|
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 Commercial |
$10.12
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.12
|
| 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: PHP Commercial |
$12.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.39
|
| Rate for Payer: Priority Health SBD |
$9.10
|
| 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
|
IP
|
$19.43
|
|
|
Service Code
|
NDC 00904535431
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$17.49 |
| Rate for Payer: Aetna American Axle |
$12.63
|
| Rate for Payer: Aetna Commercial |
$16.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.63
|
| Rate for Payer: Cash Price |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$13.60
|
| Rate for Payer: Cofinity Commercial |
$16.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.54
|
| Rate for Payer: Healthscope Commercial |
$17.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.52
|
| Rate for Payer: PHP Commercial |
$16.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.63
|
| Rate for Payer: Priority Health SBD |
$12.24
|
| Rate for Payer: UMR Bronson Commercial |
$8.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.57
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$21.17
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$19.05 |
| Rate for Payer: Aetna American Axle |
$13.76
|
| Rate for Payer: Aetna Commercial |
$17.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.76
|
| Rate for Payer: Cash Price |
$16.94
|
| Rate for Payer: Cofinity Commercial |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.94
|
| Rate for Payer: Healthscope Commercial |
$19.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.99
|
| Rate for Payer: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.76
|
| Rate for Payer: Priority Health SBD |
$13.34
|
| Rate for Payer: UMR Bronson Commercial |
$9.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.88
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$26.21
|
|
|
Service Code
|
NDC 09900000966
|
| Hospital Charge Code |
2515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$23.59 |
| Rate for Payer: Aetna American Axle |
$17.04
|
| Rate for Payer: Aetna Commercial |
$22.28
|
| Rate for Payer: Aetna Medicare |
$13.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.04
|
| Rate for Payer: BCBS Complete |
$10.48
|
| Rate for Payer: Cash Price |
$20.97
|
| Rate for Payer: Cofinity Commercial |
$18.35
|
| Rate for Payer: Cofinity Commercial |
$22.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.97
|
| Rate for Payer: Healthscope Commercial |
$23.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.28
|
| Rate for Payer: PHP Commercial |
$22.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.04
|
| Rate for Payer: Priority Health SBD |
$16.51
|
| Rate for Payer: UMR Bronson Commercial |
$9.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.66
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$26.21
|
|
|
Service Code
|
NDC 09900000966
|
| Hospital Charge Code |
2515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$23.59 |
| Rate for Payer: Aetna American Axle |
$17.04
|
| Rate for Payer: Aetna Commercial |
$22.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.04
|
| Rate for Payer: Cash Price |
$20.97
|
| Rate for Payer: Cofinity Commercial |
$18.35
|
| Rate for Payer: Cofinity Commercial |
$22.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.97
|
| Rate for Payer: Healthscope Commercial |
$23.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.28
|
| Rate for Payer: PHP Commercial |
$22.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.04
|
| Rate for Payer: Priority Health SBD |
$16.51
|
| Rate for Payer: UMR Bronson Commercial |
$11.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.66
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID
|
Facility
|
OP
|
$312.48
|
|
|
Service Code
|
NDC 00054319446
|
| Hospital Charge Code |
2515
|
|
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 Commercial |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.74
|
| 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: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health SBD |
$196.86
|
| 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/5 ML ORAL LIQUID
|
Facility
|
IP
|
$312.48
|
|
|
Service Code
|
NDC 00054319446
|
| Hospital Charge Code |
2515
|
|
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 Commercial |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.74
|
| 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: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| 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
|
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 Commercial |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.74
|
| 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: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| 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
|
$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 Commercial |
$218.74
|
| Rate for Payer: Cofinity Commercial |
$268.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$218.74
|
| 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: PHP Commercial |
$265.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.11
|
| Rate for Payer: Priority Health SBD |
$196.86
|
| 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
|
$1,047.47
|
|
|
Service Code
|
NDC 00025006131
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$460.89 |
| Max. Negotiated Rate |
$942.72 |
| Rate for Payer: Aetna American Axle |
$680.86
|
| Rate for Payer: Aetna Commercial |
$890.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$680.86
|
| Rate for Payer: Cash Price |
$837.98
|
| Rate for Payer: Cofinity Commercial |
$733.23
|
| Rate for Payer: Cofinity Commercial |
$900.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$733.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$837.98
|
| Rate for Payer: Healthscope Commercial |
$942.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$733.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$785.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$890.35
|
| Rate for Payer: PHP Commercial |
$890.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$680.86
|
| Rate for Payer: Priority Health SBD |
$659.91
|
| Rate for Payer: UMR Bronson Commercial |
$460.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$785.60
|
|
|
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 Commercial |
$254.03
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$254.03
|
| 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: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| Rate for Payer: Priority Health SBD |
$228.63
|
| 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
|
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 Commercial |
$254.03
|
| Rate for Payer: Cofinity Commercial |
$312.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$254.03
|
| 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: PHP Commercial |
$308.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.88
|
| 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
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$1,047.47
|
|
|
Service Code
|
NDC 00025006131
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$387.56 |
| Max. Negotiated Rate |
$942.72 |
| Rate for Payer: Aetna American Axle |
$680.86
|
| Rate for Payer: Aetna Commercial |
$890.35
|
| Rate for Payer: Aetna Medicare |
$523.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$680.86
|
| Rate for Payer: BCBS Complete |
$418.99
|
| Rate for Payer: Cash Price |
$837.98
|
| Rate for Payer: Cofinity Commercial |
$733.23
|
| Rate for Payer: Cofinity Commercial |
$900.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$733.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$837.98
|
| Rate for Payer: Healthscope Commercial |
$942.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$733.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$785.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$890.35
|
| Rate for Payer: PHP Commercial |
$890.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$680.86
|
| Rate for Payer: Priority Health SBD |
$659.91
|
| Rate for Payer: UMR Bronson Commercial |
$387.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$785.60
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
OP
|
$294.50
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.97 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna American Axle |
$191.43
|
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: Aetna Medicare |
$147.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.43
|
| Rate for Payer: BCBS Complete |
$117.80
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$206.15
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$206.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.43
|
| Rate for Payer: Priority Health SBD |
$185.53
|
| Rate for Payer: UMR Bronson Commercial |
$108.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET
|
Facility
|
IP
|
$294.50
|
|
|
Service Code
|
NDC 69315091001
|
| Hospital Charge Code |
2516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna American Axle |
$191.43
|
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.43
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$206.15
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$206.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.32
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.43
|
| Rate for Payer: Priority Health SBD |
$185.53
|
| Rate for Payer: UMR Bronson Commercial |
$129.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE
|
Facility
|
IP
|
$118.78
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
19451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$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 Commercial |
$102.15
|
| Rate for Payer: Cofinity Commercial |
$83.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.15
|
| 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: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.21
|
| 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
|
|
|
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: Cash Price |
$95.02
|
| Rate for Payer: Cofinity Commercial |
$102.15
|
| Rate for Payer: Cofinity Commercial |
$83.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.15
|
| 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: PHP Commercial |
$100.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.21
|
| Rate for Payer: Priority Health SBD |
$74.83
|
| Rate for Payer: UMR Bronson Commercial |
$43.95
|
| 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
|
IP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.91 |
| Max. Negotiated Rate |
$149.13 |
| Rate for Payer: Aetna American Axle |
$107.70
|
| Rate for Payer: Aetna Commercial |
$140.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.70
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$115.99
|
| Rate for Payer: Cofinity Commercial |
$142.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$149.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: PHP Commercial |
$140.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health SBD |
$104.39
|
| Rate for Payer: UMR Bronson Commercial |
$72.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.28
|
|
|
DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP
|
Facility
|
OP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
41628
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.31 |
| Max. Negotiated Rate |
$149.13 |
| Rate for Payer: Aetna American Axle |
$107.70
|
| Rate for Payer: Aetna Commercial |
$140.84
|
| Rate for Payer: Aetna Medicare |
$82.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.70
|
| Rate for Payer: BCBS Complete |
$66.28
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$115.99
|
| Rate for Payer: Cofinity Commercial |
$142.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$149.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: PHP Commercial |
$140.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health SBD |
$104.39
|
| Rate for Payer: UMR Bronson Commercial |
$61.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.28
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
OP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.31 |
| Max. Negotiated Rate |
$149.13 |
| Rate for Payer: Aetna American Axle |
$107.70
|
| Rate for Payer: Aetna Commercial |
$140.84
|
| Rate for Payer: Aetna Medicare |
$82.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.70
|
| Rate for Payer: BCBS Complete |
$66.28
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$115.99
|
| Rate for Payer: Cofinity Commercial |
$142.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$149.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: PHP Commercial |
$140.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health SBD |
$104.39
|
| Rate for Payer: UMR Bronson Commercial |
$61.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.28
|
|
|
DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE
|
Facility
|
IP
|
$165.70
|
|
|
Service Code
|
HCPCS 90715
|
| Hospital Charge Code |
118169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.91 |
| Max. Negotiated Rate |
$149.13 |
| Rate for Payer: Aetna American Axle |
$107.70
|
| Rate for Payer: Aetna Commercial |
$140.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.70
|
| Rate for Payer: Cash Price |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$115.99
|
| Rate for Payer: Cofinity Commercial |
$142.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.56
|
| Rate for Payer: Healthscope Commercial |
$149.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.84
|
| Rate for Payer: PHP Commercial |
$140.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.70
|
| Rate for Payer: Priority Health SBD |
$104.39
|
| Rate for Payer: UMR Bronson Commercial |
$72.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.28
|
|
|
DIPYRIDAMOLE 25 MG TABLET
|
Facility
|
IP
|
$249.60
|
|
|
Service Code
|
NDC 68382018701
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.82 |
| Max. Negotiated Rate |
$224.64 |
| Rate for Payer: Aetna American Axle |
$162.24
|
| Rate for Payer: Aetna Commercial |
$212.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.24
|
| Rate for Payer: Cash Price |
$199.68
|
| Rate for Payer: Cofinity Commercial |
$174.72
|
| Rate for Payer: Cofinity Commercial |
$214.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$174.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.68
|
| Rate for Payer: Healthscope Commercial |
$224.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$174.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.16
|
| Rate for Payer: PHP Commercial |
$212.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.24
|
| Rate for Payer: Priority Health SBD |
$157.25
|
| Rate for Payer: UMR Bronson Commercial |
$109.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.20
|
|
|
DIPYRIDAMOLE 25 MG TABLET
|
Facility
|
OP
|
$528.48
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.54 |
| Max. Negotiated Rate |
$475.63 |
| Rate for Payer: Aetna American Axle |
$343.51
|
| Rate for Payer: Aetna Commercial |
$449.21
|
| Rate for Payer: Aetna Medicare |
$264.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$343.51
|
| Rate for Payer: BCBS Complete |
$211.39
|
| Rate for Payer: Cash Price |
$422.78
|
| Rate for Payer: Cofinity Commercial |
$369.94
|
| Rate for Payer: Cofinity Commercial |
$454.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$369.94
|
| 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: PHP Commercial |
$449.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$343.51
|
| Rate for Payer: Priority Health SBD |
$332.94
|
| Rate for Payer: UMR Bronson Commercial |
$195.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$396.36
|
|
|
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 Commercial |
$369.94
|
| Rate for Payer: Cofinity Commercial |
$454.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$369.94
|
| 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: PHP Commercial |
$449.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$343.51
|
| 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
|
$249.60
|
|
|
Service Code
|
NDC 68382018701
|
| Hospital Charge Code |
2528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.35 |
| Max. Negotiated Rate |
$224.64 |
| Rate for Payer: Aetna American Axle |
$162.24
|
| Rate for Payer: Aetna Commercial |
$212.16
|
| Rate for Payer: Aetna Medicare |
$124.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.24
|
| Rate for Payer: BCBS Complete |
$99.84
|
| Rate for Payer: Cash Price |
$199.68
|
| Rate for Payer: Cofinity Commercial |
$174.72
|
| Rate for Payer: Cofinity Commercial |
$214.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$174.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.68
|
| Rate for Payer: Healthscope Commercial |
$224.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$174.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.16
|
| Rate for Payer: PHP Commercial |
$212.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.24
|
| Rate for Payer: Priority Health SBD |
$157.25
|
| Rate for Payer: UMR Bronson Commercial |
$92.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.20
|
|
