|
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(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
|
|
|
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: BCBS Trust/PPO |
$127.13
|
| Rate for Payer: BCN Commercial |
$127.13
|
| Rate for Payer: Cash Price |
$132.56
|
| 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
|
|
|
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
|
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
|
$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
|
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
|
|
|
DISOPYRAMIDE PHOSPHATE ER 100 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
IP
|
$1,485.92
|
|
|
Service Code
|
NDC 00025273231
|
| Hospital Charge Code |
2537
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$653.80 |
| Max. Negotiated Rate |
$1,337.33 |
| Rate for Payer: Aetna American Axle |
$965.85
|
| Rate for Payer: Aetna Commercial |
$1,263.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$965.85
|
| Rate for Payer: Cash Price |
$1,188.74
|
| Rate for Payer: Cofinity Commercial |
$1,040.14
|
| Rate for Payer: Cofinity Commercial |
$1,277.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,040.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,188.74
|
| Rate for Payer: Healthscope Commercial |
$1,337.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,040.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,114.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,263.03
|
| Rate for Payer: PHP Commercial |
$1,263.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$965.85
|
| Rate for Payer: Priority Health SBD |
$936.13
|
| Rate for Payer: UMR Bronson Commercial |
$653.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,114.44
|
|
|
DISOPYRAMIDE PHOSPHATE ER 100 MG CAPSULE,EXTENDED RELEASE
|
Facility
|
OP
|
$1,485.92
|
|
|
Service Code
|
NDC 00025273231
|
| Hospital Charge Code |
2537
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$549.79 |
| Max. Negotiated Rate |
$1,337.33 |
| Rate for Payer: Aetna American Axle |
$965.85
|
| Rate for Payer: Aetna Commercial |
$1,263.03
|
| Rate for Payer: Aetna Medicare |
$742.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$965.85
|
| Rate for Payer: BCBS Complete |
$594.37
|
| Rate for Payer: Cash Price |
$1,188.74
|
| Rate for Payer: Cofinity Commercial |
$1,040.14
|
| Rate for Payer: Cofinity Commercial |
$1,277.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,040.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,188.74
|
| Rate for Payer: Healthscope Commercial |
$1,337.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,040.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,114.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,263.03
|
| Rate for Payer: PHP Commercial |
$1,263.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$965.85
|
| Rate for Payer: Priority Health SBD |
$936.13
|
| Rate for Payer: UMR Bronson Commercial |
$549.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,114.44
|
|
|
DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME)
|
Facility
|
OP
|
$16,646.50
|
|
|
Service Code
|
CPT 36838
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,105.86 |
| Max. Negotiated Rate |
$16,646.50 |
| Rate for Payer: Aetna Medicare |
$5,508.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,620.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,620.50
|
| Rate for Payer: BCBS Complete |
$2,980.81
|
| Rate for Payer: BCBS MAPPO |
$5,296.40
|
| Rate for Payer: BCBS Trust/PPO |
$3,665.22
|
| Rate for Payer: BCN Commercial |
$3,665.22
|
| Rate for Payer: BCN Medicare Advantage |
$5,296.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,296.40
|
| Rate for Payer: Mclaren Medicaid |
$2,838.87
|
| Rate for Payer: Mclaren Medicare |
$5,296.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,561.22
|
| Rate for Payer: Meridian Medicaid |
$2,980.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,090.86
|
| Rate for Payer: Nomi Health Commercial |
$11,122.44
|
| Rate for Payer: PACE Medicare |
$5,031.58
|
| Rate for Payer: PACE SWMI |
$5,296.40
|
| Rate for Payer: PHP Medicare Advantage |
$5,296.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,838.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,646.50
|
| Rate for Payer: Priority Health Medicare |
$5,296.40
|
| Rate for Payer: Priority Health Narrow Network |
$13,317.20
|
| Rate for Payer: Railroad Medicare Medicare |
$5,296.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,216.45
|
| Rate for Payer: UHC Core |
$8,596.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,296.40
|
| Rate for Payer: UHC Exchange |
$1,105.86
|
| Rate for Payer: UHC Medicare Advantage |
$5,296.40
|
| Rate for Payer: UHCCP Medicaid |
$2,838.87
|
| Rate for Payer: VA VA |
$5,296.40
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 68084031311
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna American Axle |
$2.43
|
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
| Rate for Payer: UMR Bronson Commercial |
$1.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.80
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$372.96
|
|
|
Service Code
|
NDC 63739099510
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.00 |
| Max. Negotiated Rate |
$335.66 |
| Rate for Payer: Aetna American Axle |
$242.42
|
| Rate for Payer: Aetna Commercial |
$317.02
|
| Rate for Payer: Aetna Medicare |
$186.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.42
|
| Rate for Payer: BCBS Complete |
$149.18
|
| Rate for Payer: Cash Price |
$298.37
|
| Rate for Payer: Cofinity Commercial |
$261.07
|
| Rate for Payer: Cofinity Commercial |
$320.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.37
|
| Rate for Payer: Healthscope Commercial |
$335.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.02
|
| Rate for Payer: PHP Commercial |
$317.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.42
|
| Rate for Payer: Priority Health SBD |
$234.96
|
| Rate for Payer: UMR Bronson Commercial |
$138.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.72
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$371.45
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.44 |
| Max. Negotiated Rate |
$334.30 |
| Rate for Payer: Aetna American Axle |
$241.44
|
| Rate for Payer: Aetna Commercial |
$315.73
|
| Rate for Payer: Aetna Medicare |
$185.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.44
|
| Rate for Payer: BCBS Complete |
$148.58
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cofinity Commercial |
$260.02
|
| Rate for Payer: Cofinity Commercial |
$319.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$260.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.16
|
| Rate for Payer: Healthscope Commercial |
$334.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.73
|
| Rate for Payer: PHP Commercial |
$315.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.44
|
| Rate for Payer: Priority Health SBD |
$234.01
|
| Rate for Payer: UMR Bronson Commercial |
$137.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.59
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$251.52
|
|
|
Service Code
|
NDC 00378800801
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.06 |
| Max. Negotiated Rate |
$226.37 |
| Rate for Payer: Aetna American Axle |
$163.49
|
| Rate for Payer: Aetna Commercial |
$213.79
|
| Rate for Payer: Aetna Medicare |
$125.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.49
|
| Rate for Payer: BCBS Complete |
$100.61
|
| Rate for Payer: Cash Price |
$201.22
|
| Rate for Payer: Cofinity Commercial |
$176.06
|
| Rate for Payer: Cofinity Commercial |
$216.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$176.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.22
|
| Rate for Payer: Healthscope Commercial |
$226.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.79
|
| Rate for Payer: PHP Commercial |
$213.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.49
|
| Rate for Payer: Priority Health SBD |
$158.46
|
| Rate for Payer: UMR Bronson Commercial |
$93.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.64
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 68084031311
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna American Axle |
$2.43
|
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna Medicare |
$1.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: BCBS Complete |
$1.50
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
| Rate for Payer: UMR Bronson Commercial |
$1.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.80
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$373.92
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.35 |
| Max. Negotiated Rate |
$336.53 |
| Rate for Payer: Healthscope Commercial |
$336.53
|
| Rate for Payer: Aetna American Axle |
$243.05
|
| Rate for Payer: Aetna Commercial |
$317.83
|
| Rate for Payer: Aetna Medicare |
$186.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.05
|
| Rate for Payer: BCBS Complete |
$149.57
|
| Rate for Payer: Cash Price |
$299.14
|
| Rate for Payer: Cofinity Commercial |
$261.74
|
| Rate for Payer: Cofinity Commercial |
$321.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$299.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.83
|
| Rate for Payer: PHP Commercial |
$317.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.05
|
| Rate for Payer: Priority Health SBD |
$235.57
|
| Rate for Payer: UMR Bronson Commercial |
$138.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.44
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$425.28
|
|
|
Service Code
|
NDC 55111053201
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.12 |
| Max. Negotiated Rate |
$382.75 |
| Rate for Payer: Aetna American Axle |
$276.43
|
| Rate for Payer: Aetna Commercial |
$361.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.43
|
| Rate for Payer: Cash Price |
$340.22
|
| Rate for Payer: Cofinity Commercial |
$297.70
|
| Rate for Payer: Cofinity Commercial |
$365.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$297.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.22
|
| Rate for Payer: Healthscope Commercial |
$382.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$318.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.49
|
| Rate for Payer: PHP Commercial |
$361.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.43
|
| Rate for Payer: Priority Health SBD |
$267.93
|
| Rate for Payer: UMR Bronson Commercial |
$187.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$318.96
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$372.96
|
|
|
Service Code
|
NDC 63739099510
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.10 |
| Max. Negotiated Rate |
$335.66 |
| Rate for Payer: Aetna American Axle |
$242.42
|
| Rate for Payer: Aetna Commercial |
$317.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.42
|
| Rate for Payer: Cash Price |
$298.37
|
| Rate for Payer: Cofinity Commercial |
$261.07
|
| Rate for Payer: Cofinity Commercial |
$320.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.37
|
| Rate for Payer: Healthscope Commercial |
$335.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.02
|
| Rate for Payer: PHP Commercial |
$317.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.42
|
| Rate for Payer: Priority Health SBD |
$234.96
|
| Rate for Payer: UMR Bronson Commercial |
$164.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.72
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$371.45
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.44 |
| Max. Negotiated Rate |
$334.30 |
| Rate for Payer: Aetna American Axle |
$241.44
|
| Rate for Payer: Aetna Commercial |
$315.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.44
|
| Rate for Payer: Cash Price |
$297.16
|
| Rate for Payer: Cofinity Commercial |
$260.02
|
| Rate for Payer: Cofinity Commercial |
$319.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$260.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.16
|
| Rate for Payer: Healthscope Commercial |
$334.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$315.73
|
| Rate for Payer: PHP Commercial |
$315.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.44
|
| Rate for Payer: Priority Health SBD |
$234.01
|
| Rate for Payer: UMR Bronson Commercial |
$163.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.59
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$251.52
|
|
|
Service Code
|
NDC 00378800801
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.67 |
| Max. Negotiated Rate |
$226.37 |
| Rate for Payer: Aetna American Axle |
$163.49
|
| Rate for Payer: Aetna Commercial |
$213.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.49
|
| Rate for Payer: Cash Price |
$201.22
|
| Rate for Payer: Cofinity Commercial |
$176.06
|
| Rate for Payer: Cofinity Commercial |
$216.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$176.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.22
|
| Rate for Payer: Healthscope Commercial |
$226.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.79
|
| Rate for Payer: PHP Commercial |
$213.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.49
|
| Rate for Payer: Priority Health SBD |
$158.46
|
| Rate for Payer: UMR Bronson Commercial |
$110.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.64
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$425.28
|
|
|
Service Code
|
NDC 55111053201
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.35 |
| Max. Negotiated Rate |
$382.75 |
| Rate for Payer: Aetna American Axle |
$276.43
|
| Rate for Payer: Aetna Commercial |
$361.49
|
| Rate for Payer: Aetna Medicare |
$212.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.43
|
| Rate for Payer: BCBS Complete |
$170.11
|
| Rate for Payer: Cash Price |
$340.22
|
| Rate for Payer: Cofinity Commercial |
$297.70
|
| Rate for Payer: Cofinity Commercial |
$365.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$297.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.22
|
| Rate for Payer: Healthscope Commercial |
$382.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$318.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.49
|
| Rate for Payer: PHP Commercial |
$361.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.43
|
| Rate for Payer: Priority Health SBD |
$267.93
|
| Rate for Payer: UMR Bronson Commercial |
$157.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$318.96
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$373.92
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.52 |
| Max. Negotiated Rate |
$336.53 |
| Rate for Payer: Aetna American Axle |
$243.05
|
| Rate for Payer: Aetna Commercial |
$317.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.05
|
| Rate for Payer: Cash Price |
$299.14
|
| Rate for Payer: Cofinity Commercial |
$261.74
|
| Rate for Payer: Cofinity Commercial |
$321.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$261.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$299.14
|
| Rate for Payer: Healthscope Commercial |
$336.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.83
|
| Rate for Payer: PHP Commercial |
$317.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$243.05
|
| Rate for Payer: Priority Health SBD |
$235.57
|
| Rate for Payer: UMR Bronson Commercial |
$164.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.44
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.94
|
|
|
Service Code
|
NDC 60687021111
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna American Axle |
$1.91
|
| Rate for Payer: Aetna Commercial |
$2.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.91
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.35
|
| Rate for Payer: Healthscope Commercial |
$2.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.50
|
| Rate for Payer: PHP Commercial |
$2.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.91
|
| Rate for Payer: Priority Health SBD |
$1.85
|
| Rate for Payer: UMR Bronson Commercial |
$1.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.20
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$136.30
|
|
|
Service Code
|
NDC 57237010601
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.60
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna Medicare |
$68.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: BCBS Complete |
$54.52
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.60
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UMR Bronson Commercial |
$50.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$138.65
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.30 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna Medicare |
$69.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: BCBS Complete |
$55.46
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Cofinity Commercial |
$97.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UMR Bronson Commercial |
$51.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
