|
MELATONIN 3 MG TABLET
|
Facility
|
IP
|
$3.81
|
|
|
Service Code
|
NDC 7733351625
|
| Hospital Charge Code |
16830
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$3.43 |
| Rate for Payer: Aetna Commercial |
$3.24
|
| Rate for Payer: BCBS Trust/PPO |
$2.94
|
| Rate for Payer: BCN Commercial |
$2.94
|
| Rate for Payer: Cash Price |
$3.05
|
| Rate for Payer: Cofinity Commercial |
$3.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.05
|
| Rate for Payer: Healthscope Commercial |
$3.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.24
|
| Rate for Payer: PHP Commercial |
$3.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.35
|
| Rate for Payer: UHC Core |
$3.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.86
|
|
|
MELATONIN 3 MG TABLET
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 5026852411
|
| Hospital Charge Code |
16830
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: BCBS Trust/PPO |
$3.29
|
| Rate for Payer: BCN Commercial |
$3.29
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Cofinity Commercial |
$3.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.41
|
| Rate for Payer: Healthscope Commercial |
$3.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.62
|
| Rate for Payer: PHP Commercial |
$3.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.75
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.20
|
|
|
MELATONIN 3 MG TABLET
|
Facility
|
IP
|
$195.70
|
|
|
Service Code
|
NDC 6809411061
|
| Hospital Charge Code |
16830
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.36 |
| Max. Negotiated Rate |
$176.13 |
| Rate for Payer: Aetna Commercial |
$166.34
|
| Rate for Payer: BCBS Trust/PPO |
$151.24
|
| Rate for Payer: BCN Commercial |
$151.24
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Commercial |
$168.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Healthscope Commercial |
$176.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$166.34
|
| Rate for Payer: PHP Commercial |
$166.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$170.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$119.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$172.22
|
| Rate for Payer: UHC Core |
$163.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.78
|
|
|
MELATONIN 3 MG TABLET
|
Facility
|
IP
|
$380.70
|
|
|
Service Code
|
NDC 7733351610
|
| Hospital Charge Code |
16830
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.19 |
| Max. Negotiated Rate |
$342.63 |
| Rate for Payer: Aetna Commercial |
$323.60
|
| Rate for Payer: BCBS Trust/PPO |
$294.20
|
| Rate for Payer: BCN Commercial |
$294.20
|
| Rate for Payer: Cash Price |
$304.56
|
| Rate for Payer: Cofinity Commercial |
$327.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.56
|
| Rate for Payer: Healthscope Commercial |
$342.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$323.60
|
| Rate for Payer: PHP Commercial |
$323.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$331.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$232.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$335.02
|
| Rate for Payer: UHC Core |
$317.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.52
|
|
|
MELOXICAM 15 MG TABLET
|
Facility
|
IP
|
$340.75
|
|
|
Service Code
|
NDC 60687-199-01
|
| Hospital Charge Code |
20580
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.82 |
| Max. Negotiated Rate |
$306.68 |
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: BCBS Trust/PPO |
$263.33
|
| Rate for Payer: BCN Commercial |
$263.33
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cofinity Commercial |
$293.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.60
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$289.64
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$296.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$207.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$299.86
|
| Rate for Payer: UHC Core |
$284.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.56
|
|
|
MELOXICAM 15 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 50268-526-15
|
| Hospital Charge Code |
20580
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$133.24 |
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: BCBS Trust/PPO |
$114.41
|
| 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 |
$133.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$128.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$90.30
|
| 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
|
|
|
MELOXICAM 15 MG TABLET
|
Facility
|
IP
|
$3.41
|
|
|
Service Code
|
NDC 60687-199-11
|
| Hospital Charge Code |
20580
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: Aetna Commercial |
$2.90
|
| Rate for Payer: BCBS Trust/PPO |
$2.64
|
| Rate for Payer: BCN Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.73
|
| Rate for Payer: Cofinity Commercial |
$2.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.73
|
| Rate for Payer: Healthscope Commercial |
$3.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.90
|
| Rate for Payer: PHP Commercial |
$2.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.00
|
| Rate for Payer: UHC Core |
$2.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.56
|
|
|
MELOXICAM 15 MG TABLET
|
Facility
|
IP
|
$2.97
|
|
|
Service Code
|
NDC 50268-526-11
|
| Hospital Charge Code |
20580
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCN Commercial |
$2.30
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cofinity Commercial |
$2.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.38
|
| Rate for Payer: Healthscope Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.52
|
| Rate for Payer: PHP Commercial |
$2.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.61
|
| Rate for Payer: UHC Core |
$2.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.23
|
|
|
MELOXICAM 7.5 MG TABLET
|
Facility
|
IP
|
$39.95
|
|
|
Service Code
|
NDC 69097-158-07
|
| Hospital Charge Code |
20566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.37 |
| Max. Negotiated Rate |
$35.96 |
| Rate for Payer: Aetna Commercial |
$33.96
|
| Rate for Payer: BCBS Trust/PPO |
$30.87
|
| Rate for Payer: BCN Commercial |
$30.87
|
| Rate for Payer: Cash Price |
$31.96
|
| Rate for Payer: Cofinity Commercial |
$34.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.96
|
| Rate for Payer: Healthscope Commercial |
$35.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.96
|
| Rate for Payer: PHP Commercial |
$33.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$24.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.16
|
| Rate for Payer: UHC Core |
$33.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.96
|
|
|
MELOXICAM 7.5 MG TABLET
|
Facility
|
IP
|
$310.20
|
|
|
Service Code
|
NDC 63739-701-10
|
| Hospital Charge Code |
20566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.19 |
| Max. Negotiated Rate |
$279.18 |
| Rate for Payer: Aetna Commercial |
$263.67
|
| Rate for Payer: BCBS Trust/PPO |
$239.72
|
| Rate for Payer: BCN Commercial |
$239.72
|
| Rate for Payer: Cash Price |
$248.16
|
| Rate for Payer: Cofinity Commercial |
$266.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.16
|
| Rate for Payer: Healthscope Commercial |
$279.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$263.67
|
| Rate for Payer: PHP Commercial |
$263.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$269.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$189.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$272.98
|
| Rate for Payer: UHC Core |
$259.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.65
|
|
|
MELOXICAM 7.5 MG TABLET
|
Facility
|
IP
|
$2.43
|
|
|
Service Code
|
NDC 50268-525-11
|
| Hospital Charge Code |
20566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$2.07
|
| Rate for Payer: BCBS Trust/PPO |
$1.88
|
| Rate for Payer: BCN Commercial |
$1.88
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$2.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.94
|
| Rate for Payer: Healthscope Commercial |
$2.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.07
|
| Rate for Payer: PHP Commercial |
$2.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.14
|
| Rate for Payer: UHC Core |
$2.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.82
|
|
|
MELOXICAM 7.5 MG TABLET
|
Facility
|
IP
|
$121.03
|
|
|
Service Code
|
NDC 50268-525-15
|
| Hospital Charge Code |
20566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.82 |
| Max. Negotiated Rate |
$108.93 |
| Rate for Payer: Aetna Commercial |
$102.88
|
| Rate for Payer: BCBS Trust/PPO |
$93.53
|
| Rate for Payer: BCN Commercial |
$93.53
|
| Rate for Payer: Cash Price |
$96.82
|
| Rate for Payer: Cofinity Commercial |
$104.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.82
|
| Rate for Payer: Healthscope Commercial |
$108.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$102.88
|
| Rate for Payer: PHP Commercial |
$102.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$105.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$73.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.51
|
| Rate for Payer: UHC Core |
$101.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.77
|
|
|
MEMANTINE 10 MG TABLET
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 0591-3875-45
|
| Hospital Charge Code |
36966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna Commercial |
$2.03
|
| Rate for Payer: BCBS Trust/PPO |
$1.85
|
| Rate for Payer: BCN Commercial |
$1.85
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.91
|
| Rate for Payer: Healthscope Commercial |
$2.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.03
|
| Rate for Payer: PHP Commercial |
$2.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.10
|
| Rate for Payer: UHC Core |
$2.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.79
|
|
|
MEMANTINE 10 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 0904-6506-61
|
| Hospital Charge Code |
36966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.43 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: BCBS Trust/PPO |
$184.27
|
| Rate for Payer: BCN Commercial |
$184.27
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$207.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$145.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.84
|
| Rate for Payer: UHC Core |
$199.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
MEMANTINE 10 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 0591-3875-44
|
| Hospital Charge Code |
36966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.43 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: BCBS Trust/PPO |
$184.27
|
| Rate for Payer: BCN Commercial |
$184.27
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$207.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$145.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.84
|
| Rate for Payer: UHC Core |
$199.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
MEMANTINE 5 MG TABLET
|
Facility
|
IP
|
$220.40
|
|
|
Service Code
|
NDC 0904-6505-61
|
| Hospital Charge Code |
37170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.42 |
| Max. Negotiated Rate |
$198.36 |
| Rate for Payer: Aetna Commercial |
$187.34
|
| Rate for Payer: BCBS Trust/PPO |
$170.33
|
| Rate for Payer: BCN Commercial |
$170.33
|
| Rate for Payer: Cash Price |
$176.32
|
| Rate for Payer: Cofinity Commercial |
$189.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.32
|
| Rate for Payer: Healthscope Commercial |
$198.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$165.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$187.34
|
| Rate for Payer: PHP Commercial |
$187.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$191.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$134.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$193.95
|
| Rate for Payer: UHC Core |
$184.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$165.30
|
|
|
MEMANTINE 5 MG TABLET
|
Facility
|
IP
|
$132.81
|
|
|
Service Code
|
NDC 29300-171-16
|
| Hospital Charge Code |
37170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$119.53 |
| Rate for Payer: Aetna Commercial |
$112.89
|
| Rate for Payer: BCBS Trust/PPO |
$102.64
|
| Rate for Payer: BCN Commercial |
$102.64
|
| Rate for Payer: Cash Price |
$106.25
|
| Rate for Payer: Cofinity Commercial |
$114.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.25
|
| Rate for Payer: Healthscope Commercial |
$119.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.89
|
| Rate for Payer: PHP Commercial |
$112.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$115.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$81.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$116.87
|
| Rate for Payer: UHC Core |
$110.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.61
|
|
|
MEMANTINE 5 MG TABLET
|
Facility
|
IP
|
$1,530.47
|
|
|
Service Code
|
NDC 0456-3205-60
|
| Hospital Charge Code |
37170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$933.43 |
| Max. Negotiated Rate |
$1,377.42 |
| Rate for Payer: Aetna Commercial |
$1,300.90
|
| Rate for Payer: BCBS Trust/PPO |
$1,182.75
|
| Rate for Payer: BCN Commercial |
$1,182.75
|
| Rate for Payer: Cash Price |
$1,224.38
|
| Rate for Payer: Cofinity Commercial |
$1,316.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,224.38
|
| Rate for Payer: Healthscope Commercial |
$1,377.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,147.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,300.90
|
| Rate for Payer: PHP Commercial |
$1,300.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,071.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,331.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$933.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,346.81
|
| Rate for Payer: UHC Core |
$1,277.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,147.85
|
|
|
MEMANTINE 5 MG TABLET
|
Facility
|
IP
|
$2.25
|
|
|
Service Code
|
NDC 0591-3870-45
|
| Hospital Charge Code |
37170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.91
|
| Rate for Payer: BCBS Trust/PPO |
$1.74
|
| Rate for Payer: BCN Commercial |
$1.74
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$1.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.80
|
| Rate for Payer: Healthscope Commercial |
$2.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.91
|
| Rate for Payer: PHP Commercial |
$1.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.98
|
| Rate for Payer: UHC Core |
$1.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.69
|
|
|
MEMANTINE 5 MG TABLET
|
Facility
|
IP
|
$25.51
|
|
|
Service Code
|
NDC 0456-3205-11
|
| Hospital Charge Code |
37170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.56 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: Aetna Commercial |
$21.68
|
| Rate for Payer: BCBS Trust/PPO |
$19.71
|
| Rate for Payer: BCN Commercial |
$19.71
|
| Rate for Payer: Cash Price |
$20.41
|
| Rate for Payer: Cofinity Commercial |
$21.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.41
|
| Rate for Payer: Healthscope Commercial |
$22.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.68
|
| Rate for Payer: PHP Commercial |
$21.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.45
|
| Rate for Payer: UHC Core |
$21.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.13
|
|
|
MEMANTINE 5 MG TABLET
|
Facility
|
IP
|
$224.20
|
|
|
Service Code
|
NDC 0591-3870-44
|
| Hospital Charge Code |
37170
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.74 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: BCBS Trust/PPO |
$173.26
|
| Rate for Payer: BCN Commercial |
$173.26
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$195.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$136.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$197.30
|
| Rate for Payer: UHC Core |
$187.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
MEPERIDINE (PF) 50 MG/ML INJECTION SYRINGE
|
Facility
|
IP
|
$38.15
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
116146
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.27 |
| Max. Negotiated Rate |
$34.34 |
| Rate for Payer: Aetna Commercial |
$32.43
|
| Rate for Payer: BCBS Trust/PPO |
$29.48
|
| Rate for Payer: BCN Commercial |
$29.48
|
| Rate for Payer: Cash Price |
$30.52
|
| Rate for Payer: Cofinity Commercial |
$32.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.52
|
| Rate for Payer: Healthscope Commercial |
$34.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.43
|
| Rate for Payer: PHP Commercial |
$32.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.57
|
| Rate for Payer: UHC Core |
$31.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.61
|
|
|
MEPIVACAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$25.90
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
105638
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: BCBS Trust/PPO |
$20.02
|
| Rate for Payer: BCN Commercial |
$20.02
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.72
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.02
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$22.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.79
|
| Rate for Payer: UHC Core |
$21.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.42
|
|
|
MEROPENEM 1 GRAM/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$76.93
|
|
|
Service Code
|
HCPCS J2184
|
| Hospital Charge Code |
175972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.92 |
| Max. Negotiated Rate |
$69.24 |
| Rate for Payer: Aetna Commercial |
$65.39
|
| Rate for Payer: BCBS Trust/PPO |
$59.45
|
| Rate for Payer: BCN Commercial |
$59.45
|
| Rate for Payer: Cash Price |
$61.54
|
| Rate for Payer: Cofinity Commercial |
$66.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.54
|
| Rate for Payer: Healthscope Commercial |
$69.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.39
|
| Rate for Payer: PHP Commercial |
$65.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$66.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.70
|
| Rate for Payer: UHC Core |
$64.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.70
|
|
|
MEROPENEM 1 GRAM INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.97
|
|
|
Service Code
|
HCPCS J2185
|
| Hospital Charge Code |
17380
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.23 |
| Max. Negotiated Rate |
$22.47 |
| Rate for Payer: Aetna Commercial |
$21.22
|
| Rate for Payer: Aetna Commercial |
$20.37
|
| Rate for Payer: BCBS Trust/PPO |
$18.52
|
| Rate for Payer: BCBS Trust/PPO |
$19.30
|
| Rate for Payer: BCN Commercial |
$18.52
|
| Rate for Payer: BCN Commercial |
$19.30
|
| Rate for Payer: Cash Price |
$19.98
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cofinity Commercial |
$20.61
|
| Rate for Payer: Cofinity Commercial |
$21.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.18
|
| Rate for Payer: Healthscope Commercial |
$21.57
|
| Rate for Payer: Healthscope Commercial |
$22.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.22
|
| Rate for Payer: PHP Commercial |
$21.22
|
| Rate for Payer: PHP Commercial |
$20.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.97
|
| Rate for Payer: UHC Core |
$20.85
|
| Rate for Payer: UHC Core |
$20.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.98
|
|
