|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$14.45
|
|
|
Service Code
|
NDC 70000038801
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$13.01 |
| Rate for Payer: Aetna American Axle |
$9.39
|
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Aetna Medicare |
$7.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.39
|
| Rate for Payer: BCBS Complete |
$5.78
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Advantage |
$10.12
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$13.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.84
|
| Rate for Payer: PHP Commercial |
$12.28
|
| Rate for Payer: Priority Health SBD |
$9.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.39
|
| Rate for Payer: UHC Core |
$7.53
|
| Rate for Payer: UHC Exchange |
$5.68
|
| Rate for Payer: UMR Bronson Commercial |
$5.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.84
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$61.01
|
|
|
Service Code
|
NDC 12547017167
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.57 |
| Max. Negotiated Rate |
$54.91 |
| Rate for Payer: Aetna American Axle |
$39.66
|
| Rate for Payer: Aetna Commercial |
$51.86
|
| Rate for Payer: Aetna Medicare |
$30.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.66
|
| Rate for Payer: BCBS Complete |
$24.40
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Cofinity Advantage |
$42.71
|
| Rate for Payer: Cofinity Commercial |
$52.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.81
|
| Rate for Payer: Healthscope Commercial |
$54.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$48.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.76
|
| Rate for Payer: PHP Commercial |
$51.86
|
| Rate for Payer: Priority Health SBD |
$38.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.66
|
| Rate for Payer: UHC Core |
$31.79
|
| Rate for Payer: UHC Exchange |
$23.98
|
| Rate for Payer: UMR Bronson Commercial |
$22.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.76
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$22.84
|
|
|
Service Code
|
NDC 00904535431
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna American Axle |
$14.85
|
| Rate for Payer: Aetna Commercial |
$19.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.85
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cofinity Advantage |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$19.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.13
|
| Rate for Payer: PHP Commercial |
$19.41
|
| Rate for Payer: Priority Health SBD |
$14.39
|
| Rate for Payer: UMR Bronson Commercial |
$10.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.13
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$24.87
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.94 |
| Max. Negotiated Rate |
$22.38 |
| Rate for Payer: Aetna American Axle |
$16.17
|
| Rate for Payer: Aetna Commercial |
$21.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cofinity Advantage |
$17.41
|
| Rate for Payer: Cofinity Commercial |
$21.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Healthscope Commercial |
$22.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.65
|
| Rate for Payer: PHP Commercial |
$21.14
|
| Rate for Payer: Priority Health SBD |
$15.67
|
| Rate for Payer: UMR Bronson Commercial |
$10.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.65
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$61.01
|
|
|
Service Code
|
NDC 12547017167
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.84 |
| Max. Negotiated Rate |
$54.91 |
| Rate for Payer: Aetna American Axle |
$39.66
|
| Rate for Payer: Aetna Commercial |
$51.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.66
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Cofinity Advantage |
$42.71
|
| Rate for Payer: Cofinity Commercial |
$52.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.81
|
| Rate for Payer: Healthscope Commercial |
$54.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$51.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$45.76
|
| Rate for Payer: PHP Commercial |
$51.86
|
| Rate for Payer: Priority Health SBD |
$38.44
|
| Rate for Payer: UMR Bronson Commercial |
$26.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.76
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$22.84
|
|
|
Service Code
|
NDC 00904535431
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna American Axle |
$14.85
|
| Rate for Payer: Aetna Commercial |
$19.41
|
| Rate for Payer: Aetna Medicare |
$11.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.85
|
| Rate for Payer: BCBS Complete |
$9.14
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cofinity Advantage |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$19.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.13
|
| Rate for Payer: PHP Commercial |
$19.41
|
| Rate for Payer: Priority Health SBD |
$14.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.85
|
| Rate for Payer: UHC Core |
$11.90
|
| Rate for Payer: UHC Exchange |
$8.98
|
| Rate for Payer: UMR Bronson Commercial |
$8.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.13
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$24.87
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.20 |
| Max. Negotiated Rate |
$22.38 |
| Rate for Payer: Aetna American Axle |
$16.17
|
| Rate for Payer: Aetna Commercial |
$21.14
|
| Rate for Payer: Aetna Medicare |
$12.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.17
|
| Rate for Payer: BCBS Complete |
$9.95
|
| Rate for Payer: Cash Price |
$19.90
|
| Rate for Payer: Cofinity Advantage |
$17.41
|
| Rate for Payer: Cofinity Commercial |
$21.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.90
|
| Rate for Payer: Healthscope Commercial |
$22.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.65
|
| Rate for Payer: PHP Commercial |
$21.14
|
| Rate for Payer: Priority Health SBD |
$15.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.17
|
| Rate for Payer: UHC Core |
$12.96
|
| Rate for Payer: UHC Exchange |
$9.77
|
| Rate for Payer: UMR Bronson Commercial |
$9.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.65
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$14.45
|
|
|
Service Code
|
NDC 70000038801
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$13.01 |
| Rate for Payer: Aetna American Axle |
$9.39
|
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.39
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Advantage |
$10.12
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$13.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.84
|
| Rate for Payer: PHP Commercial |
$12.28
|
| Rate for Payer: Priority Health SBD |
$9.10
|
| Rate for Payer: UMR Bronson Commercial |
$6.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.84
|
|
|
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 |
$137.49 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna American Axle |
$203.11
|
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Advantage |
$218.74
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$218.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.36
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health SBD |
$196.86
|
| Rate for Payer: UMR Bronson Commercial |
$137.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.36
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$1,075.96
|
|
|
Service Code
|
NDC 00025006131
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$398.11 |
| Max. Negotiated Rate |
$968.36 |
| Rate for Payer: Aetna American Axle |
$699.37
|
| Rate for Payer: Aetna Commercial |
$914.57
|
| Rate for Payer: Aetna Medicare |
$537.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$699.37
|
| Rate for Payer: BCBS Complete |
$430.38
|
| Rate for Payer: Cash Price |
$860.77
|
| Rate for Payer: Cofinity Advantage |
$753.17
|
| Rate for Payer: Cofinity Commercial |
$925.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$860.77
|
| Rate for Payer: Healthscope Commercial |
$968.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$753.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$806.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$860.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$914.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$806.97
|
| Rate for Payer: PHP Commercial |
$914.57
|
| Rate for Payer: Priority Health SBD |
$677.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$699.37
|
| Rate for Payer: UHC Core |
$560.58
|
| Rate for Payer: UHC Exchange |
$422.85
|
| Rate for Payer: UMR Bronson Commercial |
$398.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$806.97
|
|
|
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 |
$111.43 |
| Max. Negotiated Rate |
$271.04 |
| Rate for Payer: Aetna American Axle |
$195.75
|
| Rate for Payer: Aetna Commercial |
$255.98
|
| Rate for Payer: Aetna Medicare |
$150.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.75
|
| Rate for Payer: BCBS Complete |
$120.46
|
| Rate for Payer: Cash Price |
$240.92
|
| Rate for Payer: Cofinity Advantage |
$210.81
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$210.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$240.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$225.86
|
| Rate for Payer: PHP Commercial |
$255.98
|
| Rate for Payer: Priority Health SBD |
$189.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$195.75
|
| Rate for Payer: UHC Core |
$156.90
|
| Rate for Payer: UHC Exchange |
$118.35
|
| Rate for Payer: UMR Bronson Commercial |
$111.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.86
|
|
|
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 |
$134.27 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna American Axle |
$235.88
|
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna Medicare |
$181.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.88
|
| Rate for Payer: BCBS Complete |
$145.16
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Advantage |
$254.03
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$254.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$272.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$290.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$272.18
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health SBD |
$228.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$235.88
|
| Rate for Payer: UHC Core |
$189.07
|
| Rate for Payer: UHC Exchange |
$142.62
|
| Rate for Payer: UMR Bronson Commercial |
$134.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$272.18
|
|
|
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 |
$115.62 |
| Max. Negotiated Rate |
$281.23 |
| Rate for Payer: Aetna American Axle |
$203.11
|
| Rate for Payer: Aetna Commercial |
$265.61
|
| Rate for Payer: Aetna Medicare |
$156.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.11
|
| Rate for Payer: BCBS Complete |
$124.99
|
| Rate for Payer: Cash Price |
$249.98
|
| Rate for Payer: Cofinity Advantage |
$218.74
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$218.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$249.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.36
|
| Rate for Payer: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health SBD |
$196.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$203.11
|
| Rate for Payer: UHC Core |
$162.80
|
| Rate for Payer: UHC Exchange |
$122.80
|
| Rate for Payer: UMR Bronson Commercial |
$115.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.36
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$1,075.96
|
|
|
Service Code
|
NDC 00025006131
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$473.42 |
| Max. Negotiated Rate |
$968.36 |
| Rate for Payer: Aetna American Axle |
$699.37
|
| Rate for Payer: Aetna Commercial |
$914.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$699.37
|
| Rate for Payer: Cash Price |
$860.77
|
| Rate for Payer: Cofinity Advantage |
$753.17
|
| Rate for Payer: Cofinity Commercial |
$925.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$860.77
|
| Rate for Payer: Healthscope Commercial |
$968.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$753.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$806.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$914.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$806.97
|
| Rate for Payer: PHP Commercial |
$914.57
|
| Rate for Payer: Priority Health SBD |
$677.85
|
| Rate for Payer: UMR Bronson Commercial |
$473.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$806.97
|
|
|
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 |
$132.51 |
| Max. Negotiated Rate |
$271.04 |
| Rate for Payer: Aetna American Axle |
$195.75
|
| Rate for Payer: Aetna Commercial |
$255.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.75
|
| Rate for Payer: Cash Price |
$240.92
|
| Rate for Payer: Cofinity Advantage |
$210.81
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$210.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$225.86
|
| Rate for Payer: PHP Commercial |
$255.98
|
| Rate for Payer: Priority Health SBD |
$189.72
|
| Rate for Payer: UMR Bronson Commercial |
$132.51
|
| 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 |
$159.68 |
| Max. Negotiated Rate |
$326.61 |
| Rate for Payer: Aetna American Axle |
$235.88
|
| Rate for Payer: Aetna Commercial |
$308.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.88
|
| Rate for Payer: Cash Price |
$290.32
|
| Rate for Payer: Cofinity Advantage |
$254.03
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$254.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$272.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$308.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$272.18
|
| Rate for Payer: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health SBD |
$228.63
|
| Rate for Payer: UMR Bronson Commercial |
$159.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$272.18
|
|
|
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 |
$43.95 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna American Axle |
$77.21
|
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: Aetna Medicare |
$59.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.21
|
| Rate for Payer: BCBS Complete |
$47.51
|
| Rate for Payer: BCBS Trust/PPO |
$94.17
|
| Rate for Payer: BCN Commercial |
$94.17
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Advantage |
$83.15
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$83.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.08
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health SBD |
$74.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.21
|
| Rate for Payer: UHC Core |
$61.88
|
| Rate for Payer: UHC Exchange |
$46.68
|
| Rate for Payer: UMR Bronson Commercial |
$43.95
|
| 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 |
$52.26 |
| Max. Negotiated Rate |
$106.90 |
| Rate for Payer: Aetna American Axle |
$77.21
|
| Rate for Payer: Aetna Commercial |
$100.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.21
|
| Rate for Payer: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Advantage |
$83.15
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$83.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$100.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.08
|
| Rate for Payer: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health SBD |
$74.83
|
| Rate for Payer: UMR Bronson Commercial |
$52.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.08
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$170.37
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.04 |
| Max. Negotiated Rate |
$155.15 |
| Rate for Payer: Aetna American Axle |
$110.74
|
| Rate for Payer: Aetna Commercial |
$144.81
|
| Rate for Payer: Aetna Medicare |
$85.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.74
|
| Rate for Payer: BCBS Complete |
$68.15
|
| Rate for Payer: BCBS Trust/PPO |
$155.15
|
| Rate for Payer: BCN Commercial |
$155.15
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Advantage |
$119.26
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$119.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$136.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: PHP Commercial |
$144.81
|
| Rate for Payer: Priority Health SBD |
$107.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.49
|
| Rate for Payer: UHC Core |
$65.49
|
| Rate for Payer: UHC Exchange |
$65.49
|
| Rate for Payer: UMR Bronson Commercial |
$63.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.78
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
IP
|
$170.37
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.96 |
| Max. Negotiated Rate |
$153.33 |
| Rate for Payer: Aetna American Axle |
$110.74
|
| Rate for Payer: Aetna Commercial |
$144.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.74
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Advantage |
$119.26
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$119.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: PHP Commercial |
$144.81
|
| Rate for Payer: Priority Health SBD |
$107.33
|
| Rate for Payer: UMR Bronson Commercial |
$74.96
|
| 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
|
OP
|
$170.37
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.04 |
| Max. Negotiated Rate |
$155.15 |
| Rate for Payer: Aetna American Axle |
$110.74
|
| Rate for Payer: Aetna Commercial |
$144.81
|
| Rate for Payer: Aetna Medicare |
$85.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.74
|
| Rate for Payer: BCBS Complete |
$68.15
|
| Rate for Payer: BCBS Trust/PPO |
$155.15
|
| Rate for Payer: BCN Commercial |
$155.15
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Advantage |
$119.26
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$119.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$136.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: PHP Commercial |
$144.81
|
| Rate for Payer: Priority Health SBD |
$107.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.49
|
| Rate for Payer: UHC Core |
$65.49
|
| Rate for Payer: UHC Exchange |
$65.49
|
| Rate for Payer: UMR Bronson Commercial |
$63.04
|
| 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 |
$74.96 |
| Max. Negotiated Rate |
$153.33 |
| Rate for Payer: Aetna American Axle |
$110.74
|
| Rate for Payer: Aetna Commercial |
$144.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.74
|
| Rate for Payer: Cash Price |
$136.30
|
| Rate for Payer: Cofinity Advantage |
$119.26
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$119.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$127.78
|
| Rate for Payer: PHP Commercial |
$144.81
|
| Rate for Payer: Priority Health SBD |
$107.33
|
| Rate for Payer: UMR Bronson Commercial |
$74.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.78
|
|
|
DIPYRIDAMOLE 25 MG TABLET
|
Facility
|
IP
|
$426.55
|
|
|
Service Code
|
NDC 68382018701
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.68 |
| Max. Negotiated Rate |
$383.89 |
| Rate for Payer: Aetna American Axle |
$277.26
|
| Rate for Payer: Aetna Commercial |
$362.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.26
|
| Rate for Payer: Cash Price |
$341.24
|
| Rate for Payer: Cofinity Advantage |
$298.58
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.24
|
| Rate for Payer: Healthscope Commercial |
$383.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.91
|
| Rate for Payer: PHP Commercial |
$362.57
|
| Rate for Payer: Priority Health SBD |
$268.73
|
| Rate for Payer: UMR Bronson Commercial |
$187.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.91
|
|
|
DIPYRIDAMOLE 25 MG TABLET
|
Facility
|
IP
|
$528.48
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.53 |
| Max. Negotiated Rate |
$475.63 |
| Rate for Payer: Aetna American Axle |
$343.51
|
| Rate for Payer: Aetna Commercial |
$449.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$343.51
|
| Rate for Payer: Cash Price |
$422.78
|
| Rate for Payer: Cofinity Advantage |
$369.94
|
| Rate for Payer: Cofinity Commercial |
$454.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$422.78
|
| Rate for Payer: Healthscope Commercial |
$475.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$369.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$396.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$449.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$396.36
|
| Rate for Payer: PHP Commercial |
$449.21
|
| Rate for Payer: Priority Health SBD |
$332.94
|
| Rate for Payer: UMR Bronson Commercial |
$232.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$396.36
|
|
|
DIPYRIDAMOLE 25 MG TABLET
|
Facility
|
OP
|
$426.55
|
|
|
Service Code
|
NDC 68382018701
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.82 |
| Max. Negotiated Rate |
$383.89 |
| Rate for Payer: Aetna American Axle |
$277.26
|
| Rate for Payer: Aetna Commercial |
$362.57
|
| Rate for Payer: Aetna Medicare |
$213.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$277.26
|
| Rate for Payer: BCBS Complete |
$170.62
|
| Rate for Payer: Cash Price |
$341.24
|
| Rate for Payer: Cofinity Advantage |
$298.58
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.24
|
| Rate for Payer: Healthscope Commercial |
$383.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$341.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$362.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.91
|
| Rate for Payer: PHP Commercial |
$362.57
|
| Rate for Payer: Priority Health SBD |
$268.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$277.26
|
| Rate for Payer: UHC Core |
$222.23
|
| Rate for Payer: UHC Exchange |
$167.63
|
| Rate for Payer: UMR Bronson Commercial |
$157.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.91
|
|
