|
FUROSEMIDE 20 MG TABLET
|
Facility
|
OP
|
$1.37
|
|
|
Service Code
|
NDC 51079-072-01
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna American Axle |
$0.89
|
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.89
|
| Rate for Payer: BCBS Complete |
$0.55
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$0.96
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$0.96
|
| 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 SBD |
$0.86
|
| Rate for Payer: UMR Bronson Commercial |
$0.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.03
|
|
|
FUROSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$79.90
|
|
|
Service Code
|
NDC 64980-562-01
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$55.93
|
| 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 SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$35.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
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 |
$55.84 |
| Max. Negotiated Rate |
$114.21 |
| Rate for Payer: Aetna American Axle |
$82.48
|
| Rate for Payer: Aetna Commercial |
$107.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$82.48
|
| Rate for Payer: Cash Price |
$101.52
|
| Rate for Payer: Cofinity Commercial |
$109.13
|
| Rate for Payer: Cofinity Commercial |
$88.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.52
|
| Rate for Payer: Healthscope Commercial |
$114.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$88.83
|
| 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 SBD |
$79.95
|
| Rate for Payer: UMR Bronson Commercial |
$55.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.18
|
|
|
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 |
$0.60 |
| Max. Negotiated Rate |
$1.23 |
| Rate for Payer: Aetna American Axle |
$0.89
|
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.89
|
| Rate for Payer: Cash Price |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$0.96
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$0.96
|
| 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 SBD |
$0.86
|
| Rate for Payer: UMR Bronson Commercial |
$0.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.03
|
|
|
FUROSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 69315-116-01
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.19 |
| Max. Negotiated Rate |
$74.02 |
| Rate for Payer: Aetna American Axle |
$53.46
|
| Rate for Payer: Aetna Commercial |
$69.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.46
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$57.58
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$74.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.91
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.58
|
| Rate for Payer: Priority Health SBD |
$51.82
|
| Rate for Payer: UMR Bronson Commercial |
$36.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.69
|
|
|
FUROSEMIDE 20 MG TABLET
|
Facility
|
IP
|
$136.30
|
|
|
Service Code
|
NDC 51079-072-20
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.97 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.60
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.41
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UMR Bronson Commercial |
$59.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
FUROSEMIDE 20 MG TABLET
|
Facility
|
OP
|
$136.30
|
|
|
Service Code
|
NDC 51079-072-20
|
| Hospital Charge Code |
3294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.60
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: BCBS Complete |
$54.52
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.41
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UMR Bronson Commercial |
$50.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
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 |
$61.01 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Cofinity Commercial |
$97.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.06
|
| 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 SBD |
$87.35
|
| Rate for Payer: UMR Bronson Commercial |
$61.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
FUROSEMIDE 40 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079-073-20
|
| Hospital Charge Code |
3295
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.24 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.64
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
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 |
$0.66 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna American Axle |
$0.97
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.97
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.04
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1.04
|
| 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 SBD |
$0.94
|
| Rate for Payer: UMR Bronson Commercial |
$0.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
FUROSEMIDE 40 MG TABLET
|
Facility
|
IP
|
$70.50
|
|
|
Service Code
|
NDC 43547-402-10
|
| Hospital Charge Code |
3295
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.82
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.92
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.35
|
| Rate for Payer: Priority Health SBD |
$44.42
|
| Rate for Payer: UMR Bronson Commercial |
$31.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
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 |
$95.72 |
| Max. Negotiated Rate |
$195.80 |
| Rate for Payer: Aetna American Axle |
$141.41
|
| Rate for Payer: Aetna Commercial |
$184.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.41
|
| Rate for Payer: Cash Price |
$174.04
|
| Rate for Payer: Cofinity Commercial |
$152.28
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$152.28
|
| 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 SBD |
$137.06
|
| Rate for Payer: UMR Bronson Commercial |
$95.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.16
|
|
|
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 |
$35.16 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$55.93
|
| 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 SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$35.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
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 |
$76.52 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna American Axle |
$113.04
|
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$121.73
|
| 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 SBD |
$109.56
|
| Rate for Payer: UMR Bronson Commercial |
$76.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.42
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$86.95
|
|
|
Service Code
|
NDC 69097-813-07
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.26 |
| Max. Negotiated Rate |
$78.26 |
| Rate for Payer: Aetna American Axle |
$56.52
|
| Rate for Payer: Aetna Commercial |
$73.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.52
|
| Rate for Payer: Cash Price |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$60.86
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$60.86
|
| 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 SBD |
$54.78
|
| Rate for Payer: UMR Bronson Commercial |
$38.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.21
|
|
|
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 |
$79.62 |
| Max. Negotiated Rate |
$162.86 |
| Rate for Payer: Aetna American Axle |
$117.62
|
| Rate for Payer: Aetna Commercial |
$153.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.62
|
| Rate for Payer: Cash Price |
$144.76
|
| Rate for Payer: Cofinity Commercial |
$126.66
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$126.66
|
| 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 SBD |
$114.00
|
| Rate for Payer: UMR Bronson Commercial |
$79.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.71
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$2.64
|
|
|
Service Code
|
NDC 60687-580-11
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna American Axle |
$1.72
|
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.72
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cofinity Commercial |
$1.85
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.11
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.24
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.85
|
| Rate for Payer: Priority Health SBD |
$1.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.98
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$89.30
|
|
|
Service Code
|
NDC 70010-108-01
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.29 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna American Axle |
$58.04
|
| Rate for Payer: Aetna Commercial |
$75.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.04
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.90
|
| Rate for Payer: PHP Commercial |
$75.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.51
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UMR Bronson Commercial |
$39.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.98
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$263.20
|
|
|
Service Code
|
NDC 60687-580-01
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.81 |
| Max. Negotiated Rate |
$236.88 |
| Rate for Payer: Aetna American Axle |
$171.08
|
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.08
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$226.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Healthscope Commercial |
$236.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$197.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$223.72
|
| Rate for Payer: PHP Commercial |
$223.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.24
|
| Rate for Payer: Priority Health SBD |
$165.82
|
| Rate for Payer: UMR Bronson Commercial |
$115.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$197.40
|
|
|
GABAPENTIN 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$508.07
|
|
|
Service Code
|
NDC 50383-311-47
|
| Hospital Charge Code |
29169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$223.55 |
| Max. Negotiated Rate |
$457.26 |
| Rate for Payer: Aetna American Axle |
$330.25
|
| Rate for Payer: Aetna Commercial |
$431.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$330.25
|
| Rate for Payer: Cash Price |
$406.46
|
| Rate for Payer: Cofinity Commercial |
$355.65
|
| Rate for Payer: Cofinity Commercial |
$436.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$406.46
|
| Rate for Payer: Healthscope Commercial |
$457.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$355.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$381.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$431.86
|
| Rate for Payer: PHP Commercial |
$431.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$355.65
|
| Rate for Payer: Priority Health SBD |
$320.08
|
| Rate for Payer: UMR Bronson Commercial |
$223.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$381.05
|
|
|
GABAPENTIN 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,524.21
|
|
|
Service Code
|
NDC 59762-5050-7
|
| Hospital Charge Code |
29169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$670.65 |
| Max. Negotiated Rate |
$1,371.79 |
| Rate for Payer: Aetna American Axle |
$990.74
|
| Rate for Payer: Aetna Commercial |
$1,295.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$990.74
|
| Rate for Payer: Cash Price |
$1,219.37
|
| Rate for Payer: Cofinity Commercial |
$1,066.95
|
| Rate for Payer: Cofinity Commercial |
$1,310.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,219.37
|
| Rate for Payer: Healthscope Commercial |
$1,371.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,066.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,143.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,295.58
|
| Rate for Payer: PHP Commercial |
$1,295.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,066.95
|
| Rate for Payer: Priority Health SBD |
$960.25
|
| Rate for Payer: UMR Bronson Commercial |
$670.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,143.16
|
|
|
GABAPENTIN 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$977.84
|
|
|
Service Code
|
NDC 65162-698-90
|
| Hospital Charge Code |
29169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$430.25 |
| Max. Negotiated Rate |
$880.06 |
| Rate for Payer: Aetna American Axle |
$635.60
|
| Rate for Payer: Aetna Commercial |
$831.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$635.60
|
| Rate for Payer: Cash Price |
$782.27
|
| Rate for Payer: Cofinity Commercial |
$684.49
|
| Rate for Payer: Cofinity Commercial |
$840.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$782.27
|
| Rate for Payer: Healthscope Commercial |
$880.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$684.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$733.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$831.16
|
| Rate for Payer: PHP Commercial |
$831.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$684.49
|
| Rate for Payer: Priority Health SBD |
$616.04
|
| Rate for Payer: UMR Bronson Commercial |
$430.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$733.38
|
|
|
GABAPENTIN 250 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$2,186.07
|
|
|
Service Code
|
NDC 0071-2012-47
|
| Hospital Charge Code |
29169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$1,967.46 |
| Rate for Payer: Aetna American Axle |
$1,420.95
|
| Rate for Payer: Aetna Commercial |
$1,858.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,420.95
|
| Rate for Payer: Cash Price |
$1,748.86
|
| Rate for Payer: Cofinity Commercial |
$1,530.25
|
| Rate for Payer: Cofinity Commercial |
$1,880.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,748.86
|
| Rate for Payer: Healthscope Commercial |
$1,967.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,530.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,639.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,858.16
|
| Rate for Payer: PHP Commercial |
$1,858.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,530.25
|
| Rate for Payer: Priority Health SBD |
$1,377.22
|
| Rate for Payer: UMR Bronson Commercial |
$961.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,639.55
|
|
|
GABAPENTIN 300 MG/6 ML (6 ML) ORAL SOLUTION
|
Facility
|
IP
|
$16.02
|
|
|
Service Code
|
NDC 42192-608-40
|
| Hospital Charge Code |
162013
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$14.42 |
| Rate for Payer: Aetna American Axle |
$10.41
|
| Rate for Payer: Aetna Commercial |
$13.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.41
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cofinity Commercial |
$11.21
|
| Rate for Payer: Cofinity Commercial |
$13.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.82
|
| Rate for Payer: Healthscope Commercial |
$14.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.62
|
| Rate for Payer: PHP Commercial |
$13.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.21
|
| Rate for Payer: Priority Health SBD |
$10.09
|
| Rate for Payer: UMR Bronson Commercial |
$7.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.02
|
|
|
GABAPENTIN 300 MG/6 ML (6 ML) ORAL SOLUTION
|
Facility
|
IP
|
$16.02
|
|
|
Service Code
|
NDC 42192-608-06
|
| Hospital Charge Code |
162013
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$14.42 |
| Rate for Payer: Aetna American Axle |
$10.41
|
| Rate for Payer: Aetna Commercial |
$13.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.41
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cofinity Commercial |
$11.21
|
| Rate for Payer: Cofinity Commercial |
$13.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.82
|
| Rate for Payer: Healthscope Commercial |
$14.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.62
|
| Rate for Payer: PHP Commercial |
$13.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.21
|
| Rate for Payer: Priority Health SBD |
$10.09
|
| Rate for Payer: UMR Bronson Commercial |
$7.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.02
|
|
