|
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
|
|
|
GELATIN ABSORBABLE EYE FILM
|
Facility
|
IP
|
$812.43
|
|
|
Service Code
|
NDC 9029703
|
| Hospital Charge Code |
28028
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$495.50 |
| Max. Negotiated Rate |
$731.19 |
| Rate for Payer: Aetna Commercial |
$690.57
|
| Rate for Payer: BCBS Trust/PPO |
$627.85
|
| Rate for Payer: BCN Commercial |
$627.85
|
| Rate for Payer: Cash Price |
$649.94
|
| Rate for Payer: Cofinity Commercial |
$698.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$649.94
|
| Rate for Payer: Healthscope Commercial |
$731.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$609.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$690.57
|
| Rate for Payer: PHP Commercial |
$690.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$568.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$706.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$495.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$714.94
|
| Rate for Payer: UHC Core |
$678.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$609.32
|
|
|
GELATIN ABSORBABLE MUCOSAL POWDER
|
Facility
|
IP
|
$190.19
|
|
|
Service Code
|
NDC 0009-0433-04
|
| Hospital Charge Code |
28017
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$116.00 |
| Max. Negotiated Rate |
$171.17 |
| Rate for Payer: Aetna Commercial |
$161.66
|
| Rate for Payer: BCBS Trust/PPO |
$146.98
|
| Rate for Payer: BCN Commercial |
$146.98
|
| Rate for Payer: Cash Price |
$152.15
|
| Rate for Payer: Cofinity Commercial |
$163.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.15
|
| Rate for Payer: Healthscope Commercial |
$171.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.66
|
| Rate for Payer: PHP Commercial |
$161.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$165.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$116.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$167.37
|
| Rate for Payer: UHC Core |
$158.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.64
|
|
|
GELATIN POWDER 1G WITH THROMBIN 5000 UNITS IN 6 ML NS
|
Facility
|
IP
|
$277.21
|
|
|
Service Code
|
NDC 0009-0003-01
|
| Hospital Charge Code |
500530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$169.07 |
| Max. Negotiated Rate |
$249.49 |
| Rate for Payer: Aetna Commercial |
$235.63
|
| Rate for Payer: BCBS Trust/PPO |
$214.23
|
| Rate for Payer: BCN Commercial |
$214.23
|
| Rate for Payer: Cash Price |
$221.77
|
| Rate for Payer: Cofinity Commercial |
$238.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.77
|
| Rate for Payer: Healthscope Commercial |
$249.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.63
|
| Rate for Payer: PHP Commercial |
$235.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$241.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$169.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$243.94
|
| Rate for Payer: UHC Core |
$231.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.91
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
IP
|
$422.18
|
|
|
Service Code
|
NDC 0009-0342-01
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$257.49 |
| Max. Negotiated Rate |
$379.96 |
| Rate for Payer: Aetna Commercial |
$358.85
|
| Rate for Payer: BCBS Trust/PPO |
$326.26
|
| Rate for Payer: BCN Commercial |
$326.26
|
| Rate for Payer: Cash Price |
$337.74
|
| Rate for Payer: Cofinity Commercial |
$363.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.74
|
| Rate for Payer: Healthscope Commercial |
$379.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$358.85
|
| Rate for Payer: PHP Commercial |
$358.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$295.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$367.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$257.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$371.52
|
| Rate for Payer: UHC Core |
$352.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.64
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE
|
Facility
|
IP
|
$659.90
|
|
|
Service Code
|
NDC 6371301974
|
| Hospital Charge Code |
28025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$402.47 |
| Max. Negotiated Rate |
$593.91 |
| Rate for Payer: Aetna Commercial |
$560.92
|
| Rate for Payer: BCBS Trust/PPO |
$509.97
|
| Rate for Payer: BCN Commercial |
$509.97
|
| Rate for Payer: Cash Price |
$527.92
|
| Rate for Payer: Cofinity Commercial |
$567.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$527.92
|
| Rate for Payer: Healthscope Commercial |
$593.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$494.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$560.92
|
| Rate for Payer: PHP Commercial |
$560.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$461.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$574.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$402.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$580.71
|
| Rate for Payer: UHC Core |
$551.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$494.92
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
IP
|
$184.84
|
|
|
Service Code
|
NDC 0009-0315-08
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$112.73 |
| Max. Negotiated Rate |
$166.36 |
| Rate for Payer: Aetna Commercial |
$157.11
|
| Rate for Payer: BCBS Trust/PPO |
$142.84
|
| Rate for Payer: BCN Commercial |
$142.84
|
| Rate for Payer: Cash Price |
$147.87
|
| Rate for Payer: Cofinity Commercial |
$158.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.87
|
| Rate for Payer: Healthscope Commercial |
$166.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$157.11
|
| Rate for Payer: PHP Commercial |
$157.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$160.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$112.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$162.66
|
| Rate for Payer: UHC Core |
$154.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.63
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE
|
Facility
|
IP
|
$270.31
|
|
|
Service Code
|
NDC 6371301972
|
| Hospital Charge Code |
28018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.86 |
| Max. Negotiated Rate |
$243.28 |
| Rate for Payer: Aetna Commercial |
$229.76
|
| Rate for Payer: BCBS Trust/PPO |
$208.90
|
| Rate for Payer: BCN Commercial |
$208.90
|
| Rate for Payer: Cash Price |
$216.25
|
| Rate for Payer: Cofinity Commercial |
$232.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.25
|
| Rate for Payer: Healthscope Commercial |
$243.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$229.76
|
| Rate for Payer: PHP Commercial |
$229.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$235.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$164.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$237.87
|
| Rate for Payer: UHC Core |
$225.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.73
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE
|
Facility
|
IP
|
$196.37
|
|
|
Service Code
|
NDC 0009-0323-01
|
| Hospital Charge Code |
28024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.77 |
| Max. Negotiated Rate |
$176.73 |
| Rate for Payer: Aetna Commercial |
$166.91
|
| Rate for Payer: BCBS Trust/PPO |
$151.75
|
| Rate for Payer: BCN Commercial |
$151.75
|
| Rate for Payer: Cash Price |
$157.10
|
| Rate for Payer: Cofinity Commercial |
$168.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.10
|
| Rate for Payer: Healthscope Commercial |
$176.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$147.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$166.91
|
| Rate for Payer: PHP Commercial |
$166.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$170.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$119.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$172.81
|
| Rate for Payer: UHC Core |
$163.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$147.28
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE
|
Facility
|
IP
|
$297.46
|
|
|
Service Code
|
NDC 6371301973
|
| Hospital Charge Code |
28024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$267.71 |
| Rate for Payer: Aetna Commercial |
$252.84
|
| Rate for Payer: BCBS Trust/PPO |
$229.88
|
| Rate for Payer: BCN Commercial |
$229.88
|
| Rate for Payer: Cash Price |
$237.97
|
| Rate for Payer: Cofinity Commercial |
$255.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$237.97
|
| Rate for Payer: Healthscope Commercial |
$267.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$223.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$252.84
|
| Rate for Payer: PHP Commercial |
$252.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$258.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$181.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.76
|
| Rate for Payer: UHC Core |
$248.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$223.10
|
|
|
GEMFIBROZIL 600 MG TABLET
|
Facility
|
IP
|
$2.03
|
|
|
Service Code
|
NDC 60687-224-11
|
| Hospital Charge Code |
3378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna Commercial |
$1.73
|
| Rate for Payer: BCBS Trust/PPO |
$1.57
|
| Rate for Payer: BCN Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cofinity Commercial |
$1.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.62
|
| Rate for Payer: Healthscope Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.73
|
| Rate for Payer: PHP Commercial |
$1.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.79
|
| Rate for Payer: UHC Core |
$1.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.52
|
|
|
GEMFIBROZIL 600 MG TABLET
|
Facility
|
IP
|
$202.35
|
|
|
Service Code
|
NDC 60687-224-01
|
| Hospital Charge Code |
3378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.41 |
| Max. Negotiated Rate |
$182.12 |
| Rate for Payer: Aetna Commercial |
$172.00
|
| Rate for Payer: BCBS Trust/PPO |
$156.38
|
| Rate for Payer: BCN Commercial |
$156.38
|
| Rate for Payer: Cash Price |
$161.88
|
| Rate for Payer: Cofinity Commercial |
$174.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.88
|
| Rate for Payer: Healthscope Commercial |
$182.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.00
|
| Rate for Payer: PHP Commercial |
$172.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$176.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$123.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$178.07
|
| Rate for Payer: UHC Core |
$168.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.76
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$18.23
|
|
|
Service Code
|
NDC 60758-188-05
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$16.41 |
| Rate for Payer: Aetna Commercial |
$15.50
|
| Rate for Payer: BCBS Trust/PPO |
$14.09
|
| Rate for Payer: BCN Commercial |
$14.09
|
| Rate for Payer: Cash Price |
$14.58
|
| Rate for Payer: Cofinity Commercial |
$15.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.58
|
| Rate for Payer: Healthscope Commercial |
$16.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.50
|
| Rate for Payer: PHP Commercial |
$15.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.04
|
| Rate for Payer: UHC Core |
$15.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.67
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$18.77
|
|
|
Service Code
|
NDC 61314-633-05
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.45 |
| Max. Negotiated Rate |
$16.89 |
| Rate for Payer: Aetna Commercial |
$15.95
|
| Rate for Payer: BCBS Trust/PPO |
$14.51
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: Cash Price |
$15.02
|
| Rate for Payer: Cofinity Commercial |
$16.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.02
|
| Rate for Payer: Healthscope Commercial |
$16.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.95
|
| Rate for Payer: PHP Commercial |
$15.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.52
|
| Rate for Payer: UHC Core |
$15.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.08
|
|
|
GENTAMICIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$116.24
|
|
|
Service Code
|
NDC 24208-580-60
|
| Hospital Charge Code |
3428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.89 |
| Max. Negotiated Rate |
$104.62 |
| Rate for Payer: Aetna Commercial |
$98.80
|
| Rate for Payer: BCBS Trust/PPO |
$89.83
|
| Rate for Payer: BCN Commercial |
$89.83
|
| Rate for Payer: Cash Price |
$92.99
|
| Rate for Payer: Cofinity Commercial |
$99.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.99
|
| Rate for Payer: Healthscope Commercial |
$104.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.80
|
| Rate for Payer: PHP Commercial |
$98.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.37
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$101.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$102.29
|
| Rate for Payer: UHC Core |
$97.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.18
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$54.76
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
3426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.40 |
| Max. Negotiated Rate |
$49.28 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: BCBS Trust/PPO |
$42.32
|
| Rate for Payer: BCN Commercial |
$42.32
|
| Rate for Payer: Cash Price |
$43.81
|
| Rate for Payer: Cofinity Commercial |
$47.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.81
|
| Rate for Payer: Healthscope Commercial |
$49.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$46.55
|
| Rate for Payer: PHP Commercial |
$46.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$47.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$33.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$48.19
|
| Rate for Payer: UHC Core |
$45.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.07
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 16729-001-01
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.96 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: BCBS Trust/PPO |
$150.73
|
| Rate for Payer: BCN Commercial |
$150.73
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$169.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$118.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.64
|
| Rate for Payer: UHC Core |
$162.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
IP
|
$175.28
|
|
|
Service Code
|
NDC 50268-358-15
|
| Hospital Charge Code |
16355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.90 |
| Max. Negotiated Rate |
$157.75 |
| Rate for Payer: Aetna Commercial |
$148.99
|
| Rate for Payer: BCBS Trust/PPO |
$135.46
|
| Rate for Payer: BCN Commercial |
$135.46
|
| Rate for Payer: Cash Price |
$140.22
|
| Rate for Payer: Cofinity Commercial |
$150.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.22
|
| Rate for Payer: Healthscope Commercial |
$157.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$148.99
|
| Rate for Payer: PHP Commercial |
$148.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$152.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$106.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.25
|
| Rate for Payer: UHC Core |
$146.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.46
|
|
|
GLIMEPIRIDE 1 MG TABLET
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
NDC 50268-358-11
|
| Hospital Charge Code |
16355
|
|
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
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$241.30
|
|
|
Service Code
|
NDC 16729-003-01
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.17 |
| Max. Negotiated Rate |
$217.17 |
| Rate for Payer: Aetna Commercial |
$205.10
|
| Rate for Payer: BCBS Trust/PPO |
$186.48
|
| Rate for Payer: BCN Commercial |
$186.48
|
| Rate for Payer: Cash Price |
$193.04
|
| Rate for Payer: Cofinity Commercial |
$207.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.04
|
| Rate for Payer: Healthscope Commercial |
$217.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$205.10
|
| Rate for Payer: PHP Commercial |
$205.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$209.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$147.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$212.34
|
| Rate for Payer: UHC Core |
$201.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.98
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$322.05
|
|
|
Service Code
|
NDC 51079-426-20
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.42 |
| Max. Negotiated Rate |
$289.84 |
| Rate for Payer: Aetna Commercial |
$273.74
|
| Rate for Payer: BCBS Trust/PPO |
$248.88
|
| Rate for Payer: BCN Commercial |
$248.88
|
| Rate for Payer: Cash Price |
$257.64
|
| Rate for Payer: Cofinity Commercial |
$276.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.64
|
| Rate for Payer: Healthscope Commercial |
$289.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$273.74
|
| Rate for Payer: PHP Commercial |
$273.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$280.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$196.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$283.40
|
| Rate for Payer: UHC Core |
$268.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.54
|
|
|
GLIMEPIRIDE 4 MG TABLET
|
Facility
|
IP
|
$3.23
|
|
|
Service Code
|
NDC 51079-426-01
|
| Hospital Charge Code |
16357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: BCBS Trust/PPO |
$2.50
|
| Rate for Payer: BCN Commercial |
$2.50
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cofinity Commercial |
$2.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.58
|
| Rate for Payer: Healthscope Commercial |
$2.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.75
|
| Rate for Payer: PHP Commercial |
$2.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.84
|
| Rate for Payer: UHC Core |
$2.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.42
|
|
|
GLIPIZIDE 10 MG TABLET
|
Facility
|
IP
|
$4.62
|
|
|
Service Code
|
NDC 51079-811-01
|
| Hospital Charge Code |
10116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.93
|
| Rate for Payer: BCBS Trust/PPO |
$3.57
|
| Rate for Payer: BCN Commercial |
$3.57
|
| Rate for Payer: Cash Price |
$3.70
|
| Rate for Payer: Cofinity Commercial |
$3.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.70
|
| Rate for Payer: Healthscope Commercial |
$4.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.93
|
| Rate for Payer: PHP Commercial |
$3.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.07
|
| Rate for Payer: UHC Core |
$3.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.46
|
|
|
GLIPIZIDE 10 MG TABLET
|
Facility
|
IP
|
$461.70
|
|
|
Service Code
|
NDC 51079-811-20
|
| Hospital Charge Code |
10116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.59 |
| Max. Negotiated Rate |
$415.53 |
| Rate for Payer: Aetna Commercial |
$392.44
|
| Rate for Payer: BCBS Trust/PPO |
$356.80
|
| Rate for Payer: BCN Commercial |
$356.80
|
| Rate for Payer: Cash Price |
$369.36
|
| Rate for Payer: Cofinity Commercial |
$397.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$369.36
|
| Rate for Payer: Healthscope Commercial |
$415.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$346.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$392.44
|
| Rate for Payer: PHP Commercial |
$392.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$323.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$401.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$281.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$406.30
|
| Rate for Payer: UHC Core |
$385.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$346.28
|
|
|
GLIPIZIDE 2.5 MG CUSTOM TABLET
|
Facility
|
IP
|
$3.29
|
|
|
Service Code
|
NDC 9900-0003-56
|
| Hospital Charge Code |
158688
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna Commercial |
$2.80
|
| Rate for Payer: BCBS Trust/PPO |
$2.54
|
| Rate for Payer: BCN Commercial |
$2.54
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Cofinity Commercial |
$2.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.63
|
| Rate for Payer: Healthscope Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.80
|
| Rate for Payer: PHP Commercial |
$2.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.90
|
| Rate for Payer: UHC Core |
$2.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.47
|
|
