|
FACIAL
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 00174
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: BCBS Complete |
$26.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$37.40
|
|
|
Service Code
|
NDC 63323-738-09
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna Commercial |
$31.79
|
| Rate for Payer: BCBS Trust/PPO |
$28.90
|
| Rate for Payer: BCN Commercial |
$28.90
|
| Rate for Payer: Cash Price |
$29.92
|
| Rate for Payer: Cofinity Commercial |
$32.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.92
|
| Rate for Payer: Healthscope Commercial |
$33.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.79
|
| Rate for Payer: PHP Commercial |
$31.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.91
|
| Rate for Payer: UHC Core |
$31.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.05
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
IP
|
$37.40
|
|
|
Service Code
|
NDC 63323-738-09
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.81 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna Commercial |
$31.79
|
| Rate for Payer: BCBS Trust/PPO |
$28.90
|
| Rate for Payer: BCN Commercial |
$28.90
|
| Rate for Payer: Cash Price |
$29.92
|
| Rate for Payer: Cofinity Commercial |
$32.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.92
|
| Rate for Payer: Healthscope Commercial |
$33.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.79
|
| Rate for Payer: PHP Commercial |
$31.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.91
|
| Rate for Payer: UHC Core |
$31.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.05
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 0904-5780-51
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.93 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: BCBS Trust/PPO |
$138.02
|
| Rate for Payer: BCN Commercial |
$138.02
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$155.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$108.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.17
|
| Rate for Payer: UHC Core |
$149.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079-966-20
|
| Hospital Charge Code |
10011
|
|
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
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$99.88
|
|
|
Service Code
|
NDC 0904-5780-17
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.92 |
| Max. Negotiated Rate |
$89.89 |
| Rate for Payer: Aetna Commercial |
$84.90
|
| Rate for Payer: BCBS Trust/PPO |
$77.19
|
| Rate for Payer: BCN Commercial |
$77.19
|
| Rate for Payer: Cash Price |
$79.90
|
| Rate for Payer: Cofinity Commercial |
$85.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.90
|
| Rate for Payer: Healthscope Commercial |
$89.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$84.90
|
| Rate for Payer: PHP Commercial |
$84.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$86.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$60.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.89
|
| Rate for Payer: UHC Core |
$83.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.91
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
NDC 63739-645-10
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: BCBS Trust/PPO |
$145.29
|
| Rate for Payer: BCN Commercial |
$145.29
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cofinity Commercial |
$161.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.40
|
| Rate for Payer: Healthscope Commercial |
$169.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$159.80
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$163.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$114.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$165.44
|
| Rate for Payer: UHC Core |
$156.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.00
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 50268-303-15
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.36 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: BCBS Trust/PPO |
$85.36
|
| Rate for Payer: BCN Commercial |
$85.36
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$96.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.20
|
| Rate for Payer: UHC Core |
$92.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 60687-595-11
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: BCBS Trust/PPO |
$3.35
|
| Rate for Payer: BCN Commercial |
$3.35
|
| Rate for Payer: Cash Price |
$3.46
|
| Rate for Payer: Cofinity Commercial |
$3.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.46
|
| Rate for Payer: Healthscope Commercial |
$3.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.68
|
| Rate for Payer: PHP Commercial |
$3.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.81
|
| Rate for Payer: UHC Core |
$3.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.25
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$432.40
|
|
|
Service Code
|
NDC 60687-595-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$263.72 |
| Max. Negotiated Rate |
$389.16 |
| Rate for Payer: Aetna Commercial |
$367.54
|
| Rate for Payer: BCBS Trust/PPO |
$334.16
|
| Rate for Payer: BCN Commercial |
$334.16
|
| Rate for Payer: Cash Price |
$345.92
|
| Rate for Payer: Cofinity Commercial |
$371.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$345.92
|
| Rate for Payer: Healthscope Commercial |
$389.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$324.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$367.54
|
| Rate for Payer: PHP Commercial |
$367.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$302.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$376.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$263.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$380.51
|
| Rate for Payer: UHC Core |
$361.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$324.30
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
NDC 51079-966-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: BCBS Trust/PPO |
$1.15
|
| Rate for Payer: BCN Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.31
|
| Rate for Payer: UHC Core |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 50268-303-11
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna Commercial |
$1.88
|
| Rate for Payer: BCBS Trust/PPO |
$1.71
|
| Rate for Payer: BCN Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$1.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.88
|
| Rate for Payer: PHP Commercial |
$1.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.94
|
| Rate for Payer: UHC Core |
$1.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.66
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$152.75
|
|
|
Service Code
|
NDC 0904-7193-61
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.16 |
| Max. Negotiated Rate |
$137.48 |
| Rate for Payer: Aetna Commercial |
$129.84
|
| Rate for Payer: BCBS Trust/PPO |
$118.05
|
| Rate for Payer: BCN Commercial |
$118.05
|
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Cofinity Commercial |
$131.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.20
|
| Rate for Payer: Healthscope Commercial |
$137.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$129.84
|
| Rate for Payer: PHP Commercial |
$129.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$132.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$93.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$134.42
|
| Rate for Payer: UHC Core |
$127.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.56
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.21
|
|
|
Service Code
|
NDC 0641-6022-01
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$10.99 |
| Rate for Payer: Aetna Commercial |
$10.38
|
| Rate for Payer: BCBS Trust/PPO |
$9.44
|
| Rate for Payer: BCN Commercial |
$9.44
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.77
|
| Rate for Payer: Healthscope Commercial |
$10.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.38
|
| Rate for Payer: PHP Commercial |
$10.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.74
|
| Rate for Payer: UHC Core |
$10.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.16
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.21
|
|
|
Service Code
|
NDC 0641-6022-25
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$10.99 |
| Rate for Payer: Aetna Commercial |
$10.38
|
| Rate for Payer: BCBS Trust/PPO |
$9.44
|
| Rate for Payer: BCN Commercial |
$9.44
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cofinity Commercial |
$10.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.77
|
| Rate for Payer: Healthscope Commercial |
$10.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.38
|
| Rate for Payer: PHP Commercial |
$10.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.74
|
| Rate for Payer: UHC Core |
$10.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.16
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.05
|
|
|
Service Code
|
NDC 67457-433-22
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: BCBS Trust/PPO |
$9.31
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.24
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.60
|
| Rate for Payer: UHC Core |
$10.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
NDC 63323-739-12
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: BCBS Trust/PPO |
$12.40
|
| Rate for Payer: BCN Commercial |
$12.40
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.12
|
| Rate for Payer: UHC Core |
$13.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.05
|
|
|
Service Code
|
NDC 67457-433-00
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: BCBS Trust/PPO |
$9.31
|
| Rate for Payer: BCN Commercial |
$9.31
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cofinity Commercial |
$10.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.64
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.24
|
| Rate for Payer: PHP Commercial |
$10.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.60
|
| Rate for Payer: UHC Core |
$10.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$2,229.50
|
|
|
Service Code
|
CPT 28060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,123.34 |
| Max. Negotiated Rate |
$2,229.50 |
| Rate for Payer: BCBS Complete |
$2,229.50
|
| Rate for Payer: Mclaren Medicaid |
$2,123.34
|
| Rate for Payer: Meridian Medicaid |
$2,229.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,123.34
|
|
|
FAT EMULSION 20 % INTRAVENOUS
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
NDC 0338-0519-13
|
| Hospital Charge Code |
10014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.98 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$170.00
|
| Rate for Payer: BCBS Trust/PPO |
$154.56
|
| Rate for Payer: BCN Commercial |
$154.56
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cofinity Commercial |
$172.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.00
|
| Rate for Payer: Healthscope Commercial |
$180.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.00
|
| Rate for Payer: PHP Commercial |
$170.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$174.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$121.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.00
|
| Rate for Payer: UHC Core |
$167.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.00
|
|
|
FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 0338-9540-03
|
| Hospital Charge Code |
191280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.93 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna Commercial |
$11.05
|
| Rate for Payer: BCBS Trust/PPO |
$10.05
|
| Rate for Payer: BCN Commercial |
$10.05
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cofinity Commercial |
$11.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.40
|
| Rate for Payer: Healthscope Commercial |
$11.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.05
|
| Rate for Payer: PHP Commercial |
$11.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.44
|
| Rate for Payer: UHC Core |
$10.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.75
|
|
|
FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS
|
Facility
|
IP
|
$22.50
|
|
|
Service Code
|
NDC 63323-820-74
|
| Hospital Charge Code |
179808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$20.25 |
| Rate for Payer: Aetna Commercial |
$19.12
|
| Rate for Payer: BCBS Trust/PPO |
$17.39
|
| Rate for Payer: BCN Commercial |
$17.39
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cofinity Commercial |
$19.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.00
|
| Rate for Payer: Healthscope Commercial |
$20.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.12
|
| Rate for Payer: PHP Commercial |
$19.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.80
|
| Rate for Payer: UHC Core |
$18.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.88
|
|
|
FEBUXOSTAT 40 MG TABLET
|
Facility
|
IP
|
$1,135.65
|
|
|
Service Code
|
NDC 64764-918-30
|
| Hospital Charge Code |
97133
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$692.63 |
| Max. Negotiated Rate |
$1,022.08 |
| Rate for Payer: Aetna Commercial |
$965.30
|
| Rate for Payer: BCBS Trust/PPO |
$877.63
|
| Rate for Payer: BCN Commercial |
$877.63
|
| Rate for Payer: Cash Price |
$908.52
|
| Rate for Payer: Cofinity Commercial |
$976.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$908.52
|
| Rate for Payer: Healthscope Commercial |
$1,022.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$851.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$965.30
|
| Rate for Payer: PHP Commercial |
$965.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$794.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$988.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$692.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$999.37
|
| Rate for Payer: UHC Core |
$948.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$851.74
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET
|
Facility
|
IP
|
$240.05
|
|
|
Service Code
|
NDC 68084-636-25
|
| Hospital Charge Code |
40010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.41 |
| Max. Negotiated Rate |
$216.04 |
| Rate for Payer: Aetna Commercial |
$204.04
|
| Rate for Payer: BCBS Trust/PPO |
$185.51
|
| Rate for Payer: BCN Commercial |
$185.51
|
| Rate for Payer: Cash Price |
$192.04
|
| Rate for Payer: Cofinity Commercial |
$206.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.04
|
| Rate for Payer: Healthscope Commercial |
$216.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$204.04
|
| Rate for Payer: PHP Commercial |
$204.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$208.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$146.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$211.24
|
| Rate for Payer: UHC Core |
$200.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.04
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET
|
Facility
|
IP
|
$5.86
|
|
|
Service Code
|
NDC 60687-629-11
|
| Hospital Charge Code |
40010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: Aetna Commercial |
$4.98
|
| Rate for Payer: BCBS Trust/PPO |
$4.53
|
| Rate for Payer: BCN Commercial |
$4.53
|
| Rate for Payer: Cash Price |
$4.69
|
| Rate for Payer: Cofinity Commercial |
$5.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.69
|
| Rate for Payer: Healthscope Commercial |
$5.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.98
|
| Rate for Payer: PHP Commercial |
$4.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.16
|
| Rate for Payer: UHC Core |
$4.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.40
|
|
