|
DEXTROSE 5 % IV BOLUS
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$18.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.85
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: BCBS MAPPO |
$17.48
|
| Rate for Payer: BCBS Trust/PPO |
$57.48
|
| Rate for Payer: BCN Commercial |
$54.36
|
| Rate for Payer: BCN Medicare Advantage |
$17.48
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.48
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: Nomi Health Commercial |
$57.33
|
| Rate for Payer: PACE Senior Care Partners |
$16.61
|
| Rate for Payer: PACE SWMI |
$17.48
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: PHP Medicare Advantage |
$17.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health HMO/PPO |
$60.83
|
| Rate for Payer: Priority Health Medicare |
$17.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.85
|
| Rate for Payer: Railroad Medicare Medicare |
$17.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.53
|
| Rate for Payer: UHC Core |
$58.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.48
|
| Rate for Payer: UHC Exchange |
$17.48
|
| Rate for Payer: UHC Medicare Advantage |
$17.48
|
| Rate for Payer: VA VA |
$17.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION
|
Facility
|
IP
|
$63.72
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.42 |
| Max. Negotiated Rate |
$57.35 |
| Rate for Payer: Aetna Commercial |
$54.16
|
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: BCBS Trust/PPO |
$52.01
|
| Rate for Payer: BCBS Trust/PPO |
$5.92
|
| Rate for Payer: BCN Commercial |
$49.24
|
| Rate for Payer: BCN Commercial |
$5.60
|
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cofinity Commercial |
$6.24
|
| Rate for Payer: Cofinity Commercial |
$54.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.98
|
| Rate for Payer: Healthscope Commercial |
$57.35
|
| Rate for Payer: Healthscope Commercial |
$6.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.16
|
| Rate for Payer: Nomi Health Commercial |
$52.25
|
| Rate for Payer: Nomi Health Commercial |
$5.95
|
| Rate for Payer: PHP Commercial |
$54.16
|
| Rate for Payer: PHP Commercial |
$6.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.42
|
| Rate for Payer: Priority Health HMO/PPO |
$6.31
|
| Rate for Payer: Priority Health HMO/PPO |
$55.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.38
|
| Rate for Payer: UHC Core |
$53.21
|
| Rate for Payer: UHC Core |
$6.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.44
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION
|
Facility
|
OP
|
$7.25
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$6.53 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: Aetna Commercial |
$54.16
|
| Rate for Payer: Aetna Medicare |
$1.89
|
| Rate for Payer: Aetna Medicare |
$16.57
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.91
|
| Rate for Payer: BCBS Complete |
$25.49
|
| Rate for Payer: BCBS Complete |
$2.90
|
| Rate for Payer: BCBS MAPPO |
$15.93
|
| Rate for Payer: BCBS MAPPO |
$1.81
|
| Rate for Payer: BCBS Trust/PPO |
$5.96
|
| Rate for Payer: BCBS Trust/PPO |
$52.38
|
| Rate for Payer: BCN Commercial |
$5.64
|
| Rate for Payer: BCN Commercial |
$49.54
|
| Rate for Payer: BCN Medicare Advantage |
$1.81
|
| Rate for Payer: BCN Medicare Advantage |
$15.93
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: Cofinity Commercial |
$54.80
|
| Rate for Payer: Cofinity Commercial |
$6.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.81
|
| Rate for Payer: Healthscope Commercial |
$57.35
|
| Rate for Payer: Healthscope Commercial |
$6.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.16
|
| Rate for Payer: Nomi Health Commercial |
$5.95
|
| Rate for Payer: Nomi Health Commercial |
$52.25
|
| Rate for Payer: PACE Senior Care Partners |
$1.72
|
| Rate for Payer: PACE Senior Care Partners |
$15.13
|
| Rate for Payer: PACE SWMI |
$1.81
|
| Rate for Payer: PACE SWMI |
$15.93
|
| Rate for Payer: PHP Commercial |
$6.16
|
| Rate for Payer: PHP Commercial |
$54.16
|
| Rate for Payer: PHP Medicare Advantage |
$15.93
|
| Rate for Payer: PHP Medicare Advantage |
$1.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.42
|
| Rate for Payer: Priority Health HMO/PPO |
$55.44
|
| Rate for Payer: Priority Health HMO/PPO |
$6.31
|
| Rate for Payer: Priority Health Medicare |
$1.83
|
| Rate for Payer: Priority Health Medicare |
$16.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.69
|
| Rate for Payer: Railroad Medicare Medicare |
$15.93
|
| Rate for Payer: Railroad Medicare Medicare |
$1.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$56.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.38
|
| Rate for Payer: UHC Core |
$6.05
|
| Rate for Payer: UHC Core |
$53.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.93
|
| Rate for Payer: UHC Exchange |
$15.93
|
| Rate for Payer: UHC Exchange |
$1.81
|
| Rate for Payer: UHC Medicare Advantage |
$15.93
|
| Rate for Payer: UHC Medicare Advantage |
$1.81
|
| Rate for Payer: VA VA |
$15.93
|
| Rate for Payer: VA VA |
$1.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.79
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$1.41
|
|
|
Service Code
|
NDC 51079028401
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna Commercial |
$1.20
|
| Rate for Payer: Aetna Medicare |
$0.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.44
|
| Rate for Payer: BCBS Complete |
$0.56
|
| Rate for Payer: BCBS MAPPO |
$0.35
|
| Rate for Payer: BCBS Trust/PPO |
$1.16
|
| Rate for Payer: BCN Commercial |
$1.10
|
| Rate for Payer: BCN Medicare Advantage |
$0.35
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$1.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.35
|
| Rate for Payer: Healthscope Commercial |
$1.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.20
|
| Rate for Payer: Nomi Health Commercial |
$1.16
|
| Rate for Payer: PACE Senior Care Partners |
$0.33
|
| Rate for Payer: PACE SWMI |
$0.35
|
| Rate for Payer: PHP Commercial |
$1.20
|
| Rate for Payer: PHP Medicare Advantage |
$0.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.92
|
| Rate for Payer: Priority Health HMO/PPO |
$1.23
|
| Rate for Payer: Priority Health Medicare |
$0.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.94
|
| Rate for Payer: Railroad Medicare Medicare |
$0.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.24
|
| Rate for Payer: UHC Core |
$1.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.35
|
| Rate for Payer: UHC Exchange |
$0.35
|
| Rate for Payer: UHC Medicare Advantage |
$0.35
|
| Rate for Payer: VA VA |
$0.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.06
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$1.41
|
|
|
Service Code
|
NDC 51079028401
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna Commercial |
$1.20
|
| Rate for Payer: BCBS Trust/PPO |
$1.15
|
| Rate for Payer: BCN Commercial |
$1.09
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$1.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.13
|
| Rate for Payer: Healthscope Commercial |
$1.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.20
|
| Rate for Payer: Nomi Health Commercial |
$1.16
|
| Rate for Payer: PHP Commercial |
$1.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.92
|
| Rate for Payer: Priority Health HMO/PPO |
$1.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.24
|
| Rate for Payer: UHC Core |
$1.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.06
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$63.45
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.07 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna Medicare |
$16.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.83
|
| Rate for Payer: BCBS Complete |
$25.38
|
| Rate for Payer: BCBS MAPPO |
$15.86
|
| Rate for Payer: BCBS Trust/PPO |
$52.16
|
| Rate for Payer: BCN Commercial |
$49.33
|
| Rate for Payer: BCN Medicare Advantage |
$15.86
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.86
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: Nomi Health Commercial |
$52.03
|
| Rate for Payer: PACE Senior Care Partners |
$15.07
|
| Rate for Payer: PACE SWMI |
$15.86
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: PHP Medicare Advantage |
$15.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| Rate for Payer: Priority Health HMO/PPO |
$55.20
|
| Rate for Payer: Priority Health Medicare |
$16.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.51
|
| Rate for Payer: Railroad Medicare Medicare |
$15.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.84
|
| Rate for Payer: UHC Core |
$52.98
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.86
|
| Rate for Payer: UHC Exchange |
$15.86
|
| Rate for Payer: UHC Medicare Advantage |
$15.86
|
| Rate for Payer: VA VA |
$15.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna Medicare |
$38.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.27
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: BCBS MAPPO |
$37.01
|
| Rate for Payer: BCBS Trust/PPO |
$121.71
|
| Rate for Payer: BCN Commercial |
$115.11
|
| Rate for Payer: BCN Medicare Advantage |
$37.01
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.01
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$38.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: PACE Senior Care Partners |
$35.16
|
| Rate for Payer: PACE SWMI |
$37.01
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: PHP Medicare Advantage |
$37.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health HMO/PPO |
$128.80
|
| Rate for Payer: Priority Health Medicare |
$37.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.19
|
| Rate for Payer: Railroad Medicare Medicare |
$37.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.28
|
| Rate for Payer: UHC Core |
$123.62
|
| Rate for Payer: UHC Dual Complete DSNP |
$37.01
|
| Rate for Payer: UHC Exchange |
$37.01
|
| Rate for Payer: UHC Medicare Advantage |
$37.01
|
| Rate for Payer: VA VA |
$37.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: BCBS Trust/PPO |
$1.22
|
| Rate for Payer: BCN Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.27
|
| Rate for Payer: Nomi Health Commercial |
$1.22
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health HMO/PPO |
$1.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.31
|
| Rate for Payer: UHC Core |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$1.49
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna Medicare |
$0.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.47
|
| Rate for Payer: BCBS Complete |
$0.60
|
| Rate for Payer: BCBS MAPPO |
$0.37
|
| Rate for Payer: BCBS Trust/PPO |
$1.22
|
| Rate for Payer: BCN Commercial |
$1.16
|
| Rate for Payer: BCN Medicare Advantage |
$0.37
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.37
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.27
|
| Rate for Payer: Nomi Health Commercial |
$1.22
|
| Rate for Payer: PACE Senior Care Partners |
$0.35
|
| Rate for Payer: PACE SWMI |
$0.37
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: PHP Medicare Advantage |
$0.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health HMO/PPO |
$1.30
|
| Rate for Payer: Priority Health Medicare |
$0.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.00
|
| Rate for Payer: Railroad Medicare Medicare |
$0.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.31
|
| Rate for Payer: UHC Core |
$1.24
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.37
|
| Rate for Payer: UHC Exchange |
$0.37
|
| Rate for Payer: UHC Medicare Advantage |
$0.37
|
| Rate for Payer: VA VA |
$0.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$63.45
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.24 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: BCBS Trust/PPO |
$51.79
|
| Rate for Payer: BCN Commercial |
$49.03
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: Nomi Health Commercial |
$52.03
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| Rate for Payer: Priority Health HMO/PPO |
$55.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.84
|
| Rate for Payer: UHC Core |
$52.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.23 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: BCBS Trust/PPO |
$120.85
|
| Rate for Payer: BCN Commercial |
$114.41
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health HMO/PPO |
$128.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.28
|
| Rate for Payer: UHC Core |
$123.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$12.86
|
|
|
Service Code
|
NDC 00536121195
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$11.57 |
| Rate for Payer: Aetna Commercial |
$10.93
|
| Rate for Payer: BCBS Trust/PPO |
$10.50
|
| Rate for Payer: BCN Commercial |
$9.94
|
| Rate for Payer: Cash Price |
$10.29
|
| Rate for Payer: Cofinity Commercial |
$11.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.29
|
| Rate for Payer: Healthscope Commercial |
$11.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.93
|
| Rate for Payer: Nomi Health Commercial |
$10.55
|
| Rate for Payer: PHP Commercial |
$10.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.36
|
| Rate for Payer: Priority Health HMO/PPO |
$11.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.32
|
| Rate for Payer: UHC Core |
$10.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.64
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
OP
|
$12.86
|
|
|
Service Code
|
NDC 00536121195
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.05 |
| Max. Negotiated Rate |
$11.57 |
| Rate for Payer: Aetna Commercial |
$10.93
|
| Rate for Payer: Aetna Medicare |
$3.34
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.02
|
| Rate for Payer: BCBS Complete |
$5.14
|
| Rate for Payer: BCBS MAPPO |
$3.21
|
| Rate for Payer: BCBS Trust/PPO |
$10.57
|
| Rate for Payer: BCN Commercial |
$10.00
|
| Rate for Payer: BCN Medicare Advantage |
$3.21
|
| Rate for Payer: Cash Price |
$10.29
|
| Rate for Payer: Cofinity Commercial |
$11.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.21
|
| Rate for Payer: Healthscope Commercial |
$11.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.93
|
| Rate for Payer: Nomi Health Commercial |
$10.55
|
| Rate for Payer: PACE Senior Care Partners |
$3.05
|
| Rate for Payer: PACE SWMI |
$3.21
|
| Rate for Payer: PHP Commercial |
$10.93
|
| Rate for Payer: PHP Medicare Advantage |
$3.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.36
|
| Rate for Payer: Priority Health HMO/PPO |
$11.19
|
| Rate for Payer: Priority Health Medicare |
$3.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.62
|
| Rate for Payer: Railroad Medicare Medicare |
$3.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.32
|
| Rate for Payer: UHC Core |
$10.74
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.21
|
| Rate for Payer: UHC Exchange |
$3.21
|
| Rate for Payer: UHC Medicare Advantage |
$3.21
|
| Rate for Payer: VA VA |
$3.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.64
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$26.95
|
|
|
Service Code
|
NDC 09629513975
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.52 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: BCBS Trust/PPO |
$22.00
|
| Rate for Payer: BCN Commercial |
$20.83
|
| Rate for Payer: Cash Price |
$21.56
|
| Rate for Payer: Cofinity Commercial |
$23.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.56
|
| Rate for Payer: Healthscope Commercial |
$24.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.91
|
| Rate for Payer: Nomi Health Commercial |
$22.10
|
| Rate for Payer: PHP Commercial |
$22.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.52
|
| Rate for Payer: Priority Health HMO/PPO |
$23.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.72
|
| Rate for Payer: UHC Core |
$22.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.21
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 25866059361
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: BCBS Trust/PPO |
$45.71
|
| Rate for Payer: BCN Commercial |
$43.28
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$48.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Healthscope Commercial |
$50.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: Nomi Health Commercial |
$45.92
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.40
|
| Rate for Payer: Priority Health HMO/PPO |
$48.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$37.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.28
|
| Rate for Payer: UHC Core |
$46.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.00
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$39.90
|
|
|
Service Code
|
NDC 45802095301
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.48 |
| Max. Negotiated Rate |
$35.91 |
| Rate for Payer: Aetna Commercial |
$33.91
|
| Rate for Payer: Aetna Medicare |
$10.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.47
|
| Rate for Payer: BCBS Complete |
$15.96
|
| Rate for Payer: BCBS MAPPO |
$9.97
|
| Rate for Payer: BCBS Trust/PPO |
$32.80
|
| Rate for Payer: BCN Commercial |
$31.02
|
| Rate for Payer: BCN Medicare Advantage |
$9.97
|
| Rate for Payer: Cash Price |
$31.92
|
| Rate for Payer: Cofinity Commercial |
$34.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.97
|
| Rate for Payer: Healthscope Commercial |
$35.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.91
|
| Rate for Payer: Nomi Health Commercial |
$32.72
|
| Rate for Payer: PACE Senior Care Partners |
$9.48
|
| Rate for Payer: PACE SWMI |
$9.97
|
| Rate for Payer: PHP Commercial |
$33.91
|
| Rate for Payer: PHP Medicare Advantage |
$9.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.93
|
| Rate for Payer: Priority Health HMO/PPO |
$34.71
|
| Rate for Payer: Priority Health Medicare |
$10.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.73
|
| Rate for Payer: Railroad Medicare Medicare |
$9.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.11
|
| Rate for Payer: UHC Core |
$33.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.97
|
| Rate for Payer: UHC Exchange |
$9.97
|
| Rate for Payer: UHC Medicare Advantage |
$9.97
|
| Rate for Payer: VA VA |
$9.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.93
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 69097052444
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.64 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: Aetna Medicare |
$12.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.31
|
| Rate for Payer: BCBS Complete |
$19.60
|
| Rate for Payer: BCBS MAPPO |
$12.25
|
| Rate for Payer: BCBS Trust/PPO |
$40.28
|
| Rate for Payer: BCN Commercial |
$38.10
|
| Rate for Payer: BCN Medicare Advantage |
$12.25
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$42.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.25
|
| Rate for Payer: Healthscope Commercial |
$44.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.65
|
| Rate for Payer: Nomi Health Commercial |
$40.18
|
| Rate for Payer: PACE Senior Care Partners |
$11.64
|
| Rate for Payer: PACE SWMI |
$12.25
|
| Rate for Payer: PHP Commercial |
$41.65
|
| Rate for Payer: PHP Medicare Advantage |
$12.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.85
|
| Rate for Payer: Priority Health HMO/PPO |
$42.63
|
| Rate for Payer: Priority Health Medicare |
$12.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.83
|
| Rate for Payer: Railroad Medicare Medicare |
$12.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$43.12
|
| Rate for Payer: UHC Core |
$40.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.25
|
| Rate for Payer: UHC Exchange |
$12.25
|
| Rate for Payer: UHC Medicare Advantage |
$12.25
|
| Rate for Payer: VA VA |
$12.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.75
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$63.35
|
|
|
Service Code
|
NDC 00067815203
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$57.02 |
| Rate for Payer: Aetna Commercial |
$53.85
|
| Rate for Payer: Aetna Medicare |
$16.47
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.80
|
| Rate for Payer: BCBS Complete |
$25.34
|
| Rate for Payer: BCBS MAPPO |
$15.84
|
| Rate for Payer: BCBS Trust/PPO |
$52.08
|
| Rate for Payer: BCN Commercial |
$49.25
|
| Rate for Payer: BCN Medicare Advantage |
$15.84
|
| Rate for Payer: Cash Price |
$50.68
|
| Rate for Payer: Cofinity Commercial |
$54.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.84
|
| Rate for Payer: Healthscope Commercial |
$57.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.85
|
| Rate for Payer: Nomi Health Commercial |
$51.95
|
| Rate for Payer: PACE Senior Care Partners |
$15.05
|
| Rate for Payer: PACE SWMI |
$15.84
|
| Rate for Payer: PHP Commercial |
$53.85
|
| Rate for Payer: PHP Medicare Advantage |
$15.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.18
|
| Rate for Payer: Priority Health HMO/PPO |
$55.11
|
| Rate for Payer: Priority Health Medicare |
$16.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.44
|
| Rate for Payer: Railroad Medicare Medicare |
$15.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.75
|
| Rate for Payer: UHC Core |
$52.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.84
|
| Rate for Payer: UHC Exchange |
$15.84
|
| Rate for Payer: UHC Medicare Advantage |
$15.84
|
| Rate for Payer: VA VA |
$15.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.51
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$63.35
|
|
|
Service Code
|
NDC 00067815203
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.18 |
| Max. Negotiated Rate |
$57.02 |
| Rate for Payer: Aetna Commercial |
$53.85
|
| Rate for Payer: BCBS Trust/PPO |
$51.71
|
| Rate for Payer: BCN Commercial |
$48.96
|
| Rate for Payer: Cash Price |
$50.68
|
| Rate for Payer: Cofinity Commercial |
$54.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.68
|
| Rate for Payer: Healthscope Commercial |
$57.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.85
|
| Rate for Payer: Nomi Health Commercial |
$51.95
|
| Rate for Payer: PHP Commercial |
$53.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.18
|
| Rate for Payer: Priority Health HMO/PPO |
$55.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.75
|
| Rate for Payer: UHC Core |
$52.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.51
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$31.15
|
|
|
Service Code
|
NDC 69097072044
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Aetna Commercial |
$26.48
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.73
|
| Rate for Payer: BCBS Complete |
$12.46
|
| Rate for Payer: BCBS MAPPO |
$7.79
|
| Rate for Payer: BCBS Trust/PPO |
$25.61
|
| Rate for Payer: BCN Commercial |
$24.22
|
| Rate for Payer: BCN Medicare Advantage |
$7.79
|
| Rate for Payer: Cash Price |
$24.92
|
| Rate for Payer: Cofinity Commercial |
$26.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.79
|
| Rate for Payer: Healthscope Commercial |
$28.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.48
|
| Rate for Payer: Nomi Health Commercial |
$25.54
|
| Rate for Payer: PACE Senior Care Partners |
$7.40
|
| Rate for Payer: PACE SWMI |
$7.79
|
| Rate for Payer: PHP Commercial |
$26.48
|
| Rate for Payer: PHP Medicare Advantage |
$7.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.25
|
| Rate for Payer: Priority Health HMO/PPO |
$27.10
|
| Rate for Payer: Priority Health Medicare |
$7.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.87
|
| Rate for Payer: Railroad Medicare Medicare |
$7.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.41
|
| Rate for Payer: UHC Core |
$26.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.79
|
| Rate for Payer: UHC Exchange |
$7.79
|
| Rate for Payer: UHC Medicare Advantage |
$7.79
|
| Rate for Payer: VA VA |
$7.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.36
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 25866059361
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: Aetna Medicare |
$14.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17.50
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: BCBS MAPPO |
$14.00
|
| Rate for Payer: BCBS Trust/PPO |
$46.04
|
| Rate for Payer: BCN Commercial |
$43.54
|
| Rate for Payer: BCN Medicare Advantage |
$14.00
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cofinity Commercial |
$48.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.00
|
| Rate for Payer: Healthscope Commercial |
$50.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: Nomi Health Commercial |
$45.92
|
| Rate for Payer: PACE Senior Care Partners |
$13.30
|
| Rate for Payer: PACE SWMI |
$14.00
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: PHP Medicare Advantage |
$14.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.40
|
| Rate for Payer: Priority Health HMO/PPO |
$48.72
|
| Rate for Payer: Priority Health Medicare |
$14.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$37.52
|
| Rate for Payer: Railroad Medicare Medicare |
$14.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.28
|
| Rate for Payer: UHC Core |
$46.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$14.00
|
| Rate for Payer: UHC Exchange |
$14.00
|
| Rate for Payer: UHC Medicare Advantage |
$14.00
|
| Rate for Payer: VA VA |
$14.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.00
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 65162083366
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.85 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: BCBS Trust/PPO |
$40.00
|
| Rate for Payer: BCN Commercial |
$37.87
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$42.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.20
|
| Rate for Payer: Healthscope Commercial |
$44.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.65
|
| Rate for Payer: Nomi Health Commercial |
$40.18
|
| Rate for Payer: PHP Commercial |
$41.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.85
|
| Rate for Payer: Priority Health HMO/PPO |
$42.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$43.12
|
| Rate for Payer: UHC Core |
$40.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.75
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$31.15
|
|
|
Service Code
|
NDC 69097072044
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Aetna Commercial |
$26.48
|
| Rate for Payer: BCBS Trust/PPO |
$25.43
|
| Rate for Payer: BCN Commercial |
$24.07
|
| Rate for Payer: Cash Price |
$24.92
|
| Rate for Payer: Cofinity Commercial |
$26.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.92
|
| Rate for Payer: Healthscope Commercial |
$28.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.48
|
| Rate for Payer: Nomi Health Commercial |
$25.54
|
| Rate for Payer: PHP Commercial |
$26.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.25
|
| Rate for Payer: Priority Health HMO/PPO |
$27.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.41
|
| Rate for Payer: UHC Core |
$26.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.36
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 69097052444
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.85 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: BCBS Trust/PPO |
$40.00
|
| Rate for Payer: BCN Commercial |
$37.87
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$42.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.20
|
| Rate for Payer: Healthscope Commercial |
$44.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.65
|
| Rate for Payer: Nomi Health Commercial |
$40.18
|
| Rate for Payer: PHP Commercial |
$41.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.85
|
| Rate for Payer: Priority Health HMO/PPO |
$42.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$43.12
|
| Rate for Payer: UHC Core |
$40.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.75
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$39.90
|
|
|
Service Code
|
NDC 45802095301
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.93 |
| Max. Negotiated Rate |
$35.91 |
| Rate for Payer: Aetna Commercial |
$33.91
|
| Rate for Payer: BCBS Trust/PPO |
$32.57
|
| Rate for Payer: BCN Commercial |
$30.83
|
| Rate for Payer: Cash Price |
$31.92
|
| Rate for Payer: Cofinity Commercial |
$34.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.92
|
| Rate for Payer: Healthscope Commercial |
$35.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.91
|
| Rate for Payer: Nomi Health Commercial |
$32.72
|
| Rate for Payer: PHP Commercial |
$33.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.93
|
| Rate for Payer: Priority Health HMO/PPO |
$34.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$35.11
|
| Rate for Payer: UHC Core |
$33.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.93
|
|
