|
G1016 SPEED OF CARE
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G1016
|
| Hospital Charge Code |
99000408
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1016 SPEED OF CARE
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G1016
|
| Hospital Charge Code |
99000408
|
|
Hospital Revenue Code
|
990
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1017 HEALTHHELPS
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G1017
|
| Hospital Charge Code |
99000409
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1017 HEALTHHELPS
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G1017
|
| Hospital Charge Code |
99000409
|
|
Hospital Revenue Code
|
990
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1018 INFINX
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G1018
|
| Hospital Charge Code |
99000410
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1018 INFINX
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G1018
|
| Hospital Charge Code |
99000410
|
|
Hospital Revenue Code
|
990
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1019 LOGICNETS AUC
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G1019
|
| Hospital Charge Code |
99000411
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1019 LOGICNETS AUC
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G1019
|
| Hospital Charge Code |
99000411
|
|
Hospital Revenue Code
|
990
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1020 CURBSIDES CDSM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G1020
|
| Hospital Charge Code |
99000422
|
|
Hospital Revenue Code
|
990
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1020 CURBSIDES CDSM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G1020
|
| Hospital Charge Code |
99000422
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1021 EHEALTHLINES CDSM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G1021
|
| Hospital Charge Code |
99000423
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1021 EHEALTHLINES CDSM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G1021
|
| Hospital Charge Code |
99000423
|
|
Hospital Revenue Code
|
990
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1022 INTERMOUNTAINS CDSM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G1022
|
| Hospital Charge Code |
99000424
|
|
Hospital Revenue Code
|
990
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1022 INTERMOUNTAINS CDSM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G1022
|
| Hospital Charge Code |
99000424
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1023 PERSICIVAS CDSM
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
CPT G1023
|
| Hospital Charge Code |
99000425
|
|
Hospital Revenue Code
|
990
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
G1023 PERSICIVAS CDSM
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
CPT G1023
|
| Hospital Charge Code |
99000425
|
|
Hospital Revenue Code
|
990
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Aetna Medicare |
$0.01
|
| Rate for Payer: ASR ASR |
$0.01
|
| Rate for Payer: ASR Commercial |
$0.01
|
| Rate for Payer: BCBS Complete |
$0.00
|
| Rate for Payer: BCBS Trust/PPO |
$0.01
|
| Rate for Payer: BCN Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cofinity Commercial |
$0.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.01
|
| Rate for Payer: Healthscope Commercial |
$0.01
|
| Rate for Payer: Healthscope Whirlpool |
$0.01
|
| Rate for Payer: Mclaren Commercial |
$0.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.01
|
| Rate for Payer: Nomi Health Commercial |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$0.01
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
OP
|
$82.25
|
|
|
Service Code
|
NDC 67877022201
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.02
|
| Rate for Payer: Aetna Medicare |
$41.12
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: ASR Commercial |
$79.78
|
| Rate for Payer: BCBS Complete |
$32.90
|
| Rate for Payer: BCBS Trust/PPO |
$67.35
|
| Rate for Payer: BCN Commercial |
$63.77
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Healthscope Whirlpool |
$79.78
|
| Rate for Payer: Mclaren Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$72.07
|
| Rate for Payer: Priority Health Narrow Network |
$57.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 67877022201
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.02
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: ASR Commercial |
$79.78
|
| Rate for Payer: BCBS Trust/PPO |
$67.03
|
| Rate for Payer: BCN Commercial |
$63.77
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Healthscope Whirlpool |
$79.78
|
| Rate for Payer: Mclaren Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$218.50
|
|
|
Service Code
|
NDC 60505011200
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.02 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna Commercial |
$196.65
|
| Rate for Payer: ASR ASR |
$211.94
|
| Rate for Payer: ASR Commercial |
$211.94
|
| Rate for Payer: BCBS Trust/PPO |
$178.06
|
| Rate for Payer: BCN Commercial |
$169.40
|
| Rate for Payer: Cash Price |
$174.80
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.80
|
| Rate for Payer: Healthscope Commercial |
$218.50
|
| Rate for Payer: Healthscope Whirlpool |
$211.94
|
| Rate for Payer: Mclaren Commercial |
$196.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.72
|
| Rate for Payer: Nomi Health Commercial |
$179.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$192.28
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
OP
|
$218.50
|
|
|
Service Code
|
NDC 60505011200
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.40 |
| Max. Negotiated Rate |
$218.50 |
| Rate for Payer: Aetna Commercial |
$196.65
|
| Rate for Payer: Aetna Medicare |
$109.25
|
| Rate for Payer: ASR ASR |
$211.94
|
| Rate for Payer: ASR Commercial |
$211.94
|
| Rate for Payer: BCBS Complete |
$87.40
|
| Rate for Payer: BCBS Trust/PPO |
$178.93
|
| Rate for Payer: BCN Commercial |
$169.40
|
| Rate for Payer: Cash Price |
$174.80
|
| Rate for Payer: Cofinity Commercial |
$205.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.80
|
| Rate for Payer: Healthscope Commercial |
$218.50
|
| Rate for Payer: Healthscope Whirlpool |
$211.94
|
| Rate for Payer: Mclaren Commercial |
$196.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.72
|
| Rate for Payer: Nomi Health Commercial |
$179.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$191.45
|
| Rate for Payer: Priority Health Narrow Network |
$153.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$192.28
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
OP
|
$190.35
|
|
|
Service Code
|
NDC 63739059110
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.14 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna Commercial |
$171.32
|
| Rate for Payer: Aetna Medicare |
$95.18
|
| Rate for Payer: ASR ASR |
$184.64
|
| Rate for Payer: ASR Commercial |
$184.64
|
| Rate for Payer: BCBS Complete |
$76.14
|
| Rate for Payer: BCBS Trust/PPO |
$155.88
|
| Rate for Payer: BCN Commercial |
$147.58
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$178.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Healthscope Whirlpool |
$184.64
|
| Rate for Payer: Mclaren Commercial |
$171.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.80
|
| Rate for Payer: Nomi Health Commercial |
$156.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$166.78
|
| Rate for Payer: Priority Health Narrow Network |
$133.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$167.51
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 00904666561
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.09 |
| Max. Negotiated Rate |
$178.60 |
| Rate for Payer: Aetna Commercial |
$160.74
|
| Rate for Payer: ASR ASR |
$173.24
|
| Rate for Payer: ASR Commercial |
$173.24
|
| Rate for Payer: BCBS Trust/PPO |
$145.54
|
| Rate for Payer: BCN Commercial |
$138.47
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$167.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$178.60
|
| Rate for Payer: Healthscope Whirlpool |
$173.24
|
| Rate for Payer: Mclaren Commercial |
$160.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.81
|
| Rate for Payer: Nomi Health Commercial |
$146.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$157.17
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
IP
|
$190.35
|
|
|
Service Code
|
NDC 63739059110
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.73 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna Commercial |
$171.32
|
| Rate for Payer: ASR ASR |
$184.64
|
| Rate for Payer: ASR Commercial |
$184.64
|
| Rate for Payer: BCBS Trust/PPO |
$155.12
|
| Rate for Payer: BCN Commercial |
$147.58
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$178.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Healthscope Whirlpool |
$184.64
|
| Rate for Payer: Mclaren Commercial |
$171.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.80
|
| Rate for Payer: Nomi Health Commercial |
$156.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$167.51
|
|
|
GABAPENTIN 100 MG CAPSULE
|
Facility
|
OP
|
$178.60
|
|
|
Service Code
|
NDC 00904666561
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.44 |
| Max. Negotiated Rate |
$178.60 |
| Rate for Payer: Aetna Commercial |
$160.74
|
| Rate for Payer: Aetna Medicare |
$89.30
|
| Rate for Payer: ASR ASR |
$173.24
|
| Rate for Payer: ASR Commercial |
$173.24
|
| Rate for Payer: BCBS Complete |
$71.44
|
| Rate for Payer: BCBS Trust/PPO |
$146.26
|
| Rate for Payer: BCN Commercial |
$138.47
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$167.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$178.60
|
| Rate for Payer: Healthscope Whirlpool |
$173.24
|
| Rate for Payer: Mclaren Commercial |
$160.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.81
|
| Rate for Payer: Nomi Health Commercial |
$146.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$156.49
|
| Rate for Payer: Priority Health Narrow Network |
$125.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$157.17
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$103.40
|
|
|
Service Code
|
NDC 67877022301
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.21 |
| Max. Negotiated Rate |
$103.40 |
| Rate for Payer: Aetna Commercial |
$93.06
|
| Rate for Payer: ASR ASR |
$100.30
|
| Rate for Payer: ASR Commercial |
$100.30
|
| Rate for Payer: BCBS Trust/PPO |
$84.26
|
| Rate for Payer: BCN Commercial |
$80.17
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Commercial |
$97.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Healthscope Commercial |
$103.40
|
| Rate for Payer: Healthscope Whirlpool |
$100.30
|
| Rate for Payer: Mclaren Commercial |
$93.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.89
|
| Rate for Payer: Nomi Health Commercial |
$84.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$90.99
|
|
