|
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
|
|
|
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 SODIUM 50 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$258.03
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.28 |
| Max. Negotiated Rate |
$232.23 |
| Rate for Payer: Aetna Commercial |
$219.33
|
| Rate for Payer: Aetna Medicare |
$67.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$80.63
|
| Rate for Payer: Amish Plain Church Group Commercial |
$80.63
|
| Rate for Payer: BCBS Complete |
$103.21
|
| Rate for Payer: BCBS MAPPO |
$64.51
|
| Rate for Payer: BCBS Trust/PPO |
$212.13
|
| Rate for Payer: BCN Commercial |
$200.62
|
| Rate for Payer: BCN Medicare Advantage |
$64.51
|
| Rate for Payer: Cash Price |
$206.42
|
| Rate for Payer: Cofinity Commercial |
$221.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$64.51
|
| Rate for Payer: Healthscope Commercial |
$232.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$67.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.33
|
| Rate for Payer: Nomi Health Commercial |
$211.58
|
| Rate for Payer: PACE Senior Care Partners |
$61.28
|
| Rate for Payer: PACE SWMI |
$64.51
|
| Rate for Payer: PHP Commercial |
$219.33
|
| Rate for Payer: PHP Medicare Advantage |
$64.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.72
|
| Rate for Payer: Priority Health HMO/PPO |
$224.49
|
| Rate for Payer: Priority Health Medicare |
$65.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$172.88
|
| Rate for Payer: Railroad Medicare Medicare |
$64.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.07
|
| Rate for Payer: UHC Core |
$215.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$64.51
|
| Rate for Payer: UHC Exchange |
$64.51
|
| Rate for Payer: UHC Medicare Advantage |
$64.51
|
| Rate for Payer: VA VA |
$64.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.52
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$258.03
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.72 |
| Max. Negotiated Rate |
$232.23 |
| Rate for Payer: Aetna Commercial |
$219.33
|
| Rate for Payer: BCBS Trust/PPO |
$210.63
|
| Rate for Payer: BCN Commercial |
$199.41
|
| Rate for Payer: Cash Price |
$206.42
|
| Rate for Payer: Cofinity Commercial |
$221.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.42
|
| Rate for Payer: Healthscope Commercial |
$232.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.33
|
| Rate for Payer: Nomi Health Commercial |
$211.58
|
| Rate for Payer: PHP Commercial |
$219.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.72
|
| Rate for Payer: Priority Health HMO/PPO |
$224.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$172.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.07
|
| Rate for Payer: UHC Core |
$215.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.52
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3.61
|
|
|
Service Code
|
NDC 51079022401
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: BCBS Trust/PPO |
$2.95
|
| Rate for Payer: BCN Commercial |
$2.79
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cofinity Commercial |
$3.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.89
|
| Rate for Payer: Healthscope Commercial |
$3.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.07
|
| Rate for Payer: Nomi Health Commercial |
$2.96
|
| Rate for Payer: PHP Commercial |
$3.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.35
|
| Rate for Payer: Priority Health HMO/PPO |
$3.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.18
|
| Rate for Payer: UHC Core |
$3.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.71
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$145.23
|
|
|
Service Code
|
NDC 61442010360
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.40 |
| Max. Negotiated Rate |
$130.71 |
| Rate for Payer: Aetna Commercial |
$123.45
|
| Rate for Payer: BCBS Trust/PPO |
$118.55
|
| Rate for Payer: BCN Commercial |
$112.23
|
| Rate for Payer: Cash Price |
$116.18
|
| Rate for Payer: Cofinity Commercial |
$124.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.18
|
| Rate for Payer: Healthscope Commercial |
$130.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.45
|
| Rate for Payer: Nomi Health Commercial |
$119.09
|
| Rate for Payer: PHP Commercial |
$123.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.40
|
| Rate for Payer: Priority Health HMO/PPO |
$126.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$97.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$127.80
|
| Rate for Payer: UHC Core |
$121.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.92
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$145.23
|
|
|
Service Code
|
NDC 61442010360
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.49 |
| Max. Negotiated Rate |
$130.71 |
| Rate for Payer: Aetna Commercial |
$123.45
|
| Rate for Payer: Aetna Medicare |
$37.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$45.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$45.38
|
| Rate for Payer: BCBS Complete |
$58.09
|
| Rate for Payer: BCBS MAPPO |
$36.31
|
| Rate for Payer: BCBS Trust/PPO |
$119.39
|
| Rate for Payer: BCN Commercial |
$112.92
|
| Rate for Payer: BCN Medicare Advantage |
$36.31
|
| Rate for Payer: Cash Price |
$116.18
|
| Rate for Payer: Cofinity Commercial |
$124.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$36.31
|
| Rate for Payer: Healthscope Commercial |
$130.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$108.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$38.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$123.45
|
| Rate for Payer: Nomi Health Commercial |
$119.09
|
| Rate for Payer: PACE Senior Care Partners |
$34.49
|
| Rate for Payer: PACE SWMI |
$36.31
|
| Rate for Payer: PHP Commercial |
$123.45
|
| Rate for Payer: PHP Medicare Advantage |
$36.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.40
|
| Rate for Payer: Priority Health HMO/PPO |
$126.35
|
| Rate for Payer: Priority Health Medicare |
$36.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$97.30
|
| Rate for Payer: Railroad Medicare Medicare |
$36.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$127.80
|
| Rate for Payer: UHC Core |
$121.27
|
| Rate for Payer: UHC Dual Complete DSNP |
$36.31
|
| Rate for Payer: UHC Exchange |
$36.31
|
| Rate for Payer: UHC Medicare Advantage |
$36.31
|
| Rate for Payer: VA VA |
$36.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$108.92
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 68084033311
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.49
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$3.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.61
|
| Rate for Payer: Healthscope Commercial |
$4.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.83
|
| Rate for Payer: Nomi Health Commercial |
$3.70
|
| Rate for Payer: PHP Commercial |
$3.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.93
|
| Rate for Payer: Priority Health HMO/PPO |
$3.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.97
|
| Rate for Payer: UHC Core |
$3.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.38
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$361.00
|
|
|
Service Code
|
NDC 51079022420
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna Commercial |
$306.85
|
| Rate for Payer: BCBS Trust/PPO |
$294.68
|
| Rate for Payer: BCN Commercial |
$278.98
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cofinity Commercial |
$310.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$288.80
|
| Rate for Payer: Healthscope Commercial |
$324.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$270.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.85
|
| Rate for Payer: Nomi Health Commercial |
$296.02
|
| Rate for Payer: PHP Commercial |
$306.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.65
|
| Rate for Payer: Priority Health HMO/PPO |
$314.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$241.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$317.68
|
| Rate for Payer: UHC Core |
$301.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.75
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$3.61
|
|
|
Service Code
|
NDC 51079022401
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: Aetna Medicare |
$0.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.13
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.13
|
| Rate for Payer: BCBS Complete |
$1.44
|
| Rate for Payer: BCBS MAPPO |
$0.90
|
| Rate for Payer: BCBS Trust/PPO |
$2.97
|
| Rate for Payer: BCN Commercial |
$2.81
|
| Rate for Payer: BCN Medicare Advantage |
$0.90
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cofinity Commercial |
$3.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.90
|
| Rate for Payer: Healthscope Commercial |
$3.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.07
|
| Rate for Payer: Nomi Health Commercial |
$2.96
|
| Rate for Payer: PACE Senior Care Partners |
$0.86
|
| Rate for Payer: PACE SWMI |
$0.90
|
| Rate for Payer: PHP Commercial |
$3.07
|
| Rate for Payer: PHP Medicare Advantage |
$0.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.35
|
| Rate for Payer: Priority Health HMO/PPO |
$3.14
|
| Rate for Payer: Priority Health Medicare |
$0.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.42
|
| Rate for Payer: Railroad Medicare Medicare |
$0.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.18
|
| Rate for Payer: UHC Core |
$3.01
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.90
|
| Rate for Payer: UHC Exchange |
$0.90
|
| Rate for Payer: UHC Medicare Advantage |
$0.90
|
| Rate for Payer: VA VA |
$0.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.71
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$450.30
|
|
|
Service Code
|
NDC 68084033301
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$292.69 |
| Max. Negotiated Rate |
$405.27 |
| Rate for Payer: Aetna Commercial |
$382.75
|
| Rate for Payer: BCBS Trust/PPO |
$367.58
|
| Rate for Payer: BCN Commercial |
$347.99
|
| Rate for Payer: Cash Price |
$360.24
|
| Rate for Payer: Cofinity Commercial |
$387.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.24
|
| Rate for Payer: Healthscope Commercial |
$405.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.75
|
| Rate for Payer: Nomi Health Commercial |
$369.25
|
| Rate for Payer: PHP Commercial |
$382.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.69
|
| Rate for Payer: Priority Health HMO/PPO |
$391.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$301.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$396.26
|
| Rate for Payer: UHC Core |
$376.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.73
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$450.30
|
|
|
Service Code
|
NDC 68084033301
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.95 |
| Max. Negotiated Rate |
$405.27 |
| Rate for Payer: Aetna Commercial |
$382.75
|
| Rate for Payer: Aetna Medicare |
$117.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$140.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$140.72
|
| Rate for Payer: BCBS Complete |
$180.12
|
| Rate for Payer: BCBS MAPPO |
$112.58
|
| Rate for Payer: BCBS Trust/PPO |
$370.19
|
| Rate for Payer: BCN Commercial |
$350.11
|
| Rate for Payer: BCN Medicare Advantage |
$112.58
|
| Rate for Payer: Cash Price |
$360.24
|
| Rate for Payer: Cofinity Commercial |
$387.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$112.58
|
| Rate for Payer: Healthscope Commercial |
$405.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$337.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$118.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$129.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.75
|
| Rate for Payer: Nomi Health Commercial |
$369.25
|
| Rate for Payer: PACE Senior Care Partners |
$106.95
|
| Rate for Payer: PACE SWMI |
$112.58
|
| Rate for Payer: PHP Commercial |
$382.75
|
| Rate for Payer: PHP Medicare Advantage |
$112.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.69
|
| Rate for Payer: Priority Health HMO/PPO |
$391.76
|
| Rate for Payer: Priority Health Medicare |
$113.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$301.70
|
| Rate for Payer: Railroad Medicare Medicare |
$112.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$396.26
|
| Rate for Payer: UHC Core |
$376.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$112.58
|
| Rate for Payer: UHC Exchange |
$112.58
|
| Rate for Payer: UHC Medicare Advantage |
$112.58
|
| Rate for Payer: VA VA |
$112.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.73
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$361.00
|
|
|
Service Code
|
NDC 51079022420
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.74 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna Commercial |
$306.85
|
| Rate for Payer: Aetna Medicare |
$93.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$112.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$112.81
|
| Rate for Payer: BCBS Complete |
$144.40
|
| Rate for Payer: BCBS MAPPO |
$90.25
|
| Rate for Payer: BCBS Trust/PPO |
$296.78
|
| Rate for Payer: BCN Commercial |
$280.68
|
| Rate for Payer: BCN Medicare Advantage |
$90.25
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cofinity Commercial |
$310.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$288.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$90.25
|
| Rate for Payer: Healthscope Commercial |
$324.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$270.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$94.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$103.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.85
|
| Rate for Payer: Nomi Health Commercial |
$296.02
|
| Rate for Payer: PACE Senior Care Partners |
$85.74
|
| Rate for Payer: PACE SWMI |
$90.25
|
| Rate for Payer: PHP Commercial |
$306.85
|
| Rate for Payer: PHP Medicare Advantage |
$90.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.65
|
| Rate for Payer: Priority Health HMO/PPO |
$314.07
|
| Rate for Payer: Priority Health Medicare |
$91.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$241.87
|
| Rate for Payer: Railroad Medicare Medicare |
$90.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$317.68
|
| Rate for Payer: UHC Core |
$301.44
|
| Rate for Payer: UHC Dual Complete DSNP |
$90.25
|
| Rate for Payer: UHC Exchange |
$90.25
|
| Rate for Payer: UHC Medicare Advantage |
$90.25
|
| Rate for Payer: VA VA |
$90.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.75
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 68084033311
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Aetna Medicare |
$1.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.41
|
| Rate for Payer: BCBS Complete |
$1.80
|
| Rate for Payer: BCBS MAPPO |
$1.13
|
| Rate for Payer: BCBS Trust/PPO |
$3.71
|
| Rate for Payer: BCN Commercial |
$3.51
|
| Rate for Payer: BCN Medicare Advantage |
$1.13
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$3.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.13
|
| Rate for Payer: Healthscope Commercial |
$4.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.83
|
| Rate for Payer: Nomi Health Commercial |
$3.70
|
| Rate for Payer: PACE Senior Care Partners |
$1.07
|
| Rate for Payer: PACE SWMI |
$1.13
|
| Rate for Payer: PHP Commercial |
$3.83
|
| Rate for Payer: PHP Medicare Advantage |
$1.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.93
|
| Rate for Payer: Priority Health HMO/PPO |
$3.92
|
| Rate for Payer: Priority Health Medicare |
$1.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.02
|
| Rate for Payer: Railroad Medicare Medicare |
$1.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.97
|
| Rate for Payer: UHC Core |
$3.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.13
|
| Rate for Payer: UHC Exchange |
$1.13
|
| Rate for Payer: UHC Medicare Advantage |
$1.13
|
| Rate for Payer: VA VA |
$1.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.38
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$381.90
|
|
|
Service Code
|
NDC 51079011820
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.70 |
| Max. Negotiated Rate |
$343.71 |
| Rate for Payer: Aetna Commercial |
$324.62
|
| Rate for Payer: Aetna Medicare |
$99.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$119.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$119.34
|
| Rate for Payer: BCBS Complete |
$152.76
|
| Rate for Payer: BCBS MAPPO |
$95.47
|
| Rate for Payer: BCBS Trust/PPO |
$313.96
|
| Rate for Payer: BCN Commercial |
$296.93
|
| Rate for Payer: BCN Medicare Advantage |
$95.47
|
| Rate for Payer: Cash Price |
$305.52
|
| Rate for Payer: Cofinity Commercial |
$328.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$95.47
|
| Rate for Payer: Healthscope Commercial |
$343.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$286.43
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$100.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$109.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.62
|
| Rate for Payer: Nomi Health Commercial |
$313.16
|
| Rate for Payer: PACE Senior Care Partners |
$90.70
|
| Rate for Payer: PACE SWMI |
$95.47
|
| Rate for Payer: PHP Commercial |
$324.62
|
| Rate for Payer: PHP Medicare Advantage |
$95.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.24
|
| Rate for Payer: Priority Health HMO/PPO |
$332.25
|
| Rate for Payer: Priority Health Medicare |
$96.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$255.87
|
| Rate for Payer: Railroad Medicare Medicare |
$95.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$336.07
|
| Rate for Payer: UHC Core |
$318.89
|
| Rate for Payer: UHC Dual Complete DSNP |
$95.47
|
| Rate for Payer: UHC Exchange |
$95.47
|
| Rate for Payer: UHC Medicare Advantage |
$95.47
|
| Rate for Payer: VA VA |
$95.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$286.43
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$437.95
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.01 |
| Max. Negotiated Rate |
$394.15 |
| Rate for Payer: Aetna Commercial |
$372.26
|
| Rate for Payer: Aetna Medicare |
$113.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$136.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$136.86
|
| Rate for Payer: BCBS Complete |
$175.18
|
| Rate for Payer: BCBS MAPPO |
$109.49
|
| Rate for Payer: BCBS Trust/PPO |
$360.04
|
| Rate for Payer: BCN Commercial |
$340.51
|
| Rate for Payer: BCN Medicare Advantage |
$109.49
|
| Rate for Payer: Cash Price |
$350.36
|
| Rate for Payer: Cofinity Commercial |
$376.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$350.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$109.49
|
| Rate for Payer: Healthscope Commercial |
$394.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$328.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$114.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$125.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$372.26
|
| Rate for Payer: Nomi Health Commercial |
$359.12
|
| Rate for Payer: PACE Senior Care Partners |
$104.01
|
| Rate for Payer: PACE SWMI |
$109.49
|
| Rate for Payer: PHP Commercial |
$372.26
|
| Rate for Payer: PHP Medicare Advantage |
$109.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.67
|
| Rate for Payer: Priority Health HMO/PPO |
$381.02
|
| Rate for Payer: Priority Health Medicare |
$110.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$293.43
|
| Rate for Payer: Railroad Medicare Medicare |
$109.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$385.40
|
| Rate for Payer: UHC Core |
$365.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$109.49
|
| Rate for Payer: UHC Exchange |
$109.49
|
| Rate for Payer: UHC Medicare Advantage |
$109.49
|
| Rate for Payer: VA VA |
$109.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$328.46
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 51079011801
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$0.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.19
|
| Rate for Payer: BCBS Complete |
$1.53
|
| Rate for Payer: BCBS MAPPO |
$0.96
|
| Rate for Payer: BCBS Trust/PPO |
$3.14
|
| Rate for Payer: BCN Commercial |
$2.97
|
| Rate for Payer: BCN Medicare Advantage |
$0.96
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.96
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Nomi Health Commercial |
$3.13
|
| Rate for Payer: PACE Senior Care Partners |
$0.91
|
| Rate for Payer: PACE SWMI |
$0.96
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: PHP Medicare Advantage |
$0.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health HMO/PPO |
$3.32
|
| Rate for Payer: Priority Health Medicare |
$0.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.56
|
| Rate for Payer: Railroad Medicare Medicare |
$0.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.36
|
| Rate for Payer: UHC Core |
$3.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.96
|
| Rate for Payer: UHC Exchange |
$0.96
|
| Rate for Payer: UHC Medicare Advantage |
$0.96
|
| Rate for Payer: VA VA |
$0.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 60687036911
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Aetna Medicare |
$1.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.37
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.37
|
| Rate for Payer: BCBS Complete |
$1.75
|
| Rate for Payer: BCBS MAPPO |
$1.09
|
| Rate for Payer: BCBS Trust/PPO |
$3.60
|
| Rate for Payer: BCN Commercial |
$3.41
|
| Rate for Payer: BCN Medicare Advantage |
$1.09
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cofinity Commercial |
$3.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.09
|
| Rate for Payer: Healthscope Commercial |
$3.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.72
|
| Rate for Payer: Nomi Health Commercial |
$3.59
|
| Rate for Payer: PACE Senior Care Partners |
$1.04
|
| Rate for Payer: PACE SWMI |
$1.09
|
| Rate for Payer: PHP Commercial |
$3.72
|
| Rate for Payer: PHP Medicare Advantage |
$1.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.85
|
| Rate for Payer: Priority Health HMO/PPO |
$3.81
|
| Rate for Payer: Priority Health Medicare |
$1.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.93
|
| Rate for Payer: Railroad Medicare Medicare |
$1.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.85
|
| Rate for Payer: UHC Core |
$3.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.09
|
| Rate for Payer: UHC Exchange |
$1.09
|
| Rate for Payer: UHC Medicare Advantage |
$1.09
|
| Rate for Payer: VA VA |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.29
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$381.90
|
|
|
Service Code
|
NDC 51079011820
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$248.24 |
| Max. Negotiated Rate |
$343.71 |
| Rate for Payer: Aetna Commercial |
$324.62
|
| Rate for Payer: BCBS Trust/PPO |
$311.74
|
| Rate for Payer: BCN Commercial |
$295.13
|
| Rate for Payer: Cash Price |
$305.52
|
| 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: Lakeland Regional Health Systems Commercial |
$286.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.62
|
| Rate for Payer: Nomi Health Commercial |
$313.16
|
| Rate for Payer: PHP Commercial |
$324.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.24
|
| Rate for Payer: Priority Health HMO/PPO |
$332.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$255.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$336.07
|
| Rate for Payer: UHC Core |
$318.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$286.43
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$398.05
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.54 |
| Max. Negotiated Rate |
$358.25 |
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: Aetna Medicare |
$103.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$124.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$124.39
|
| Rate for Payer: BCBS Complete |
$159.22
|
| Rate for Payer: BCBS MAPPO |
$99.51
|
| Rate for Payer: BCBS Trust/PPO |
$327.24
|
| Rate for Payer: BCN Commercial |
$309.48
|
| Rate for Payer: BCN Medicare Advantage |
$99.51
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$99.51
|
| Rate for Payer: Healthscope Commercial |
$358.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$298.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$104.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$114.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$338.34
|
| Rate for Payer: Nomi Health Commercial |
$326.40
|
| Rate for Payer: PACE Senior Care Partners |
$94.54
|
| Rate for Payer: PACE SWMI |
$99.51
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: PHP Medicare Advantage |
$99.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.73
|
| Rate for Payer: Priority Health HMO/PPO |
$346.30
|
| Rate for Payer: Priority Health Medicare |
$100.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$266.69
|
| Rate for Payer: Railroad Medicare Medicare |
$99.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$350.28
|
| Rate for Payer: UHC Core |
$332.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$99.51
|
| Rate for Payer: UHC Exchange |
$99.51
|
| Rate for Payer: UHC Medicare Advantage |
$99.51
|
| Rate for Payer: VA VA |
$99.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$298.54
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079011801
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: BCBS Trust/PPO |
$3.12
|
| Rate for Payer: BCN Commercial |
$2.95
|
| Rate for Payer: Cash Price |
$3.06
|
| 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: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Nomi Health Commercial |
$3.13
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health HMO/PPO |
$3.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.36
|
| Rate for Payer: UHC Core |
$3.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$398.05
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.73 |
| Max. Negotiated Rate |
$358.25 |
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: BCBS Trust/PPO |
$324.93
|
| Rate for Payer: BCN Commercial |
$307.61
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Healthscope Commercial |
$358.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$298.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$338.34
|
| Rate for Payer: Nomi Health Commercial |
$326.40
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.73
|
| Rate for Payer: Priority Health HMO/PPO |
$346.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$266.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$350.28
|
| Rate for Payer: UHC Core |
$332.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$298.54
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 60687036911
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: BCBS Trust/PPO |
$3.58
|
| Rate for Payer: BCN Commercial |
$3.38
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cofinity Commercial |
$3.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.50
|
| Rate for Payer: Healthscope Commercial |
$3.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.72
|
| Rate for Payer: Nomi Health Commercial |
$3.59
|
| Rate for Payer: PHP Commercial |
$3.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.85
|
| Rate for Payer: Priority Health HMO/PPO |
$3.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.85
|
| Rate for Payer: UHC Core |
$3.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.29
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$437.95
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.67 |
| Max. Negotiated Rate |
$394.15 |
| Rate for Payer: Aetna Commercial |
$372.26
|
| Rate for Payer: BCBS Trust/PPO |
$357.50
|
| Rate for Payer: BCN Commercial |
$338.45
|
| Rate for Payer: Cash Price |
$350.36
|
| Rate for Payer: Cofinity Commercial |
$376.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$350.36
|
| Rate for Payer: Healthscope Commercial |
$394.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$328.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$372.26
|
| Rate for Payer: Nomi Health Commercial |
$359.12
|
| Rate for Payer: PHP Commercial |
$372.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.67
|
| Rate for Payer: Priority Health HMO/PPO |
$381.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$293.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$385.40
|
| Rate for Payer: UHC Core |
$365.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$328.46
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$154.86
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.66 |
| Max. Negotiated Rate |
$139.37 |
| Rate for Payer: Aetna Commercial |
$131.63
|
| Rate for Payer: Aetna Commercial |
$23.39
|
| Rate for Payer: Aetna Commercial |
$235.89
|
| Rate for Payer: BCBS Trust/PPO |
$126.41
|
| Rate for Payer: BCBS Trust/PPO |
$226.54
|
| Rate for Payer: BCBS Trust/PPO |
$22.46
|
| Rate for Payer: BCN Commercial |
$119.68
|
| Rate for Payer: BCN Commercial |
$214.47
|
| Rate for Payer: BCN Commercial |
$21.27
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$123.89
|
| Rate for Payer: Cash Price |
$222.02
|
| Rate for Payer: Cofinity Commercial |
$133.18
|
| Rate for Payer: Cofinity Commercial |
$23.67
|
| Rate for Payer: Cofinity Commercial |
$238.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.02
|
| Rate for Payer: Healthscope Commercial |
$24.77
|
| Rate for Payer: Healthscope Commercial |
$139.37
|
| Rate for Payer: Healthscope Commercial |
$249.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.89
|
| Rate for Payer: Nomi Health Commercial |
$227.57
|
| Rate for Payer: Nomi Health Commercial |
$126.99
|
| Rate for Payer: Nomi Health Commercial |
$22.57
|
| Rate for Payer: PHP Commercial |
$235.89
|
| Rate for Payer: PHP Commercial |
$131.63
|
| Rate for Payer: PHP Commercial |
$23.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.39
|
| Rate for Payer: Priority Health HMO/PPO |
$241.44
|
| Rate for Payer: Priority Health HMO/PPO |
$23.94
|
| Rate for Payer: Priority Health HMO/PPO |
$134.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$103.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$136.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$244.22
|
| Rate for Payer: UHC Core |
$129.31
|
| Rate for Payer: UHC Core |
$22.98
|
| Rate for Payer: UHC Core |
$231.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.14
|
|
