|
FUROSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$1.37
|
|
|
Service Code
|
NDC 51079-072-01
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: BCBS Trust/PPO |
$1.06
|
| Rate for Payer: BCN Commercial |
$1.06
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$1.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.10
|
| Rate for Payer: Healthscope Commercial |
$1.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.16
|
| Rate for Payer: PHP Commercial |
$1.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.21
|
| Rate for Payer: UHC Core |
$1.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.03
|
|
|
FUROSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$126.90
|
|
|
Service Code
|
NDC 0904-7177-61
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.40 |
| Max. Negotiated Rate |
$114.21 |
| Rate for Payer: Aetna Commercial |
$107.86
|
| Rate for Payer: BCBS Trust/PPO |
$98.07
|
| Rate for Payer: BCN Commercial |
$98.07
|
| Rate for Payer: Cash Price |
$101.52
|
| Rate for Payer: Cofinity Commercial |
$109.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.52
|
| Rate for Payer: Healthscope Commercial |
$114.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$107.86
|
| Rate for Payer: PHP Commercial |
$107.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$110.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$111.67
|
| Rate for Payer: UHC Core |
$105.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.18
|
|
|
FUROSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$368.95
|
|
|
Service Code
|
NDC 0054-8297-25
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.02 |
| Max. Negotiated Rate |
$332.06 |
| Rate for Payer: Aetna Commercial |
$313.61
|
| Rate for Payer: BCBS Trust/PPO |
$285.12
|
| Rate for Payer: BCN Commercial |
$285.12
|
| Rate for Payer: Cash Price |
$295.16
|
| Rate for Payer: Cofinity Commercial |
$317.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$295.16
|
| Rate for Payer: Healthscope Commercial |
$332.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$276.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$313.61
|
| Rate for Payer: PHP Commercial |
$313.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$320.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$225.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$324.68
|
| Rate for Payer: UHC Core |
$308.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$276.71
|
|
|
FUROSEMIDE 40 MG TABLET
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
NDC 51079-073-01
|
| Hospital Charge Code |
3295
|
|
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
|
|
|
FUROSEMIDE 40 MG TABLET
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 0904-7178-61
|
| Hospital Charge Code |
3295
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.56 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: BCBS Trust/PPO |
$107.15
|
| Rate for Payer: BCN Commercial |
$107.15
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$120.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$84.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.01
|
| Rate for Payer: UHC Core |
$115.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
FUROSEMIDE 40 MG TABLET
|
Facility
|
IP
|
$413.60
|
|
|
Service Code
|
NDC 0054-8299-25
|
| Hospital Charge Code |
3295
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$252.25 |
| Max. Negotiated Rate |
$372.24 |
| Rate for Payer: Aetna Commercial |
$351.56
|
| Rate for Payer: BCBS Trust/PPO |
$319.63
|
| Rate for Payer: BCN Commercial |
$319.63
|
| Rate for Payer: Cash Price |
$330.88
|
| Rate for Payer: Cofinity Commercial |
$355.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$330.88
|
| Rate for Payer: Healthscope Commercial |
$372.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$310.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$351.56
|
| Rate for Payer: PHP Commercial |
$351.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$289.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$359.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$252.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$363.97
|
| Rate for Payer: UHC Core |
$345.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$310.20
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$79.90
|
|
|
Service Code
|
NDC 67877-222-01
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.73 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: BCBS Trust/PPO |
$61.75
|
| Rate for Payer: BCN Commercial |
$61.75
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$68.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$71.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$69.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$48.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.31
|
| Rate for Payer: UHC Core |
$66.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$217.55
|
|
|
Service Code
|
NDC 60505-0112-0
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.68 |
| Max. Negotiated Rate |
$195.80 |
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: BCBS Trust/PPO |
$168.12
|
| Rate for Payer: BCN Commercial |
$168.12
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$187.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.04
|
| Rate for Payer: Healthscope Commercial |
$195.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$184.92
|
| Rate for Payer: PHP Commercial |
$184.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$189.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$132.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$191.44
|
| Rate for Payer: UHC Core |
$181.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.16
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$183.30
|
|
|
Service Code
|
NDC 63739-591-10
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.79 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: BCBS Trust/PPO |
$141.65
|
| Rate for Payer: BCN Commercial |
$141.65
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$155.80
|
| Rate for Payer: PHP Commercial |
$155.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$159.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$111.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$161.30
|
| Rate for Payer: UHC Core |
$153.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.48
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$180.95
|
|
|
Service Code
|
NDC 63739-902-10
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.36 |
| Max. Negotiated Rate |
$162.86 |
| Rate for Payer: Aetna Commercial |
$153.81
|
| Rate for Payer: BCBS Trust/PPO |
$139.84
|
| Rate for Payer: BCN Commercial |
$139.84
|
| Rate for Payer: Cash Price |
$144.76
|
| Rate for Payer: Cofinity Commercial |
$155.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$144.76
|
| Rate for Payer: Healthscope Commercial |
$162.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$135.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$153.81
|
| Rate for Payer: PHP Commercial |
$153.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$157.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$110.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$159.24
|
| Rate for Payer: UHC Core |
$151.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.71
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 0904-6665-61
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.06 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: BCBS Trust/PPO |
$134.39
|
| Rate for Payer: BCN Commercial |
$134.39
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$130.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$151.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$106.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$153.03
|
| Rate for Payer: UHC Core |
$145.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.42
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$101.05
|
|
|
Service Code
|
NDC 67877-223-01
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.63 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: BCBS Trust/PPO |
$78.09
|
| Rate for Payer: BCN Commercial |
$78.09
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$86.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.84
|
| Rate for Payer: Healthscope Commercial |
$90.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.89
|
| Rate for Payer: PHP Commercial |
$85.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$87.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$61.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.92
|
| Rate for Payer: UHC Core |
$84.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$2.54
|
|
|
Service Code
|
NDC 68084-762-11
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna Commercial |
$2.16
|
| Rate for Payer: BCBS Trust/PPO |
$1.96
|
| Rate for Payer: BCN Commercial |
$1.96
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.03
|
| Rate for Payer: Healthscope Commercial |
$2.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.16
|
| Rate for Payer: PHP Commercial |
$2.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.24
|
| Rate for Payer: UHC Core |
$2.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.90
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$249.10
|
|
|
Service Code
|
NDC 0904-6666-61
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.93 |
| Max. Negotiated Rate |
$224.19 |
| Rate for Payer: Aetna Commercial |
$211.74
|
| Rate for Payer: BCBS Trust/PPO |
$192.50
|
| Rate for Payer: BCN Commercial |
$192.50
|
| Rate for Payer: Cash Price |
$199.28
|
| Rate for Payer: Cofinity Commercial |
$214.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.28
|
| Rate for Payer: Healthscope Commercial |
$224.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$211.74
|
| Rate for Payer: PHP Commercial |
$211.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$216.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$151.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$219.21
|
| Rate for Payer: UHC Core |
$208.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.82
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
NDC 60687-591-11
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna Commercial |
$2.32
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.11
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.32
|
| Rate for Payer: PHP Commercial |
$2.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.40
|
| Rate for Payer: UHC Core |
$2.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.05
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$253.80
|
|
|
Service Code
|
NDC 68084-762-01
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.79 |
| Max. Negotiated Rate |
$228.42 |
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: BCBS Trust/PPO |
$196.14
|
| Rate for Payer: BCN Commercial |
$196.14
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$218.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$228.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$215.73
|
| Rate for Payer: PHP Commercial |
$215.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$220.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$223.34
|
| Rate for Payer: UHC Core |
$211.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.35
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$274.95
|
|
|
Service Code
|
NDC 63739-903-10
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.69 |
| Max. Negotiated Rate |
$247.46 |
| Rate for Payer: Aetna Commercial |
$233.71
|
| Rate for Payer: BCBS Trust/PPO |
$212.48
|
| Rate for Payer: BCN Commercial |
$212.48
|
| Rate for Payer: Cash Price |
$219.96
|
| Rate for Payer: Cofinity Commercial |
$236.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.96
|
| Rate for Payer: Healthscope Commercial |
$247.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$206.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$233.71
|
| Rate for Payer: PHP Commercial |
$233.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$239.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$241.96
|
| Rate for Payer: UHC Core |
$229.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$206.21
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$230.30
|
|
|
Service Code
|
NDC 63739-236-10
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.46 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna Commercial |
$195.76
|
| Rate for Payer: BCBS Trust/PPO |
$177.98
|
| Rate for Payer: BCN Commercial |
$177.98
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$195.76
|
| Rate for Payer: PHP Commercial |
$195.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$200.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$140.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$202.66
|
| Rate for Payer: UHC Core |
$192.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$272.60
|
|
|
Service Code
|
NDC 60687-591-01
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.26 |
| Max. Negotiated Rate |
$245.34 |
| Rate for Payer: Aetna Commercial |
$231.71
|
| Rate for Payer: BCBS Trust/PPO |
$210.67
|
| Rate for Payer: BCN Commercial |
$210.67
|
| Rate for Payer: Cash Price |
$218.08
|
| Rate for Payer: Cofinity Commercial |
$234.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.08
|
| Rate for Payer: Healthscope Commercial |
$245.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$231.71
|
| Rate for Payer: PHP Commercial |
$231.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$237.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$166.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$239.89
|
| Rate for Payer: UHC Core |
$227.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.45
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 0904-6667-61
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.39 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: BCBS Trust/PPO |
$207.03
|
| Rate for Payer: BCN Commercial |
$207.03
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.72
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$233.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$163.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$235.75
|
| Rate for Payer: UHC Core |
$223.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.92
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$145.70
|
|
|
Service Code
|
NDC 67877-224-01
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.86 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna Commercial |
$123.84
|
| Rate for Payer: BCBS Trust/PPO |
$112.60
|
| Rate for Payer: BCN Commercial |
$112.60
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$125.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.56
|
| Rate for Payer: Healthscope Commercial |
$131.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$123.84
|
| Rate for Payer: PHP Commercial |
$123.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$126.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$88.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.22
|
| Rate for Payer: UHC Core |
$121.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.28
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$239.70
|
|
|
Service Code
|
NDC 63739-984-10
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.19 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna Commercial |
$203.74
|
| Rate for Payer: BCBS Trust/PPO |
$185.24
|
| Rate for Payer: BCN Commercial |
$185.24
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$206.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$215.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$203.74
|
| Rate for Payer: PHP Commercial |
$203.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$208.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$146.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.94
|
| Rate for Payer: UHC Core |
$200.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$32.10
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.58 |
| Max. Negotiated Rate |
$28.89 |
| Rate for Payer: Aetna Commercial |
$27.28
|
| Rate for Payer: Aetna Commercial |
$109.14
|
| Rate for Payer: BCBS Trust/PPO |
$99.23
|
| Rate for Payer: BCBS Trust/PPO |
$24.81
|
| Rate for Payer: BCN Commercial |
$99.23
|
| Rate for Payer: BCN Commercial |
$24.81
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cofinity Commercial |
$110.42
|
| Rate for Payer: Cofinity Commercial |
$27.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.72
|
| Rate for Payer: Healthscope Commercial |
$115.56
|
| Rate for Payer: Healthscope Commercial |
$28.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.14
|
| Rate for Payer: PHP Commercial |
$109.14
|
| Rate for Payer: PHP Commercial |
$27.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$89.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$111.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$78.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$112.99
|
| Rate for Payer: UHC Core |
$107.21
|
| Rate for Payer: UHC Core |
$26.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.08
|
|
|
GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN
|
Facility
|
IP
|
$77.62
|
|
|
Service Code
|
HCPCS A9579
|
| Hospital Charge Code |
118272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.34 |
| Max. Negotiated Rate |
$69.86 |
| Rate for Payer: Aetna Commercial |
$65.98
|
| Rate for Payer: BCBS Trust/PPO |
$59.98
|
| Rate for Payer: BCN Commercial |
$59.98
|
| Rate for Payer: Cash Price |
$62.10
|
| Rate for Payer: Cofinity Commercial |
$66.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.10
|
| Rate for Payer: Healthscope Commercial |
$69.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.98
|
| Rate for Payer: PHP Commercial |
$65.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.31
|
| Rate for Payer: UHC Core |
$64.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.22
|
|
|
GALANTAMINE 4 MG TABLET
|
Facility
|
IP
|
$12.04
|
|
|
Service Code
|
NDC 68084-729-11
|
| Hospital Charge Code |
29806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.34 |
| Max. Negotiated Rate |
$10.84 |
| Rate for Payer: Aetna Commercial |
$10.23
|
| Rate for Payer: BCBS Trust/PPO |
$9.30
|
| Rate for Payer: BCN Commercial |
$9.30
|
| Rate for Payer: Cash Price |
$9.63
|
| Rate for Payer: Cofinity Commercial |
$10.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.63
|
| Rate for Payer: Healthscope Commercial |
$10.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.23
|
| Rate for Payer: PHP Commercial |
$10.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.60
|
| Rate for Payer: UHC Core |
$10.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.03
|
|
