|
DRUG TEST(S), PRESUMPTIVE READ BY DIRECT OPTICAL OBSERVATION
|
Professional
|
Both
|
$12.00
|
|
|
Service Code
|
HCPCS G0477
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$12.82 |
| Rate for Payer: BCBS Complete |
$4.80
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.82
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$121.54
|
|
|
Service Code
|
NDC 0904-6452-04
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.13 |
| Max. Negotiated Rate |
$109.39 |
| Rate for Payer: Aetna Commercial |
$103.31
|
| Rate for Payer: BCBS Trust/PPO |
$93.93
|
| Rate for Payer: BCN Commercial |
$93.93
|
| Rate for Payer: Cash Price |
$97.23
|
| Rate for Payer: Cofinity Commercial |
$104.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$97.23
|
| Rate for Payer: Healthscope Commercial |
$109.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$103.31
|
| Rate for Payer: PHP Commercial |
$103.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$85.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$105.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$74.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.96
|
| Rate for Payer: UHC Core |
$101.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.16
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$117.65
|
|
|
Service Code
|
NDC 60687-723-21
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.75 |
| Max. Negotiated Rate |
$105.88 |
| Rate for Payer: Aetna Commercial |
$100.00
|
| Rate for Payer: BCBS Trust/PPO |
$90.92
|
| Rate for Payer: BCN Commercial |
$90.92
|
| Rate for Payer: Cash Price |
$94.12
|
| Rate for Payer: Cofinity Commercial |
$101.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$94.12
|
| Rate for Payer: Healthscope Commercial |
$105.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$88.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$100.00
|
| Rate for Payer: PHP Commercial |
$100.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$102.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$71.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$103.53
|
| Rate for Payer: UHC Core |
$98.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$88.24
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$492.00
|
|
|
Service Code
|
NDC 0904-7043-61
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$300.07 |
| Max. Negotiated Rate |
$442.80 |
| Rate for Payer: Aetna Commercial |
$418.20
|
| Rate for Payer: BCBS Trust/PPO |
$380.22
|
| Rate for Payer: BCN Commercial |
$380.22
|
| Rate for Payer: Cash Price |
$393.60
|
| Rate for Payer: Cofinity Commercial |
$423.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$393.60
|
| Rate for Payer: Healthscope Commercial |
$442.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$369.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$418.20
|
| Rate for Payer: PHP Commercial |
$418.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$344.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$428.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$300.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$432.96
|
| Rate for Payer: UHC Core |
$410.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$369.00
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$7.89
|
|
|
Service Code
|
NDC 68084-675-11
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$7.10 |
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: BCBS Trust/PPO |
$6.10
|
| Rate for Payer: BCN Commercial |
$6.10
|
| Rate for Payer: Cash Price |
$6.31
|
| Rate for Payer: Cofinity Commercial |
$6.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.31
|
| Rate for Payer: Healthscope Commercial |
$7.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.71
|
| Rate for Payer: PHP Commercial |
$6.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.94
|
| Rate for Payer: UHC Core |
$6.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.92
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$236.60
|
|
|
Service Code
|
NDC 68084-675-21
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.30 |
| Max. Negotiated Rate |
$212.94 |
| Rate for Payer: Aetna Commercial |
$201.11
|
| Rate for Payer: BCBS Trust/PPO |
$182.84
|
| Rate for Payer: BCN Commercial |
$182.84
|
| Rate for Payer: Cash Price |
$189.28
|
| Rate for Payer: Cofinity Commercial |
$203.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.28
|
| Rate for Payer: Healthscope Commercial |
$212.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$201.11
|
| Rate for Payer: PHP Commercial |
$201.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$205.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$144.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$208.21
|
| Rate for Payer: UHC Core |
$197.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.45
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$3.93
|
|
|
Service Code
|
NDC 60687-723-11
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: BCBS Trust/PPO |
$3.04
|
| Rate for Payer: BCN Commercial |
$3.04
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cofinity Commercial |
$3.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.14
|
| Rate for Payer: Healthscope Commercial |
$3.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.34
|
| Rate for Payer: PHP Commercial |
$3.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.46
|
| Rate for Payer: UHC Core |
$3.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.95
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$1,721.84
|
|
|
Service Code
|
NDC 0002-3235-60
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,050.15 |
| Max. Negotiated Rate |
$1,549.66 |
| Rate for Payer: Aetna Commercial |
$1,463.56
|
| Rate for Payer: BCBS Trust/PPO |
$1,330.64
|
| Rate for Payer: BCN Commercial |
$1,330.64
|
| Rate for Payer: Cash Price |
$1,377.47
|
| Rate for Payer: Cofinity Commercial |
$1,480.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,377.47
|
| Rate for Payer: Healthscope Commercial |
$1,549.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,291.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,463.56
|
| Rate for Payer: PHP Commercial |
$1,463.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,205.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,498.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,050.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,515.22
|
| Rate for Payer: UHC Core |
$1,437.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,291.38
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$80.37
|
|
|
Service Code
|
NDC 57237-018-30
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.02 |
| Max. Negotiated Rate |
$72.33 |
| Rate for Payer: Aetna Commercial |
$68.31
|
| Rate for Payer: BCBS Trust/PPO |
$62.11
|
| Rate for Payer: BCN Commercial |
$62.11
|
| Rate for Payer: Cash Price |
$64.30
|
| Rate for Payer: Cofinity Commercial |
$69.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.30
|
| Rate for Payer: Healthscope Commercial |
$72.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.31
|
| Rate for Payer: PHP Commercial |
$68.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$69.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$49.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.73
|
| Rate for Payer: UHC Core |
$67.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.28
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$349.44
|
|
|
Service Code
|
NDC 0904-6453-61
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$213.12 |
| Max. Negotiated Rate |
$314.50 |
| Rate for Payer: Aetna Commercial |
$297.02
|
| Rate for Payer: BCBS Trust/PPO |
$270.05
|
| Rate for Payer: BCN Commercial |
$270.05
|
| Rate for Payer: Cash Price |
$279.55
|
| Rate for Payer: Cofinity Commercial |
$300.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$279.55
|
| Rate for Payer: Healthscope Commercial |
$314.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$297.02
|
| Rate for Payer: PHP Commercial |
$297.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$244.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$304.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$213.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$307.51
|
| Rate for Payer: UHC Core |
$291.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.08
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$439.68
|
|
|
Service Code
|
NDC 0904-7044-61
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.16 |
| Max. Negotiated Rate |
$395.71 |
| Rate for Payer: Aetna Commercial |
$373.73
|
| Rate for Payer: BCBS Trust/PPO |
$339.78
|
| Rate for Payer: BCN Commercial |
$339.78
|
| Rate for Payer: Cash Price |
$351.74
|
| Rate for Payer: Cofinity Commercial |
$378.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$351.74
|
| Rate for Payer: Healthscope Commercial |
$395.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$329.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$373.73
|
| Rate for Payer: PHP Commercial |
$373.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$307.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$382.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$386.92
|
| Rate for Payer: UHC Core |
$367.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$329.76
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$78.96
|
|
|
Service Code
|
NDC 57237-019-30
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.16 |
| Max. Negotiated Rate |
$71.06 |
| Rate for Payer: Aetna Commercial |
$67.12
|
| Rate for Payer: BCBS Trust/PPO |
$61.02
|
| Rate for Payer: BCN Commercial |
$61.02
|
| Rate for Payer: Cash Price |
$63.17
|
| Rate for Payer: Cofinity Commercial |
$67.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.17
|
| Rate for Payer: Healthscope Commercial |
$71.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.12
|
| Rate for Payer: PHP Commercial |
$67.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$68.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$48.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$69.48
|
| Rate for Payer: UHC Core |
$65.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.22
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$394.56
|
|
|
Service Code
|
NDC 0904-6454-61
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.64 |
| Max. Negotiated Rate |
$355.10 |
| Rate for Payer: Aetna Commercial |
$335.38
|
| Rate for Payer: BCBS Trust/PPO |
$304.92
|
| Rate for Payer: BCN Commercial |
$304.92
|
| Rate for Payer: Cash Price |
$315.65
|
| Rate for Payer: Cofinity Commercial |
$339.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$315.65
|
| Rate for Payer: Healthscope Commercial |
$355.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$295.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$335.38
|
| Rate for Payer: PHP Commercial |
$335.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$343.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$240.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$347.21
|
| Rate for Payer: UHC Core |
$329.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$295.92
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$373.44
|
|
|
Service Code
|
NDC 0904-7045-61
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$227.76 |
| Max. Negotiated Rate |
$336.10 |
| Rate for Payer: Aetna Commercial |
$317.42
|
| Rate for Payer: BCBS Trust/PPO |
$288.59
|
| Rate for Payer: BCN Commercial |
$288.59
|
| Rate for Payer: Cash Price |
$298.75
|
| Rate for Payer: Cofinity Commercial |
$321.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.75
|
| Rate for Payer: Healthscope Commercial |
$336.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$317.42
|
| Rate for Payer: PHP Commercial |
$317.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$261.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$324.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$227.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$328.63
|
| Rate for Payer: UHC Core |
$311.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.08
|
|
|
DUODERM CGF DRESSING 4X4
|
Facility
|
IP
|
$7.74
|
|
|
Service Code
|
NDC 6845510697
|
| Hospital Charge Code |
150727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$6.97 |
| Rate for Payer: Aetna Commercial |
$6.58
|
| Rate for Payer: BCBS Trust/PPO |
$5.98
|
| Rate for Payer: BCN Commercial |
$5.98
|
| Rate for Payer: Cash Price |
$6.19
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.19
|
| Rate for Payer: Healthscope Commercial |
$6.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.58
|
| Rate for Payer: PHP Commercial |
$6.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.81
|
| Rate for Payer: UHC Core |
$6.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.80
|
|
|
EMOLLIENT COMBINATION NO.92 TOPICAL LOTION
|
Facility
|
IP
|
$14.34
|
|
|
Service Code
|
NDC 5280048826
|
| Hospital Charge Code |
170369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$12.91 |
| Rate for Payer: Aetna Commercial |
$12.19
|
| Rate for Payer: BCBS Trust/PPO |
$11.08
|
| Rate for Payer: BCN Commercial |
$11.08
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.47
|
| Rate for Payer: Healthscope Commercial |
$12.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.19
|
| Rate for Payer: PHP Commercial |
$12.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.62
|
| Rate for Payer: UHC Core |
$11.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.76
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,387.84
|
|
|
Service Code
|
NDC 0597-0152-37
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$846.44 |
| Max. Negotiated Rate |
$1,249.06 |
| Rate for Payer: Aetna Commercial |
$1,179.66
|
| Rate for Payer: BCBS Trust/PPO |
$1,072.52
|
| Rate for Payer: BCN Commercial |
$1,072.52
|
| Rate for Payer: Cash Price |
$1,110.27
|
| Rate for Payer: Cofinity Commercial |
$1,193.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,110.27
|
| Rate for Payer: Healthscope Commercial |
$1,249.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,040.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,179.66
|
| Rate for Payer: PHP Commercial |
$1,179.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$971.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,207.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$846.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,221.30
|
| Rate for Payer: UHC Core |
$1,158.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,040.88
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,387.84
|
|
|
Service Code
|
NDC 0597-0153-37
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$846.44 |
| Max. Negotiated Rate |
$1,249.06 |
| Rate for Payer: Aetna Commercial |
$1,179.66
|
| Rate for Payer: BCBS Trust/PPO |
$1,072.52
|
| Rate for Payer: BCN Commercial |
$1,072.52
|
| Rate for Payer: Cash Price |
$1,110.27
|
| Rate for Payer: Cofinity Commercial |
$1,193.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,110.27
|
| Rate for Payer: Healthscope Commercial |
$1,249.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,040.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,179.66
|
| Rate for Payer: PHP Commercial |
$1,179.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$971.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,207.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$846.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,221.30
|
| Rate for Payer: UHC Core |
$1,158.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,040.88
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
IP
|
$6,646.02
|
|
|
Service Code
|
NDC 61958-0701-1
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,053.41 |
| Max. Negotiated Rate |
$5,981.42 |
| Rate for Payer: Aetna Commercial |
$5,649.12
|
| Rate for Payer: BCBS Trust/PPO |
$5,136.04
|
| Rate for Payer: BCN Commercial |
$5,136.04
|
| Rate for Payer: Cash Price |
$5,316.82
|
| Rate for Payer: Cofinity Commercial |
$5,715.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,316.82
|
| Rate for Payer: Healthscope Commercial |
$5,981.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,984.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,649.12
|
| Rate for Payer: PHP Commercial |
$5,649.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,652.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,782.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4,053.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,848.50
|
| Rate for Payer: UHC Core |
$5,549.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,984.52
|
|
|
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.38
|
|
|
Service Code
|
NDC 0143-9787-10
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.82 |
| Max. Negotiated Rate |
$17.44 |
| Rate for Payer: Aetna Commercial |
$16.47
|
| Rate for Payer: BCBS Trust/PPO |
$14.98
|
| Rate for Payer: BCN Commercial |
$14.98
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cofinity Commercial |
$16.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.50
|
| Rate for Payer: Healthscope Commercial |
$17.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.47
|
| Rate for Payer: PHP Commercial |
$16.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.05
|
| Rate for Payer: UHC Core |
$16.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.54
|
|
|
ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND CURETTAGE)
|
Facility
|
OP
|
$553.73
|
|
|
Service Code
|
CPT 57505
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$162.36 |
| Max. Negotiated Rate |
$553.73 |
| Rate for Payer: BCBS Complete |
$553.73
|
| Rate for Payer: BCCCP Commercial |
$162.36
|
| Rate for Payer: Mclaren Medicaid |
$527.36
|
| Rate for Payer: Meridian Medicaid |
$553.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$527.36
|
|
|
ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE
|
Facility
|
OP
|
$3,425.99
|
|
|
Service Code
|
CPT 58353
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,262.85 |
| Max. Negotiated Rate |
$3,425.99 |
| Rate for Payer: BCBS Complete |
$3,425.99
|
| Rate for Payer: Mclaren Medicaid |
$3,262.85
|
| Rate for Payer: Meridian Medicaid |
$3,425.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,262.85
|
|
|
ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$137.25
|
|
|
Service Code
|
CPT 58100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$107.56 |
| Max. Negotiated Rate |
$137.25 |
| Rate for Payer: BCBS Complete |
$137.25
|
| Rate for Payer: BCCCP Commercial |
$107.56
|
| Rate for Payer: Mclaren Medicaid |
$130.71
|
| Rate for Payer: Meridian Medicaid |
$137.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$130.71
|
|
|
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$38.34
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105903
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.38 |
| Max. Negotiated Rate |
$34.51 |
| Rate for Payer: Aetna Commercial |
$32.59
|
| Rate for Payer: Aetna Commercial |
$27.85
|
| Rate for Payer: Aetna Commercial |
$52.77
|
| Rate for Payer: Aetna Commercial |
$87.37
|
| Rate for Payer: BCBS Trust/PPO |
$25.32
|
| Rate for Payer: BCBS Trust/PPO |
$29.63
|
| Rate for Payer: BCBS Trust/PPO |
$79.44
|
| Rate for Payer: BCBS Trust/PPO |
$47.98
|
| Rate for Payer: BCN Commercial |
$47.98
|
| Rate for Payer: BCN Commercial |
$29.63
|
| Rate for Payer: BCN Commercial |
$79.44
|
| Rate for Payer: BCN Commercial |
$25.32
|
| Rate for Payer: Cash Price |
$30.67
|
| Rate for Payer: Cash Price |
$82.23
|
| Rate for Payer: Cash Price |
$26.21
|
| Rate for Payer: Cash Price |
$49.66
|
| Rate for Payer: Cofinity Commercial |
$53.39
|
| Rate for Payer: Cofinity Commercial |
$28.17
|
| Rate for Payer: Cofinity Commercial |
$32.97
|
| Rate for Payer: Cofinity Commercial |
$88.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.67
|
| Rate for Payer: Healthscope Commercial |
$92.51
|
| Rate for Payer: Healthscope Commercial |
$29.48
|
| Rate for Payer: Healthscope Commercial |
$34.51
|
| Rate for Payer: Healthscope Commercial |
$55.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.77
|
| Rate for Payer: PHP Commercial |
$52.77
|
| Rate for Payer: PHP Commercial |
$87.37
|
| Rate for Payer: PHP Commercial |
$27.85
|
| Rate for Payer: PHP Commercial |
$32.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$54.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$89.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$62.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$37.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$54.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.74
|
| Rate for Payer: UHC Core |
$27.35
|
| Rate for Payer: UHC Core |
$51.84
|
| Rate for Payer: UHC Core |
$32.01
|
| Rate for Payer: UHC Core |
$85.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.09
|
|
|
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$219.76
|
|
|
Service Code
|
HCPCS J1650
|
| Hospital Charge Code |
105904
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.03 |
| Max. Negotiated Rate |
$197.78 |
| Rate for Payer: Aetna Commercial |
$186.80
|
| Rate for Payer: Aetna Commercial |
$63.32
|
| Rate for Payer: Aetna Commercial |
$90.19
|
| Rate for Payer: Aetna Commercial |
$33.36
|
| Rate for Payer: Aetna Commercial |
$38.77
|
| Rate for Payer: Aetna Commercial |
$30.68
|
| Rate for Payer: BCBS Trust/PPO |
$169.83
|
| Rate for Payer: BCBS Trust/PPO |
$82.00
|
| Rate for Payer: BCBS Trust/PPO |
$57.57
|
| Rate for Payer: BCBS Trust/PPO |
$35.25
|
| Rate for Payer: BCBS Trust/PPO |
$27.90
|
| Rate for Payer: BCBS Trust/PPO |
$30.33
|
| Rate for Payer: BCN Commercial |
$169.83
|
| Rate for Payer: BCN Commercial |
$27.90
|
| Rate for Payer: BCN Commercial |
$35.25
|
| Rate for Payer: BCN Commercial |
$82.00
|
| Rate for Payer: BCN Commercial |
$30.33
|
| Rate for Payer: BCN Commercial |
$57.57
|
| Rate for Payer: Cash Price |
$28.88
|
| Rate for Payer: Cash Price |
$59.60
|
| Rate for Payer: Cash Price |
$36.49
|
| Rate for Payer: Cash Price |
$175.81
|
| Rate for Payer: Cash Price |
$84.89
|
| Rate for Payer: Cash Price |
$31.40
|
| Rate for Payer: Cofinity Commercial |
$64.07
|
| Rate for Payer: Cofinity Commercial |
$91.25
|
| Rate for Payer: Cofinity Commercial |
$188.99
|
| Rate for Payer: Cofinity Commercial |
$31.05
|
| Rate for Payer: Cofinity Commercial |
$33.76
|
| Rate for Payer: Cofinity Commercial |
$39.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.60
|
| Rate for Payer: Healthscope Commercial |
$32.49
|
| Rate for Payer: Healthscope Commercial |
$95.50
|
| Rate for Payer: Healthscope Commercial |
$197.78
|
| Rate for Payer: Healthscope Commercial |
$35.32
|
| Rate for Payer: Healthscope Commercial |
$41.05
|
| Rate for Payer: Healthscope Commercial |
$67.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$164.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.19
|
| Rate for Payer: PHP Commercial |
$63.32
|
| Rate for Payer: PHP Commercial |
$30.68
|
| Rate for Payer: PHP Commercial |
$33.36
|
| Rate for Payer: PHP Commercial |
$38.77
|
| Rate for Payer: PHP Commercial |
$90.19
|
| Rate for Payer: PHP Commercial |
$186.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$191.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$92.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$64.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$64.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$134.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$93.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$193.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.54
|
| Rate for Payer: UHC Core |
$183.50
|
| Rate for Payer: UHC Core |
$38.08
|
| Rate for Payer: UHC Core |
$32.77
|
| Rate for Payer: UHC Core |
$88.60
|
| Rate for Payer: UHC Core |
$30.14
|
| Rate for Payer: UHC Core |
$62.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$164.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.44
|
|
