|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$43.87
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.76 |
| Max. Negotiated Rate |
$39.48 |
| Rate for Payer: Aetna Commercial |
$37.29
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: BCBS Trust/PPO |
$43.27
|
| Rate for Payer: BCBS Trust/PPO |
$45.00
|
| Rate for Payer: BCBS Trust/PPO |
$33.90
|
| Rate for Payer: BCBS Trust/PPO |
$51.92
|
| Rate for Payer: BCN Commercial |
$45.00
|
| Rate for Payer: BCN Commercial |
$43.27
|
| Rate for Payer: BCN Commercial |
$33.90
|
| Rate for Payer: BCN Commercial |
$51.92
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$35.10
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$37.73
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$39.48
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.50
|
| Rate for Payer: PHP Commercial |
$37.29
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$38.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$48.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$58.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$50.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$40.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.13
|
| Rate for Payer: UHC Core |
$48.62
|
| Rate for Payer: UHC Core |
$46.75
|
| Rate for Payer: UHC Core |
$36.63
|
| Rate for Payer: UHC Core |
$56.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.39
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.64 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: BCBS Trust/PPO |
$54.03
|
| Rate for Payer: BCN Commercial |
$54.03
|
| 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: Healthscope Commercial |
$62.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$60.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.53
|
| Rate for Payer: UHC Core |
$58.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.64 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: BCBS Trust/PPO |
$54.03
|
| Rate for Payer: BCN Commercial |
$54.03
|
| 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: Healthscope Commercial |
$62.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$60.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.53
|
| Rate for Payer: UHC Core |
$58.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.44
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$67.19
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.98 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: BCBS Trust/PPO |
$43.27
|
| Rate for Payer: BCBS Trust/PPO |
$51.92
|
| Rate for Payer: BCN Commercial |
$43.27
|
| Rate for Payer: BCN Commercial |
$51.92
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.11
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$58.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$48.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$40.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.13
|
| Rate for Payer: UHC Core |
$46.75
|
| Rate for Payer: UHC Core |
$56.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.39
|
|
|
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 |
$38.86 |
| 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 |
$49.24
|
| Rate for Payer: BCBS Trust/PPO |
$5.60
|
| Rate for Payer: BCN Commercial |
$5.60
|
| Rate for Payer: BCN Commercial |
$49.24
|
| 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: Healthscope Commercial |
$6.52
|
| Rate for Payer: Healthscope Commercial |
$57.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.16
|
| Rate for Payer: PHP Commercial |
$6.16
|
| Rate for Payer: PHP Commercial |
$54.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.42
|
| 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: Van Buren County Sheriff Dept. Commercial |
$47.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.44
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 51079-284-01
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Aetna Commercial |
$1.18
|
| Rate for Payer: BCBS Trust/PPO |
$1.07
|
| Rate for Payer: BCN Commercial |
$1.07
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cofinity Commercial |
$1.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.11
|
| Rate for Payer: Healthscope Commercial |
$1.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.18
|
| Rate for Payer: PHP Commercial |
$1.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.22
|
| Rate for Payer: UHC Core |
$1.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.04
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$63.45
|
|
|
Service Code
|
NDC 0172-3926-60
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.70 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: BCBS Trust/PPO |
$49.03
|
| 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 Multiplan/Beech St/PHCS |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.70
|
| 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
|
$1.30
|
|
|
Service Code
|
NDC 51079-285-01
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$1.17 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: BCBS Trust/PPO |
$1.00
|
| Rate for Payer: BCN Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$1.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.04
|
| Rate for Payer: Healthscope Commercial |
$1.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.10
|
| Rate for Payer: PHP Commercial |
$1.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.14
|
| Rate for Payer: UHC Core |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.98
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$129.25
|
|
|
Service Code
|
NDC 51079-285-20
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.83 |
| Max. Negotiated Rate |
$116.32 |
| Rate for Payer: Aetna Commercial |
$109.86
|
| Rate for Payer: BCBS Trust/PPO |
$99.88
|
| Rate for Payer: BCN Commercial |
$99.88
|
| Rate for Payer: Cash Price |
$103.40
|
| Rate for Payer: Cofinity Commercial |
$111.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.40
|
| Rate for Payer: Healthscope Commercial |
$116.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$109.86
|
| Rate for Payer: PHP Commercial |
$109.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$112.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$78.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$113.74
|
| Rate for Payer: UHC Core |
$107.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.94
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 63739-073-10
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.20 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna Commercial |
$83.90
|
| Rate for Payer: BCBS Trust/PPO |
$76.28
|
| Rate for Payer: BCN Commercial |
$76.28
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.90
|
| Rate for Payer: PHP Commercial |
$83.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$85.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$60.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$86.86
|
| Rate for Payer: UHC Core |
$82.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.02
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$12.48
|
|
|
Service Code
|
NDC 0536-1211-95
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.61 |
| Max. Negotiated Rate |
$11.23 |
| Rate for Payer: Aetna Commercial |
$10.61
|
| Rate for Payer: BCBS Trust/PPO |
$9.64
|
| Rate for Payer: BCN Commercial |
$9.64
|
| Rate for Payer: Cash Price |
$9.98
|
| Rate for Payer: Cofinity Commercial |
$10.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.98
|
| Rate for Payer: Healthscope Commercial |
$11.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.61
|
| Rate for Payer: PHP Commercial |
$10.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.98
|
| Rate for Payer: UHC Core |
$10.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.36
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 2586659361
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.15 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: BCBS Trust/PPO |
$43.28
|
| 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 Multiplan/Beech St/PHCS |
$47.60
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$48.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.15
|
| 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
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 65162-833-66
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: BCBS Trust/PPO |
$37.87
|
| 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 Multiplan/Beech St/PHCS |
$41.65
|
| Rate for Payer: PHP Commercial |
$41.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$42.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$29.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$43.12
|
| Rate for Payer: UHC Core |
$40.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.75
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$32.90
|
|
|
Service Code
|
NDC 69097-524-44
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.07 |
| Max. Negotiated Rate |
$29.61 |
| Rate for Payer: Aetna Commercial |
$27.96
|
| Rate for Payer: BCBS Trust/PPO |
$25.43
|
| Rate for Payer: BCN Commercial |
$25.43
|
| Rate for Payer: Cash Price |
$26.32
|
| Rate for Payer: Cofinity Commercial |
$28.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.32
|
| Rate for Payer: Healthscope Commercial |
$29.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.96
|
| Rate for Payer: PHP Commercial |
$27.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.95
|
| Rate for Payer: UHC Core |
$27.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.68
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$37.80
|
|
|
Service Code
|
NDC 45802-953-01
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.05 |
| Max. Negotiated Rate |
$34.02 |
| Rate for Payer: Aetna Commercial |
$32.13
|
| Rate for Payer: BCBS Trust/PPO |
$29.21
|
| Rate for Payer: BCN Commercial |
$29.21
|
| Rate for Payer: Cash Price |
$30.24
|
| Rate for Payer: Cofinity Commercial |
$32.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.24
|
| Rate for Payer: Healthscope Commercial |
$34.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.13
|
| Rate for Payer: PHP Commercial |
$32.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.26
|
| Rate for Payer: UHC Core |
$31.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.35
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$176.75
|
|
|
Service Code
|
NDC 63481-684-47
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$159.08 |
| Rate for Payer: Aetna Commercial |
$150.24
|
| Rate for Payer: BCBS Trust/PPO |
$136.59
|
| Rate for Payer: BCN Commercial |
$136.59
|
| Rate for Payer: Cash Price |
$141.40
|
| Rate for Payer: Cofinity Commercial |
$152.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.40
|
| Rate for Payer: Healthscope Commercial |
$159.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$150.24
|
| Rate for Payer: PHP Commercial |
$150.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$153.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$107.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$155.54
|
| Rate for Payer: UHC Core |
$147.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.56
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$224.19
|
|
|
Service Code
|
NDC 61442-102-60
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.73 |
| Max. Negotiated Rate |
$201.77 |
| Rate for Payer: Aetna Commercial |
$190.56
|
| Rate for Payer: BCBS Trust/PPO |
$173.25
|
| Rate for Payer: BCN Commercial |
$173.25
|
| Rate for Payer: Cash Price |
$179.35
|
| Rate for Payer: Cofinity Commercial |
$192.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.35
|
| Rate for Payer: Healthscope Commercial |
$201.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$190.56
|
| Rate for Payer: PHP Commercial |
$190.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$195.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$136.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$197.29
|
| Rate for Payer: UHC Core |
$187.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.14
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 68084-333-11
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: BCBS Trust/PPO |
$3.49
|
| 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 Multiplan/Beech St/PHCS |
$3.83
|
| Rate for Payer: PHP Commercial |
$3.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.75
|
| 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
|
$3.61
|
|
|
Service Code
|
NDC 51079-224-01
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: BCBS Trust/PPO |
$2.79
|
| 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 Multiplan/Beech St/PHCS |
$3.07
|
| Rate for Payer: PHP Commercial |
$3.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.20
|
| 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
|
$361.00
|
|
|
Service Code
|
NDC 51079-224-20
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.17 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna Commercial |
$306.85
|
| Rate for Payer: BCBS Trust/PPO |
$278.98
|
| 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 Multiplan/Beech St/PHCS |
$306.85
|
| Rate for Payer: PHP Commercial |
$306.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$314.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$220.17
|
| 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
|
IP
|
$450.30
|
|
|
Service Code
|
NDC 68084-333-01
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$274.64 |
| Max. Negotiated Rate |
$405.27 |
| Rate for Payer: Aetna Commercial |
$382.76
|
| Rate for Payer: BCBS Trust/PPO |
$347.99
|
| 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 |
$337.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$382.76
|
| Rate for Payer: PHP Commercial |
$382.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$315.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$391.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$274.64
|
| 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 |
$337.72
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$143.82
|
|
|
Service Code
|
NDC 61442-103-60
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.72 |
| Max. Negotiated Rate |
$129.44 |
| Rate for Payer: Aetna Commercial |
$122.25
|
| Rate for Payer: BCBS Trust/PPO |
$111.14
|
| Rate for Payer: BCN Commercial |
$111.14
|
| Rate for Payer: Cash Price |
$115.06
|
| Rate for Payer: Cofinity Commercial |
$123.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$115.06
|
| Rate for Payer: Healthscope Commercial |
$129.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$122.25
|
| Rate for Payer: PHP Commercial |
$122.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$125.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$87.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.56
|
| Rate for Payer: UHC Core |
$120.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.86
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$381.90
|
|
|
Service Code
|
NDC 51079-118-20
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.92 |
| Max. Negotiated Rate |
$343.71 |
| Rate for Payer: Aetna Commercial |
$324.62
|
| Rate for Payer: BCBS Trust/PPO |
$295.13
|
| 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 |
$286.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$324.62
|
| Rate for Payer: PHP Commercial |
$324.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$267.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$332.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$232.92
|
| 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 |
$286.42
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079-118-01
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: BCBS Trust/PPO |
$2.95
|
| 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 |
$2.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.25
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.33
|
| 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 |
$2.86
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3.96
|
|
|
Service Code
|
NDC 60687-369-11
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: BCBS Trust/PPO |
$3.06
|
| Rate for Payer: BCN Commercial |
$3.06
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Cofinity Commercial |
$3.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.17
|
| Rate for Payer: Healthscope Commercial |
$3.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.37
|
| Rate for Payer: PHP Commercial |
$3.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.77
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.48
|
| Rate for Payer: UHC Core |
$3.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.97
|
|
