|
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
|
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
|
|
|
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
|
|
|
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 |
$74.03
|
| 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 |
$77.31
|
| 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 |
$74.03
|
| 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
|
$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
|
$218.50
|
|
|
Service Code
|
NDC 60505011200
|
| Hospital Charge Code |
18309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.03 |
| 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 |
$142.03
|
| 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 |
$171.31
|
| Rate for Payer: Aetna Medicare |
$95.17
|
| 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 |
$171.31
|
| 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
|
$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 |
$171.31
|
| 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 |
$171.31
|
| 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
|
$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 |
$142.03
|
| 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
|
$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 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 |
$74.03
|
| 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 |
$77.31
|
| 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 |
$74.03
|
| 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 300 MG CAPSULE
|
Facility
|
OP
|
$103.40
|
|
|
Service Code
|
NDC 67877022301
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.36 |
| Max. Negotiated Rate |
$103.40 |
| Rate for Payer: Aetna Commercial |
$93.06
|
| Rate for Payer: Aetna Medicare |
$51.70
|
| Rate for Payer: ASR ASR |
$100.30
|
| Rate for Payer: ASR Commercial |
$100.30
|
| Rate for Payer: BCBS Complete |
$41.36
|
| Rate for Payer: BCBS Trust/PPO |
$84.67
|
| 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: Priority Health HMO/PPO/Tiered Network |
$90.60
|
| Rate for Payer: Priority Health Narrow Network |
$72.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$90.99
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
OP
|
$251.45
|
|
|
Service Code
|
NDC 00904666661
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.58 |
| Max. Negotiated Rate |
$251.45 |
| Rate for Payer: Aetna Commercial |
$226.31
|
| Rate for Payer: Aetna Medicare |
$125.72
|
| Rate for Payer: ASR ASR |
$243.91
|
| Rate for Payer: ASR Commercial |
$243.91
|
| Rate for Payer: BCBS Complete |
$100.58
|
| Rate for Payer: BCBS Trust/PPO |
$205.91
|
| Rate for Payer: BCN Commercial |
$194.95
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$236.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$251.45
|
| Rate for Payer: Healthscope Whirlpool |
$243.91
|
| Rate for Payer: Mclaren Commercial |
$226.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: Nomi Health Commercial |
$206.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$220.32
|
| Rate for Payer: Priority Health Narrow Network |
$176.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$221.28
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 00904666661
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$251.45 |
| Rate for Payer: Aetna Commercial |
$226.31
|
| Rate for Payer: ASR ASR |
$243.91
|
| Rate for Payer: ASR Commercial |
$243.91
|
| Rate for Payer: BCBS Trust/PPO |
$204.91
|
| Rate for Payer: BCN Commercial |
$194.95
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$236.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$251.45
|
| Rate for Payer: Healthscope Whirlpool |
$243.91
|
| Rate for Payer: Mclaren Commercial |
$226.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: Nomi Health Commercial |
$206.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$221.28
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
OP
|
$277.30
|
|
|
Service Code
|
NDC 63739090310
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.92 |
| Max. Negotiated Rate |
$277.30 |
| Rate for Payer: Aetna Commercial |
$249.57
|
| Rate for Payer: Aetna Medicare |
$138.65
|
| Rate for Payer: ASR ASR |
$268.98
|
| Rate for Payer: ASR Commercial |
$268.98
|
| Rate for Payer: BCBS Complete |
$110.92
|
| Rate for Payer: BCBS Trust/PPO |
$227.08
|
| Rate for Payer: BCN Commercial |
$214.99
|
| Rate for Payer: Cash Price |
$221.84
|
| Rate for Payer: Cofinity Commercial |
$260.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.84
|
| Rate for Payer: Healthscope Commercial |
$277.30
|
| Rate for Payer: Healthscope Whirlpool |
$268.98
|
| Rate for Payer: Mclaren Commercial |
$249.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.71
|
| Rate for Payer: Nomi Health Commercial |
$227.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$242.97
|
| Rate for Payer: Priority Health Narrow Network |
$194.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.02
|
|
|
GABAPENTIN 300 MG CAPSULE
|
Facility
|
IP
|
$277.30
|
|
|
Service Code
|
NDC 63739090310
|
| Hospital Charge Code |
18308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.25 |
| Max. Negotiated Rate |
$277.30 |
| Rate for Payer: Aetna Commercial |
$249.57
|
| Rate for Payer: ASR ASR |
$268.98
|
| Rate for Payer: ASR Commercial |
$268.98
|
| Rate for Payer: BCBS Trust/PPO |
$225.97
|
| Rate for Payer: BCN Commercial |
$214.99
|
| Rate for Payer: Cash Price |
$221.84
|
| Rate for Payer: Cofinity Commercial |
$260.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.84
|
| Rate for Payer: Healthscope Commercial |
$277.30
|
| Rate for Payer: Healthscope Whirlpool |
$268.98
|
| Rate for Payer: Mclaren Commercial |
$249.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.71
|
| Rate for Payer: Nomi Health Commercial |
$227.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.02
|
|
|
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
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
OP
|
$239.70
|
|
|
Service Code
|
NDC 63739098410
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.88 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: Aetna Medicare |
$119.85
|
| Rate for Payer: ASR ASR |
$232.51
|
| Rate for Payer: ASR Commercial |
$232.51
|
| Rate for Payer: BCBS Complete |
$95.88
|
| Rate for Payer: BCBS Trust/PPO |
$196.29
|
| Rate for Payer: BCN Commercial |
$185.84
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$225.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$239.70
|
| Rate for Payer: Healthscope Whirlpool |
$232.51
|
| Rate for Payer: Mclaren Commercial |
$215.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.75
|
| Rate for Payer: Nomi Health Commercial |
$196.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$210.03
|
| Rate for Payer: Priority Health Narrow Network |
$168.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$210.94
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$239.70
|
|
|
Service Code
|
NDC 63739098410
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.81 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: ASR ASR |
$232.51
|
| Rate for Payer: ASR Commercial |
$232.51
|
| Rate for Payer: BCBS Trust/PPO |
$195.33
|
| Rate for Payer: BCN Commercial |
$185.84
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$225.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$239.70
|
| Rate for Payer: Healthscope Whirlpool |
$232.51
|
| Rate for Payer: Mclaren Commercial |
$215.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.75
|
| Rate for Payer: Nomi Health Commercial |
$196.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$210.94
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
IP
|
$272.60
|
|
|
Service Code
|
NDC 00904666761
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.19 |
| Max. Negotiated Rate |
$272.60 |
| Rate for Payer: Aetna Commercial |
$245.34
|
| Rate for Payer: ASR ASR |
$264.42
|
| Rate for Payer: ASR Commercial |
$264.42
|
| Rate for Payer: BCBS Trust/PPO |
$222.14
|
| Rate for Payer: BCN Commercial |
$211.35
|
| Rate for Payer: Cash Price |
$218.08
|
| Rate for Payer: Cofinity Commercial |
$256.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.08
|
| Rate for Payer: Healthscope Commercial |
$272.60
|
| Rate for Payer: Healthscope Whirlpool |
$264.42
|
| Rate for Payer: Mclaren Commercial |
$245.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$231.71
|
| Rate for Payer: Nomi Health Commercial |
$223.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$239.89
|
|
|
GABAPENTIN 400 MG CAPSULE
|
Facility
|
OP
|
$272.60
|
|
|
Service Code
|
NDC 00904666761
|
| Hospital Charge Code |
18307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.04 |
| Max. Negotiated Rate |
$272.60 |
| Rate for Payer: Aetna Commercial |
$245.34
|
| Rate for Payer: Aetna Medicare |
$136.30
|
| Rate for Payer: ASR ASR |
$264.42
|
| Rate for Payer: ASR Commercial |
$264.42
|
| Rate for Payer: BCBS Complete |
$109.04
|
| Rate for Payer: BCBS Trust/PPO |
$223.23
|
| Rate for Payer: BCN Commercial |
$211.35
|
| Rate for Payer: Cash Price |
$218.08
|
| Rate for Payer: Cofinity Commercial |
$256.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.08
|
| Rate for Payer: Healthscope Commercial |
$272.60
|
| Rate for Payer: Healthscope Whirlpool |
$264.42
|
| Rate for Payer: Mclaren Commercial |
$245.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$231.71
|
| Rate for Payer: Nomi Health Commercial |
$223.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$238.85
|
| Rate for Payer: Priority Health Narrow Network |
$191.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$239.89
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$32.10
|
|
|
Service Code
|
HCPCS A9577
|
| Hospital Charge Code |
41137
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$32.10 |
| Rate for Payer: Aetna Commercial |
$28.89
|
| Rate for Payer: Aetna Commercial |
$115.56
|
| Rate for Payer: Aetna Commercial |
$86.67
|
| Rate for Payer: ASR ASR |
$124.55
|
| Rate for Payer: ASR ASR |
$31.14
|
| Rate for Payer: ASR ASR |
$93.41
|
| Rate for Payer: ASR Commercial |
$31.14
|
| Rate for Payer: ASR Commercial |
$124.55
|
| Rate for Payer: ASR Commercial |
$93.41
|
| Rate for Payer: BCBS Trust/PPO |
$78.47
|
| Rate for Payer: BCBS Trust/PPO |
$104.63
|
| Rate for Payer: BCBS Trust/PPO |
$26.16
|
| Rate for Payer: BCN Commercial |
$99.55
|
| Rate for Payer: BCN Commercial |
$74.66
|
| Rate for Payer: BCN Commercial |
$24.89
|
| Rate for Payer: Cash Price |
$25.68
|
| Rate for Payer: Cash Price |
$102.72
|
| Rate for Payer: Cash Price |
$77.04
|
| Rate for Payer: Cofinity Commercial |
$90.52
|
| Rate for Payer: Cofinity Commercial |
$120.70
|
| Rate for Payer: Cofinity Commercial |
$30.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.04
|
| Rate for Payer: Healthscope Commercial |
$128.40
|
| Rate for Payer: Healthscope Commercial |
$32.10
|
| Rate for Payer: Healthscope Commercial |
$96.30
|
| Rate for Payer: Healthscope Whirlpool |
$31.14
|
| Rate for Payer: Healthscope Whirlpool |
$124.55
|
| Rate for Payer: Healthscope Whirlpool |
$93.41
|
| Rate for Payer: Mclaren Commercial |
$28.89
|
| Rate for Payer: Mclaren Commercial |
$115.56
|
| Rate for Payer: Mclaren Commercial |
$86.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.14
|
| Rate for Payer: Nomi Health Commercial |
$26.32
|
| Rate for Payer: Nomi Health Commercial |
$105.29
|
| Rate for Payer: Nomi Health Commercial |
$78.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$84.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$112.99
|
|
