|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$13.49
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$12.14 |
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: BCBS Trust/PPO |
$10.43
|
| Rate for Payer: BCBS Trust/PPO |
$9.37
|
| Rate for Payer: BCBS Trust/PPO |
$15.96
|
| Rate for Payer: BCN Commercial |
$15.96
|
| Rate for Payer: BCN Commercial |
$10.43
|
| Rate for Payer: BCN Commercial |
$9.37
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$18.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.55
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.44
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$11.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.87
|
| Rate for Payer: UHC Core |
$11.26
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: UHC Core |
$17.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 1 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$20.51
|
|
|
Service Code
|
NDC 1254717162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.51 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna Commercial |
$17.43
|
| Rate for Payer: BCBS Trust/PPO |
$15.85
|
| 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 Multiplan/Beech St/PHCS |
$17.43
|
| Rate for Payer: PHP Commercial |
$17.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.51
|
| 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
|
IP
|
$312.48
|
|
|
Service Code
|
NDC 0378-0415-01
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.58 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: BCBS Trust/PPO |
$241.48
|
| 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 Multiplan/Beech St/PHCS |
$265.61
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$271.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$190.58
|
| 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
|
IP
|
$361.95
|
|
|
Service Code
|
NDC 59762-1061-1
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.75 |
| Max. Negotiated Rate |
$325.76 |
| Rate for Payer: Aetna Commercial |
$307.66
|
| Rate for Payer: BCBS Trust/PPO |
$279.71
|
| Rate for Payer: BCN Commercial |
$279.71
|
| Rate for Payer: Cash Price |
$289.56
|
| Rate for Payer: Cofinity Commercial |
$311.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.56
|
| Rate for Payer: Healthscope Commercial |
$325.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$307.66
|
| Rate for Payer: PHP Commercial |
$307.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$314.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$220.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$318.52
|
| Rate for Payer: UHC Core |
$302.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.46
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$286.90
|
|
|
Service Code
|
NDC 69315-910-01
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.98 |
| Max. Negotiated Rate |
$258.21 |
| Rate for Payer: Aetna Commercial |
$243.86
|
| Rate for Payer: BCBS Trust/PPO |
$221.72
|
| Rate for Payer: BCN Commercial |
$221.72
|
| Rate for Payer: Cash Price |
$229.52
|
| Rate for Payer: Cofinity Commercial |
$246.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.52
|
| Rate for Payer: Healthscope Commercial |
$258.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$243.86
|
| Rate for Payer: PHP Commercial |
$243.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$249.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$174.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.47
|
| Rate for Payer: UHC Core |
$239.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.18
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$415.95
|
|
|
Service Code
|
NDC 0406-1236-01
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.69 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: BCBS Trust/PPO |
$321.45
|
| 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 Multiplan/Beech St/PHCS |
$353.56
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$361.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$253.69
|
| 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
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE
|
Facility
|
IP
|
$115.61
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.51 |
| Max. Negotiated Rate |
$104.05 |
| Rate for Payer: Aetna Commercial |
$98.27
|
| Rate for Payer: BCBS Trust/PPO |
$89.34
|
| Rate for Payer: BCN Commercial |
$89.34
|
| Rate for Payer: Cash Price |
$92.49
|
| Rate for Payer: Cofinity Commercial |
$99.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$92.49
|
| Rate for Payer: Healthscope Commercial |
$104.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.27
|
| Rate for Payer: PHP Commercial |
$98.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$100.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$101.74
|
| Rate for Payer: UHC Core |
$96.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.71
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
IP
|
$161.17
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.30 |
| Max. Negotiated Rate |
$145.05 |
| Rate for Payer: Aetna Commercial |
$136.99
|
| Rate for Payer: BCBS Trust/PPO |
$124.55
|
| Rate for Payer: BCN Commercial |
$124.55
|
| Rate for Payer: Cash Price |
$128.94
|
| Rate for Payer: Cofinity Commercial |
$138.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$128.94
|
| Rate for Payer: Healthscope Commercial |
$145.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$120.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$136.99
|
| Rate for Payer: PHP Commercial |
$136.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$140.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$98.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$141.83
|
| Rate for Payer: UHC Core |
$134.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$120.88
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$327.84
|
|
|
Service Code
|
NDC 68084-313-11
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.95 |
| Max. Negotiated Rate |
$295.06 |
| Rate for Payer: Aetna Commercial |
$278.66
|
| Rate for Payer: BCBS Trust/PPO |
$253.35
|
| Rate for Payer: BCN Commercial |
$253.35
|
| Rate for Payer: Cash Price |
$262.27
|
| Rate for Payer: Cofinity Commercial |
$281.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.27
|
| Rate for Payer: Healthscope Commercial |
$295.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$278.66
|
| Rate for Payer: PHP Commercial |
$278.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$285.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$288.50
|
| Rate for Payer: UHC Core |
$273.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.88
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$202.35
|
|
|
Service Code
|
NDC 68382-106-01
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.41 |
| Max. Negotiated Rate |
$182.12 |
| Rate for Payer: Aetna Commercial |
$172.00
|
| Rate for Payer: BCBS Trust/PPO |
$156.38
|
| Rate for Payer: BCN Commercial |
$156.38
|
| Rate for Payer: Cash Price |
$161.88
|
| Rate for Payer: Cofinity Commercial |
$174.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.88
|
| Rate for Payer: Healthscope Commercial |
$182.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.00
|
| Rate for Payer: PHP Commercial |
$172.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.64
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$176.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$123.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$178.07
|
| Rate for Payer: UHC Core |
$168.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.76
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$327.84
|
|
|
Service Code
|
NDC 68084-313-01
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.95 |
| Max. Negotiated Rate |
$295.06 |
| Rate for Payer: Aetna Commercial |
$278.66
|
| Rate for Payer: BCBS Trust/PPO |
$253.35
|
| Rate for Payer: BCN Commercial |
$253.35
|
| Rate for Payer: Cash Price |
$262.27
|
| Rate for Payer: Cofinity Commercial |
$281.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.27
|
| Rate for Payer: Healthscope Commercial |
$295.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$278.66
|
| Rate for Payer: PHP Commercial |
$278.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$285.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$288.50
|
| Rate for Payer: UHC Core |
$273.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.88
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$319.68
|
|
|
Service Code
|
NDC 0904-6615-61
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.97 |
| Max. Negotiated Rate |
$287.71 |
| Rate for Payer: Aetna Commercial |
$271.73
|
| Rate for Payer: BCBS Trust/PPO |
$247.05
|
| Rate for Payer: BCN Commercial |
$247.05
|
| Rate for Payer: Cash Price |
$255.74
|
| Rate for Payer: Cofinity Commercial |
$274.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.74
|
| Rate for Payer: Healthscope Commercial |
$287.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$271.73
|
| Rate for Payer: PHP Commercial |
$271.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$278.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$194.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$281.32
|
| Rate for Payer: UHC Core |
$266.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.76
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$87.56
|
|
|
Service Code
|
NDC 60687-211-21
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.40 |
| Max. Negotiated Rate |
$78.80 |
| Rate for Payer: Aetna Commercial |
$74.43
|
| Rate for Payer: BCBS Trust/PPO |
$67.67
|
| Rate for Payer: BCN Commercial |
$67.67
|
| Rate for Payer: Cash Price |
$70.05
|
| Rate for Payer: Cofinity Commercial |
$75.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.05
|
| Rate for Payer: Healthscope Commercial |
$78.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.43
|
| Rate for Payer: PHP Commercial |
$74.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$76.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.05
|
| Rate for Payer: UHC Core |
$73.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.67
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 62756-796-88
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.56 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: BCBS Trust/PPO |
$107.15
|
| 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 Multiplan/Beech St/PHCS |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$120.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$84.56
|
| 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
|
$195.05
|
|
|
Service Code
|
NDC 0832-7122-11
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.96 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: BCBS Trust/PPO |
$150.73
|
| 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 Multiplan/Beech St/PHCS |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$169.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$118.96
|
| 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
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.92
|
|
|
Service Code
|
NDC 60687-211-11
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Aetna Commercial |
$2.48
|
| Rate for Payer: BCBS Trust/PPO |
$2.26
|
| Rate for Payer: BCN Commercial |
$2.26
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cofinity Commercial |
$2.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.34
|
| Rate for Payer: Healthscope Commercial |
$2.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.48
|
| Rate for Payer: PHP Commercial |
$2.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.57
|
| Rate for Payer: UHC Core |
$2.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.19
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3.34
|
|
|
Service Code
|
NDC 68084-776-11
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: Aetna Commercial |
$2.84
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$2.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.67
|
| Rate for Payer: Healthscope Commercial |
$3.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.84
|
| Rate for Payer: PHP Commercial |
$2.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.94
|
| Rate for Payer: UHC Core |
$2.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.50
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$272.60
|
|
|
Service Code
|
NDC 62756-797-88
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.26 |
| Max. Negotiated Rate |
$245.34 |
| Rate for Payer: Aetna Commercial |
$231.71
|
| Rate for Payer: BCBS Trust/PPO |
$210.67
|
| Rate for Payer: BCN Commercial |
$210.67
|
| Rate for Payer: Cash Price |
$218.08
|
| Rate for Payer: Cofinity Commercial |
$234.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.08
|
| Rate for Payer: Healthscope Commercial |
$245.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$231.71
|
| Rate for Payer: PHP Commercial |
$231.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$237.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$166.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$239.89
|
| Rate for Payer: UHC Core |
$227.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.45
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$333.70
|
|
|
Service Code
|
NDC 68084-776-01
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.52 |
| Max. Negotiated Rate |
$300.33 |
| Rate for Payer: Aetna Commercial |
$283.64
|
| Rate for Payer: BCBS Trust/PPO |
$257.88
|
| Rate for Payer: BCN Commercial |
$257.88
|
| Rate for Payer: Cash Price |
$266.96
|
| Rate for Payer: Cofinity Commercial |
$286.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.96
|
| Rate for Payer: Healthscope Commercial |
$300.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$250.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$283.64
|
| Rate for Payer: PHP Commercial |
$283.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$290.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$203.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$293.66
|
| Rate for Payer: UHC Core |
$278.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$250.28
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$159.80
|
|
|
Service Code
|
NDC 57237-047-01
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna Commercial |
$135.83
|
| Rate for Payer: BCBS Trust/PPO |
$123.49
|
| Rate for Payer: BCN Commercial |
$123.49
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$137.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$143.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.83
|
| Rate for Payer: PHP Commercial |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$139.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$97.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$140.62
|
| Rate for Payer: UHC Core |
$133.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.85
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$333.70
|
|
|
Service Code
|
NDC 0904-6860-61
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.52 |
| Max. Negotiated Rate |
$300.33 |
| Rate for Payer: Aetna Commercial |
$283.64
|
| Rate for Payer: BCBS Trust/PPO |
$257.88
|
| Rate for Payer: BCN Commercial |
$257.88
|
| Rate for Payer: Cash Price |
$266.96
|
| Rate for Payer: Cofinity Commercial |
$286.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.96
|
| Rate for Payer: Healthscope Commercial |
$300.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$250.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$283.64
|
| Rate for Payer: PHP Commercial |
$283.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$290.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$203.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$293.66
|
| Rate for Payer: UHC Core |
$278.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$250.28
|
|
|
DIVALPROEX 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$378.35
|
|
|
Service Code
|
NDC 0832-7124-01
|
| Hospital Charge Code |
2553
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.76 |
| Max. Negotiated Rate |
$340.52 |
| Rate for Payer: Aetna Commercial |
$321.60
|
| Rate for Payer: BCBS Trust/PPO |
$292.39
|
| Rate for Payer: BCN Commercial |
$292.39
|
| Rate for Payer: Cash Price |
$302.68
|
| Rate for Payer: Cofinity Commercial |
$325.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$302.68
|
| Rate for Payer: Healthscope Commercial |
$340.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$283.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$321.60
|
| Rate for Payer: PHP Commercial |
$321.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$329.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$230.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$332.95
|
| Rate for Payer: UHC Core |
$315.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$283.76
|
|
|
DIVALPROEX 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3.79
|
|
|
Service Code
|
NDC 0832-7124-89
|
| Hospital Charge Code |
2553
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.31 |
| Max. Negotiated Rate |
$3.41 |
| Rate for Payer: Aetna Commercial |
$3.22
|
| Rate for Payer: BCBS Trust/PPO |
$2.93
|
| Rate for Payer: BCN Commercial |
$2.93
|
| Rate for Payer: Cash Price |
$3.03
|
| Rate for Payer: Cofinity Commercial |
$3.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.03
|
| Rate for Payer: Healthscope Commercial |
$3.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.22
|
| Rate for Payer: PHP Commercial |
$3.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.34
|
| Rate for Payer: UHC Core |
$3.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.84
|
|
|
DIVALPROEX 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.44
|
|
|
Service Code
|
NDC 68084-782-11
|
| Hospital Charge Code |
2553
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Aetna Commercial |
$2.07
|
| Rate for Payer: BCBS Trust/PPO |
$1.89
|
| Rate for Payer: BCN Commercial |
$1.89
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cofinity Commercial |
$2.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.95
|
| Rate for Payer: Healthscope Commercial |
$2.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.07
|
| Rate for Payer: PHP Commercial |
$2.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.15
|
| Rate for Payer: UHC Core |
$2.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.83
|
|
|
DIVALPROEX 500 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$340.75
|
|
|
Service Code
|
NDC 0904-6861-61
|
| Hospital Charge Code |
2553
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.82 |
| Max. Negotiated Rate |
$306.68 |
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: BCBS Trust/PPO |
$263.33
|
| Rate for Payer: BCN Commercial |
$263.33
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cofinity Commercial |
$293.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.60
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$289.64
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$296.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$207.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$299.86
|
| Rate for Payer: UHC Core |
$284.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.56
|
|
