|
DIPHENHYDRAMINE-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$20.51
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.87 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna Commercial |
$17.43
|
| Rate for Payer: Aetna Medicare |
$5.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.41
|
| Rate for Payer: BCBS Complete |
$8.20
|
| Rate for Payer: BCBS MAPPO |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$16.86
|
| Rate for Payer: BCN Commercial |
$15.95
|
| Rate for Payer: BCN Medicare Advantage |
$5.13
|
| Rate for Payer: Cash Price |
$16.41
|
| Rate for Payer: Cofinity Commercial |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.13
|
| Rate for Payer: Healthscope Commercial |
$18.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.43
|
| Rate for Payer: Nomi Health Commercial |
$16.82
|
| Rate for Payer: PACE Senior Care Partners |
$4.87
|
| Rate for Payer: PACE SWMI |
$5.13
|
| Rate for Payer: PHP Commercial |
$17.43
|
| Rate for Payer: PHP Medicare Advantage |
$5.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.33
|
| Rate for Payer: Priority Health HMO/PPO |
$17.84
|
| Rate for Payer: Priority Health Medicare |
$5.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.74
|
| Rate for Payer: Railroad Medicare Medicare |
$5.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.05
|
| Rate for Payer: UHC Core |
$17.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.13
|
| Rate for Payer: UHC Exchange |
$5.13
|
| Rate for Payer: UHC Medicare Advantage |
$5.13
|
| Rate for Payer: VA VA |
$5.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.38
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$20.51
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna Commercial |
$17.43
|
| Rate for Payer: BCBS Trust/PPO |
$16.74
|
| Rate for Payer: BCN Commercial |
$15.85
|
| Rate for Payer: Cash Price |
$16.41
|
| Rate for Payer: Cofinity Commercial |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.41
|
| Rate for Payer: Healthscope Commercial |
$18.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.43
|
| Rate for Payer: Nomi Health Commercial |
$16.82
|
| Rate for Payer: PHP Commercial |
$17.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.33
|
| Rate for Payer: Priority Health HMO/PPO |
$17.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.05
|
| Rate for Payer: UHC Core |
$17.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.38
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$294.50
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.94 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: Aetna Medicare |
$76.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$92.03
|
| Rate for Payer: Amish Plain Church Group Commercial |
$92.03
|
| Rate for Payer: BCBS Complete |
$117.80
|
| Rate for Payer: BCBS MAPPO |
$73.62
|
| Rate for Payer: BCBS Trust/PPO |
$242.11
|
| Rate for Payer: BCN Commercial |
$228.97
|
| Rate for Payer: BCN Medicare Advantage |
$73.62
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$73.62
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$77.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$84.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: Nomi Health Commercial |
$241.49
|
| Rate for Payer: PACE Senior Care Partners |
$69.94
|
| Rate for Payer: PACE SWMI |
$73.62
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: PHP Medicare Advantage |
$73.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.42
|
| Rate for Payer: Priority Health HMO/PPO |
$256.22
|
| Rate for Payer: Priority Health Medicare |
$74.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$197.32
|
| Rate for Payer: Railroad Medicare Medicare |
$73.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$259.16
|
| Rate for Payer: UHC Core |
$245.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$73.62
|
| Rate for Payer: UHC Exchange |
$73.62
|
| Rate for Payer: UHC Medicare Advantage |
$73.62
|
| Rate for Payer: VA VA |
$73.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.11 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: BCBS Trust/PPO |
$255.08
|
| Rate for Payer: BCN Commercial |
$241.48
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health HMO/PPO |
$271.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$209.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$274.98
|
| Rate for Payer: UHC Core |
$260.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.36
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.19 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna Medicare |
$94.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$113.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$113.41
|
| Rate for Payer: BCBS Complete |
$145.16
|
| Rate for Payer: BCBS MAPPO |
$90.72
|
| Rate for Payer: BCBS Trust/PPO |
$298.34
|
| Rate for Payer: BCN Commercial |
$282.15
|
| Rate for Payer: BCN Medicare Advantage |
$90.72
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$90.72
|
| Rate for Payer: Healthscope Commercial |
$326.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$272.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$95.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: PACE Senior Care Partners |
$86.19
|
| Rate for Payer: PACE SWMI |
$90.72
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: PHP Medicare Advantage |
$90.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health HMO/PPO |
$315.72
|
| Rate for Payer: Priority Health Medicare |
$91.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$243.14
|
| Rate for Payer: Railroad Medicare Medicare |
$90.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$319.35
|
| Rate for Payer: UHC Core |
$303.02
|
| Rate for Payer: UHC Dual Complete DSNP |
$90.72
|
| Rate for Payer: UHC Exchange |
$90.72
|
| Rate for Payer: UHC Medicare Advantage |
$90.72
|
| Rate for Payer: VA VA |
$90.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$272.18
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$415.95
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$270.37 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: BCBS Trust/PPO |
$339.54
|
| Rate for Payer: BCN Commercial |
$321.45
|
| Rate for Payer: Cash Price |
$332.76
|
| Rate for Payer: Cofinity Commercial |
$357.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.76
|
| Rate for Payer: Healthscope Commercial |
$374.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$311.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.56
|
| Rate for Payer: Nomi Health Commercial |
$341.08
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.37
|
| Rate for Payer: Priority Health HMO/PPO |
$361.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$278.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$366.04
|
| Rate for Payer: UHC Core |
$347.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$311.96
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.21 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna Medicare |
$81.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$97.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$97.65
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: BCBS MAPPO |
$78.12
|
| Rate for Payer: BCBS Trust/PPO |
$256.89
|
| Rate for Payer: BCN Commercial |
$242.95
|
| Rate for Payer: BCN Medicare Advantage |
$78.12
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.12
|
| Rate for Payer: Healthscope Commercial |
$281.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$89.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: PACE Senior Care Partners |
$74.21
|
| Rate for Payer: PACE SWMI |
$78.12
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: PHP Medicare Advantage |
$78.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health HMO/PPO |
$271.86
|
| Rate for Payer: Priority Health Medicare |
$78.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$209.36
|
| Rate for Payer: Railroad Medicare Medicare |
$78.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$274.98
|
| Rate for Payer: UHC Core |
$260.92
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.12
|
| Rate for Payer: UHC Exchange |
$78.12
|
| Rate for Payer: UHC Medicare Advantage |
$78.12
|
| Rate for Payer: VA VA |
$78.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.36
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$235.88 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: BCBS Trust/PPO |
$296.24
|
| Rate for Payer: BCN Commercial |
$280.45
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$290.32
|
| Rate for Payer: Healthscope Commercial |
$326.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$272.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health HMO/PPO |
$315.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$243.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$319.35
|
| Rate for Payer: UHC Core |
$303.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$272.18
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$415.95
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.79 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: Aetna Medicare |
$108.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$129.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$129.98
|
| Rate for Payer: BCBS Complete |
$166.38
|
| Rate for Payer: BCBS MAPPO |
$103.99
|
| Rate for Payer: BCBS Trust/PPO |
$341.95
|
| Rate for Payer: BCN Commercial |
$323.40
|
| Rate for Payer: BCN Medicare Advantage |
$103.99
|
| Rate for Payer: Cash Price |
$332.76
|
| Rate for Payer: Cofinity Commercial |
$357.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$103.99
|
| Rate for Payer: Healthscope Commercial |
$374.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$311.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$109.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$119.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.56
|
| Rate for Payer: Nomi Health Commercial |
$341.08
|
| Rate for Payer: PACE Senior Care Partners |
$98.79
|
| Rate for Payer: PACE SWMI |
$103.99
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: PHP Medicare Advantage |
$103.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$270.37
|
| Rate for Payer: Priority Health HMO/PPO |
$361.88
|
| Rate for Payer: Priority Health Medicare |
$105.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$278.69
|
| Rate for Payer: Railroad Medicare Medicare |
$103.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$366.04
|
| Rate for Payer: UHC Core |
$347.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$103.99
|
| Rate for Payer: UHC Exchange |
$103.99
|
| Rate for Payer: UHC Medicare Advantage |
$103.99
|
| Rate for Payer: VA VA |
$103.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$311.96
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$294.50
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.42 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: BCBS Trust/PPO |
$240.40
|
| Rate for Payer: BCN Commercial |
$227.59
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: Nomi Health Commercial |
$241.49
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.42
|
| Rate for Payer: Priority Health HMO/PPO |
$256.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$197.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$259.16
|
| Rate for Payer: UHC Core |
$245.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE
|
Facility
|
IP
|
$118.78
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.21 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: BCBS Trust/PPO |
$96.96
|
| Rate for Payer: BCN Commercial |
$91.79
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Commercial |
$102.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.02
|
| Rate for Payer: Healthscope Commercial |
$106.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: Nomi Health Commercial |
$97.40
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.21
|
| Rate for Payer: Priority Health HMO/PPO |
$103.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$79.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.53
|
| Rate for Payer: UHC Core |
$99.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.08
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE
|
Facility
|
OP
|
$118.78
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.21 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: Aetna Medicare |
$30.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$37.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$37.12
|
| Rate for Payer: BCBS Complete |
$47.51
|
| Rate for Payer: BCBS MAPPO |
$29.70
|
| Rate for Payer: BCBS Trust/PPO |
$97.65
|
| Rate for Payer: BCN Commercial |
$92.35
|
| Rate for Payer: BCN Medicare Advantage |
$29.70
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Commercial |
$102.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29.70
|
| Rate for Payer: Healthscope Commercial |
$106.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: Nomi Health Commercial |
$97.40
|
| Rate for Payer: PACE Senior Care Partners |
$28.21
|
| Rate for Payer: PACE SWMI |
$29.70
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: PHP Medicare Advantage |
$29.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.21
|
| Rate for Payer: Priority Health HMO/PPO |
$103.34
|
| Rate for Payer: Priority Health Medicare |
$29.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$79.58
|
| Rate for Payer: Railroad Medicare Medicare |
$29.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.53
|
| Rate for Payer: UHC Core |
$99.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$29.70
|
| Rate for Payer: UHC Exchange |
$29.70
|
| Rate for Payer: UHC Medicare Advantage |
$29.70
|
| Rate for Payer: VA VA |
$29.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.08
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
OP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.35 |
| Max. Negotiated Rate |
$149.13 |
| Rate for Payer: Aetna Commercial |
$140.84
|
| Rate for Payer: Aetna Medicare |
$43.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$51.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$51.78
|
| Rate for Payer: BCBS Complete |
$66.28
|
| Rate for Payer: BCBS MAPPO |
$41.42
|
| Rate for Payer: BCBS Trust/PPO |
$136.22
|
| Rate for Payer: BCN Commercial |
$128.83
|
| Rate for Payer: BCN Medicare Advantage |
$41.42
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$142.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.42
|
| Rate for Payer: Healthscope Commercial |
$149.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$43.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: Nomi Health Commercial |
$135.87
|
| Rate for Payer: PACE Senior Care Partners |
$39.35
|
| Rate for Payer: PACE SWMI |
$41.42
|
| Rate for Payer: PHP Commercial |
$140.84
|
| Rate for Payer: PHP Medicare Advantage |
$41.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health HMO/PPO |
$144.16
|
| Rate for Payer: Priority Health Medicare |
$41.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$111.02
|
| Rate for Payer: Railroad Medicare Medicare |
$41.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$145.82
|
| Rate for Payer: UHC Core |
$138.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$41.42
|
| Rate for Payer: UHC Exchange |
$41.42
|
| Rate for Payer: UHC Medicare Advantage |
$41.42
|
| Rate for Payer: VA VA |
$41.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.28
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
IP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.70 |
| Max. Negotiated Rate |
$149.13 |
| Rate for Payer: Aetna Commercial |
$140.84
|
| Rate for Payer: BCBS Trust/PPO |
$135.26
|
| Rate for Payer: BCN Commercial |
$128.05
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$142.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$149.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: Nomi Health Commercial |
$135.87
|
| Rate for Payer: PHP Commercial |
$140.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health HMO/PPO |
$144.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$111.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$145.82
|
| Rate for Payer: UHC Core |
$138.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.28
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$338.88
|
|
|
Service Code
|
NDC 00904661561
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.48 |
| Max. Negotiated Rate |
$304.99 |
| Rate for Payer: Aetna Commercial |
$288.05
|
| Rate for Payer: Aetna Medicare |
$88.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$105.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$105.90
|
| Rate for Payer: BCBS Complete |
$135.55
|
| Rate for Payer: BCBS MAPPO |
$84.72
|
| Rate for Payer: BCBS Trust/PPO |
$278.59
|
| Rate for Payer: BCN Commercial |
$263.48
|
| Rate for Payer: BCN Medicare Advantage |
$84.72
|
| Rate for Payer: Cash Price |
$271.10
|
| Rate for Payer: Cofinity Commercial |
$291.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$84.72
|
| Rate for Payer: Healthscope Commercial |
$304.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$254.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$88.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$97.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.05
|
| Rate for Payer: Nomi Health Commercial |
$277.88
|
| Rate for Payer: PACE Senior Care Partners |
$80.48
|
| Rate for Payer: PACE SWMI |
$84.72
|
| Rate for Payer: PHP Commercial |
$288.05
|
| Rate for Payer: PHP Medicare Advantage |
$84.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.27
|
| Rate for Payer: Priority Health HMO/PPO |
$294.83
|
| Rate for Payer: Priority Health Medicare |
$85.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$227.05
|
| Rate for Payer: Railroad Medicare Medicare |
$84.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$298.21
|
| Rate for Payer: UHC Core |
$282.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$84.72
|
| Rate for Payer: UHC Exchange |
$84.72
|
| Rate for Payer: UHC Medicare Advantage |
$84.72
|
| Rate for Payer: VA VA |
$84.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$254.16
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$373.92
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.81 |
| Max. Negotiated Rate |
$336.53 |
| Rate for Payer: Aetna Commercial |
$317.83
|
| Rate for Payer: Aetna Medicare |
$97.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$116.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$116.85
|
| Rate for Payer: BCBS Complete |
$149.57
|
| Rate for Payer: BCBS MAPPO |
$93.48
|
| Rate for Payer: BCBS Trust/PPO |
$307.40
|
| Rate for Payer: BCN Commercial |
$290.72
|
| Rate for Payer: BCN Medicare Advantage |
$93.48
|
| Rate for Payer: Cash Price |
$299.14
|
| Rate for Payer: Cofinity Commercial |
$321.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$299.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$93.48
|
| Rate for Payer: Healthscope Commercial |
$336.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$98.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$107.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.83
|
| Rate for Payer: Nomi Health Commercial |
$306.61
|
| Rate for Payer: PACE Senior Care Partners |
$88.81
|
| Rate for Payer: PACE SWMI |
$93.48
|
| Rate for Payer: PHP Commercial |
$317.83
|
| Rate for Payer: PHP Medicare Advantage |
$93.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.05
|
| Rate for Payer: Priority Health HMO/PPO |
$325.31
|
| Rate for Payer: Priority Health Medicare |
$94.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$250.53
|
| Rate for Payer: Railroad Medicare Medicare |
$93.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$329.05
|
| Rate for Payer: UHC Core |
$312.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$93.48
|
| Rate for Payer: UHC Exchange |
$93.48
|
| Rate for Payer: UHC Medicare Advantage |
$93.48
|
| Rate for Payer: VA VA |
$93.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.44
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 68084031311
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: BCBS Trust/PPO |
$3.05
|
| Rate for Payer: BCN Commercial |
$2.89
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: Nomi Health Commercial |
$3.07
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health HMO/PPO |
$3.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.29
|
| Rate for Payer: UHC Core |
$3.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.80
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$371.45
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.44 |
| Max. Negotiated Rate |
$334.30 |
| Rate for Payer: Aetna Commercial |
$315.73
|
| Rate for Payer: BCBS Trust/PPO |
$303.21
|
| Rate for Payer: BCN Commercial |
$287.06
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cofinity Commercial |
$319.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.16
|
| Rate for Payer: Healthscope Commercial |
$334.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.73
|
| Rate for Payer: Nomi Health Commercial |
$304.59
|
| Rate for Payer: PHP Commercial |
$315.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.44
|
| Rate for Payer: Priority Health HMO/PPO |
$323.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$248.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$326.88
|
| Rate for Payer: UHC Core |
$310.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.59
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 68084031311
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna Medicare |
$0.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.17
|
| Rate for Payer: BCBS Complete |
$1.50
|
| Rate for Payer: BCBS MAPPO |
$0.94
|
| Rate for Payer: BCBS Trust/PPO |
$3.07
|
| Rate for Payer: BCN Commercial |
$2.91
|
| Rate for Payer: BCN Medicare Advantage |
$0.94
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.94
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: Nomi Health Commercial |
$3.07
|
| Rate for Payer: PACE Senior Care Partners |
$0.89
|
| Rate for Payer: PACE SWMI |
$0.94
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: PHP Medicare Advantage |
$0.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health HMO/PPO |
$3.25
|
| Rate for Payer: Priority Health Medicare |
$0.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.51
|
| Rate for Payer: Railroad Medicare Medicare |
$0.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.29
|
| Rate for Payer: UHC Core |
$3.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.94
|
| Rate for Payer: UHC Exchange |
$0.94
|
| Rate for Payer: UHC Medicare Advantage |
$0.94
|
| Rate for Payer: VA VA |
$0.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.80
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$371.45
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.22 |
| Max. Negotiated Rate |
$334.30 |
| Rate for Payer: Aetna Commercial |
$315.73
|
| Rate for Payer: Aetna Medicare |
$96.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$116.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$116.08
|
| Rate for Payer: BCBS Complete |
$148.58
|
| Rate for Payer: BCBS MAPPO |
$92.86
|
| Rate for Payer: BCBS Trust/PPO |
$305.37
|
| Rate for Payer: BCN Commercial |
$288.80
|
| Rate for Payer: BCN Medicare Advantage |
$92.86
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cofinity Commercial |
$319.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$92.86
|
| Rate for Payer: Healthscope Commercial |
$334.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$97.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$106.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.73
|
| Rate for Payer: Nomi Health Commercial |
$304.59
|
| Rate for Payer: PACE Senior Care Partners |
$88.22
|
| Rate for Payer: PACE SWMI |
$92.86
|
| Rate for Payer: PHP Commercial |
$315.73
|
| Rate for Payer: PHP Medicare Advantage |
$92.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.44
|
| Rate for Payer: Priority Health HMO/PPO |
$323.16
|
| Rate for Payer: Priority Health Medicare |
$93.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$248.87
|
| Rate for Payer: Railroad Medicare Medicare |
$92.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$326.88
|
| Rate for Payer: UHC Core |
$310.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$92.86
|
| Rate for Payer: UHC Exchange |
$92.86
|
| Rate for Payer: UHC Medicare Advantage |
$92.86
|
| Rate for Payer: VA VA |
$92.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.59
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$338.88
|
|
|
Service Code
|
NDC 00904661561
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.27 |
| Max. Negotiated Rate |
$304.99 |
| Rate for Payer: Aetna Commercial |
$288.05
|
| Rate for Payer: BCBS Trust/PPO |
$276.63
|
| Rate for Payer: BCN Commercial |
$261.89
|
| Rate for Payer: Cash Price |
$271.10
|
| Rate for Payer: Cofinity Commercial |
$291.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.10
|
| Rate for Payer: Healthscope Commercial |
$304.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$254.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.05
|
| Rate for Payer: Nomi Health Commercial |
$277.88
|
| Rate for Payer: PHP Commercial |
$288.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.27
|
| Rate for Payer: Priority Health HMO/PPO |
$294.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$227.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$298.21
|
| Rate for Payer: UHC Core |
$282.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$254.16
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$373.92
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$243.05 |
| Max. Negotiated Rate |
$336.53 |
| Rate for Payer: Aetna Commercial |
$317.83
|
| Rate for Payer: BCBS Trust/PPO |
$305.23
|
| Rate for Payer: BCN Commercial |
$288.97
|
| Rate for Payer: Cash Price |
$299.14
|
| Rate for Payer: Cofinity Commercial |
$321.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$299.14
|
| Rate for Payer: Healthscope Commercial |
$336.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.83
|
| Rate for Payer: Nomi Health Commercial |
$306.61
|
| Rate for Payer: PHP Commercial |
$317.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.05
|
| Rate for Payer: Priority Health HMO/PPO |
$325.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$250.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$329.05
|
| Rate for Payer: UHC Core |
$312.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.44
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.12 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: BCBS Trust/PPO |
$113.18
|
| Rate for Payer: BCN Commercial |
$107.15
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Nomi Health Commercial |
$113.69
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health HMO/PPO |
$120.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$92.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.01
|
| Rate for Payer: UHC Core |
$115.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.94
|
|
|
Service Code
|
NDC 60687021111
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna Commercial |
$2.50
|
| Rate for Payer: BCBS Trust/PPO |
$2.40
|
| Rate for Payer: BCN Commercial |
$2.27
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.35
|
| Rate for Payer: Healthscope Commercial |
$2.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.50
|
| Rate for Payer: Nomi Health Commercial |
$2.41
|
| Rate for Payer: PHP Commercial |
$2.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.91
|
| Rate for Payer: Priority Health HMO/PPO |
$2.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.59
|
| Rate for Payer: UHC Core |
$2.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.20
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 00832712211
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.78 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: BCBS Trust/PPO |
$159.22
|
| Rate for Payer: BCN Commercial |
$150.73
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Nomi Health Commercial |
$159.94
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health HMO/PPO |
$169.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.64
|
| Rate for Payer: UHC Core |
$162.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
