Commercial |
$86.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.86
|
| Rate for Payer: Nomi Health Commercial |
$105.29
|
| Rate for Payer: Nomi Health Commercial |
$26.32
|
| Rate for Payer: Nomi Health Commercial |
$78.97
|
| Rate for Payer: PHP Commercial |
$27.29
|
| Rate for Payer: PHP Commercial |
$109.14
|
| Rate for Payer: PHP Commercial |
$81.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.86
|
| Rate for Payer: Priority Health HMO/PPO |
$83.78
|
| Rate for Payer: Priority Health HMO/PPO |
$27.93
|
| Rate for Payer: Priority Health HMO/PPO |
$111.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$64.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$86.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$112.99
|
| Rate for Payer: UHC Core |
$107.21
|
| Rate for Payer: UHC Core |
$80.41
|
| Rate for Payer: UHC Core |
$26.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.07
|
|
|
GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN
|
Facility
|
OP
|
$77.62
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.43 |
| Max. Negotiated Rate |
$69.86 |
| Rate for Payer: Aetna Commercial |
$65.98
|
| Rate for Payer: Aetna Medicare |
$20.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.26
|
| Rate for Payer: BCBS Complete |
$31.05
|
| Rate for Payer: BCBS MAPPO |
$19.41
|
| Rate for Payer: BCBS Trust/PPO |
$63.81
|
| Rate for Payer: BCN Commercial |
$60.35
|
| Rate for Payer: BCN Medicare Advantage |
$19.41
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cofinity Commercial |
$66.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19.41
|
| Rate for Payer: Healthscope Commercial |
$69.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.98
|
| Rate for Payer: Nomi Health Commercial |
$63.65
|
| Rate for Payer: PACE Senior Care Partners |
$18.43
|
| Rate for Payer: PACE SWMI |
$19.41
|
| Rate for Payer: PHP Commercial |
$65.98
|
| Rate for Payer: PHP Medicare Advantage |
$19.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.45
|
| Rate for Payer: Priority Health HMO/PPO |
$67.53
|
| Rate for Payer: Priority Health Medicare |
$19.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.01
|
| Rate for Payer: Railroad Medicare Medicare |
$19.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.31
|
| Rate for Payer: UHC Core |
$64.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$19.41
|
| Rate for Payer: UHC Exchange |
$19.41
|
| Rate for Payer: UHC Medicare Advantage |
$19.41
|
| Rate for Payer: VA VA |
$19.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.22
|
|
|
GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN
|
Facility
|
IP
|
$77.62
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.45 |
| Max. Negotiated Rate |
$69.86 |
| Rate for Payer: Aetna Commercial |
$65.98
|
| Rate for Payer: BCBS Trust/PPO |
$63.36
|
| Rate for Payer: BCN Commercial |
$59.98
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cofinity Commercial |
$66.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.10
|
| Rate for Payer: Healthscope Commercial |
$69.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.98
|
| Rate for Payer: Nomi Health Commercial |
$63.65
|
| Rate for Payer: PHP Commercial |
$65.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.45
|
| Rate for Payer: Priority Health HMO/PPO |
$67.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$52.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.31
|
| Rate for Payer: UHC Core |
$64.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.22
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$631.68
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$410.59 |
| Max. Negotiated Rate |
$568.51 |
| Rate for Payer: Aetna Commercial |
$536.93
|
| Rate for Payer: BCBS Trust/PPO |
$515.64
|
| Rate for Payer: BCN Commercial |
$488.16
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cofinity Commercial |
$543.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.34
|
| Rate for Payer: Healthscope Commercial |
$568.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$473.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.93
|
| Rate for Payer: Nomi Health Commercial |
$517.98
|
| Rate for Payer: PHP Commercial |
$536.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$410.59
|
| Rate for Payer: Priority Health HMO/PPO |
$549.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$423.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$555.88
|
| Rate for Payer: UHC Core |
$527.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$473.76
|
|
|
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$631.68
|
|
|
Service Code
|
HCPCS A9581
|
| Hospital Charge Code |
93574
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.02 |
| Max. Negotiated Rate |
$568.51 |
| Rate for Payer: Aetna Commercial |
$536.93
|
| Rate for Payer: Aetna Medicare |
$164.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$197.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$197.40
|
| Rate for Payer: BCBS Complete |
$252.67
|
| Rate for Payer: BCBS MAPPO |
$157.92
|
| Rate for Payer: BCBS Trust/PPO |
$519.30
|
| Rate for Payer: BCN Commercial |
$491.13
|
| Rate for Payer: BCN Medicare Advantage |
$157.92
|
| Rate for Payer: Cash Price |
$505.34
|
| Rate for Payer: Cofinity Commercial |
$543.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$505.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$568.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$473.76
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$165.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$181.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.93
|
| Rate for Payer: Nomi Health Commercial |
$517.98
|
| Rate for Payer: PACE Senior Care Partners |
$150.02
|
| Rate for Payer: PACE SWMI |
$157.92
|
| Rate for Payer: PHP Commercial |
$536.93
|
| Rate for Payer: PHP Medicare Advantage |
$157.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$410.59
|
| Rate for Payer: Priority Health HMO/PPO |
$549.56
|
| Rate for Payer: Priority Health Medicare |
$159.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$423.23
|
| Rate for Payer: Railroad Medicare Medicare |
$157.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$555.88
|
| Rate for Payer: UHC Core |
$527.45
|
| Rate for Payer: UHC Dual Complete DSNP |
$157.92
|
| Rate for Payer: UHC Exchange |
$157.92
|
| Rate for Payer: UHC Medicare Advantage |
$157.92
|
| Rate for Payer: VA VA |
$157.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$473.76
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$361.31
|
|
|
Service Code
|
NDC 68084072921
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.81 |
| Max. Negotiated Rate |
$325.18 |
| Rate for Payer: Aetna Commercial |
$307.11
|
| Rate for Payer: Aetna Medicare |
$93.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$112.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$112.91
|
| Rate for Payer: BCBS Complete |
$144.52
|
| Rate for Payer: BCBS MAPPO |
$90.33
|
| Rate for Payer: BCBS Trust/PPO |
$297.03
|
| Rate for Payer: BCN Commercial |
$280.92
|
| Rate for Payer: BCN Medicare Advantage |
$90.33
|
| Rate for Payer: Cash Price |
$289.05
|
| Rate for Payer: Cofinity Commercial |
$310.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$90.33
|
| Rate for Payer: Healthscope Commercial |
$325.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$270.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$94.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$103.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.11
|
| Rate for Payer: Nomi Health Commercial |
$296.27
|
| Rate for Payer: PACE Senior Care Partners |
$85.81
|
| Rate for Payer: PACE SWMI |
$90.33
|
| Rate for Payer: PHP Commercial |
$307.11
|
| Rate for Payer: PHP Medicare Advantage |
$90.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.85
|
| Rate for Payer: Priority Health HMO/PPO |
$314.34
|
| Rate for Payer: Priority Health Medicare |
$91.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$242.08
|
| Rate for Payer: Railroad Medicare Medicare |
$90.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$317.95
|
| Rate for Payer: UHC Core |
$301.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$90.33
|
| Rate for Payer: UHC Exchange |
$90.33
|
| Rate for Payer: UHC Medicare Advantage |
$90.33
|
| Rate for Payer: VA VA |
$90.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.98
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$12.05
|
|
|
Service Code
|
NDC 68084072911
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$10.85 |
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: BCBS Trust/PPO |
$9.84
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Healthscope Commercial |
$10.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.24
|
| Rate for Payer: Nomi Health Commercial |
$9.88
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.83
|
| Rate for Payer: Priority Health HMO/PPO |
$10.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.60
|
| Rate for Payer: UHC Core |
$10.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$361.31
|
|
|
Service Code
|
NDC 68084072921
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.85 |
| Max. Negotiated Rate |
$325.18 |
| Rate for Payer: Aetna Commercial |
$307.11
|
| Rate for Payer: BCBS Trust/PPO |
$294.94
|
| Rate for Payer: BCN Commercial |
$279.22
|
| Rate for Payer: Cash Price |
$289.05
|
| Rate for Payer: Cofinity Commercial |
$310.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.05
|
| Rate for Payer: Healthscope Commercial |
$325.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$270.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.11
|
| Rate for Payer: Nomi Health Commercial |
$296.27
|
| Rate for Payer: PHP Commercial |
$307.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.85
|
| Rate for Payer: Priority Health HMO/PPO |
$314.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$242.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$317.95
|
| Rate for Payer: UHC Core |
$301.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.98
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
NDC 68084072911
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$10.85 |
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna Medicare |
$3.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.77
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: BCBS MAPPO |
$3.01
|
| Rate for Payer: BCBS Trust/PPO |
$9.91
|
| Rate for Payer: BCN Commercial |
$9.37
|
| Rate for Payer: BCN Medicare Advantage |
$3.01
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.01
|
| Rate for Payer: Healthscope Commercial |
$10.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.24
|
| Rate for Payer: Nomi Health Commercial |
$9.88
|
| Rate for Payer: PACE Senior Care Partners |
$2.86
|
| Rate for Payer: PACE SWMI |
$3.01
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: PHP Medicare Advantage |
$3.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.83
|
| Rate for Payer: Priority Health HMO/PPO |
$10.48
|
| Rate for Payer: Priority Health Medicare |
$3.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.07
|
| Rate for Payer: Railroad Medicare Medicare |
$3.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.60
|
| Rate for Payer: UHC Core |
$10.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.01
|
| Rate for Payer: UHC Exchange |
$3.01
|
| Rate for Payer: UHC Medicare Advantage |
$3.01
|
| Rate for Payer: VA VA |
$3.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$199.77
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
10101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.45 |
| Max. Negotiated Rate |
$179.79 |
| Rate for Payer: Aetna Commercial |
$169.80
|
| Rate for Payer: Aetna Medicare |
$51.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.43
|
| Rate for Payer: BCBS Complete |
$79.91
|
| Rate for Payer: BCBS MAPPO |
$49.94
|
| Rate for Payer: BCBS Trust/PPO |
$164.23
|
| Rate for Payer: BCN Commercial |
$155.32
|
| Rate for Payer: BCN Medicare Advantage |
$49.94
|
| Rate for Payer: Cash Price |
$159.82
|
| Rate for Payer: Cofinity Commercial |
$171.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49.94
|
| Rate for Payer: Healthscope Commercial |
$179.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.83
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.80
|
| Rate for Payer: Nomi Health Commercial |
$163.81
|
| Rate for Payer: PACE Senior Care Partners |
$47.45
|
| Rate for Payer: PACE SWMI |
$49.94
|
| Rate for Payer: PHP Commercial |
$169.80
|
| Rate for Payer: PHP Medicare Advantage |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.85
|
| Rate for Payer: Priority Health HMO/PPO |
$173.80
|
| Rate for Payer: Priority Health Medicare |
$50.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$133.85
|
| Rate for Payer: Railroad Medicare Medicare |
$49.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$175.80
|
| Rate for Payer: UHC Core |
$166.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$49.94
|
| Rate for Payer: UHC Exchange |
$49.94
|
| Rate for Payer: UHC Medicare Advantage |
$49.94
|
| Rate for Payer: VA VA |
$49.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.83
|
|
