|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$1,721.84
|
|
|
Service Code
|
NDC 00002323560
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$408.94 |
| Max. Negotiated Rate |
$1,549.66 |
| Rate for Payer: Aetna Commercial |
$1,463.56
|
| Rate for Payer: Aetna Medicare |
$447.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$538.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$538.08
|
| Rate for Payer: BCBS Complete |
$688.74
|
| Rate for Payer: BCBS MAPPO |
$430.46
|
| Rate for Payer: BCBS Trust/PPO |
$1,415.52
|
| Rate for Payer: BCN Commercial |
$1,338.73
|
| Rate for Payer: BCN Medicare Advantage |
$430.46
|
| Rate for Payer: Cash Price |
$1,377.47
|
| Rate for Payer: Cofinity Commercial |
$1,480.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,377.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$430.46
|
| Rate for Payer: Healthscope Commercial |
$1,549.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,291.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$451.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$495.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,463.56
|
| Rate for Payer: Nomi Health Commercial |
$1,411.91
|
| Rate for Payer: PACE Senior Care Partners |
$408.94
|
| Rate for Payer: PACE SWMI |
$430.46
|
| Rate for Payer: PHP Commercial |
$1,463.56
|
| Rate for Payer: PHP Medicare Advantage |
$430.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,119.20
|
| Rate for Payer: Priority Health HMO/PPO |
$1,498.00
|
| Rate for Payer: Priority Health Medicare |
$434.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,153.63
|
| Rate for Payer: Railroad Medicare Medicare |
$430.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,515.22
|
| Rate for Payer: UHC Core |
$1,437.74
|
| Rate for Payer: UHC Dual Complete DSNP |
$430.46
|
| Rate for Payer: UHC Exchange |
$430.46
|
| Rate for Payer: UHC Medicare Advantage |
$430.46
|
| Rate for Payer: VA VA |
$430.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,291.38
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$500.64
|
|
|
Service Code
|
NDC 00904704361
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.90 |
| Max. Negotiated Rate |
$450.58 |
| Rate for Payer: Aetna Commercial |
$425.54
|
| Rate for Payer: Aetna Medicare |
$130.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$156.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$156.45
|
| Rate for Payer: BCBS Complete |
$200.26
|
| Rate for Payer: BCBS MAPPO |
$125.16
|
| Rate for Payer: BCBS Trust/PPO |
$411.58
|
| Rate for Payer: BCN Commercial |
$389.25
|
| Rate for Payer: BCN Medicare Advantage |
$125.16
|
| Rate for Payer: Cash Price |
$400.51
|
| Rate for Payer: Cofinity Commercial |
$430.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$400.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.16
|
| Rate for Payer: Healthscope Commercial |
$450.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$375.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$131.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$143.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$425.54
|
| Rate for Payer: Nomi Health Commercial |
$410.52
|
| Rate for Payer: PACE Senior Care Partners |
$118.90
|
| Rate for Payer: PACE SWMI |
$125.16
|
| Rate for Payer: PHP Commercial |
$425.54
|
| Rate for Payer: PHP Medicare Advantage |
$125.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$325.42
|
| Rate for Payer: Priority Health HMO/PPO |
$435.56
|
| Rate for Payer: Priority Health Medicare |
$126.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$335.43
|
| Rate for Payer: Railroad Medicare Medicare |
$125.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$440.56
|
| Rate for Payer: UHC Core |
$418.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.16
|
| Rate for Payer: UHC Exchange |
$125.16
|
| Rate for Payer: UHC Medicare Advantage |
$125.16
|
| Rate for Payer: VA VA |
$125.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$375.48
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$236.60
|
|
|
Service Code
|
NDC 68084067521
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.79 |
| Max. Negotiated Rate |
$212.94 |
| Rate for Payer: Aetna Commercial |
$201.11
|
| Rate for Payer: BCBS Trust/PPO |
$193.14
|
| Rate for Payer: BCN Commercial |
$182.84
|
| Rate for Payer: Cash Price |
$189.28
|
| Rate for Payer: Cofinity Commercial |
$203.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$189.28
|
| Rate for Payer: Healthscope Commercial |
$212.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.11
|
| Rate for Payer: Nomi Health Commercial |
$194.01
|
| Rate for Payer: PHP Commercial |
$201.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.79
|
| Rate for Payer: Priority Health HMO/PPO |
$205.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$158.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$208.21
|
| Rate for Payer: UHC Core |
$197.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.45
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$127.01
|
|
|
Service Code
|
NDC 60687072321
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.16 |
| Max. Negotiated Rate |
$114.31 |
| Rate for Payer: Aetna Commercial |
$107.96
|
| Rate for Payer: Aetna Medicare |
$33.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$39.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$39.69
|
| Rate for Payer: BCBS Complete |
$50.80
|
| Rate for Payer: BCBS MAPPO |
$31.75
|
| Rate for Payer: BCBS Trust/PPO |
$104.41
|
| Rate for Payer: BCN Commercial |
$98.75
|
| Rate for Payer: BCN Medicare Advantage |
$31.75
|
| Rate for Payer: Cash Price |
$101.61
|
| Rate for Payer: Cofinity Commercial |
$109.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$31.75
|
| Rate for Payer: Healthscope Commercial |
$114.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$33.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$36.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.96
|
| Rate for Payer: Nomi Health Commercial |
$104.15
|
| Rate for Payer: PACE Senior Care Partners |
$30.16
|
| Rate for Payer: PACE SWMI |
$31.75
|
| Rate for Payer: PHP Commercial |
$107.96
|
| Rate for Payer: PHP Medicare Advantage |
$31.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.56
|
| Rate for Payer: Priority Health HMO/PPO |
$110.50
|
| Rate for Payer: Priority Health Medicare |
$32.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$85.10
|
| Rate for Payer: Railroad Medicare Medicare |
$31.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$111.77
|
| Rate for Payer: UHC Core |
$106.05
|
| Rate for Payer: UHC Dual Complete DSNP |
$31.75
|
| Rate for Payer: UHC Exchange |
$31.75
|
| Rate for Payer: UHC Medicare Advantage |
$31.75
|
| Rate for Payer: VA VA |
$31.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.26
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 60687072311
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Medicare |
$1.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.32
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.32
|
| Rate for Payer: BCBS Complete |
$1.70
|
| Rate for Payer: BCBS MAPPO |
$1.06
|
| Rate for Payer: BCBS Trust/PPO |
$3.49
|
| Rate for Payer: BCN Commercial |
$3.30
|
| Rate for Payer: BCN Medicare Advantage |
$1.06
|
| Rate for Payer: Cash Price |
$3.39
|
| Rate for Payer: Cofinity Commercial |
$3.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.06
|
| Rate for Payer: Healthscope Commercial |
$3.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: Nomi Health Commercial |
$3.48
|
| Rate for Payer: PACE Senior Care Partners |
$1.01
|
| Rate for Payer: PACE SWMI |
$1.06
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: PHP Medicare Advantage |
$1.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.76
|
| Rate for Payer: Priority Health HMO/PPO |
$3.69
|
| Rate for Payer: Priority Health Medicare |
$1.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.84
|
| Rate for Payer: Railroad Medicare Medicare |
$1.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.73
|
| Rate for Payer: UHC Core |
$3.54
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.06
|
| Rate for Payer: UHC Exchange |
$1.06
|
| Rate for Payer: UHC Medicare Advantage |
$1.06
|
| Rate for Payer: VA VA |
$1.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.18
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 60687072311
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: BCBS Trust/PPO |
$3.46
|
| Rate for Payer: BCN Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$3.39
|
| Rate for Payer: Cofinity Commercial |
$3.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.39
|
| Rate for Payer: Healthscope Commercial |
$3.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: Nomi Health Commercial |
$3.48
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.76
|
| Rate for Payer: Priority Health HMO/PPO |
$3.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.73
|
| Rate for Payer: UHC Core |
$3.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.18
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$500.64
|
|
|
Service Code
|
NDC 00904704361
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$325.42 |
| Max. Negotiated Rate |
$450.58 |
| Rate for Payer: Aetna Commercial |
$425.54
|
| Rate for Payer: BCBS Trust/PPO |
$408.67
|
| Rate for Payer: BCN Commercial |
$386.89
|
| Rate for Payer: Cash Price |
$400.51
|
| Rate for Payer: Cofinity Commercial |
$430.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$400.51
|
| Rate for Payer: Healthscope Commercial |
$450.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$375.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$425.54
|
| Rate for Payer: Nomi Health Commercial |
$410.52
|
| Rate for Payer: PHP Commercial |
$425.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$325.42
|
| Rate for Payer: Priority Health HMO/PPO |
$435.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$335.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$440.56
|
| Rate for Payer: UHC Core |
$418.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$375.48
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$1,721.84
|
|
|
Service Code
|
NDC 00002323560
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,119.20 |
| Max. Negotiated Rate |
$1,549.66 |
| Rate for Payer: Aetna Commercial |
$1,463.56
|
| Rate for Payer: BCBS Trust/PPO |
$1,405.54
|
| Rate for Payer: BCN Commercial |
$1,330.64
|
| Rate for Payer: Cash Price |
$1,377.47
|
| Rate for Payer: Cofinity Commercial |
$1,480.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,377.47
|
| Rate for Payer: Healthscope Commercial |
$1,549.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,291.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,463.56
|
| Rate for Payer: Nomi Health Commercial |
$1,411.91
|
| Rate for Payer: PHP Commercial |
$1,463.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,119.20
|
| Rate for Payer: Priority Health HMO/PPO |
$1,498.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,153.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,515.22
|
| Rate for Payer: UHC Core |
$1,437.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,291.38
|
|
|
DULOXETINE 20 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$127.01
|
|
|
Service Code
|
NDC 60687072321
|
| Hospital Charge Code |
39275
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$114.31 |
| Rate for Payer: Aetna Commercial |
$107.96
|
| Rate for Payer: BCBS Trust/PPO |
$103.68
|
| Rate for Payer: BCN Commercial |
$98.15
|
| Rate for Payer: Cash Price |
$101.61
|
| Rate for Payer: Cofinity Commercial |
$109.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$101.61
|
| Rate for Payer: Healthscope Commercial |
$114.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$95.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$107.96
|
| Rate for Payer: Nomi Health Commercial |
$104.15
|
| Rate for Payer: PHP Commercial |
$107.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.56
|
| Rate for Payer: Priority Health HMO/PPO |
$110.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$85.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$111.77
|
| Rate for Payer: UHC Core |
$106.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$95.26
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$445.44
|
|
|
Service Code
|
NDC 00904704461
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$289.54 |
| Max. Negotiated Rate |
$400.90 |
| Rate for Payer: Aetna Commercial |
$378.62
|
| Rate for Payer: BCBS Trust/PPO |
$363.61
|
| Rate for Payer: BCN Commercial |
$344.24
|
| Rate for Payer: Cash Price |
$356.35
|
| Rate for Payer: Cofinity Commercial |
$383.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$356.35
|
| Rate for Payer: Healthscope Commercial |
$400.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$334.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$378.62
|
| Rate for Payer: Nomi Health Commercial |
$365.26
|
| Rate for Payer: PHP Commercial |
$378.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$289.54
|
| Rate for Payer: Priority Health HMO/PPO |
$387.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$298.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$391.99
|
| Rate for Payer: UHC Core |
$371.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$334.08
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$445.44
|
|
|
Service Code
|
NDC 00904704461
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.79 |
| Max. Negotiated Rate |
$400.90 |
| Rate for Payer: Aetna Commercial |
$378.62
|
| Rate for Payer: Aetna Medicare |
$115.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$139.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$139.20
|
| Rate for Payer: BCBS Complete |
$178.18
|
| Rate for Payer: BCBS MAPPO |
$111.36
|
| Rate for Payer: BCBS Trust/PPO |
$366.20
|
| Rate for Payer: BCN Commercial |
$346.33
|
| Rate for Payer: BCN Medicare Advantage |
$111.36
|
| Rate for Payer: Cash Price |
$356.35
|
| Rate for Payer: Cofinity Commercial |
$383.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$356.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$111.36
|
| Rate for Payer: Healthscope Commercial |
$400.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$334.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$116.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$128.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$378.62
|
| Rate for Payer: Nomi Health Commercial |
$365.26
|
| Rate for Payer: PACE Senior Care Partners |
$105.79
|
| Rate for Payer: PACE SWMI |
$111.36
|
| Rate for Payer: PHP Commercial |
$378.62
|
| Rate for Payer: PHP Medicare Advantage |
$111.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$289.54
|
| Rate for Payer: Priority Health HMO/PPO |
$387.53
|
| Rate for Payer: Priority Health Medicare |
$112.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$298.44
|
| Rate for Payer: Railroad Medicare Medicare |
$111.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$391.99
|
| Rate for Payer: UHC Core |
$371.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$111.36
|
| Rate for Payer: UHC Exchange |
$111.36
|
| Rate for Payer: UHC Medicare Advantage |
$111.36
|
| Rate for Payer: VA VA |
$111.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$334.08
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$119.15
|
|
|
Service Code
|
NDC 57237001830
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.45 |
| Max. Negotiated Rate |
$107.24 |
| Rate for Payer: Aetna Commercial |
$101.28
|
| Rate for Payer: BCBS Trust/PPO |
$97.26
|
| Rate for Payer: BCN Commercial |
$92.08
|
| Rate for Payer: Cash Price |
$95.32
|
| Rate for Payer: Cofinity Commercial |
$102.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.32
|
| Rate for Payer: Healthscope Commercial |
$107.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.28
|
| Rate for Payer: Nomi Health Commercial |
$97.70
|
| Rate for Payer: PHP Commercial |
$101.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.45
|
| Rate for Payer: Priority Health HMO/PPO |
$103.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$79.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.85
|
| Rate for Payer: UHC Core |
$99.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.36
|
|
|
DULOXETINE 30 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$119.15
|
|
|
Service Code
|
NDC 57237001830
|
| Hospital Charge Code |
39276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.30 |
| Max. Negotiated Rate |
$107.24 |
| Rate for Payer: Aetna Commercial |
$101.28
|
| Rate for Payer: Aetna Medicare |
$30.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$37.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$37.23
|
| Rate for Payer: BCBS Complete |
$47.66
|
| Rate for Payer: BCBS MAPPO |
$29.79
|
| Rate for Payer: BCBS Trust/PPO |
$97.95
|
| Rate for Payer: BCN Commercial |
$92.64
|
| Rate for Payer: BCN Medicare Advantage |
$29.79
|
| Rate for Payer: Cash Price |
$95.32
|
| Rate for Payer: Cofinity Commercial |
$102.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29.79
|
| Rate for Payer: Healthscope Commercial |
$107.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.28
|
| Rate for Payer: Nomi Health Commercial |
$97.70
|
| Rate for Payer: PACE Senior Care Partners |
$28.30
|
| Rate for Payer: PACE SWMI |
$29.79
|
| Rate for Payer: PHP Commercial |
$101.28
|
| Rate for Payer: PHP Medicare Advantage |
$29.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.45
|
| Rate for Payer: Priority Health HMO/PPO |
$103.66
|
| Rate for Payer: Priority Health Medicare |
$30.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$79.83
|
| Rate for Payer: Railroad Medicare Medicare |
$29.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.85
|
| Rate for Payer: UHC Core |
$99.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$29.79
|
| Rate for Payer: UHC Exchange |
$29.79
|
| Rate for Payer: UHC Medicare Advantage |
$29.79
|
| Rate for Payer: VA VA |
$29.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.36
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$114.92
|
|
|
Service Code
|
NDC 57237001930
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.70 |
| Max. Negotiated Rate |
$103.43 |
| Rate for Payer: Aetna Commercial |
$97.68
|
| Rate for Payer: BCBS Trust/PPO |
$93.81
|
| Rate for Payer: BCN Commercial |
$88.81
|
| Rate for Payer: Cash Price |
$91.94
|
| Rate for Payer: Cofinity Commercial |
$98.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.94
|
| Rate for Payer: Healthscope Commercial |
$103.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.68
|
| Rate for Payer: Nomi Health Commercial |
$94.23
|
| Rate for Payer: PHP Commercial |
$97.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.70
|
| Rate for Payer: Priority Health HMO/PPO |
$99.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$101.13
|
| Rate for Payer: UHC Core |
$95.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.19
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$114.92
|
|
|
Service Code
|
NDC 57237001930
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.29 |
| Max. Negotiated Rate |
$103.43 |
| Rate for Payer: Aetna Commercial |
$97.68
|
| Rate for Payer: Aetna Medicare |
$29.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$35.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$35.91
|
| Rate for Payer: BCBS Complete |
$45.97
|
| Rate for Payer: BCBS MAPPO |
$28.73
|
| Rate for Payer: BCBS Trust/PPO |
$94.48
|
| Rate for Payer: BCN Commercial |
$89.35
|
| Rate for Payer: BCN Medicare Advantage |
$28.73
|
| Rate for Payer: Cash Price |
$91.94
|
| Rate for Payer: Cofinity Commercial |
$98.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$28.73
|
| Rate for Payer: Healthscope Commercial |
$103.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$30.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.68
|
| Rate for Payer: Nomi Health Commercial |
$94.23
|
| Rate for Payer: PACE Senior Care Partners |
$27.29
|
| Rate for Payer: PACE SWMI |
$28.73
|
| Rate for Payer: PHP Commercial |
$97.68
|
| Rate for Payer: PHP Medicare Advantage |
$28.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.70
|
| Rate for Payer: Priority Health HMO/PPO |
$99.98
|
| Rate for Payer: Priority Health Medicare |
$29.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.00
|
| Rate for Payer: Railroad Medicare Medicare |
$28.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$101.13
|
| Rate for Payer: UHC Core |
$95.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$28.73
|
| Rate for Payer: UHC Exchange |
$28.73
|
| Rate for Payer: UHC Medicare Advantage |
$28.73
|
| Rate for Payer: VA VA |
$28.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.19
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$380.64
|
|
|
Service Code
|
NDC 00904704561
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.40 |
| Max. Negotiated Rate |
$342.58 |
| Rate for Payer: Aetna Commercial |
$323.54
|
| Rate for Payer: Aetna Medicare |
$98.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$118.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$118.95
|
| Rate for Payer: BCBS Complete |
$152.26
|
| Rate for Payer: BCBS MAPPO |
$95.16
|
| Rate for Payer: BCBS Trust/PPO |
$312.92
|
| Rate for Payer: BCN Commercial |
$295.95
|
| Rate for Payer: BCN Medicare Advantage |
$95.16
|
| Rate for Payer: Cash Price |
$304.51
|
| Rate for Payer: Cofinity Commercial |
$327.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$95.16
|
| Rate for Payer: Healthscope Commercial |
$342.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$99.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$109.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$323.54
|
| Rate for Payer: Nomi Health Commercial |
$312.12
|
| Rate for Payer: PACE Senior Care Partners |
$90.40
|
| Rate for Payer: PACE SWMI |
$95.16
|
| Rate for Payer: PHP Commercial |
$323.54
|
| Rate for Payer: PHP Medicare Advantage |
$95.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$247.42
|
| Rate for Payer: Priority Health HMO/PPO |
$331.16
|
| Rate for Payer: Priority Health Medicare |
$96.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$255.03
|
| Rate for Payer: Railroad Medicare Medicare |
$95.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$334.96
|
| Rate for Payer: UHC Core |
$317.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$95.16
|
| Rate for Payer: UHC Exchange |
$95.16
|
| Rate for Payer: UHC Medicare Advantage |
$95.16
|
| Rate for Payer: VA VA |
$95.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.48
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$380.64
|
|
|
Service Code
|
NDC 00904704561
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.42 |
| Max. Negotiated Rate |
$342.58 |
| Rate for Payer: Aetna Commercial |
$323.54
|
| Rate for Payer: BCBS Trust/PPO |
$310.72
|
| Rate for Payer: BCN Commercial |
$294.16
|
| Rate for Payer: Cash Price |
$304.51
|
| Rate for Payer: Cofinity Commercial |
$327.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.51
|
| Rate for Payer: Healthscope Commercial |
$342.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$323.54
|
| Rate for Payer: Nomi Health Commercial |
$312.12
|
| Rate for Payer: PHP Commercial |
$323.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$247.42
|
| Rate for Payer: Priority Health HMO/PPO |
$331.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$255.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$334.96
|
| Rate for Payer: UHC Core |
$317.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.48
|
|
|
DUODERM CGF DRESSING 4X4
|
Facility
|
OP
|
$7.74
|
|
|
Service Code
|
NDC 68455010697
|
| Hospital Charge Code |
150727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$6.97 |
| Rate for Payer: Aetna Commercial |
$6.58
|
| Rate for Payer: Aetna Medicare |
$2.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.42
|
| Rate for Payer: BCBS Complete |
$3.10
|
| Rate for Payer: BCBS MAPPO |
$1.94
|
| Rate for Payer: BCBS Trust/PPO |
$6.36
|
| Rate for Payer: BCN Commercial |
$6.02
|
| Rate for Payer: BCN Medicare Advantage |
$1.94
|
| Rate for Payer: Cash Price |
$6.19
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.94
|
| Rate for Payer: Healthscope Commercial |
$6.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.58
|
| Rate for Payer: Nomi Health Commercial |
$6.35
|
| Rate for Payer: PACE Senior Care Partners |
$1.84
|
| Rate for Payer: PACE SWMI |
$1.94
|
| Rate for Payer: PHP Commercial |
$6.58
|
| Rate for Payer: PHP Medicare Advantage |
$1.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.03
|
| Rate for Payer: Priority Health HMO/PPO |
$6.73
|
| Rate for Payer: Priority Health Medicare |
$1.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.19
|
| Rate for Payer: Railroad Medicare Medicare |
$1.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.81
|
| Rate for Payer: UHC Core |
$6.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.94
|
| Rate for Payer: UHC Exchange |
$1.94
|
| Rate for Payer: UHC Medicare Advantage |
$1.94
|
| Rate for Payer: VA VA |
$1.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.80
|
|
|
DUODERM CGF DRESSING 4X4
|
Facility
|
IP
|
$7.74
|
|
|
Service Code
|
NDC 68455010697
|
| Hospital Charge Code |
150727
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$6.97 |
| Rate for Payer: Aetna Commercial |
$6.58
|
| Rate for Payer: BCBS Trust/PPO |
$6.32
|
| Rate for Payer: BCN Commercial |
$5.98
|
| Rate for Payer: Cash Price |
$6.19
|
| Rate for Payer: Cofinity Commercial |
$6.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.19
|
| Rate for Payer: Healthscope Commercial |
$6.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.58
|
| Rate for Payer: Nomi Health Commercial |
$6.35
|
| Rate for Payer: PHP Commercial |
$6.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.03
|
| Rate for Payer: Priority Health HMO/PPO |
$6.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.81
|
| Rate for Payer: UHC Core |
$6.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.80
|
|
|
EMOLLIENT COMBINATION NO.92 TOPICAL LOTION
|
Facility
|
OP
|
$14.34
|
|
|
Service Code
|
NDC 52800048826
|
| Hospital Charge Code |
170369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$12.91 |
| Rate for Payer: Aetna Commercial |
$12.19
|
| Rate for Payer: Aetna Medicare |
$3.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.48
|
| Rate for Payer: BCBS Complete |
$5.74
|
| Rate for Payer: BCBS MAPPO |
$3.58
|
| Rate for Payer: BCBS Trust/PPO |
$11.79
|
| Rate for Payer: BCN Commercial |
$11.15
|
| Rate for Payer: BCN Medicare Advantage |
$3.58
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.58
|
| Rate for Payer: Healthscope Commercial |
$12.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.76
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.19
|
| Rate for Payer: Nomi Health Commercial |
$11.76
|
| Rate for Payer: PACE Senior Care Partners |
$3.41
|
| Rate for Payer: PACE SWMI |
$3.58
|
| Rate for Payer: PHP Commercial |
$12.19
|
| Rate for Payer: PHP Medicare Advantage |
$3.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.32
|
| Rate for Payer: Priority Health HMO/PPO |
$12.48
|
| Rate for Payer: Priority Health Medicare |
$3.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.61
|
| Rate for Payer: Railroad Medicare Medicare |
$3.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.62
|
| Rate for Payer: UHC Core |
$11.97
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.58
|
| Rate for Payer: UHC Exchange |
$3.58
|
| Rate for Payer: UHC Medicare Advantage |
$3.58
|
| Rate for Payer: VA VA |
$3.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.76
|
|
|
EMOLLIENT COMBINATION NO.92 TOPICAL LOTION
|
Facility
|
IP
|
$14.34
|
|
|
Service Code
|
NDC 52800048826
|
| Hospital Charge Code |
170369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$12.91 |
| Rate for Payer: Aetna Commercial |
$12.19
|
| Rate for Payer: BCBS Trust/PPO |
$11.71
|
| Rate for Payer: BCN Commercial |
$11.08
|
| Rate for Payer: Cash Price |
$11.47
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.47
|
| Rate for Payer: Healthscope Commercial |
$12.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.19
|
| Rate for Payer: Nomi Health Commercial |
$11.76
|
| Rate for Payer: PHP Commercial |
$12.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.32
|
| Rate for Payer: Priority Health HMO/PPO |
$12.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.62
|
| Rate for Payer: UHC Core |
$11.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.76
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$929.15 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: BCBS Trust/PPO |
$1,166.87
|
| Rate for Payer: BCN Commercial |
$1,104.69
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: Nomi Health Commercial |
$1,172.16
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health HMO/PPO |
$1,243.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$957.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,257.92
|
| Rate for Payer: UHC Core |
$1,193.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.10
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$339.50 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$371.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$446.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$446.71
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: BCBS MAPPO |
$357.36
|
| Rate for Payer: BCBS Trust/PPO |
$1,175.16
|
| Rate for Payer: BCN Commercial |
$1,111.41
|
| Rate for Payer: BCN Medicare Advantage |
$357.36
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$357.36
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$375.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$410.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: Nomi Health Commercial |
$1,172.16
|
| Rate for Payer: PACE Senior Care Partners |
$339.50
|
| Rate for Payer: PACE SWMI |
$357.36
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: PHP Medicare Advantage |
$357.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health HMO/PPO |
$1,243.63
|
| Rate for Payer: Priority Health Medicare |
$360.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$957.74
|
| Rate for Payer: Railroad Medicare Medicare |
$357.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,257.92
|
| Rate for Payer: UHC Core |
$1,193.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$357.36
|
| Rate for Payer: UHC Exchange |
$357.36
|
| Rate for Payer: UHC Medicare Advantage |
$357.36
|
| Rate for Payer: VA VA |
$357.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.10
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$339.50 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$371.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$446.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$446.71
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: BCBS MAPPO |
$357.36
|
| Rate for Payer: BCBS Trust/PPO |
$1,175.16
|
| Rate for Payer: BCN Commercial |
$1,111.41
|
| Rate for Payer: BCN Medicare Advantage |
$357.36
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$357.36
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$375.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$410.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: Nomi Health Commercial |
$1,172.16
|
| Rate for Payer: PACE Senior Care Partners |
$339.50
|
| Rate for Payer: PACE SWMI |
$357.36
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: PHP Medicare Advantage |
$357.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health HMO/PPO |
$1,243.63
|
| Rate for Payer: Priority Health Medicare |
$360.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$957.74
|
| Rate for Payer: Railroad Medicare Medicare |
$357.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,257.92
|
| Rate for Payer: UHC Core |
$1,193.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$357.36
|
| Rate for Payer: UHC Exchange |
$357.36
|
| Rate for Payer: UHC Medicare Advantage |
$357.36
|
| Rate for Payer: VA VA |
$357.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.10
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$929.15 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: BCBS Trust/PPO |
$1,166.87
|
| Rate for Payer: BCN Commercial |
$1,104.69
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: Nomi Health Commercial |
$1,172.16
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health HMO/PPO |
$1,243.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$957.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,257.92
|
| Rate for Payer: UHC Core |
$1,193.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.10
|
|
