|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$10.88
|
|
|
Service Code
|
NDC 9900-0001-91
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.64 |
| Max. Negotiated Rate |
$9.79 |
| Rate for Payer: Aetna Commercial |
$9.25
|
| Rate for Payer: BCBS Trust/PPO |
$8.41
|
| Rate for Payer: BCN Commercial |
$8.41
|
| Rate for Payer: Cash Price |
$8.70
|
| Rate for Payer: Cofinity Commercial |
$9.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.70
|
| Rate for Payer: Healthscope Commercial |
$9.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.25
|
| Rate for Payer: PHP Commercial |
$9.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.57
|
| Rate for Payer: UHC Core |
$9.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.16
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP
|
Facility
IP
|
$13.23
|
|
|
Service Code
|
NDC 0121-1761-30
|
| Hospital Charge Code |
38285
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$11.91 |
| Rate for Payer: Aetna Commercial |
$11.25
|
| Rate for Payer: BCBS Trust/PPO |
$10.22
|
| Rate for Payer: BCN Commercial |
$10.22
|
| Rate for Payer: Cash Price |
$10.58
|
| Rate for Payer: Cofinity Commercial |
$11.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.58
|
| Rate for Payer: Healthscope Commercial |
$11.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.25
|
| Rate for Payer: PHP Commercial |
$11.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.64
|
| Rate for Payer: UHC Core |
$11.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.92
|
|
|
ALVIMOPAN 12 MG CAPSULE
|
Facility
IP
|
$20,184.24
|
|
|
Service Code
|
NDC 67919-020-10
|
| Hospital Charge Code |
91870
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12,310.37 |
| Max. Negotiated Rate |
$18,165.82 |
| Rate for Payer: Aetna Commercial |
$17,156.60
|
| Rate for Payer: BCBS Trust/PPO |
$15,598.38
|
| Rate for Payer: BCN Commercial |
$15,598.38
|
| Rate for Payer: Cash Price |
$16,147.39
|
| Rate for Payer: Cofinity Commercial |
$17,358.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16,147.39
|
| Rate for Payer: Healthscope Commercial |
$18,165.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15,138.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17,156.60
|
| Rate for Payer: PHP Commercial |
$17,156.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14,128.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,560.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12,310.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17,762.13
|
| Rate for Payer: UHC Core |
$16,853.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15,138.18
|
|
|
AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$31.15
|
|
|
Service Code
|
HCPCS J0280
|
| Hospital Charge Code |
113386
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.00 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Aetna Commercial |
$26.48
|
| Rate for Payer: BCBS Trust/PPO |
$24.07
|
| Rate for Payer: BCN Commercial |
$24.07
|
| Rate for Payer: Cash Price |
$24.92
|
| Rate for Payer: Cofinity Commercial |
$26.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.92
|
| Rate for Payer: Healthscope Commercial |
$28.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.48
|
| Rate for Payer: PHP Commercial |
$26.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.41
|
| Rate for Payer: UHC Core |
$26.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.36
|
|
|
AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
IP
|
$68.98
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.07 |
| Max. Negotiated Rate |
$62.08 |
| Rate for Payer: Aetna Commercial |
$58.63
|
| Rate for Payer: BCBS Trust/PPO |
$53.31
|
| Rate for Payer: BCN Commercial |
$53.31
|
| Rate for Payer: Cash Price |
$55.18
|
| Rate for Payer: Cofinity Commercial |
$59.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.18
|
| Rate for Payer: Healthscope Commercial |
$62.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.63
|
| Rate for Payer: PHP Commercial |
$58.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$60.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.70
|
| Rate for Payer: UHC Core |
$57.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.74
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$242.52
|
|
|
Service Code
|
NDC 51672-4025-4
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.91 |
| Max. Negotiated Rate |
$218.27 |
| Rate for Payer: Aetna Commercial |
$206.14
|
| Rate for Payer: BCBS Trust/PPO |
$187.42
|
| Rate for Payer: BCN Commercial |
$187.42
|
| Rate for Payer: Cash Price |
$194.02
|
| Rate for Payer: Cofinity Commercial |
$208.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.02
|
| Rate for Payer: Healthscope Commercial |
$218.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.14
|
| Rate for Payer: PHP Commercial |
$206.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$210.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$147.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.42
|
| Rate for Payer: UHC Core |
$202.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.89
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$200.45
|
|
|
Service Code
|
NDC 0245-0147-01
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.25 |
| Max. Negotiated Rate |
$180.40 |
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: BCBS Trust/PPO |
$154.91
|
| Rate for Payer: BCN Commercial |
$154.91
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$180.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.38
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$174.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$122.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.40
|
| Rate for Payer: UHC Core |
$167.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.34
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$451.20
|
|
|
Service Code
|
NDC 0904-6993-61
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$275.19 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: BCBS Trust/PPO |
$348.69
|
| Rate for Payer: BCN Commercial |
$348.69
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.96
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$338.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$383.52
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$315.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$392.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$275.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$397.06
|
| Rate for Payer: UHC Core |
$376.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$338.40
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$327.75
|
|
|
Service Code
|
NDC 68084-371-11
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.89 |
| Max. Negotiated Rate |
$294.98 |
| Rate for Payer: Aetna Commercial |
$278.59
|
| Rate for Payer: BCBS Trust/PPO |
$253.29
|
| Rate for Payer: BCN Commercial |
$253.29
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cofinity Commercial |
$281.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.20
|
| Rate for Payer: Healthscope Commercial |
$294.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$278.59
|
| Rate for Payer: PHP Commercial |
$278.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$285.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$288.42
|
| Rate for Payer: UHC Core |
$273.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.81
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$2.01
|
|
|
Service Code
|
NDC 0245-0147-89
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna Commercial |
$1.71
|
| Rate for Payer: BCBS Trust/PPO |
$1.55
|
| Rate for Payer: BCN Commercial |
$1.55
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.61
|
| Rate for Payer: Healthscope Commercial |
$1.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.71
|
| Rate for Payer: PHP Commercial |
$1.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.77
|
| Rate for Payer: UHC Core |
$1.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.51
|
|
|
AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
IP
|
$191.35
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$116.70 |
| Max. Negotiated Rate |
$172.22 |
| Rate for Payer: Aetna Commercial |
$162.65
|
| Rate for Payer: BCBS Trust/PPO |
$147.88
|
| Rate for Payer: BCN Commercial |
$147.88
|
| Rate for Payer: Cash Price |
$153.08
|
| Rate for Payer: Cofinity Commercial |
$164.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.08
|
| Rate for Payer: Healthscope Commercial |
$172.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$143.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$162.65
|
| Rate for Payer: PHP Commercial |
$162.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$166.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$116.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$168.39
|
| Rate for Payer: UHC Core |
$159.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$143.51
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$26.36
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
9065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.08 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.41
|
| Rate for Payer: Aetna Commercial |
$19.93
|
| Rate for Payer: Aetna Commercial |
$11.21
|
| Rate for Payer: BCBS Trust/PPO |
$20.37
|
| Rate for Payer: BCBS Trust/PPO |
$10.19
|
| Rate for Payer: BCBS Trust/PPO |
$18.12
|
| Rate for Payer: BCN Commercial |
$10.19
|
| Rate for Payer: BCN Commercial |
$18.12
|
| Rate for Payer: BCN Commercial |
$20.37
|
| Rate for Payer: Cash Price |
$21.09
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cash Price |
$10.55
|
| Rate for Payer: Cofinity Commercial |
$20.17
|
| Rate for Payer: Cofinity Commercial |
$22.67
|
| Rate for Payer: Cofinity Commercial |
$11.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.76
|
| Rate for Payer: Healthscope Commercial |
$11.87
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Healthscope Commercial |
$21.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.93
|
| Rate for Payer: PHP Commercial |
$19.93
|
| Rate for Payer: PHP Commercial |
$22.41
|
| Rate for Payer: PHP Commercial |
$11.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.61
|
| Rate for Payer: UHC Core |
$22.01
|
| Rate for Payer: UHC Core |
$19.58
|
| Rate for Payer: UHC Core |
$11.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.77
|
|
|
AMIODARONE 50 MG/ML IV (CODE)
|
Facility
IP
|
$26.36
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
163703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.08 |
| Max. Negotiated Rate |
$23.72 |
| Rate for Payer: Aetna Commercial |
$22.41
|
| Rate for Payer: BCBS Trust/PPO |
$20.37
|
| Rate for Payer: BCN Commercial |
$20.37
|
| Rate for Payer: Cash Price |
$21.09
|
| Rate for Payer: Cofinity Commercial |
$22.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.09
|
| Rate for Payer: Healthscope Commercial |
$23.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.41
|
| Rate for Payer: PHP Commercial |
$22.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.20
|
| Rate for Payer: UHC Core |
$22.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.77
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$136.30
|
|
|
Service Code
|
NDC 16729-171-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.13 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: BCBS Trust/PPO |
$105.33
|
| Rate for Payer: BCN Commercial |
$105.33
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$118.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$83.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.94
|
| Rate for Payer: UHC Core |
$113.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$2.19
|
|
|
Service Code
|
NDC 51079-131-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$1.97 |
| Rate for Payer: Aetna Commercial |
$1.86
|
| Rate for Payer: BCBS Trust/PPO |
$1.69
|
| Rate for Payer: BCN Commercial |
$1.69
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.75
|
| Rate for Payer: Healthscope Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.86
|
| Rate for Payer: PHP Commercial |
$1.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.93
|
| Rate for Payer: UHC Core |
$1.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.64
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$319.60
|
|
|
Service Code
|
NDC 0781-1486-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.92 |
| Max. Negotiated Rate |
$287.64 |
| Rate for Payer: Aetna Commercial |
$271.66
|
| Rate for Payer: BCBS Trust/PPO |
$246.99
|
| Rate for Payer: BCN Commercial |
$246.99
|
| Rate for Payer: Cash Price |
$255.68
|
| Rate for Payer: Cofinity Commercial |
$274.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.68
|
| Rate for Payer: Healthscope Commercial |
$287.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$271.66
|
| Rate for Payer: PHP Commercial |
$271.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$278.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$194.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$281.25
|
| Rate for Payer: UHC Core |
$266.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.70
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$218.55
|
|
|
Service Code
|
NDC 51079-131-20
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.29 |
| Max. Negotiated Rate |
$196.70 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: BCBS Trust/PPO |
$168.90
|
| Rate for Payer: BCN Commercial |
$168.90
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$196.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.77
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$190.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$133.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$192.32
|
| Rate for Payer: UHC Core |
$182.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.91
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$240.35
|
|
|
Service Code
|
NDC 0904-0201-61
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.59 |
| Max. Negotiated Rate |
$216.32 |
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: BCBS Trust/PPO |
$185.74
|
| Rate for Payer: BCN Commercial |
$185.74
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$204.30
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$209.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$146.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$211.51
|
| Rate for Payer: UHC Core |
$200.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$225.15
|
|
|
Service Code
|
NDC 0904-7184-61
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.32 |
| Max. Negotiated Rate |
$202.64 |
| Rate for Payer: Aetna Commercial |
$191.38
|
| Rate for Payer: BCBS Trust/PPO |
$174.00
|
| Rate for Payer: BCN Commercial |
$174.00
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$193.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$202.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.38
|
| Rate for Payer: PHP Commercial |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$195.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$137.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.13
|
| Rate for Payer: UHC Core |
$188.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.86
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$226.10
|
|
|
Service Code
|
NDC 50268-039-15
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$203.49 |
| Rate for Payer: Aetna Commercial |
$192.18
|
| Rate for Payer: BCBS Trust/PPO |
$174.73
|
| Rate for Payer: BCN Commercial |
$174.73
|
| Rate for Payer: Cash Price |
$180.88
|
| Rate for Payer: Cofinity Commercial |
$194.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.88
|
| Rate for Payer: Healthscope Commercial |
$203.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$192.18
|
| Rate for Payer: PHP Commercial |
$192.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$196.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$137.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.97
|
| Rate for Payer: UHC Core |
$188.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.58
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$254.88
|
|
|
Service Code
|
NDC 0603-2214-21
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.45 |
| Max. Negotiated Rate |
$229.39 |
| Rate for Payer: Aetna Commercial |
$216.65
|
| Rate for Payer: BCBS Trust/PPO |
$196.97
|
| Rate for Payer: BCN Commercial |
$196.97
|
| Rate for Payer: Cash Price |
$203.90
|
| Rate for Payer: Cofinity Commercial |
$219.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.90
|
| Rate for Payer: Healthscope Commercial |
$229.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$216.65
|
| Rate for Payer: PHP Commercial |
$216.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$221.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$155.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$224.29
|
| Rate for Payer: UHC Core |
$212.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.16
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$336.30
|
|
|
Service Code
|
NDC 0904-7185-61
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.11 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: BCBS Trust/PPO |
$259.89
|
| Rate for Payer: BCN Commercial |
$259.89
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$292.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$205.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$295.94
|
| Rate for Payer: UHC Core |
$280.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$409.45
|
|
|
Service Code
|
NDC 0904-0202-61
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$249.72 |
| Max. Negotiated Rate |
$368.50 |
| Rate for Payer: Aetna Commercial |
$348.03
|
| Rate for Payer: BCBS Trust/PPO |
$316.42
|
| Rate for Payer: BCN Commercial |
$316.42
|
| Rate for Payer: Cash Price |
$327.56
|
| Rate for Payer: Cofinity Commercial |
$352.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.56
|
| Rate for Payer: Healthscope Commercial |
$368.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$307.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$348.03
|
| Rate for Payer: PHP Commercial |
$348.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$356.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$249.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$360.32
|
| Rate for Payer: UHC Core |
$341.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$307.09
|
|
|
AMITRIPTYLINE 50 MG TABLET
|
Facility
IP
|
$4.53
|
|
|
Service Code
|
NDC 50268-039-11
|
| Hospital Charge Code |
436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.85
|
| Rate for Payer: BCBS Trust/PPO |
$3.50
|
| Rate for Payer: BCN Commercial |
$3.50
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cofinity Commercial |
$3.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.62
|
| Rate for Payer: Healthscope Commercial |
$4.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.85
|
| Rate for Payer: PHP Commercial |
$3.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.99
|
| Rate for Payer: UHC Core |
$3.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.40
|
|
|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$157.45
|
|
|
Service Code
|
NDC 0904-6371-61
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.03 |
| Max. Negotiated Rate |
$141.70 |
| Rate for Payer: Aetna Commercial |
$133.83
|
| Rate for Payer: BCBS Trust/PPO |
$121.68
|
| Rate for Payer: BCN Commercial |
$121.68
|
| Rate for Payer: Cash Price |
$125.96
|
| Rate for Payer: Cofinity Commercial |
$135.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.96
|
| Rate for Payer: Healthscope Commercial |
$141.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$118.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.83
|
| Rate for Payer: PHP Commercial |
$133.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$136.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$96.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$138.56
|
| Rate for Payer: UHC Core |
$131.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$118.09
|
|
