|
GLIPIZIDE 5 MG TABLET
|
Facility
|
IP
|
$206.15
|
|
|
Service Code
|
NDC 51079-810-20
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.73 |
| Max. Negotiated Rate |
$185.54 |
| Rate for Payer: Aetna Commercial |
$175.23
|
| Rate for Payer: BCBS Trust/PPO |
$159.31
|
| Rate for Payer: BCN Commercial |
$159.31
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Cofinity Commercial |
$177.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.92
|
| Rate for Payer: Healthscope Commercial |
$185.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.23
|
| Rate for Payer: PHP Commercial |
$175.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$179.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$125.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$181.41
|
| Rate for Payer: UHC Core |
$172.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.61
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
IP
|
$227.05
|
|
|
Service Code
|
NDC 0904-6637-61
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.48 |
| Max. Negotiated Rate |
$204.34 |
| Rate for Payer: Aetna Commercial |
$192.99
|
| Rate for Payer: BCBS Trust/PPO |
$175.46
|
| Rate for Payer: BCN Commercial |
$175.46
|
| Rate for Payer: Cash Price |
$181.64
|
| Rate for Payer: Cofinity Commercial |
$195.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$181.64
|
| Rate for Payer: Healthscope Commercial |
$204.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$192.99
|
| Rate for Payer: PHP Commercial |
$192.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$197.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$138.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$199.80
|
| Rate for Payer: UHC Core |
$189.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.29
|
|
|
GLIPIZIDE 5 MG TABLET
|
Facility
|
IP
|
$2.07
|
|
|
Service Code
|
NDC 51079-810-01
|
| Hospital Charge Code |
10117
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna Commercial |
$1.76
|
| Rate for Payer: BCBS Trust/PPO |
$1.60
|
| Rate for Payer: BCN Commercial |
$1.60
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.66
|
| Rate for Payer: Healthscope Commercial |
$1.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.76
|
| Rate for Payer: PHP Commercial |
$1.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.82
|
| Rate for Payer: UHC Core |
$1.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.55
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 59651-270-01
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.72 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: BCBS Trust/PPO |
$225.19
|
| Rate for Payer: BCN Commercial |
$225.19
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$253.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$177.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$256.43
|
| Rate for Payer: UHC Core |
$243.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$316.80
|
|
|
Service Code
|
NDC 0049-0178-07
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.22 |
| Max. Negotiated Rate |
$285.12 |
| Rate for Payer: Aetna Commercial |
$269.28
|
| Rate for Payer: BCBS Trust/PPO |
$244.82
|
| Rate for Payer: BCN Commercial |
$244.82
|
| Rate for Payer: Cash Price |
$253.44
|
| Rate for Payer: Cofinity Commercial |
$272.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.44
|
| Rate for Payer: Healthscope Commercial |
$285.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$269.28
|
| Rate for Payer: PHP Commercial |
$269.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$275.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$193.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$278.78
|
| Rate for Payer: UHC Core |
$264.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.60
|
|
|
GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$285.95
|
|
|
Service Code
|
NDC 59762-0542-1
|
| Hospital Charge Code |
37650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.40 |
| Max. Negotiated Rate |
$257.36 |
| Rate for Payer: Aetna Commercial |
$243.06
|
| Rate for Payer: BCBS Trust/PPO |
$220.98
|
| Rate for Payer: BCN Commercial |
$220.98
|
| Rate for Payer: Cash Price |
$228.76
|
| Rate for Payer: Cofinity Commercial |
$245.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.76
|
| Rate for Payer: Healthscope Commercial |
$257.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$214.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$243.06
|
| Rate for Payer: PHP Commercial |
$243.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$248.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$174.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$251.64
|
| Rate for Payer: UHC Core |
$238.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$214.46
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4.92
|
|
|
Service Code
|
NDC 60687-480-11
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$4.18
|
| Rate for Payer: BCBS Trust/PPO |
$3.80
|
| Rate for Payer: BCN Commercial |
$3.80
|
| Rate for Payer: Cash Price |
$3.94
|
| Rate for Payer: Cofinity Commercial |
$4.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.94
|
| Rate for Payer: Healthscope Commercial |
$4.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.18
|
| Rate for Payer: PHP Commercial |
$4.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.33
|
| Rate for Payer: UHC Core |
$4.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.69
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$139.59
|
|
|
Service Code
|
NDC 59651-268-30
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.14 |
| Max. Negotiated Rate |
$125.63 |
| Rate for Payer: Aetna Commercial |
$118.65
|
| Rate for Payer: BCBS Trust/PPO |
$107.88
|
| Rate for Payer: BCN Commercial |
$107.88
|
| Rate for Payer: Cash Price |
$111.67
|
| Rate for Payer: Cofinity Commercial |
$120.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.67
|
| Rate for Payer: Healthscope Commercial |
$125.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$118.65
|
| Rate for Payer: PHP Commercial |
$118.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$121.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$85.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.84
|
| Rate for Payer: UHC Core |
$116.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.69
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$141.56
|
|
|
Service Code
|
NDC 68084-295-21
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.34 |
| Max. Negotiated Rate |
$127.40 |
| Rate for Payer: Aetna Commercial |
$120.33
|
| Rate for Payer: BCBS Trust/PPO |
$109.40
|
| Rate for Payer: BCN Commercial |
$109.40
|
| Rate for Payer: Cash Price |
$113.25
|
| Rate for Payer: Cofinity Commercial |
$121.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.25
|
| Rate for Payer: Healthscope Commercial |
$127.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$120.33
|
| Rate for Payer: PHP Commercial |
$120.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$123.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$86.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$124.57
|
| Rate for Payer: UHC Core |
$118.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.17
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$147.60
|
|
|
Service Code
|
NDC 60687-480-21
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.02 |
| Max. Negotiated Rate |
$132.84 |
| Rate for Payer: Aetna Commercial |
$125.46
|
| Rate for Payer: BCBS Trust/PPO |
$114.07
|
| Rate for Payer: BCN Commercial |
$114.07
|
| Rate for Payer: Cash Price |
$118.08
|
| Rate for Payer: Cofinity Commercial |
$126.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.08
|
| Rate for Payer: Healthscope Commercial |
$132.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.46
|
| Rate for Payer: PHP Commercial |
$125.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$128.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$90.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$129.89
|
| Rate for Payer: UHC Core |
$123.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.70
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$4.72
|
|
|
Service Code
|
NDC 68084-295-11
|
| Hospital Charge Code |
37648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$4.01
|
| Rate for Payer: BCBS Trust/PPO |
$3.65
|
| Rate for Payer: BCN Commercial |
$3.65
|
| Rate for Payer: Cash Price |
$3.78
|
| Rate for Payer: Cofinity Commercial |
$4.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.78
|
| Rate for Payer: Healthscope Commercial |
$4.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.01
|
| Rate for Payer: PHP Commercial |
$4.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.15
|
| Rate for Payer: UHC Core |
$3.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.54
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION
|
Facility
|
IP
|
$407.28
|
|
|
Service Code
|
HCPCS J1611
|
| Hospital Charge Code |
168350
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$248.40 |
| Max. Negotiated Rate |
$366.55 |
| Rate for Payer: Aetna Commercial |
$346.19
|
| Rate for Payer: Aetna Commercial |
$346.17
|
| Rate for Payer: BCBS Trust/PPO |
$314.75
|
| Rate for Payer: BCBS Trust/PPO |
$314.73
|
| Rate for Payer: BCN Commercial |
$314.75
|
| Rate for Payer: BCN Commercial |
$314.73
|
| Rate for Payer: Cash Price |
$325.81
|
| Rate for Payer: Cash Price |
$325.82
|
| Rate for Payer: Cofinity Commercial |
$350.26
|
| Rate for Payer: Cofinity Commercial |
$350.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.82
|
| Rate for Payer: Healthscope Commercial |
$366.55
|
| Rate for Payer: Healthscope Commercial |
$366.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$346.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$346.17
|
| Rate for Payer: PHP Commercial |
$346.17
|
| Rate for Payer: PHP Commercial |
$346.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$285.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$354.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$354.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$248.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$248.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$358.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$358.39
|
| Rate for Payer: UHC Core |
$340.06
|
| Rate for Payer: UHC Core |
$340.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.46
|
|
|
GLUCAGON (HUMAN RECOMBINANT) 1 MG/ML SOLUTION FOR INJECTION VIAL
|
Facility
|
IP
|
$569.77
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
119849
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$347.50 |
| Max. Negotiated Rate |
$512.79 |
| Rate for Payer: Aetna Commercial |
$484.30
|
| Rate for Payer: Aetna Commercial |
$484.31
|
| Rate for Payer: BCBS Trust/PPO |
$440.33
|
| Rate for Payer: BCBS Trust/PPO |
$440.32
|
| Rate for Payer: BCN Commercial |
$440.32
|
| Rate for Payer: BCN Commercial |
$440.33
|
| Rate for Payer: Cash Price |
$455.82
|
| Rate for Payer: Cash Price |
$455.82
|
| Rate for Payer: Cofinity Commercial |
$490.01
|
| Rate for Payer: Cofinity Commercial |
$490.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$455.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$455.82
|
| Rate for Payer: Healthscope Commercial |
$512.80
|
| Rate for Payer: Healthscope Commercial |
$512.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$427.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$427.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$484.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$484.30
|
| Rate for Payer: PHP Commercial |
$484.30
|
| Rate for Payer: PHP Commercial |
$484.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$398.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$398.85
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$495.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$495.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$347.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$347.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$501.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$501.41
|
| Rate for Payer: UHC Core |
$475.77
|
| Rate for Payer: UHC Core |
$475.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$427.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$427.33
|
|
|
GLYBURIDE 2.5 MG TABLET
|
Facility
|
IP
|
$86.95
|
|
|
Service Code
|
NDC 23155-057-01
|
| Hospital Charge Code |
10126
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.03 |
| Max. Negotiated Rate |
$78.26 |
| Rate for Payer: Aetna Commercial |
$73.91
|
| Rate for Payer: BCBS Trust/PPO |
$67.19
|
| Rate for Payer: BCN Commercial |
$67.19
|
| Rate for Payer: Cash Price |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$74.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.56
|
| Rate for Payer: Healthscope Commercial |
$78.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.91
|
| Rate for Payer: PHP Commercial |
$73.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$75.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$76.52
|
| Rate for Payer: UHC Core |
$72.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.21
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY
|
Facility
|
IP
|
$42.30
|
|
|
Service Code
|
NDC 58980-410-12
|
| Hospital Charge Code |
15053
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.80 |
| Max. Negotiated Rate |
$38.07 |
| Rate for Payer: Aetna Commercial |
$35.96
|
| Rate for Payer: BCBS Trust/PPO |
$32.69
|
| Rate for Payer: BCN Commercial |
$32.69
|
| Rate for Payer: Cash Price |
$33.84
|
| Rate for Payer: Cofinity Commercial |
$36.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.84
|
| Rate for Payer: Healthscope Commercial |
$38.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.96
|
| Rate for Payer: PHP Commercial |
$35.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$36.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.22
|
| Rate for Payer: UHC Core |
$35.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.72
|
|
|
GLYCERIN (CHILD) RECTAL SUPPOSITORY
|
Facility
|
IP
|
$41.04
|
|
|
Service Code
|
NDC 58980-409-12
|
| Hospital Charge Code |
3492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.03 |
| Max. Negotiated Rate |
$36.94 |
| Rate for Payer: Aetna Commercial |
$34.88
|
| Rate for Payer: BCBS Trust/PPO |
$31.72
|
| Rate for Payer: BCN Commercial |
$31.72
|
| Rate for Payer: Cash Price |
$32.83
|
| Rate for Payer: Cofinity Commercial |
$35.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.83
|
| Rate for Payer: Healthscope Commercial |
$36.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.88
|
| Rate for Payer: PHP Commercial |
$34.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$35.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.12
|
| Rate for Payer: UHC Core |
$34.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.78
|
|
|
GLYCINE 1.5 % UROLOGIC SOLUTION FOR IRRIGATION
|
Facility
|
IP
|
$194.88
|
|
|
Service Code
|
NDC 0338-0289-47
|
| Hospital Charge Code |
3493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.86 |
| Max. Negotiated Rate |
$175.39 |
| Rate for Payer: Aetna Commercial |
$165.65
|
| Rate for Payer: BCBS Trust/PPO |
$150.60
|
| Rate for Payer: BCN Commercial |
$150.60
|
| Rate for Payer: Cash Price |
$155.90
|
| Rate for Payer: Cofinity Commercial |
$167.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.90
|
| Rate for Payer: Healthscope Commercial |
$175.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.65
|
| Rate for Payer: PHP Commercial |
$165.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$169.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$118.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.49
|
| Rate for Payer: UHC Core |
$162.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.16
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$17.10
|
|
|
Service Code
|
HCPCS J1596
|
| Hospital Charge Code |
3497
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$15.39 |
| Rate for Payer: Aetna Commercial |
$14.54
|
| Rate for Payer: Aetna Commercial |
$22.93
|
| Rate for Payer: Aetna Commercial |
$38.81
|
| Rate for Payer: Aetna Commercial |
$27.14
|
| Rate for Payer: Aetna Commercial |
$20.41
|
| Rate for Payer: BCBS Trust/PPO |
$20.85
|
| Rate for Payer: BCBS Trust/PPO |
$13.21
|
| Rate for Payer: BCBS Trust/PPO |
$18.55
|
| Rate for Payer: BCBS Trust/PPO |
$24.68
|
| Rate for Payer: BCBS Trust/PPO |
$35.29
|
| Rate for Payer: BCN Commercial |
$35.29
|
| Rate for Payer: BCN Commercial |
$18.55
|
| Rate for Payer: BCN Commercial |
$13.21
|
| Rate for Payer: BCN Commercial |
$20.85
|
| Rate for Payer: BCN Commercial |
$24.68
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$25.54
|
| Rate for Payer: Cash Price |
$13.68
|
| Rate for Payer: Cash Price |
$19.21
|
| Rate for Payer: Cash Price |
$36.53
|
| Rate for Payer: Cofinity Commercial |
$14.71
|
| Rate for Payer: Cofinity Commercial |
$27.46
|
| Rate for Payer: Cofinity Commercial |
$39.27
|
| Rate for Payer: Cofinity Commercial |
$23.20
|
| Rate for Payer: Cofinity Commercial |
$20.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.54
|
| Rate for Payer: Healthscope Commercial |
$41.09
|
| Rate for Payer: Healthscope Commercial |
$24.28
|
| Rate for Payer: Healthscope Commercial |
$15.39
|
| Rate for Payer: Healthscope Commercial |
$28.74
|
| Rate for Payer: Healthscope Commercial |
$21.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.41
|
| Rate for Payer: PHP Commercial |
$38.81
|
| Rate for Payer: PHP Commercial |
$22.93
|
| Rate for Payer: PHP Commercial |
$20.41
|
| Rate for Payer: PHP Commercial |
$27.14
|
| Rate for Payer: PHP Commercial |
$14.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.18
|
| Rate for Payer: UHC Core |
$20.05
|
| Rate for Payer: UHC Core |
$22.53
|
| Rate for Payer: UHC Core |
$26.66
|
| Rate for Payer: UHC Core |
$14.28
|
| Rate for Payer: UHC Core |
$38.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.24
|
|
|
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLN (CUSTOM)
|
Facility
|
IP
|
$442.67
|
|
|
Service Code
|
NDC 0900-0002-30
|
| Hospital Charge Code |
158482
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$269.98 |
| Max. Negotiated Rate |
$398.40 |
| Rate for Payer: Aetna Commercial |
$376.27
|
| Rate for Payer: BCBS Trust/PPO |
$342.10
|
| Rate for Payer: BCN Commercial |
$342.10
|
| Rate for Payer: Cash Price |
$354.14
|
| Rate for Payer: Cofinity Commercial |
$380.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$354.14
|
| Rate for Payer: Healthscope Commercial |
$398.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$332.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$376.27
|
| Rate for Payer: PHP Commercial |
$376.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$309.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$385.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$269.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$389.55
|
| Rate for Payer: UHC Core |
$369.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$332.00
|
|
|
GLYCOPYRROLATE 1 MG TABLET
|
Facility
|
IP
|
$244.40
|
|
|
Service Code
|
NDC 23155-606-01
|
| Hospital Charge Code |
10130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.06 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: BCBS Trust/PPO |
$188.87
|
| Rate for Payer: BCN Commercial |
$188.87
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.74
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$212.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$149.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$215.07
|
| Rate for Payer: UHC Core |
$204.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.30
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$3.80
|
|
|
Service Code
|
NDC 0121-1744-10
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Aetna Commercial |
$3.23
|
| Rate for Payer: BCBS Trust/PPO |
$2.94
|
| Rate for Payer: BCN Commercial |
$2.94
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cofinity Commercial |
$3.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.04
|
| Rate for Payer: Healthscope Commercial |
$3.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.23
|
| Rate for Payer: PHP Commercial |
$3.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.34
|
| Rate for Payer: UHC Core |
$3.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.85
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$7.11
|
|
|
Service Code
|
NDC 0121-1744-05
|
| Hospital Charge Code |
3542
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna Commercial |
$6.04
|
| Rate for Payer: BCBS Trust/PPO |
$5.49
|
| Rate for Payer: BCN Commercial |
$5.49
|
| Rate for Payer: Cash Price |
$5.69
|
| Rate for Payer: Cofinity Commercial |
$6.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.69
|
| Rate for Payer: Healthscope Commercial |
$6.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.04
|
| Rate for Payer: PHP Commercial |
$6.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.26
|
| Rate for Payer: UHC Core |
$5.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.33
|
|
|
GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$1,268.25
|
|
|
Service Code
|
NDC 63824-008-50
|
| Hospital Charge Code |
170771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$773.51 |
| Max. Negotiated Rate |
$1,141.42 |
| Rate for Payer: Aetna Commercial |
$1,078.01
|
| Rate for Payer: BCBS Trust/PPO |
$980.10
|
| Rate for Payer: BCN Commercial |
$980.10
|
| Rate for Payer: Cash Price |
$1,014.60
|
| Rate for Payer: Cofinity Commercial |
$1,090.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,014.60
|
| Rate for Payer: Healthscope Commercial |
$1,141.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$951.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,078.01
|
| Rate for Payer: PHP Commercial |
$1,078.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$887.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,103.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$773.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,116.06
|
| Rate for Payer: UHC Core |
$1,058.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$951.19
|
|
|
GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$368.16
|
|
|
Service Code
|
NDC 68084-572-01
|
| Hospital Charge Code |
170771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.54 |
| Max. Negotiated Rate |
$331.34 |
| Rate for Payer: Aetna Commercial |
$312.94
|
| Rate for Payer: BCBS Trust/PPO |
$284.51
|
| Rate for Payer: BCN Commercial |
$284.51
|
| Rate for Payer: Cash Price |
$294.53
|
| Rate for Payer: Cofinity Commercial |
$316.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$294.53
|
| Rate for Payer: Healthscope Commercial |
$331.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$276.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$312.94
|
| Rate for Payer: PHP Commercial |
$312.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$320.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$224.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$323.98
|
| Rate for Payer: UHC Core |
$307.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$276.12
|
|
|
GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR
|
Facility
|
IP
|
$3.69
|
|
|
Service Code
|
NDC 68084-572-11
|
| Hospital Charge Code |
170771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$3.32 |
| Rate for Payer: Aetna Commercial |
$3.14
|
| Rate for Payer: BCBS Trust/PPO |
$2.85
|
| Rate for Payer: BCN Commercial |
$2.85
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cofinity Commercial |
$3.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.95
|
| Rate for Payer: Healthscope Commercial |
$3.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.14
|
| Rate for Payer: PHP Commercial |
$3.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.25
|
| Rate for Payer: UHC Core |
$3.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.77
|
|
