|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$119.70
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.10 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna Commercial |
$101.75
|
| Rate for Payer: Aetna Medicare |
$31.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$37.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$37.41
|
| Rate for Payer: BCBS Complete |
$22.16
|
| Rate for Payer: BCBS MAPPO |
$29.93
|
| Rate for Payer: BCBS Trust/PPO |
$98.41
|
| Rate for Payer: BCN Commercial |
$98.41
|
| Rate for Payer: BCN Medicare Advantage |
$29.93
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Commercial |
$102.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29.93
|
| Rate for Payer: Healthscope Commercial |
$107.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.78
|
| Rate for Payer: Mclaren Medicaid |
$21.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31.42
|
| Rate for Payer: Meridian Medicaid |
$22.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.41
|
| Rate for Payer: Molina Medicare/Medicaid |
$32.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Nomi Health Commercial |
$98.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: PACE Senior Care Partners |
$28.43
|
| Rate for Payer: PACE SWMI |
$29.93
|
| Rate for Payer: PHP Commercial |
$101.75
|
| Rate for Payer: PHP Medicare Advantage |
$29.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$21.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$104.14
|
| Rate for Payer: Priority Health Medicare |
$30.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$83.31
|
| Rate for Payer: Railroad Medicare Medicare |
$29.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.34
|
| Rate for Payer: UHC Core |
$99.95
|
| Rate for Payer: UHC Exchange |
$29.93
|
| Rate for Payer: UHC Medicaid |
$21.10
|
| Rate for Payer: UHC Medicare Advantage |
$29.93
|
| Rate for Payer: UHCCP Medicaid |
$21.10
|
| Rate for Payer: VA VA |
$29.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.78
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$168.70
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.42 |
| Max. Negotiated Rate |
$151.83 |
| Rate for Payer: Aetna Commercial |
$143.40
|
| Rate for Payer: BCBS Trust/PPO |
$139.33
|
| Rate for Payer: BCN Commercial |
$139.33
|
| Rate for Payer: Cash Price |
$134.96
|
| Rate for Payer: Cofinity Commercial |
$145.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.96
|
| Rate for Payer: Healthscope Commercial |
$151.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.40
|
| Rate for Payer: Nomi Health Commercial |
$138.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.53
|
| Rate for Payer: PHP Commercial |
$143.40
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$146.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$117.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$148.46
|
| Rate for Payer: UHC Core |
$140.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.53
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$119.70
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.31 |
| Max. Negotiated Rate |
$107.73 |
| Rate for Payer: Aetna Commercial |
$101.75
|
| Rate for Payer: BCBS Trust/PPO |
$98.86
|
| Rate for Payer: BCN Commercial |
$98.86
|
| Rate for Payer: Cash Price |
$95.76
|
| Rate for Payer: Cofinity Commercial |
$102.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.76
|
| Rate for Payer: Healthscope Commercial |
$107.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.75
|
| Rate for Payer: Nomi Health Commercial |
$98.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.78
|
| Rate for Payer: PHP Commercial |
$101.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$104.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$83.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$105.34
|
| Rate for Payer: UHC Core |
$99.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.78
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$1.69
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna Commercial |
$1.44
|
| Rate for Payer: Aetna Medicare |
$0.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.53
|
| Rate for Payer: BCBS Complete |
$0.31
|
| Rate for Payer: BCBS MAPPO |
$0.42
|
| Rate for Payer: BCBS Trust/PPO |
$1.39
|
| Rate for Payer: BCN Commercial |
$1.39
|
| Rate for Payer: BCN Medicare Advantage |
$0.42
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cofinity Commercial |
$1.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.42
|
| Rate for Payer: Healthscope Commercial |
$1.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.27
|
| Rate for Payer: Mclaren Medicaid |
$0.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.44
|
| Rate for Payer: Meridian Medicaid |
$0.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.49
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.44
|
| Rate for Payer: Nomi Health Commercial |
$1.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.27
|
| Rate for Payer: PACE Senior Care Partners |
$0.40
|
| Rate for Payer: PACE SWMI |
$0.42
|
| Rate for Payer: PHP Commercial |
$1.44
|
| Rate for Payer: PHP Medicare Advantage |
$0.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.30
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1.47
|
| Rate for Payer: Priority Health Medicare |
$0.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.18
|
| Rate for Payer: Railroad Medicare Medicare |
$0.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.49
|
| Rate for Payer: UHC Core |
$1.41
|
| Rate for Payer: UHC Exchange |
$0.42
|
| Rate for Payer: UHC Medicaid |
$0.30
|
| Rate for Payer: UHC Medicare Advantage |
$0.42
|
| Rate for Payer: UHCCP Medicaid |
$0.30
|
| Rate for Payer: VA VA |
$0.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.27
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.69
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna Commercial |
$1.44
|
| Rate for Payer: BCBS Trust/PPO |
$1.40
|
| Rate for Payer: BCN Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cofinity Commercial |
$1.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.35
|
| Rate for Payer: Healthscope Commercial |
$1.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.44
|
| Rate for Payer: Nomi Health Commercial |
$1.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.49
|
| Rate for Payer: UHC Core |
$1.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.27
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$168.70
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.74 |
| Max. Negotiated Rate |
$151.83 |
| Rate for Payer: Aetna Commercial |
$143.40
|
| Rate for Payer: Aetna Medicare |
$43.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.72
|
| Rate for Payer: BCBS Complete |
$31.23
|
| Rate for Payer: BCBS MAPPO |
$42.17
|
| Rate for Payer: BCBS Trust/PPO |
$138.69
|
| Rate for Payer: BCN Commercial |
$138.69
|
| Rate for Payer: BCN Medicare Advantage |
$42.17
|
| Rate for Payer: Cash Price |
$134.96
|
| Rate for Payer: Cofinity Commercial |
$145.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$42.17
|
| Rate for Payer: Healthscope Commercial |
$151.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.53
|
| Rate for Payer: Mclaren Medicaid |
$29.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$44.28
|
| Rate for Payer: Meridian Medicaid |
$31.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.50
|
| Rate for Payer: Molina Medicare/Medicaid |
$46.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.40
|
| Rate for Payer: Nomi Health Commercial |
$138.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.53
|
| Rate for Payer: PACE Senior Care Partners |
$40.07
|
| Rate for Payer: PACE SWMI |
$42.17
|
| Rate for Payer: PHP Commercial |
$143.40
|
| Rate for Payer: PHP Medicare Advantage |
$42.17
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$146.77
|
| Rate for Payer: Priority Health Medicare |
$42.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$117.42
|
| Rate for Payer: Railroad Medicare Medicare |
$42.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$148.46
|
| Rate for Payer: UHC Core |
$140.86
|
| Rate for Payer: UHC Exchange |
$42.17
|
| Rate for Payer: UHC Medicaid |
$29.74
|
| Rate for Payer: UHC Medicare Advantage |
$42.17
|
| Rate for Payer: UHCCP Medicaid |
$29.74
|
| Rate for Payer: VA VA |
$42.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.53
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Medicare |
$3.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.79
|
| Rate for Payer: BCBS Complete |
$2.25
|
| Rate for Payer: BCBS MAPPO |
$3.03
|
| Rate for Payer: BCBS Trust/PPO |
$9.97
|
| Rate for Payer: BCN Commercial |
$9.97
|
| Rate for Payer: BCN Medicare Advantage |
$3.03
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.03
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Mclaren Medicaid |
$2.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.18
|
| Rate for Payer: Meridian Medicaid |
$2.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.49
|
| Rate for Payer: Molina Medicare/Medicaid |
$3.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Nomi Health Commercial |
$9.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: PACE Senior Care Partners |
$2.88
|
| Rate for Payer: PACE SWMI |
$3.03
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Medicare Advantage |
$3.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$10.55
|
| Rate for Payer: Priority Health Medicare |
$3.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.44
|
| Rate for Payer: Railroad Medicare Medicare |
$3.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: UHC Exchange |
$3.03
|
| Rate for Payer: UHC Medicaid |
$2.14
|
| Rate for Payer: UHC Medicare Advantage |
$3.03
|
| Rate for Payer: UHCCP Medicaid |
$2.14
|
| Rate for Payer: VA VA |
$3.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: BCBS Trust/PPO |
$10.02
|
| Rate for Payer: BCN Commercial |
$10.02
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Nomi Health Commercial |
$9.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$10.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: BCBS Trust/PPO |
$11.14
|
| Rate for Payer: BCBS Trust/PPO |
$10.02
|
| Rate for Payer: BCBS Trust/PPO |
$17.05
|
| Rate for Payer: BCN Commercial |
$11.14
|
| Rate for Payer: BCN Commercial |
$10.02
|
| Rate for Payer: BCN Commercial |
$17.05
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| 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 Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Nomi Health Commercial |
$9.95
|
| Rate for Payer: Nomi Health Commercial |
$11.06
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$17.97
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$11.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$10.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: UHC Core |
$17.24
|
| Rate for Payer: UHC Core |
$11.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Medicare |
$5.37
|
| Rate for Payer: Aetna Medicare |
$3.15
|
| Rate for Payer: Aetna Medicare |
$3.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.45
|
| Rate for Payer: BCBS Complete |
$2.50
|
| Rate for Payer: BCBS Complete |
$2.25
|
| Rate for Payer: BCBS Complete |
$3.82
|
| Rate for Payer: BCBS MAPPO |
$5.16
|
| Rate for Payer: BCBS MAPPO |
$3.03
|
| Rate for Payer: BCBS MAPPO |
$3.37
|
| Rate for Payer: BCBS Trust/PPO |
$9.97
|
| Rate for Payer: BCBS Trust/PPO |
$11.09
|
| Rate for Payer: BCBS Trust/PPO |
$16.98
|
| Rate for Payer: BCN Commercial |
$11.09
|
| Rate for Payer: BCN Commercial |
$16.98
|
| Rate for Payer: BCN Commercial |
$9.97
|
| Rate for Payer: BCN Medicare Advantage |
$5.16
|
| Rate for Payer: BCN Medicare Advantage |
$3.37
|
| Rate for Payer: BCN Medicare Advantage |
$3.03
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$9.70
|
| 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 |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.37
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.03
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| 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: Mclaren Medicaid |
$2.14
|
| Rate for Payer: Mclaren Medicaid |
$3.64
|
| Rate for Payer: Mclaren Medicaid |
$2.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.18
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.42
|
| Rate for Payer: Meridian Medicaid |
$3.82
|
| Rate for Payer: Meridian Medicaid |
$2.25
|
| Rate for Payer: Meridian Medicaid |
$2.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.94
|
| Rate for Payer: Molina Medicare/Medicaid |
$5.68
|
| Rate for Payer: Molina Medicare/Medicaid |
$3.71
|
| Rate for Payer: Molina Medicare/Medicaid |
$3.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Nomi Health Commercial |
$16.93
|
| Rate for Payer: Nomi Health Commercial |
$11.06
|
| Rate for Payer: Nomi Health Commercial |
$9.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.10
|
| Rate for Payer: PACE Senior Care Partners |
$3.20
|
| Rate for Payer: PACE Senior Care Partners |
$2.88
|
| Rate for Payer: PACE Senior Care Partners |
$4.90
|
| Rate for Payer: PACE SWMI |
$5.16
|
| Rate for Payer: PACE SWMI |
$3.37
|
| Rate for Payer: PACE SWMI |
$3.03
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: PHP Medicare Advantage |
$3.37
|
| Rate for Payer: PHP Medicare Advantage |
$3.03
|
| Rate for Payer: PHP Medicare Advantage |
$5.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$11.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$10.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$17.97
|
| Rate for Payer: Priority Health Medicare |
$5.21
|
| Rate for Payer: Priority Health Medicare |
$3.41
|
| Rate for Payer: Priority Health Medicare |
$3.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.44
|
| Rate for Payer: Railroad Medicare Medicare |
$3.37
|
| Rate for Payer: Railroad Medicare Medicare |
$5.16
|
| Rate for Payer: Railroad Medicare Medicare |
$3.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.67
|
| Rate for Payer: UHC Core |
$10.13
|
| Rate for Payer: UHC Core |
$17.24
|
| Rate for Payer: UHC Core |
$11.26
|
| Rate for Payer: UHC Exchange |
$5.16
|
| Rate for Payer: UHC Exchange |
$3.37
|
| Rate for Payer: UHC Exchange |
$3.03
|
| Rate for Payer: UHC Medicaid |
$2.14
|
| Rate for Payer: UHC Medicaid |
$3.64
|
| Rate for Payer: UHC Medicaid |
$2.38
|
| Rate for Payer: UHC Medicare Advantage |
$3.37
|
| Rate for Payer: UHC Medicare Advantage |
$3.03
|
| Rate for Payer: UHC Medicare Advantage |
$5.16
|
| Rate for Payer: UHCCP Medicaid |
$2.38
|
| Rate for Payer: UHCCP Medicaid |
$2.14
|
| Rate for Payer: UHCCP Medicaid |
$3.64
|
| Rate for Payer: VA VA |
$3.03
|
| Rate for Payer: VA VA |
$5.16
|
| Rate for Payer: VA VA |
$3.37
|
| 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
|
OP
|
$20.51
|
|
|
Service Code
|
NDC 12547017162
|
| Hospital Charge Code |
22409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.62 |
| 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 |
$3.80
|
| Rate for Payer: BCBS MAPPO |
$5.13
|
| Rate for Payer: BCBS Trust/PPO |
$16.86
|
| Rate for Payer: BCN Commercial |
$16.86
|
| 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: Mclaren Medicaid |
$3.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.38
|
| Rate for Payer: Meridian Medicaid |
$3.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.90
|
| Rate for Payer: Molina Medicare/Medicaid |
$5.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.43
|
| Rate for Payer: Nomi Health Commercial |
$16.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.38
|
| 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 Choice Medicaid |
$3.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$17.84
|
| Rate for Payer: Priority Health Medicare |
$5.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.27
|
| 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 Exchange |
$5.13
|
| Rate for Payer: UHC Medicaid |
$3.62
|
| Rate for Payer: UHC Medicare Advantage |
$5.13
|
| Rate for Payer: UHCCP Medicaid |
$3.62
|
| 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 |
$14.27 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: Aetna Commercial |
$17.43
|
| Rate for Payer: BCBS Trust/PPO |
$16.94
|
| Rate for Payer: BCN Commercial |
$16.94
|
| 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: Opus (Opus Packaging Group) HMA |
$15.38
|
| Rate for Payer: PHP Commercial |
$17.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$17.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.27
|
| 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
|
$362.90
|
|
|
Service Code
|
NDC 59762106101
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.98 |
| 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 |
$67.17
|
| Rate for Payer: BCBS MAPPO |
$90.72
|
| Rate for Payer: BCBS Trust/PPO |
$298.34
|
| Rate for Payer: BCN Commercial |
$298.34
|
| 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: Mclaren Medicaid |
$63.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$95.26
|
| Rate for Payer: Meridian Medicaid |
$67.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.33
|
| Rate for Payer: Molina Medicare/Medicaid |
$99.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Nomi Health Commercial |
$297.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$272.18
|
| 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 Choice Medicaid |
$63.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$315.72
|
| Rate for Payer: Priority Health Medicare |
$91.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$252.58
|
| 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 Exchange |
$90.72
|
| Rate for Payer: UHC Medicaid |
$63.98
|
| Rate for Payer: UHC Medicare Advantage |
$90.72
|
| Rate for Payer: UHCCP Medicaid |
$63.98
|
| 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 |
$289.50 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$353.56
|
| Rate for Payer: BCBS Trust/PPO |
$343.53
|
| Rate for Payer: BCN Commercial |
$343.53
|
| 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: Opus (Opus Packaging Group) HMA |
$311.96
|
| Rate for Payer: PHP Commercial |
$353.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$361.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$289.50
|
| 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
|
IP
|
$301.15
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$209.60 |
| Max. Negotiated Rate |
$271.04 |
| Rate for Payer: Aetna Commercial |
$255.98
|
| Rate for Payer: BCBS Trust/PPO |
$248.72
|
| Rate for Payer: BCN Commercial |
$248.72
|
| Rate for Payer: Cash Price |
$240.92
|
| Rate for Payer: Cofinity Commercial |
$258.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.92
|
| Rate for Payer: Healthscope Commercial |
$271.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.98
|
| Rate for Payer: Nomi Health Commercial |
$246.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$225.86
|
| Rate for Payer: PHP Commercial |
$255.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$262.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$209.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.01
|
| Rate for Payer: UHC Core |
$251.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.86
|
|
|
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 |
$252.58 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: BCBS Trust/PPO |
$299.72
|
| Rate for Payer: BCN Commercial |
$299.72
|
| 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: 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: Opus (Opus Packaging Group) HMA |
$272.18
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$315.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$252.58
|
| 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
|
$301.15
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.09 |
| Max. Negotiated Rate |
$271.04 |
| Rate for Payer: Aetna Commercial |
$255.98
|
| Rate for Payer: Aetna Medicare |
$78.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$94.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$94.11
|
| Rate for Payer: BCBS Complete |
$55.74
|
| Rate for Payer: BCBS MAPPO |
$75.29
|
| Rate for Payer: BCBS Trust/PPO |
$247.58
|
| Rate for Payer: BCN Commercial |
$247.58
|
| Rate for Payer: BCN Medicare Advantage |
$75.29
|
| Rate for Payer: Cash Price |
$240.92
|
| Rate for Payer: Cofinity Commercial |
$258.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$75.29
|
| Rate for Payer: Healthscope Commercial |
$271.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.86
|
| Rate for Payer: Mclaren Medicaid |
$53.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$79.05
|
| Rate for Payer: Meridian Medicaid |
$55.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$86.58
|
| Rate for Payer: Molina Medicare/Medicaid |
$82.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.98
|
| Rate for Payer: Nomi Health Commercial |
$246.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$225.86
|
| Rate for Payer: PACE Senior Care Partners |
$71.52
|
| Rate for Payer: PACE SWMI |
$75.29
|
| Rate for Payer: PHP Commercial |
$255.98
|
| Rate for Payer: PHP Medicare Advantage |
$75.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$53.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$262.00
|
| Rate for Payer: Priority Health Medicare |
$76.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$209.60
|
| Rate for Payer: Railroad Medicare Medicare |
$75.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.01
|
| Rate for Payer: UHC Core |
$251.46
|
| Rate for Payer: UHC Exchange |
$75.29
|
| Rate for Payer: UHC Medicaid |
$53.09
|
| Rate for Payer: UHC Medicare Advantage |
$75.29
|
| Rate for Payer: UHCCP Medicaid |
$53.09
|
| Rate for Payer: VA VA |
$75.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.86
|
|
|
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 |
$217.49 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: BCBS Trust/PPO |
$258.08
|
| Rate for Payer: BCN Commercial |
$258.08
|
| 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: Opus (Opus Packaging Group) HMA |
$234.36
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$271.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$217.49
|
| 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
|
$415.95
|
|
|
Service Code
|
NDC 00406123601
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.33 |
| 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 |
$76.99
|
| Rate for Payer: BCBS MAPPO |
$103.99
|
| Rate for Payer: BCBS Trust/PPO |
$341.95
|
| Rate for Payer: BCN Commercial |
$341.95
|
| 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: Mclaren Medicaid |
$73.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$109.19
|
| Rate for Payer: Meridian Medicaid |
$76.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$119.59
|
| Rate for Payer: Molina Medicare/Medicaid |
$114.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.56
|
| Rate for Payer: Nomi Health Commercial |
$341.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$311.96
|
| 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 Choice Medicaid |
$73.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$361.88
|
| Rate for Payer: Priority Health Medicare |
$105.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$289.50
|
| 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 Exchange |
$103.99
|
| Rate for Payer: UHC Medicaid |
$73.33
|
| Rate for Payer: UHC Medicare Advantage |
$103.99
|
| Rate for Payer: UHCCP Medicaid |
$73.33
|
| 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
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 00378041501
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.09 |
| 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 |
$57.84
|
| Rate for Payer: BCBS MAPPO |
$78.12
|
| Rate for Payer: BCBS Trust/PPO |
$256.89
|
| Rate for Payer: BCN Commercial |
$256.89
|
| 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: Mclaren Medicaid |
$55.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.03
|
| Rate for Payer: Meridian Medicaid |
$57.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$89.84
|
| Rate for Payer: Molina Medicare/Medicaid |
$85.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Nomi Health Commercial |
$256.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.36
|
| 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 Choice Medicaid |
$55.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$271.86
|
| Rate for Payer: Priority Health Medicare |
$78.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$217.49
|
| 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 Exchange |
$78.12
|
| Rate for Payer: UHC Medicaid |
$55.09
|
| Rate for Payer: UHC Medicare Advantage |
$78.12
|
| Rate for Payer: UHCCP Medicaid |
$55.09
|
| Rate for Payer: VA VA |
$78.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.36
|
|
|
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 |
$20.94 |
| 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 |
$21.99
|
| Rate for Payer: BCBS MAPPO |
$29.70
|
| Rate for Payer: BCBS Trust/PPO |
$97.65
|
| Rate for Payer: BCN Commercial |
$97.65
|
| 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: Mclaren Medicaid |
$20.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31.18
|
| Rate for Payer: Meridian Medicaid |
$21.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.15
|
| Rate for Payer: Molina Medicare/Medicaid |
$32.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: Nomi Health Commercial |
$97.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.08
|
| 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 Choice Medicaid |
$20.94
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$103.34
|
| Rate for Payer: Priority Health Medicare |
$29.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$82.67
|
| 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 Exchange |
$29.70
|
| Rate for Payer: UHC Medicaid |
$20.94
|
| Rate for Payer: UHC Medicare Advantage |
$29.70
|
| Rate for Payer: UHCCP Medicaid |
$20.94
|
| Rate for Payer: VA VA |
$29.70
|
| 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
|
IP
|
$118.78
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.67 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: BCBS Trust/PPO |
$98.10
|
| Rate for Payer: BCN Commercial |
$98.10
|
| 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: Opus (Opus Packaging Group) HMA |
$89.08
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$103.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$82.67
|
| 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
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
OP
|
$170.37
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.04 |
| Max. Negotiated Rate |
$153.33 |
| Rate for Payer: Aetna Commercial |
$144.81
|
| Rate for Payer: Aetna Medicare |
$44.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$53.24
|
| Rate for Payer: Amish Plain Church Group Commercial |
$53.24
|
| Rate for Payer: BCBS Complete |
$31.54
|
| Rate for Payer: BCBS MAPPO |
$42.59
|
| Rate for Payer: BCBS Trust/PPO |
$140.06
|
| Rate for Payer: BCN Commercial |
$140.06
|
| Rate for Payer: BCN Medicare Advantage |
$42.59
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Commercial |
$146.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$42.59
|
| Rate for Payer: Healthscope Commercial |
$153.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.78
|
| Rate for Payer: Mclaren Medicaid |
$30.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$44.72
|
| Rate for Payer: Meridian Medicaid |
$31.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.98
|
| Rate for Payer: Molina Medicare/Medicaid |
$46.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Nomi Health Commercial |
$139.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: PACE Senior Care Partners |
$40.46
|
| Rate for Payer: PACE SWMI |
$42.59
|
| Rate for Payer: PHP Commercial |
$144.81
|
| Rate for Payer: PHP Medicare Advantage |
$42.59
|
| Rate for Payer: Priority Health Choice Medicaid |
$30.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$148.22
|
| Rate for Payer: Priority Health Medicare |
$43.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$118.58
|
| Rate for Payer: Railroad Medicare Medicare |
$42.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$149.93
|
| Rate for Payer: UHC Core |
$142.26
|
| Rate for Payer: UHC Exchange |
$42.59
|
| Rate for Payer: UHC Medicaid |
$30.04
|
| Rate for Payer: UHC Medicare Advantage |
$42.59
|
| Rate for Payer: UHCCP Medicaid |
$30.04
|
| Rate for Payer: VA VA |
$42.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.78
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
IP
|
$170.37
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.58 |
| Max. Negotiated Rate |
$153.33 |
| Rate for Payer: Aetna Commercial |
$144.81
|
| Rate for Payer: BCBS Trust/PPO |
$140.71
|
| Rate for Payer: BCN Commercial |
$140.71
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Commercial |
$146.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.30
|
| Rate for Payer: Healthscope Commercial |
$153.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Nomi Health Commercial |
$139.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: PHP Commercial |
$144.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$148.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$118.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$149.93
|
| Rate for Payer: UHC Core |
$142.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.78
|
|
|
DISORDERS OF GALLBLADDER AND BILIARY TRACT
|
Facility
|
IP
|
$8,680.04
|
|
|
Service Code
|
APR-DRG 2844
|
| Min. Negotiated Rate |
$8,266.71 |
| Max. Negotiated Rate |
$8,680.04 |
| Rate for Payer: BCBS Complete |
$8,680.04
|
| Rate for Payer: Mclaren Medicaid |
$8,266.71
|
| Rate for Payer: Meridian Medicaid |
$8,680.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,266.71
|
| Rate for Payer: UHC Medicaid |
$8,266.71
|
| Rate for Payer: UHCCP Medicaid |
$8,266.71
|
|
