|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
OP
|
$223.25
|
|
|
Service Code
|
NDC 62756013902
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.60 |
| Max. Negotiated Rate |
$200.92 |
| Rate for Payer: Aetna American Axle |
$145.11
|
| Rate for Payer: Aetna Commercial |
$189.76
|
| Rate for Payer: Aetna Medicare |
$111.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.11
|
| Rate for Payer: BCBS Complete |
$89.30
|
| Rate for Payer: Cash Price |
$178.60
|
| Rate for Payer: Cofinity Commercial |
$156.28
|
| Rate for Payer: Cofinity Commercial |
$192.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$189.76
|
| Rate for Payer: PHP Commercial |
$189.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.11
|
| Rate for Payer: Priority Health SBD |
$140.65
|
| Rate for Payer: UMR Bronson Commercial |
$82.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.44
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
OP
|
$197.40
|
|
|
Service Code
|
NDC 71093012204
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.04 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna Medicare |
$98.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: BCBS Complete |
$78.96
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UMR Bronson Commercial |
$73.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 67877022401
|
| Hospital Charge Code |
18307
|
|
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: Cofinity Medicare Advantage |
$103.64
|
| 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 Commercial |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| 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 50 MG/1 ML ORAL SOLUTION CUSTOM (NICU)
|
Facility
|
IP
|
$2.08
|
|
|
Service Code
|
NDC 09900001884
|
| 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: Cofinity Medicare Advantage |
$1.46
|
| 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 Commercial |
$1.77
|
| Rate for Payer: PHP Commercial |
$1.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.35
|
| 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 50 MG/1 ML ORAL SOLUTION CUSTOM (NICU)
|
Facility
|
OP
|
$2.08
|
|
|
Service Code
|
NDC 09900001884
|
| Hospital Charge Code |
301189
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.87 |
| Rate for Payer: Aetna Medicare |
$1.04
|
| 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: BCBS Complete |
$0.83
|
| Rate for Payer: Cash Price |
$1.66
|
| Rate for Payer: Cofinity Commercial |
$1.46
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.46
|
| 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 Commercial |
$1.77
|
| Rate for Payer: PHP Commercial |
$1.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.35
|
| Rate for Payer: Priority Health SBD |
$1.31
|
| Rate for Payer: UMR Bronson Commercial |
$0.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.56
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$2.46
|
|
|
Service Code
|
NDC 60687050711
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna American Axle |
$1.60
|
| Rate for Payer: Aetna Commercial |
$2.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.60
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$1.72
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.97
|
| Rate for Payer: Healthscope Commercial |
$2.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.09
|
| Rate for Payer: PHP Commercial |
$2.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.60
|
| Rate for Payer: Priority Health SBD |
$1.55
|
| Rate for Payer: UMR Bronson Commercial |
$1.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.84
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$441.80
|
|
|
Service Code
|
NDC 68462012601
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.39 |
| Max. Negotiated Rate |
$397.62 |
| Rate for Payer: PHP Commercial |
$375.53
|
| 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: Cofinity Medicare Advantage |
$309.26
|
| 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 Commercial |
$375.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.17
|
| 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
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
NDC 00904682361
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.36 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna American Axle |
$148.20
|
| Rate for Payer: Aetna Commercial |
$193.80
|
| Rate for Payer: Aetna Medicare |
$114.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.20
|
| Rate for Payer: BCBS Complete |
$91.20
|
| Rate for Payer: Cash Price |
$182.40
|
| Rate for Payer: Cofinity Commercial |
$159.60
|
| Rate for Payer: Cofinity Commercial |
$196.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$159.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.40
|
| Rate for Payer: Healthscope Commercial |
$205.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$171.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$193.80
|
| Rate for Payer: PHP Commercial |
$193.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.20
|
| Rate for Payer: Priority Health SBD |
$143.64
|
| Rate for Payer: UMR Bronson Commercial |
$84.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$171.00
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$245.10
|
|
|
Service Code
|
NDC 60687050701
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.84 |
| Max. Negotiated Rate |
$220.59 |
| Rate for Payer: Aetna American Axle |
$159.32
|
| Rate for Payer: Aetna Commercial |
$208.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.32
|
| Rate for Payer: Cash Price |
$196.08
|
| Rate for Payer: Cofinity Commercial |
$171.57
|
| Rate for Payer: Cofinity Commercial |
$210.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.08
|
| Rate for Payer: Healthscope Commercial |
$220.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.34
|
| Rate for Payer: PHP Commercial |
$208.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.32
|
| Rate for Payer: Priority Health SBD |
$154.41
|
| Rate for Payer: UMR Bronson Commercial |
$107.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.82
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$192.70
|
|
|
Service Code
|
NDC 71093011104
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.79 |
| Max. Negotiated Rate |
$173.43 |
| Rate for Payer: Aetna American Axle |
$125.26
|
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.26
|
| Rate for Payer: Cash Price |
$154.16
|
| Rate for Payer: Cofinity Commercial |
$134.89
|
| Rate for Payer: Cofinity Commercial |
$165.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.16
|
| Rate for Payer: Healthscope Commercial |
$173.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$134.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$144.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.80
|
| Rate for Payer: PHP Commercial |
$163.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.26
|
| Rate for Payer: Priority Health SBD |
$121.40
|
| Rate for Payer: UMR Bronson Commercial |
$84.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$144.52
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
OP
|
$265.55
|
|
|
Service Code
|
NDC 65862052301
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.25 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Aetna American Axle |
$172.61
|
| Rate for Payer: Aetna Commercial |
$225.72
|
| Rate for Payer: Aetna Medicare |
$132.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.61
|
| Rate for Payer: BCBS Complete |
$106.22
|
| Rate for Payer: Cash Price |
$212.44
|
| Rate for Payer: Cofinity Commercial |
$185.88
|
| Rate for Payer: Cofinity Commercial |
$228.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$185.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.44
|
| Rate for Payer: Healthscope Commercial |
$239.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.72
|
| Rate for Payer: PHP Commercial |
$225.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.61
|
| Rate for Payer: Priority Health SBD |
$167.30
|
| Rate for Payer: UMR Bronson Commercial |
$98.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.16
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
NDC 00904682361
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.32 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna American Axle |
$148.20
|
| Rate for Payer: Aetna Commercial |
$193.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.20
|
| Rate for Payer: Cash Price |
$182.40
|
| Rate for Payer: Cofinity Commercial |
$159.60
|
| Rate for Payer: Cofinity Commercial |
$196.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$159.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.40
|
| Rate for Payer: Healthscope Commercial |
$205.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$171.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$193.80
|
| Rate for Payer: PHP Commercial |
$193.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$148.20
|
| Rate for Payer: Priority Health SBD |
$143.64
|
| Rate for Payer: UMR Bronson Commercial |
$100.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$171.00
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$265.55
|
|
|
Service Code
|
NDC 65862052301
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.84 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Aetna American Axle |
$172.61
|
| Rate for Payer: Aetna Commercial |
$225.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.61
|
| Rate for Payer: Cash Price |
$212.44
|
| Rate for Payer: Cofinity Commercial |
$185.88
|
| Rate for Payer: Cofinity Commercial |
$228.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$185.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.44
|
| Rate for Payer: Healthscope Commercial |
$239.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$225.72
|
| Rate for Payer: PHP Commercial |
$225.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.61
|
| Rate for Payer: Priority Health SBD |
$167.30
|
| Rate for Payer: UMR Bronson Commercial |
$116.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.16
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
OP
|
$2.46
|
|
|
Service Code
|
NDC 60687050711
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna American Axle |
$1.60
|
| Rate for Payer: Aetna Commercial |
$2.09
|
| Rate for Payer: Aetna Medicare |
$1.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.60
|
| Rate for Payer: BCBS Complete |
$0.98
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$1.72
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.97
|
| Rate for Payer: Healthscope Commercial |
$2.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.09
|
| Rate for Payer: PHP Commercial |
$2.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.60
|
| Rate for Payer: Priority Health SBD |
$1.55
|
| Rate for Payer: UMR Bronson Commercial |
$0.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.84
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
IP
|
$291.36
|
|
|
Service Code
|
NDC 00228263611
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.20 |
| Max. Negotiated Rate |
$262.22 |
| Rate for Payer: Aetna American Axle |
$189.38
|
| Rate for Payer: Aetna Commercial |
$247.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.38
|
| Rate for Payer: Cash Price |
$233.09
|
| Rate for Payer: Cofinity Commercial |
$203.95
|
| Rate for Payer: Cofinity Commercial |
$250.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.09
|
| Rate for Payer: Healthscope Commercial |
$262.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.66
|
| Rate for Payer: PHP Commercial |
$247.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.38
|
| Rate for Payer: Priority Health SBD |
$183.56
|
| Rate for Payer: UMR Bronson Commercial |
$128.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.52
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
OP
|
$192.70
|
|
|
Service Code
|
NDC 71093011104
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.30 |
| Max. Negotiated Rate |
$173.43 |
| Rate for Payer: Aetna American Axle |
$125.26
|
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Medicare |
$96.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.26
|
| Rate for Payer: BCBS Complete |
$77.08
|
| Rate for Payer: Cash Price |
$154.16
|
| Rate for Payer: Cofinity Commercial |
$134.89
|
| Rate for Payer: Cofinity Commercial |
$165.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.16
|
| Rate for Payer: Healthscope Commercial |
$173.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$134.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$144.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.80
|
| Rate for Payer: PHP Commercial |
$163.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.26
|
| Rate for Payer: Priority Health SBD |
$121.40
|
| Rate for Payer: UMR Bronson Commercial |
$71.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$144.52
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
OP
|
$291.36
|
|
|
Service Code
|
NDC 00228263611
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$262.22 |
| Rate for Payer: Cofinity Commercial |
$250.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.95
|
| Rate for Payer: Aetna American Axle |
$189.38
|
| Rate for Payer: Aetna Commercial |
$247.66
|
| Rate for Payer: Aetna Medicare |
$145.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.38
|
| Rate for Payer: BCBS Complete |
$116.54
|
| Rate for Payer: Cash Price |
$233.09
|
| Rate for Payer: Cofinity Commercial |
$203.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.09
|
| Rate for Payer: Healthscope Commercial |
$262.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.66
|
| Rate for Payer: PHP Commercial |
$247.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.38
|
| Rate for Payer: Priority Health SBD |
$183.56
|
| Rate for Payer: UMR Bronson Commercial |
$107.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.52
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
OP
|
$245.10
|
|
|
Service Code
|
NDC 60687050701
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.69 |
| Max. Negotiated Rate |
$220.59 |
| Rate for Payer: Aetna American Axle |
$159.32
|
| Rate for Payer: Aetna Commercial |
$208.34
|
| Rate for Payer: Aetna Medicare |
$122.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.32
|
| Rate for Payer: BCBS Complete |
$98.04
|
| Rate for Payer: Cash Price |
$196.08
|
| Rate for Payer: Cofinity Commercial |
$171.57
|
| Rate for Payer: Cofinity Commercial |
$210.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.08
|
| Rate for Payer: Healthscope Commercial |
$220.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.34
|
| Rate for Payer: PHP Commercial |
$208.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.32
|
| Rate for Payer: Priority Health SBD |
$154.41
|
| Rate for Payer: UMR Bronson Commercial |
$90.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.82
|
|
|
GABAPENTIN 600 MG TABLET
|
Facility
|
OP
|
$441.80
|
|
|
Service Code
|
NDC 68462012601
|
| Hospital Charge Code |
25855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.47 |
| Max. Negotiated Rate |
$397.62 |
| Rate for Payer: Aetna American Axle |
$287.17
|
| Rate for Payer: Aetna Commercial |
$375.53
|
| Rate for Payer: Aetna Medicare |
$220.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.17
|
| Rate for Payer: BCBS Complete |
$176.72
|
| Rate for Payer: Cash Price |
$353.44
|
| Rate for Payer: Cofinity Commercial |
$309.26
|
| Rate for Payer: Cofinity Commercial |
$379.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$309.26
|
| 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 Commercial |
$375.53
|
| Rate for Payer: PHP Commercial |
$375.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.17
|
| Rate for Payer: Priority Health SBD |
$278.33
|
| Rate for Payer: UMR Bronson Commercial |
$163.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.35
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$128.40
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.50 |
| Max. Negotiated Rate |
$115.56 |
| Rate for Payer: Aetna American Axle |
$83.46
|
| Rate for Payer: Aetna American Axle |
$20.86
|
| Rate for Payer: Aetna American Axle |
$41.73
|
| Rate for Payer: Aetna Commercial |
$27.28
|
| Rate for Payer: Aetna Commercial |
$109.14
|
| Rate for Payer: Aetna Commercial |
$54.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.86
|
| Rate for Payer: Cash Price |
$51.36
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cofinity Commercial |
$89.88
|
| Rate for Payer: Cofinity Commercial |
$27.61
|
| Rate for Payer: Cofinity Commercial |
$22.47
|
| Rate for Payer: Cofinity Commercial |
$55.21
|
| Rate for Payer: Cofinity Commercial |
$44.94
|
| Rate for Payer: Cofinity Commercial |
$110.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$89.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.68
|
| Rate for Payer: Healthscope Commercial |
$28.89
|
| Rate for Payer: Healthscope Commercial |
$115.56
|
| Rate for Payer: Healthscope Commercial |
$57.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$89.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.28
|
| Rate for Payer: PHP Commercial |
$54.57
|
| Rate for Payer: PHP Commercial |
$27.28
|
| Rate for Payer: PHP Commercial |
$109.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.46
|
| Rate for Payer: Priority Health SBD |
$40.45
|
| Rate for Payer: Priority Health SBD |
$20.22
|
| Rate for Payer: Priority Health SBD |
$80.89
|
| Rate for Payer: UMR Bronson Commercial |
$56.50
|
| Rate for Payer: UMR Bronson Commercial |
$28.25
|
| Rate for Payer: UMR Bronson Commercial |
$14.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.08
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$642.00
|
|
|
Service Code
|
HCPCS A9578
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$577.80 |
| Rate for Payer: Aetna American Axle |
$417.30
|
| Rate for Payer: Aetna Commercial |
$545.70
|
| Rate for Payer: Aetna Medicare |
$321.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$417.30
|
| Rate for Payer: BCBS Complete |
$256.80
|
| Rate for Payer: BCBS Trust/PPO |
$2.36
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cofinity Commercial |
$449.40
|
| Rate for Payer: Cofinity Commercial |
$552.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$449.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$513.60
|
| Rate for Payer: Healthscope Commercial |
$577.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$449.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$481.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$545.70
|
| Rate for Payer: PHP Commercial |
$545.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$417.30
|
| Rate for Payer: Priority Health SBD |
$404.46
|
| Rate for Payer: UMR Bronson Commercial |
$237.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$481.50
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$64.20
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$57.78 |
| Rate for Payer: Aetna American Axle |
$41.73
|
| Rate for Payer: Aetna American Axle |
$20.86
|
| Rate for Payer: Aetna American Axle |
$83.46
|
| Rate for Payer: Aetna Commercial |
$54.57
|
| Rate for Payer: Aetna Commercial |
$109.14
|
| Rate for Payer: Aetna Commercial |
$27.28
|
| Rate for Payer: Aetna Medicare |
$16.05
|
| Rate for Payer: Aetna Medicare |
$64.20
|
| Rate for Payer: Aetna Medicare |
$32.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.86
|
| Rate for Payer: BCBS Complete |
$12.84
|
| Rate for Payer: BCBS Complete |
$25.68
|
| Rate for Payer: BCBS Complete |
$51.36
|
| Rate for Payer: BCBS Trust/PPO |
$2.39
|
| Rate for Payer: BCBS Trust/PPO |
$2.39
|
| Rate for Payer: BCBS Trust/PPO |
$2.39
|
| Rate for Payer: BCN Commercial |
$2.39
|
| Rate for Payer: BCN Commercial |
$2.39
|
| Rate for Payer: BCN Commercial |
$2.39
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cash Price |
$51.36
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cash Price |
$51.36
|
| Rate for Payer: Cofinity Commercial |
$27.61
|
| Rate for Payer: Cofinity Commercial |
$110.42
|
| Rate for Payer: Cofinity Commercial |
$89.88
|
| Rate for Payer: Cofinity Commercial |
$22.47
|
| Rate for Payer: Cofinity Commercial |
$44.94
|
| Rate for Payer: Cofinity Commercial |
$55.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$89.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.36
|
| Rate for Payer: Healthscope Commercial |
$57.78
|
| Rate for Payer: Healthscope Commercial |
$28.89
|
| Rate for Payer: Healthscope Commercial |
$115.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$89.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.57
|
| Rate for Payer: PHP Commercial |
$54.57
|
| Rate for Payer: PHP Commercial |
$109.14
|
| Rate for Payer: PHP Commercial |
$27.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.73
|
| Rate for Payer: Priority Health SBD |
$20.22
|
| Rate for Payer: Priority Health SBD |
$40.45
|
| Rate for Payer: Priority Health SBD |
$80.89
|
| Rate for Payer: UMR Bronson Commercial |
$23.75
|
| Rate for Payer: UMR Bronson Commercial |
$47.51
|
| Rate for Payer: UMR Bronson Commercial |
$11.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.15
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
HCPCS A9578
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$282.48 |
| Max. Negotiated Rate |
$577.80 |
| Rate for Payer: Aetna American Axle |
$417.30
|
| Rate for Payer: Aetna Commercial |
$545.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$417.30
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cofinity Commercial |
$449.40
|
| Rate for Payer: Cofinity Commercial |
$552.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$449.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$513.60
|
| Rate for Payer: Healthscope Commercial |
$577.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$449.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$481.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$545.70
|
| Rate for Payer: PHP Commercial |
$545.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$417.30
|
| Rate for Payer: Priority Health SBD |
$404.46
|
| Rate for Payer: UMR Bronson Commercial |
$282.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$481.50
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
152500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna American Axle |
$13.00
|
| Rate for Payer: Aetna Commercial |
$17.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Cofinity Commercial |
$17.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.00
|
| Rate for Payer: Healthscope Commercial |
$18.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.00
|
| Rate for Payer: PHP Commercial |
$17.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.00
|
| Rate for Payer: Priority Health SBD |
$12.60
|
| Rate for Payer: UMR Bronson Commercial |
$8.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.00
|
|
|
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS A9585
|
| Hospital Charge Code |
152500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna American Axle |
$13.00
|
| Rate for Payer: Aetna Commercial |
$17.00
|
| Rate for Payer: Aetna Medicare |
$10.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.00
|
| Rate for Payer: BCBS Complete |
$8.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.40
|
| Rate for Payer: BCN Commercial |
$0.40
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cash Price |
$16.00
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Cofinity Commercial |
$17.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.00
|
| Rate for Payer: Healthscope Commercial |
$18.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.00
|
| Rate for Payer: PHP Commercial |
$17.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.00
|
| Rate for Payer: Priority Health SBD |
$12.60
|
| Rate for Payer: UMR Bronson Commercial |
$7.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.00
|
|
