|
MINERAL OIL ENEMA
|
Facility
|
IP
|
$46.89
|
|
|
Service Code
|
NDC 9629512753
|
| Hospital Charge Code |
5087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.60 |
| Max. Negotiated Rate |
$42.20 |
| Rate for Payer: Aetna Commercial |
$39.86
|
| Rate for Payer: BCBS Trust/PPO |
$36.24
|
| Rate for Payer: BCN Commercial |
$36.24
|
| Rate for Payer: Cash Price |
$37.51
|
| Rate for Payer: Cofinity Commercial |
$40.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.51
|
| Rate for Payer: Healthscope Commercial |
$42.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.86
|
| Rate for Payer: PHP Commercial |
$39.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$40.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$28.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$41.26
|
| Rate for Payer: UHC Core |
$39.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.17
|
|
|
MINOXIDIL 10 MG TABLET
|
Facility
|
IP
|
$262.08
|
|
|
Service Code
|
NDC 68084-205-01
|
| Hospital Charge Code |
5114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.84 |
| Max. Negotiated Rate |
$235.87 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: BCBS Trust/PPO |
$202.54
|
| Rate for Payer: BCN Commercial |
$202.54
|
| Rate for Payer: Cash Price |
$209.66
|
| Rate for Payer: Cofinity Commercial |
$225.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.66
|
| Rate for Payer: Healthscope Commercial |
$235.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$222.77
|
| Rate for Payer: PHP Commercial |
$222.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$228.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$159.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$230.63
|
| Rate for Payer: UHC Core |
$218.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.56
|
|
|
MINOXIDIL 10 MG TABLET
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 68084-205-11
|
| Hospital Charge Code |
5114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: BCBS Trust/PPO |
$2.03
|
| Rate for Payer: BCN Commercial |
$2.03
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$2.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.24
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.31
|
| Rate for Payer: UHC Core |
$2.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.97
|
|
|
MINOXIDIL 10 MG TABLET
|
Facility
|
IP
|
$198.55
|
|
|
Service Code
|
NDC 53489-387-01
|
| Hospital Charge Code |
5114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.10 |
| Max. Negotiated Rate |
$178.70 |
| Rate for Payer: Aetna Commercial |
$168.77
|
| Rate for Payer: BCBS Trust/PPO |
$153.44
|
| Rate for Payer: BCN Commercial |
$153.44
|
| Rate for Payer: Cash Price |
$158.84
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.84
|
| Rate for Payer: Healthscope Commercial |
$178.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$168.77
|
| Rate for Payer: PHP Commercial |
$168.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$172.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$121.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$174.72
|
| Rate for Payer: UHC Core |
$165.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.91
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4,613.39
|
|
|
Service Code
|
NDC 0469-2601-90
|
| Hospital Charge Code |
161790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,813.71 |
| Max. Negotiated Rate |
$4,152.05 |
| Rate for Payer: Aetna Commercial |
$3,921.38
|
| Rate for Payer: BCBS Trust/PPO |
$3,565.23
|
| Rate for Payer: BCN Commercial |
$3,565.23
|
| Rate for Payer: Cash Price |
$3,690.71
|
| Rate for Payer: Cofinity Commercial |
$3,967.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,690.71
|
| Rate for Payer: Healthscope Commercial |
$4,152.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,460.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,921.38
|
| Rate for Payer: PHP Commercial |
$3,921.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,229.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,013.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2,813.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,059.78
|
| Rate for Payer: UHC Core |
$3,852.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,460.04
|
|
|
MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,537.80
|
|
|
Service Code
|
NDC 0469-2601-30
|
| Hospital Charge Code |
161790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$937.90 |
| Max. Negotiated Rate |
$1,384.02 |
| Rate for Payer: Aetna Commercial |
$1,307.13
|
| Rate for Payer: BCBS Trust/PPO |
$1,188.41
|
| Rate for Payer: BCN Commercial |
$1,188.41
|
| Rate for Payer: Cash Price |
$1,230.24
|
| Rate for Payer: Cofinity Commercial |
$1,322.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,230.24
|
| Rate for Payer: Healthscope Commercial |
$1,384.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,153.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,307.13
|
| Rate for Payer: PHP Commercial |
$1,307.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,076.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,337.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$937.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,353.26
|
| Rate for Payer: UHC Core |
$1,284.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,153.35
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$88.01
|
|
|
Service Code
|
NDC 0052-0106-06
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.68 |
| Max. Negotiated Rate |
$79.21 |
| Rate for Payer: Aetna Commercial |
$74.81
|
| Rate for Payer: BCBS Trust/PPO |
$68.01
|
| Rate for Payer: BCN Commercial |
$68.01
|
| Rate for Payer: Cash Price |
$70.41
|
| Rate for Payer: Cofinity Commercial |
$75.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.41
|
| Rate for Payer: Healthscope Commercial |
$79.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.81
|
| Rate for Payer: PHP Commercial |
$74.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$76.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.45
|
| Rate for Payer: UHC Core |
$73.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.01
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$440.01
|
|
|
Service Code
|
NDC 0052-0106-30
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.36 |
| Max. Negotiated Rate |
$396.01 |
| Rate for Payer: Aetna Commercial |
$374.01
|
| Rate for Payer: BCBS Trust/PPO |
$340.04
|
| Rate for Payer: BCN Commercial |
$340.04
|
| Rate for Payer: Cash Price |
$352.01
|
| Rate for Payer: Cofinity Commercial |
$378.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.01
|
| Rate for Payer: Healthscope Commercial |
$396.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$374.01
|
| Rate for Payer: PHP Commercial |
$374.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$382.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$387.21
|
| Rate for Payer: UHC Core |
$367.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.01
|
|
|
MIRTAZAPINE 15 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$101.46
|
|
|
Service Code
|
NDC 65862-021-06
|
| Hospital Charge Code |
29531
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.88 |
| Max. Negotiated Rate |
$91.31 |
| Rate for Payer: Aetna Commercial |
$86.24
|
| Rate for Payer: BCBS Trust/PPO |
$78.41
|
| Rate for Payer: BCN Commercial |
$78.41
|
| Rate for Payer: Cash Price |
$81.17
|
| Rate for Payer: Cofinity Commercial |
$87.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.17
|
| Rate for Payer: Healthscope Commercial |
$91.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$86.24
|
| Rate for Payer: PHP Commercial |
$86.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$88.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$61.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$89.28
|
| Rate for Payer: UHC Core |
$84.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.10
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$195.70
|
|
|
Service Code
|
NDC 68084-119-11
|
| Hospital Charge Code |
17466
|
|
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
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
NDC 51079-086-01
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: BCBS Trust/PPO |
$2.71
|
| Rate for Payer: BCN Commercial |
$2.71
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cofinity Commercial |
$3.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.81
|
| Rate for Payer: Healthscope Commercial |
$3.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.98
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.09
|
| Rate for Payer: UHC Core |
$2.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.63
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$195.70
|
|
|
Service Code
|
NDC 68084-119-01
|
| Hospital Charge Code |
17466
|
|
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
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$350.15
|
|
|
Service Code
|
NDC 51079-086-20
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$213.56 |
| Max. Negotiated Rate |
$315.14 |
| Rate for Payer: Aetna Commercial |
$297.63
|
| Rate for Payer: BCBS Trust/PPO |
$270.60
|
| Rate for Payer: BCN Commercial |
$270.60
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$301.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$315.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$297.63
|
| Rate for Payer: PHP Commercial |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$245.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$304.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$213.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$308.13
|
| Rate for Payer: UHC Core |
$292.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.61
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$37.37
|
|
|
Service Code
|
NDC 13107-031-34
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.79 |
| Max. Negotiated Rate |
$33.63 |
| Rate for Payer: Aetna Commercial |
$31.76
|
| Rate for Payer: BCBS Trust/PPO |
$28.88
|
| Rate for Payer: BCN Commercial |
$28.88
|
| Rate for Payer: Cash Price |
$29.90
|
| Rate for Payer: Cofinity Commercial |
$32.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.90
|
| Rate for Payer: Healthscope Commercial |
$33.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.76
|
| Rate for Payer: PHP Commercial |
$31.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.89
|
| Rate for Payer: UHC Core |
$31.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.03
|
|
|
MIRTAZAPINE 15 MG TABLET
|
Facility
|
IP
|
$279.65
|
|
|
Service Code
|
NDC 0904-6519-61
|
| Hospital Charge Code |
17466
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.56 |
| Max. Negotiated Rate |
$251.68 |
| Rate for Payer: Aetna Commercial |
$237.70
|
| Rate for Payer: BCBS Trust/PPO |
$216.11
|
| Rate for Payer: BCN Commercial |
$216.11
|
| Rate for Payer: Cash Price |
$223.72
|
| Rate for Payer: Cofinity Commercial |
$240.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.72
|
| Rate for Payer: Healthscope Commercial |
$251.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$209.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$237.70
|
| Rate for Payer: PHP Commercial |
$237.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$243.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$170.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$246.09
|
| Rate for Payer: UHC Core |
$233.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$209.74
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
IP
|
$282.10
|
|
|
Service Code
|
NDC 57664-510-83
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.05 |
| Max. Negotiated Rate |
$253.89 |
| Rate for Payer: Aetna Commercial |
$239.78
|
| Rate for Payer: BCBS Trust/PPO |
$218.01
|
| Rate for Payer: BCN Commercial |
$218.01
|
| Rate for Payer: Cash Price |
$225.68
|
| Rate for Payer: Cofinity Commercial |
$242.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.68
|
| Rate for Payer: Healthscope Commercial |
$253.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.78
|
| Rate for Payer: PHP Commercial |
$239.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$245.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$172.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.25
|
| Rate for Payer: UHC Core |
$235.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.58
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
IP
|
$8.32
|
|
|
Service Code
|
NDC 60687-584-11
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$7.49 |
| Rate for Payer: Aetna Commercial |
$7.07
|
| Rate for Payer: BCBS Trust/PPO |
$6.43
|
| Rate for Payer: BCN Commercial |
$6.43
|
| Rate for Payer: Cash Price |
$6.66
|
| Rate for Payer: Cofinity Commercial |
$7.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.66
|
| Rate for Payer: Healthscope Commercial |
$7.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.07
|
| Rate for Payer: PHP Commercial |
$7.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.32
|
| Rate for Payer: UHC Core |
$6.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.24
|
|
|
MIRTAZAPINE 7.5 MG TABLET
|
Facility
|
IP
|
$249.42
|
|
|
Service Code
|
NDC 60687-584-21
|
| Hospital Charge Code |
38421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.12 |
| Max. Negotiated Rate |
$224.48 |
| Rate for Payer: Aetna Commercial |
$212.01
|
| Rate for Payer: BCBS Trust/PPO |
$192.75
|
| Rate for Payer: BCN Commercial |
$192.75
|
| Rate for Payer: Cash Price |
$199.54
|
| Rate for Payer: Cofinity Commercial |
$214.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.54
|
| Rate for Payer: Healthscope Commercial |
$224.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$212.01
|
| Rate for Payer: PHP Commercial |
$212.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$217.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$152.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$219.49
|
| Rate for Payer: UHC Core |
$208.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.06
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$177.41
|
|
|
Service Code
|
NDC 59762-5007-1
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.20 |
| Max. Negotiated Rate |
$159.67 |
| Rate for Payer: Aetna Commercial |
$150.80
|
| Rate for Payer: BCBS Trust/PPO |
$137.10
|
| Rate for Payer: BCN Commercial |
$137.10
|
| Rate for Payer: Cash Price |
$141.93
|
| Rate for Payer: Cofinity Commercial |
$152.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.93
|
| Rate for Payer: Healthscope Commercial |
$159.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$150.80
|
| Rate for Payer: PHP Commercial |
$150.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$154.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$108.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$156.12
|
| Rate for Payer: UHC Core |
$148.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.06
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$196.65
|
|
|
Service Code
|
NDC 70954-443-10
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.94 |
| Max. Negotiated Rate |
$176.98 |
| Rate for Payer: Aetna Commercial |
$167.15
|
| Rate for Payer: BCBS Trust/PPO |
$151.97
|
| Rate for Payer: BCN Commercial |
$151.97
|
| Rate for Payer: Cash Price |
$157.32
|
| Rate for Payer: Cofinity Commercial |
$169.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.32
|
| Rate for Payer: Healthscope Commercial |
$176.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$147.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$167.15
|
| Rate for Payer: PHP Commercial |
$167.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$171.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$119.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$173.05
|
| Rate for Payer: UHC Core |
$164.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$147.49
|
|
|
MISOPROSTOL 100 MCG TABLET
|
Facility
|
IP
|
$177.12
|
|
|
Service Code
|
NDC 43386-160-06
|
| Hospital Charge Code |
10628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.03 |
| Max. Negotiated Rate |
$159.41 |
| Rate for Payer: Aetna Commercial |
$150.55
|
| Rate for Payer: BCBS Trust/PPO |
$136.88
|
| Rate for Payer: BCN Commercial |
$136.88
|
| Rate for Payer: Cash Price |
$141.70
|
| Rate for Payer: Cofinity Commercial |
$152.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.70
|
| Rate for Payer: Healthscope Commercial |
$159.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$150.55
|
| Rate for Payer: PHP Commercial |
$150.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$154.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$108.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$155.87
|
| Rate for Payer: UHC Core |
$147.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.84
|
|
|
MOLASSES
|
Facility
|
IP
|
$6.48
|
|
|
Service Code
|
NDC 9900-0011-18
|
| Hospital Charge Code |
500563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$5.83 |
| Rate for Payer: Aetna Commercial |
$5.51
|
| Rate for Payer: BCBS Trust/PPO |
$5.01
|
| Rate for Payer: BCN Commercial |
$5.01
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: Cofinity Commercial |
$5.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.18
|
| Rate for Payer: Healthscope Commercial |
$5.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.51
|
| Rate for Payer: PHP Commercial |
$5.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.70
|
| Rate for Payer: UHC Core |
$5.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.86
|
|
|
MOLASSES
|
Facility
|
IP
|
$23.94
|
|
|
Service Code
|
NDC 0990-0000-75
|
| Hospital Charge Code |
500563
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.60 |
| Max. Negotiated Rate |
$21.55 |
| Rate for Payer: Aetna Commercial |
$20.35
|
| Rate for Payer: BCBS Trust/PPO |
$18.50
|
| Rate for Payer: BCN Commercial |
$18.50
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.15
|
| Rate for Payer: Healthscope Commercial |
$21.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.35
|
| Rate for Payer: PHP Commercial |
$20.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.07
|
| Rate for Payer: UHC Core |
$19.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.96
|
|
|
MONALISA TOUCH, SERIES, UP TO 3 VISITS
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 00561
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$720.00 |
| Max. Negotiated Rate |
$1,260.00 |
| Rate for Payer: BCBS Complete |
$720.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,260.00
|
|
|
MONALISA TOUCH, SINGLE TREATMENT FOLLOWING A SERIES
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 00562
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: BCBS Complete |
$240.00
|
| Rate for Payer: Cash Price |
$480.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$420.00
|
|
