|
DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$361.92
|
|
|
Service Code
|
NDC 16571020310
|
| Hospital Charge Code |
15339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$228.01 |
| Max. Negotiated Rate |
$325.73 |
| Rate for Payer: Aetna Commercial |
$307.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.25
|
| Rate for Payer: Cash Price |
$289.54
|
| Rate for Payer: Cofinity Advantage |
$253.34
|
| Rate for Payer: Cofinity Commercial |
$311.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.54
|
| Rate for Payer: Healthscope Commercial |
$325.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$271.44
|
| Rate for Payer: PHP Commercial |
$307.63
|
| Rate for Payer: Priority Health SBD |
$228.01
|
|
|
DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$361.92
|
|
|
Service Code
|
NDC 16571020310
|
| Hospital Charge Code |
15339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.23 |
| Max. Negotiated Rate |
$325.73 |
| Rate for Payer: Aetna Commercial |
$307.63
|
| Rate for Payer: Aetna Medicare |
$180.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.25
|
| Rate for Payer: BCBS Complete |
$144.77
|
| Rate for Payer: Cash Price |
$289.54
|
| Rate for Payer: Cofinity Advantage |
$253.34
|
| Rate for Payer: Cofinity Commercial |
$311.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.54
|
| Rate for Payer: Healthscope Commercial |
$325.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$289.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$271.44
|
| Rate for Payer: PHP Commercial |
$307.63
|
| Rate for Payer: Priority Health SBD |
$228.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$235.25
|
| Rate for Payer: UHC Core |
$188.56
|
| Rate for Payer: UHC Exchange |
$142.23
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$381.90
|
|
|
Service Code
|
NDC 51079011820
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.09 |
| Max. Negotiated Rate |
$343.71 |
| Rate for Payer: Aetna Commercial |
$324.62
|
| Rate for Payer: Aetna Medicare |
$190.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.24
|
| Rate for Payer: BCBS Complete |
$152.76
|
| Rate for Payer: Cash Price |
$305.52
|
| Rate for Payer: Cofinity Advantage |
$267.33
|
| Rate for Payer: Cofinity Commercial |
$328.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.52
|
| Rate for Payer: Healthscope Commercial |
$343.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$305.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$286.43
|
| Rate for Payer: PHP Commercial |
$324.62
|
| Rate for Payer: Priority Health SBD |
$240.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.24
|
| Rate for Payer: UHC Core |
$198.97
|
| Rate for Payer: UHC Exchange |
$150.09
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 60687036911
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Aetna Medicare |
$2.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.98
|
| Rate for Payer: BCBS Complete |
$1.84
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Cofinity Advantage |
$3.21
|
| Rate for Payer: Cofinity Commercial |
$3.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.67
|
| Rate for Payer: Healthscope Commercial |
$4.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.90
|
| Rate for Payer: Priority Health SBD |
$2.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.98
|
| Rate for Payer: UHC Core |
$2.39
|
| Rate for Payer: UHC Exchange |
$1.80
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079011801
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Advantage |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.87
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health SBD |
$2.41
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$381.90
|
|
|
Service Code
|
NDC 51079011820
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.60 |
| Max. Negotiated Rate |
$343.71 |
| Rate for Payer: Aetna Commercial |
$324.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.24
|
| Rate for Payer: Cash Price |
$305.52
|
| Rate for Payer: Cofinity Advantage |
$267.33
|
| Rate for Payer: Cofinity Commercial |
$328.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.52
|
| Rate for Payer: Healthscope Commercial |
$343.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$286.43
|
| Rate for Payer: PHP Commercial |
$324.62
|
| Rate for Payer: Priority Health SBD |
$240.60
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 00591079401
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$275.37 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Advantage |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$327.82
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health SBD |
$275.37
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 60687036911
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.98
|
| Rate for Payer: Cash Price |
$3.67
|
| Rate for Payer: Cofinity Advantage |
$3.21
|
| Rate for Payer: Cofinity Commercial |
$3.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.67
|
| Rate for Payer: Healthscope Commercial |
$4.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.90
|
| Rate for Payer: Priority Health SBD |
$2.89
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$437.10
|
|
|
Service Code
|
NDC 00591079401
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.78 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna Medicare |
$218.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: BCBS Complete |
$174.84
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Advantage |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$349.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$327.82
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health SBD |
$275.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$284.12
|
| Rate for Payer: UHC Core |
$227.73
|
| Rate for Payer: UHC Exchange |
$171.78
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 51079011801
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$1.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: BCBS Complete |
$1.53
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Advantage |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.87
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.48
|
| Rate for Payer: UHC Core |
$1.99
|
| Rate for Payer: UHC Exchange |
$1.50
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$458.85
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.33 |
| Max. Negotiated Rate |
$412.96 |
| Rate for Payer: Aetna Commercial |
$390.02
|
| Rate for Payer: Aetna Medicare |
$229.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$298.25
|
| Rate for Payer: BCBS Complete |
$183.54
|
| Rate for Payer: Cash Price |
$367.08
|
| Rate for Payer: Cofinity Advantage |
$321.19
|
| Rate for Payer: Cofinity Commercial |
$394.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$367.08
|
| Rate for Payer: Healthscope Commercial |
$412.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$367.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$390.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$344.14
|
| Rate for Payer: PHP Commercial |
$390.02
|
| Rate for Payer: Priority Health SBD |
$289.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$298.25
|
| Rate for Payer: UHC Core |
$239.06
|
| Rate for Payer: UHC Exchange |
$180.33
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$458.85
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$289.08 |
| Max. Negotiated Rate |
$412.96 |
| Rate for Payer: Aetna Commercial |
$390.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$298.25
|
| Rate for Payer: Cash Price |
$367.08
|
| Rate for Payer: Cofinity Advantage |
$321.19
|
| Rate for Payer: Cofinity Commercial |
$394.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$367.08
|
| Rate for Payer: Healthscope Commercial |
$412.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$390.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$344.14
|
| Rate for Payer: PHP Commercial |
$390.02
|
| Rate for Payer: Priority Health SBD |
$289.08
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$41.39
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.56 |
| Max. Negotiated Rate |
$37.25 |
| Rate for Payer: Aetna Commercial |
$35.18
|
| Rate for Payer: Aetna Commercial |
$27.62
|
| Rate for Payer: Aetna Commercial |
$235.89
|
| Rate for Payer: Aetna Commercial |
$29.91
|
| Rate for Payer: Aetna Commercial |
$23.39
|
| Rate for Payer: Aetna Medicare |
$13.76
|
| Rate for Payer: Aetna Medicare |
$138.76
|
| Rate for Payer: Aetna Medicare |
$16.25
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: Aetna Medicare |
$17.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: BCBS Complete |
$16.56
|
| Rate for Payer: BCBS Complete |
$111.01
|
| Rate for Payer: BCBS Complete |
$13.00
|
| Rate for Payer: BCBS Complete |
$11.01
|
| Rate for Payer: BCBS Complete |
$14.08
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: Cash Price |
$28.15
|
| Rate for Payer: Cash Price |
$222.02
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$25.99
|
| Rate for Payer: Cash Price |
$222.02
|
| Rate for Payer: Cash Price |
$25.99
|
| Rate for Payer: Cash Price |
$28.15
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cofinity Advantage |
$28.97
|
| Rate for Payer: Cofinity Advantage |
$24.63
|
| Rate for Payer: Cofinity Advantage |
$194.26
|
| Rate for Payer: Cofinity Advantage |
$19.26
|
| Rate for Payer: Cofinity Advantage |
$22.74
|
| Rate for Payer: Cofinity Commercial |
$27.94
|
| Rate for Payer: Cofinity Commercial |
$238.67
|
| Rate for Payer: Cofinity Commercial |
$30.26
|
| Rate for Payer: Cofinity Commercial |
$35.60
|
| Rate for Payer: Cofinity Commercial |
$23.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.02
|
| Rate for Payer: Healthscope Commercial |
$249.77
|
| Rate for Payer: Healthscope Commercial |
$37.25
|
| Rate for Payer: Healthscope Commercial |
$31.67
|
| Rate for Payer: Healthscope Commercial |
$29.24
|
| Rate for Payer: Healthscope Commercial |
$24.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$222.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.39
|
| Rate for Payer: PHP Commercial |
$27.62
|
| Rate for Payer: PHP Commercial |
$235.89
|
| Rate for Payer: PHP Commercial |
$23.39
|
| Rate for Payer: PHP Commercial |
$35.18
|
| Rate for Payer: PHP Commercial |
$29.91
|
| Rate for Payer: Priority Health SBD |
$20.47
|
| Rate for Payer: Priority Health SBD |
$22.17
|
| Rate for Payer: Priority Health SBD |
$26.08
|
| Rate for Payer: Priority Health SBD |
$174.84
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$41.39
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$37.25 |
| Rate for Payer: Aetna Commercial |
$35.18
|
| Rate for Payer: Aetna Commercial |
$235.89
|
| Rate for Payer: Aetna Commercial |
$23.39
|
| Rate for Payer: Aetna Commercial |
$27.62
|
| Rate for Payer: Aetna Commercial |
$29.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.90
|
| Rate for Payer: Cash Price |
$25.99
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cash Price |
$222.02
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$28.15
|
| Rate for Payer: Cofinity Advantage |
$24.63
|
| Rate for Payer: Cofinity Advantage |
$22.74
|
| Rate for Payer: Cofinity Advantage |
$28.97
|
| Rate for Payer: Cofinity Advantage |
$19.26
|
| Rate for Payer: Cofinity Advantage |
$194.26
|
| Rate for Payer: Cofinity Commercial |
$35.60
|
| Rate for Payer: Cofinity Commercial |
$27.94
|
| Rate for Payer: Cofinity Commercial |
$30.26
|
| Rate for Payer: Cofinity Commercial |
$238.67
|
| Rate for Payer: Cofinity Commercial |
$23.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.11
|
| Rate for Payer: Healthscope Commercial |
$29.24
|
| Rate for Payer: Healthscope Commercial |
$37.25
|
| Rate for Payer: Healthscope Commercial |
$249.77
|
| Rate for Payer: Healthscope Commercial |
$24.77
|
| Rate for Payer: Healthscope Commercial |
$31.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$208.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.04
|
| Rate for Payer: PHP Commercial |
$23.39
|
| Rate for Payer: PHP Commercial |
$29.91
|
| Rate for Payer: PHP Commercial |
$35.18
|
| Rate for Payer: PHP Commercial |
$235.89
|
| Rate for Payer: PHP Commercial |
$27.62
|
| Rate for Payer: Priority Health SBD |
$22.17
|
| Rate for Payer: Priority Health SBD |
$20.47
|
| Rate for Payer: Priority Health SBD |
$174.84
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: Priority Health SBD |
$26.08
|
|
|
DICYCLOMINE 20 MG TABLET
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Aetna Commercial |
$364.99
|
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: Aetna Commercial |
$331.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$279.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.79
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cash Price |
$312.36
|
| Rate for Payer: Cash Price |
$343.52
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cofinity Advantage |
$273.31
|
| Rate for Payer: Cofinity Advantage |
$300.58
|
| Rate for Payer: Cofinity Advantage |
$3.01
|
| Rate for Payer: Cofinity Advantage |
$238.53
|
| Rate for Payer: Cofinity Commercial |
$369.28
|
| Rate for Payer: Cofinity Commercial |
$335.79
|
| Rate for Payer: Cofinity Commercial |
$3.70
|
| Rate for Payer: Cofinity Commercial |
$293.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.44
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Healthscope Commercial |
$386.46
|
| Rate for Payer: Healthscope Commercial |
$351.40
|
| Rate for Payer: Healthscope Commercial |
$3.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$322.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$255.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.23
|
| Rate for Payer: PHP Commercial |
$331.88
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: PHP Commercial |
$3.65
|
| Rate for Payer: PHP Commercial |
$364.99
|
| Rate for Payer: Priority Health SBD |
$270.52
|
| Rate for Payer: Priority Health SBD |
$245.98
|
| Rate for Payer: Priority Health SBD |
$2.71
|
| Rate for Payer: Priority Health SBD |
$214.67
|
|
|
DICYCLOMINE 20 MG TABLET
|
Facility
|
OP
|
$390.45
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.69 |
| Max. Negotiated Rate |
$351.40 |
| Rate for Payer: Aetna Commercial |
$331.88
|
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Aetna Commercial |
$364.99
|
| Rate for Payer: Aetna Commercial |
$289.64
|
| Rate for Payer: Aetna Medicare |
$195.22
|
| Rate for Payer: Aetna Medicare |
$2.15
|
| Rate for Payer: Aetna Medicare |
$214.70
|
| Rate for Payer: Aetna Medicare |
$170.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$279.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.79
|
| Rate for Payer: BCBS Complete |
$1.72
|
| Rate for Payer: BCBS Complete |
$156.18
|
| Rate for Payer: BCBS Complete |
$136.30
|
| Rate for Payer: BCBS Complete |
$171.76
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: Cash Price |
$312.36
|
| Rate for Payer: Cash Price |
$343.52
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cash Price |
$343.52
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cash Price |
$272.60
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cash Price |
$312.36
|
| Rate for Payer: Cofinity Advantage |
$3.01
|
| Rate for Payer: Cofinity Advantage |
$238.53
|
| Rate for Payer: Cofinity Advantage |
$300.58
|
| Rate for Payer: Cofinity Advantage |
$273.31
|
| Rate for Payer: Cofinity Commercial |
$293.05
|
| Rate for Payer: Cofinity Commercial |
$3.70
|
| Rate for Payer: Cofinity Commercial |
$335.79
|
| Rate for Payer: Cofinity Commercial |
$369.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.36
|
| Rate for Payer: Healthscope Commercial |
$386.46
|
| Rate for Payer: Healthscope Commercial |
$306.68
|
| Rate for Payer: Healthscope Commercial |
$3.87
|
| Rate for Payer: Healthscope Commercial |
$351.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$312.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$272.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$343.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$322.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$255.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.23
|
| Rate for Payer: PHP Commercial |
$364.99
|
| Rate for Payer: PHP Commercial |
$331.88
|
| Rate for Payer: PHP Commercial |
$3.65
|
| Rate for Payer: PHP Commercial |
$289.64
|
| Rate for Payer: Priority Health SBD |
$214.67
|
| Rate for Payer: Priority Health SBD |
$270.52
|
| Rate for Payer: Priority Health SBD |
$2.71
|
| Rate for Payer: Priority Health SBD |
$245.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Core |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
| Rate for Payer: UHC Exchange |
$18.69
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$5,262.89
|
|
|
Service Code
|
APR-DRG 2401
|
| Min. Negotiated Rate |
$5,012.28 |
| Max. Negotiated Rate |
$5,262.89 |
| Rate for Payer: BCBS Complete |
$5,262.89
|
| Rate for Payer: Mclaren Medicaid |
$5,012.28
|
| Rate for Payer: Meridian Medicaid |
$5,262.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$5,012.28
|
| Rate for Payer: UHC Medicaid |
$5,012.28
|
| Rate for Payer: UHCCP Medicaid |
$5,012.28
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$12,707.77
|
|
|
Service Code
|
APR-DRG 2404
|
| Min. Negotiated Rate |
$12,102.64 |
| Max. Negotiated Rate |
$12,707.77 |
| Rate for Payer: BCBS Complete |
$12,707.77
|
| Rate for Payer: Mclaren Medicaid |
$12,102.64
|
| Rate for Payer: Meridian Medicaid |
$12,707.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$12,102.64
|
| Rate for Payer: UHC Medicaid |
$12,102.64
|
| Rate for Payer: UHCCP Medicaid |
$12,102.64
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$6,407.77
|
|
|
Service Code
|
APR-DRG 2402
|
| Min. Negotiated Rate |
$6,102.64 |
| Max. Negotiated Rate |
$6,407.77 |
| Rate for Payer: BCBS Complete |
$6,407.77
|
| Rate for Payer: Mclaren Medicaid |
$6,102.64
|
| Rate for Payer: Meridian Medicaid |
$6,407.77
|
| Rate for Payer: Priority Health Choice Medicaid |
$6,102.64
|
| Rate for Payer: UHC Medicaid |
$6,102.64
|
| Rate for Payer: UHCCP Medicaid |
$6,102.64
|
|
|
DIGESTIVE MALIGNANCY
|
Facility
|
IP
|
$9,194.59
|
|
|
Service Code
|
APR-DRG 2403
|
| Min. Negotiated Rate |
$8,756.75 |
| Max. Negotiated Rate |
$9,194.59 |
| Rate for Payer: BCBS Complete |
$9,194.59
|
| Rate for Payer: Mclaren Medicaid |
$8,756.75
|
| Rate for Payer: Meridian Medicaid |
$9,194.59
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,756.75
|
| Rate for Payer: UHC Medicaid |
$8,756.75
|
| Rate for Payer: UHCCP Medicaid |
$8,756.75
|
|
|
DIGESTIVE MALIGNANCY WITH CC
|
Facility
|
IP
|
$19,716.48
|
|
|
Service Code
|
MSDRG 375
|
| Min. Negotiated Rate |
$9,430.72 |
| Max. Negotiated Rate |
$19,716.48 |
| Rate for Payer: Aetna Medicare |
$10,324.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12,408.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12,408.84
|
| Rate for Payer: BCBS MAPPO |
$9,927.07
|
| Rate for Payer: BCBS Trust/PPO |
$18,665.54
|
| Rate for Payer: BCN Commercial |
$18,665.54
|
| Rate for Payer: BCN Medicare Advantage |
$9,927.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,927.07
|
| Rate for Payer: Mclaren Medicare |
$9,927.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10,423.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11,416.13
|
| Rate for Payer: Molina Medicare/Medicaid |
$10,919.78
|
| Rate for Payer: Nomi Health Commercial |
$15,603.84
|
| Rate for Payer: PACE Medicare |
$9,430.72
|
| Rate for Payer: PACE SWMI |
$9,927.07
|
| Rate for Payer: PHP Medicare Advantage |
$9,927.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$19,501.34
|
| Rate for Payer: Priority Health Medicare |
$9,927.07
|
| Rate for Payer: Priority Health Tiered Network |
$15,601.07
|
| Rate for Payer: Railroad Medicare Medicare |
$9,927.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19,716.48
|
| Rate for Payer: UHC Core |
$16,495.32
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9,927.07
|
| Rate for Payer: UHC Exchange |
$13,471.32
|
| Rate for Payer: VA VA |
$9,927.07
|
|
|
DIGESTIVE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$34,860.81
|
|
|
Service Code
|
MSDRG 374
|
| Min. Negotiated Rate |
$16,251.98 |
| Max. Negotiated Rate |
$34,860.81 |
| Rate for Payer: Aetna Medicare |
$17,791.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,384.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,384.19
|
| Rate for Payer: BCBS MAPPO |
$17,107.35
|
| Rate for Payer: BCBS Trust/PPO |
$32,506.69
|
| Rate for Payer: BCN Commercial |
$32,506.69
|
| Rate for Payer: BCN Medicare Advantage |
$17,107.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17,107.35
|
| Rate for Payer: Mclaren Medicare |
$17,107.35
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17,962.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,673.45
|
| Rate for Payer: Molina Medicare/Medicaid |
$18,818.08
|
| Rate for Payer: Nomi Health Commercial |
$27,589.23
|
| Rate for Payer: PACE Medicare |
$16,251.98
|
| Rate for Payer: PACE SWMI |
$17,107.35
|
| Rate for Payer: PHP Medicare Advantage |
$17,107.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$34,480.42
|
| Rate for Payer: Priority Health Medicare |
$17,107.35
|
| Rate for Payer: Priority Health Tiered Network |
$27,584.33
|
| Rate for Payer: Railroad Medicare Medicare |
$17,107.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34,860.81
|
| Rate for Payer: UHC Core |
$29,165.45
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$17,107.35
|
| Rate for Payer: UHC Exchange |
$23,818.70
|
| Rate for Payer: VA VA |
$17,107.35
|
|
|
DIGESTIVE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$15,066.09
|
|
|
Service Code
|
MSDRG 376
|
| Min. Negotiated Rate |
$7,336.09 |
| Max. Negotiated Rate |
$15,066.09 |
| Rate for Payer: Aetna Medicare |
$8,031.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9,652.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9,652.75
|
| Rate for Payer: BCBS MAPPO |
$7,722.20
|
| Rate for Payer: BCBS Trust/PPO |
$14,262.49
|
| Rate for Payer: BCN Commercial |
$14,262.49
|
| Rate for Payer: BCN Medicare Advantage |
$7,722.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7,722.20
|
| Rate for Payer: Mclaren Medicare |
$7,722.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8,108.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8,880.53
|
| Rate for Payer: Molina Medicare/Medicaid |
$8,494.42
|
| Rate for Payer: Nomi Health Commercial |
$11,923.47
|
| Rate for Payer: PACE Medicare |
$7,336.09
|
| Rate for Payer: PACE SWMI |
$7,722.20
|
| Rate for Payer: PHP Medicare Advantage |
$7,722.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$14,901.69
|
| Rate for Payer: Priority Health Medicare |
$7,722.20
|
| Rate for Payer: Priority Health Tiered Network |
$11,921.35
|
| Rate for Payer: Railroad Medicare Medicare |
$7,722.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15,066.09
|
| Rate for Payer: UHC Core |
$12,604.68
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$7,722.20
|
| Rate for Payer: UHC Exchange |
$10,293.93
|
| Rate for Payer: VA VA |
$7,722.20
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET
|
Facility
|
OP
|
$475.20
|
|
|
Service Code
|
NDC 60687085801
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.75 |
| Max. Negotiated Rate |
$427.68 |
| Rate for Payer: Aetna Commercial |
$403.92
|
| Rate for Payer: Aetna Medicare |
$237.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.88
|
| Rate for Payer: BCBS Complete |
$190.08
|
| Rate for Payer: Cash Price |
$380.16
|
| Rate for Payer: Cofinity Advantage |
$332.64
|
| Rate for Payer: Cofinity Commercial |
$408.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.16
|
| Rate for Payer: Healthscope Commercial |
$427.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$380.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.40
|
| Rate for Payer: PHP Commercial |
$403.92
|
| Rate for Payer: Priority Health SBD |
$299.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$308.88
|
| Rate for Payer: UHC Core |
$247.58
|
| Rate for Payer: UHC Exchange |
$186.75
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET
|
Facility
|
IP
|
$475.20
|
|
|
Service Code
|
NDC 60687085801
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$299.38 |
| Max. Negotiated Rate |
$427.68 |
| Rate for Payer: Aetna Commercial |
$403.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.88
|
| Rate for Payer: Cash Price |
$380.16
|
| Rate for Payer: Cofinity Advantage |
$332.64
|
| Rate for Payer: Cofinity Commercial |
$408.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.16
|
| Rate for Payer: Healthscope Commercial |
$427.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.40
|
| Rate for Payer: PHP Commercial |
$403.92
|
| Rate for Payer: Priority Health SBD |
$299.38
|
|
