|
GABAPENTIN 300 MG/6 ML (6 ML) ORAL SOLUTION
|
Facility
|
IP
|
$15.05
|
|
|
Service Code
|
NDC 50383-311-06
|
| Hospital Charge Code |
162013
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.62 |
| Max. Negotiated Rate |
$13.54 |
| Rate for Payer: Aetna American Axle |
$9.78
|
| Rate for Payer: Aetna Commercial |
$12.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.78
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cofinity Commercial |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$12.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.04
|
| Rate for Payer: Healthscope Commercial |
$13.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.79
|
| Rate for Payer: PHP Commercial |
$12.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.54
|
| Rate for Payer: Priority Health SBD |
$9.48
|
| Rate for Payer: UMR Bronson Commercial |
$6.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.29
|
|
|
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
|
|
|
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 CAPSULE
|
Facility
|
IP
|
$230.30
|
|
|
Service Code
|
NDC 63739-236-10
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.33 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.70
|
| Rate for Payer: Aetna Commercial |
$195.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.70
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| 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 SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$101.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
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 |
$111.67 |
| Max. Negotiated Rate |
$228.42 |
| Rate for Payer: Aetna American Axle |
$164.97
|
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.97
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Commercial |
$177.66
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$177.66
|
| 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 SBD |
$159.89
|
| Rate for Payer: UMR Bronson Commercial |
$111.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.35
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$481.75
|
|
|
Service Code
|
NDC 67877-223-05
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$211.97 |
| Max. Negotiated Rate |
$433.58 |
| Rate for Payer: Aetna American Axle |
$313.14
|
| Rate for Payer: Aetna Commercial |
$409.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$313.14
|
| Rate for Payer: Cash Price |
$385.40
|
| Rate for Payer: Cofinity Commercial |
$337.22
|
| Rate for Payer: Cofinity Commercial |
$414.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$385.40
|
| Rate for Payer: Healthscope Commercial |
$433.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$337.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$361.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$409.49
|
| Rate for Payer: PHP Commercial |
$409.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$337.22
|
| Rate for Payer: Priority Health SBD |
$303.50
|
| Rate for Payer: UMR Bronson Commercial |
$211.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$361.31
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$180.95
|
|
|
Service Code
|
NDC 62756-138-02
|
| Hospital Charge Code |
18308
|
|
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 300 MG CAPSULE
|
Facility
|
IP
|
$274.95
|
|
|
Service Code
|
NDC 63739-903-10
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.98 |
| Max. Negotiated Rate |
$247.46 |
| Rate for Payer: Aetna American Axle |
$178.72
|
| Rate for Payer: Aetna Commercial |
$233.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.72
|
| Rate for Payer: Cash Price |
$219.96
|
| Rate for Payer: Cofinity Commercial |
$192.46
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$192.46
|
| 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 SBD |
$173.22
|
| Rate for Payer: UMR Bronson Commercial |
$120.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$206.21
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 70010-109-01
|
| Hospital Charge Code |
18308
|
|
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
|
|
|
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 |
$1.12 |
| Max. Negotiated Rate |
$2.29 |
| Rate for Payer: Aetna American Axle |
$1.65
|
| Rate for Payer: Aetna Commercial |
$2.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.65
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cofinity Commercial |
$1.78
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1.78
|
| 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 SBD |
$1.60
|
| Rate for Payer: UMR Bronson Commercial |
$1.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.90
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 58657-621-01
|
| Hospital Charge Code |
18308
|
|
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
|
|
|
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 |
$44.46 |
| Max. Negotiated Rate |
$90.94 |
| Rate for Payer: Aetna American Axle |
$65.68
|
| Rate for Payer: Aetna Commercial |
$85.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.68
|
| Rate for Payer: Cash Price |
$80.84
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$70.74
|
| 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 SBD |
$63.66
|
| Rate for Payer: UMR Bronson Commercial |
$44.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.79
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$274.95
|
|
|
Service Code
|
NDC 63739-904-10
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.98 |
| Max. Negotiated Rate |
$247.46 |
| Rate for Payer: Aetna American Axle |
$178.72
|
| Rate for Payer: Aetna Commercial |
$233.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.72
|
| Rate for Payer: Cash Price |
$219.96
|
| Rate for Payer: Cofinity Commercial |
$192.46
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$192.46
|
| 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 SBD |
$173.22
|
| Rate for Payer: UMR Bronson Commercial |
$120.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$206.21
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$223.25
|
|
|
Service Code
|
NDC 62756-139-02
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.23 |
| Max. Negotiated Rate |
$200.92 |
| Rate for Payer: Aetna American Axle |
$145.11
|
| Rate for Payer: Aetna Commercial |
$189.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.11
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$156.28
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$200.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$189.76
|
| Rate for Payer: PHP Commercial |
$189.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.28
|
| Rate for Payer: Priority Health SBD |
$140.65
|
| Rate for Payer: UMR Bronson Commercial |
$98.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.44
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
NDC 60687-602-01
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.12 |
| Max. Negotiated Rate |
$380.70 |
| Rate for Payer: Aetna American Axle |
$274.95
|
| Rate for Payer: Aetna Commercial |
$359.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.95
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$296.10
|
| Rate for Payer: Cofinity Commercial |
$363.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$380.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$359.55
|
| Rate for Payer: PHP Commercial |
$359.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.10
|
| Rate for Payer: Priority Health SBD |
$266.49
|
| Rate for Payer: UMR Bronson Commercial |
$186.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.25
|
|
|
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 |
$64.11 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna American Axle |
$94.70
|
| Rate for Payer: Aetna Commercial |
$123.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.70
|
| Rate for Payer: Cash Price |
$116.56
|
| Rate for Payer: Cofinity Commercial |
$101.99
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$101.99
|
| 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 SBD |
$91.79
|
| Rate for Payer: UMR Bronson Commercial |
$64.11
|
| 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 |
$105.47 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna American Axle |
$155.80
|
| Rate for Payer: Aetna Commercial |
$203.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.80
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$167.79
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$167.79
|
| 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 SBD |
$151.01
|
| Rate for Payer: UMR Bronson Commercial |
$105.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 60687-602-11
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna American Axle |
$2.75
|
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.96
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.17
|
|
|
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 |
$117.88 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna American Axle |
$174.14
|
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.14
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$187.53
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$187.53
|
| 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 SBD |
$168.78
|
| Rate for Payer: UMR Bronson Commercial |
$117.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.92
|
|
|
GABAPENTIN 50 MG/1 ML ORAL SOLUTION CUSTOM (NICU)
|
Facility
|
IP
|
$2.08
|
|
|
Service Code
|
NDC 9900-0018-84
|
| Hospital Charge Code |
301189
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna American Axle |
$1.35
|
| Rate for Payer: Aetna Commercial |
$1.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.35
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cofinity Commercial |
$1.46
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.66
|
| Rate for Payer: Healthscope Commercial |
$1.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.77
|
| Rate for Payer: PHP Commercial |
$1.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.46
|
| Rate for Payer: Priority Health SBD |
$1.31
|
| Rate for Payer: UMR Bronson Commercial |
$0.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.56
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$2.34
|
|
|
Service Code
|
NDC 60687-507-11
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.11 |
| Rate for Payer: Aetna American Axle |
$1.52
|
| Rate for Payer: Aetna Commercial |
$1.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.52
|
| Rate for Payer: Cash Price |
$1.87
|
| Rate for Payer: Cofinity Commercial |
$1.64
|
| Rate for Payer: Cofinity Commercial |
$2.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.87
|
| Rate for Payer: Healthscope Commercial |
$2.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.99
|
| Rate for Payer: PHP Commercial |
$1.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: Priority Health SBD |
$1.47
|
| Rate for Payer: UMR Bronson Commercial |
$1.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.76
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$223.25
|
|
|
Service Code
|
NDC 0904-6823-61
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.23 |
| Max. Negotiated Rate |
$200.92 |
| Rate for Payer: Aetna American Axle |
$145.11
|
| Rate for Payer: Aetna Commercial |
$189.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.11
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Cofinity Commercial |
$156.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.60
|
| Rate for Payer: Healthscope Commercial |
$200.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$189.76
|
| Rate for Payer: PHP Commercial |
$189.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.28
|
| Rate for Payer: Priority Health SBD |
$140.65
|
| Rate for Payer: UMR Bronson Commercial |
$98.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.44
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$289.92
|
|
|
Service Code
|
NDC 0228-2636-11
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.56 |
| Max. Negotiated Rate |
$260.93 |
| Rate for Payer: Aetna American Axle |
$188.45
|
| Rate for Payer: Aetna Commercial |
$246.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.45
|
| Rate for Payer: Cash Price |
$231.94
|
| Rate for Payer: Cofinity Commercial |
$202.94
|
| Rate for Payer: Cofinity Commercial |
$249.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.94
|
| Rate for Payer: Healthscope Commercial |
$260.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$246.43
|
| Rate for Payer: PHP Commercial |
$246.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.94
|
| Rate for Payer: Priority Health SBD |
$182.65
|
| Rate for Payer: UMR Bronson Commercial |
$127.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.44
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$233.70
|
|
|
Service Code
|
NDC 60687-507-01
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.83 |
| Max. Negotiated Rate |
$210.33 |
| Rate for Payer: Aetna American Axle |
$151.90
|
| Rate for Payer: Aetna Commercial |
$198.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.90
|
| Rate for Payer: Cash Price |
$186.96
|
| Rate for Payer: Cofinity Commercial |
$163.59
|
| Rate for Payer: Cofinity Commercial |
$200.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.96
|
| Rate for Payer: Healthscope Commercial |
$210.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$163.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$175.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$198.64
|
| Rate for Payer: PHP Commercial |
$198.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.59
|
| Rate for Payer: Priority Health SBD |
$147.23
|
| Rate for Payer: UMR Bronson Commercial |
$102.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$175.28
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$441.80
|
|
|
Service Code
|
NDC 68462-126-01
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.39 |
| Max. Negotiated Rate |
$397.62 |
| Rate for Payer: Aetna American Axle |
$287.17
|
| Rate for Payer: Aetna Commercial |
$375.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.17
|
| Rate for Payer: Cash Price |
$353.44
|
| Rate for Payer: Cofinity Commercial |
$309.26
|
| Rate for Payer: Cofinity Commercial |
$379.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.44
|
| Rate for Payer: Healthscope Commercial |
$397.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$375.53
|
| Rate for Payer: PHP Commercial |
$375.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$309.26
|
| Rate for Payer: Priority Health SBD |
$278.33
|
| Rate for Payer: UMR Bronson Commercial |
$194.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.35
|
|
