|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$21.15
|
|
|
Service Code
|
NDC 69097072044
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$19.04 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Aetna Medicare |
$5.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.61
|
| Rate for Payer: BCBS Complete |
$3.91
|
| Rate for Payer: BCBS MAPPO |
$5.29
|
| Rate for Payer: BCBS Trust/PPO |
$17.39
|
| Rate for Payer: BCN Commercial |
$17.39
|
| Rate for Payer: BCN Medicare Advantage |
$5.29
|
| Rate for Payer: Cash Price |
$16.92
|
| Rate for Payer: Cofinity Commercial |
$18.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.29
|
| Rate for Payer: Healthscope Commercial |
$19.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.86
|
| Rate for Payer: Mclaren Medicaid |
$3.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.55
|
| Rate for Payer: Meridian Medicaid |
$3.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.08
|
| Rate for Payer: Molina Medicare/Medicaid |
$5.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.98
|
| Rate for Payer: Nomi Health Commercial |
$17.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.86
|
| Rate for Payer: PACE Senior Care Partners |
$5.02
|
| Rate for Payer: PACE SWMI |
$5.29
|
| Rate for Payer: PHP Commercial |
$17.98
|
| Rate for Payer: PHP Medicare Advantage |
$5.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.73
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$18.40
|
| Rate for Payer: Priority Health Medicare |
$5.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.72
|
| Rate for Payer: Railroad Medicare Medicare |
$5.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.61
|
| Rate for Payer: UHC Core |
$17.66
|
| Rate for Payer: UHC Exchange |
$5.29
|
| Rate for Payer: UHC Medicaid |
$3.73
|
| Rate for Payer: UHC Medicare Advantage |
$5.29
|
| Rate for Payer: UHCCP Medicaid |
$3.73
|
| Rate for Payer: VA VA |
$5.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.86
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$39.90
|
|
|
Service Code
|
NDC 45802095301
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.03 |
| 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 |
$7.39
|
| Rate for Payer: BCBS MAPPO |
$9.97
|
| Rate for Payer: BCBS Trust/PPO |
$32.80
|
| Rate for Payer: BCN Commercial |
$32.80
|
| 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: Mclaren Medicaid |
$7.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.47
|
| Rate for Payer: Meridian Medicaid |
$7.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.47
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.91
|
| Rate for Payer: Nomi Health Commercial |
$32.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.93
|
| 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 Choice Medicaid |
$7.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$34.71
|
| Rate for Payer: Priority Health Medicare |
$10.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.77
|
| 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 Exchange |
$9.97
|
| Rate for Payer: UHC Medicaid |
$7.03
|
| Rate for Payer: UHC Medicare Advantage |
$9.97
|
| Rate for Payer: UHCCP Medicaid |
$7.03
|
| Rate for Payer: VA VA |
$9.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.93
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$21.15
|
|
|
Service Code
|
NDC 69097072044
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$19.04 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: BCBS Trust/PPO |
$17.47
|
| Rate for Payer: BCN Commercial |
$17.47
|
| Rate for Payer: Cash Price |
$16.92
|
| Rate for Payer: Cofinity Commercial |
$18.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.92
|
| Rate for Payer: Healthscope Commercial |
$19.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.98
|
| Rate for Payer: Nomi Health Commercial |
$17.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.86
|
| Rate for Payer: PHP Commercial |
$17.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$18.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.61
|
| Rate for Payer: UHC Core |
$17.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.86
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 65162083366
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.10 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: BCBS Trust/PPO |
$40.47
|
| Rate for Payer: BCN Commercial |
$40.47
|
| 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: Opus (Opus Packaging Group) HMA |
$36.75
|
| Rate for Payer: PHP Commercial |
$41.65
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$42.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.10
|
| 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
|
$68.60
|
|
|
Service Code
|
NDC 00067815203
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.75 |
| Max. Negotiated Rate |
$61.74 |
| Rate for Payer: Aetna Commercial |
$58.31
|
| Rate for Payer: BCBS Trust/PPO |
$56.66
|
| Rate for Payer: BCN Commercial |
$56.66
|
| Rate for Payer: Cash Price |
$54.88
|
| Rate for Payer: Cofinity Commercial |
$59.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.88
|
| Rate for Payer: Healthscope Commercial |
$61.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.31
|
| Rate for Payer: Nomi Health Commercial |
$56.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$51.45
|
| Rate for Payer: PHP Commercial |
$58.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$59.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.37
|
| Rate for Payer: UHC Core |
$57.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.45
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 25866059361
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.87 |
| 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 |
$10.37
|
| Rate for Payer: BCBS MAPPO |
$14.00
|
| Rate for Payer: BCBS Trust/PPO |
$46.04
|
| Rate for Payer: BCN Commercial |
$46.04
|
| 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: Mclaren Medicaid |
$9.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.70
|
| Rate for Payer: Meridian Medicaid |
$10.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$15.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.60
|
| Rate for Payer: Nomi Health Commercial |
$45.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.00
|
| 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 Choice Medicaid |
$9.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$48.72
|
| Rate for Payer: Priority Health Medicare |
$14.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.98
|
| 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 Exchange |
$14.00
|
| Rate for Payer: UHC Medicaid |
$9.87
|
| Rate for Payer: UHC Medicare Advantage |
$14.00
|
| Rate for Payer: UHCCP Medicaid |
$9.87
|
| 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 69097052444
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.10 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: BCBS Trust/PPO |
$40.47
|
| Rate for Payer: BCN Commercial |
$40.47
|
| 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: Opus (Opus Packaging Group) HMA |
$36.75
|
| Rate for Payer: PHP Commercial |
$41.65
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$42.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.10
|
| 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
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 65162083366
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.64 |
| 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 |
$9.07
|
| Rate for Payer: BCBS MAPPO |
$12.25
|
| Rate for Payer: BCBS Trust/PPO |
$40.28
|
| Rate for Payer: BCN Commercial |
$40.28
|
| 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: Mclaren Medicaid |
$8.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.86
|
| Rate for Payer: Meridian Medicaid |
$9.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.09
|
| Rate for Payer: Molina Medicare/Medicaid |
$13.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.65
|
| Rate for Payer: Nomi Health Commercial |
$40.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.75
|
| 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 Choice Medicaid |
$8.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$42.63
|
| Rate for Payer: Priority Health Medicare |
$12.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.10
|
| 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 Exchange |
$12.25
|
| Rate for Payer: UHC Medicaid |
$8.64
|
| Rate for Payer: UHC Medicare Advantage |
$12.25
|
| Rate for Payer: UHCCP Medicaid |
$8.64
|
| Rate for Payer: VA VA |
$12.25
|
| 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 |
$27.77 |
| Max. Negotiated Rate |
$35.91 |
| Rate for Payer: Aetna Commercial |
$33.91
|
| Rate for Payer: BCBS Trust/PPO |
$32.95
|
| Rate for Payer: BCN Commercial |
$32.95
|
| 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: Opus (Opus Packaging Group) HMA |
$29.93
|
| Rate for Payer: PHP Commercial |
$33.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$34.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.77
|
| 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
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 69097052444
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.64 |
| 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 |
$9.07
|
| Rate for Payer: BCBS MAPPO |
$12.25
|
| Rate for Payer: BCBS Trust/PPO |
$40.28
|
| Rate for Payer: BCN Commercial |
$40.28
|
| 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: Mclaren Medicaid |
$8.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$12.86
|
| Rate for Payer: Meridian Medicaid |
$9.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.09
|
| Rate for Payer: Molina Medicare/Medicaid |
$13.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.65
|
| Rate for Payer: Nomi Health Commercial |
$40.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.75
|
| 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 Choice Medicaid |
$8.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$42.63
|
| Rate for Payer: Priority Health Medicare |
$12.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.10
|
| 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 Exchange |
$12.25
|
| Rate for Payer: UHC Medicaid |
$8.64
|
| Rate for Payer: UHC Medicare Advantage |
$12.25
|
| Rate for Payer: UHCCP Medicaid |
$8.64
|
| Rate for Payer: VA VA |
$12.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.75
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$31.15
|
|
|
Service Code
|
NDC 43598097710
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.49 |
| 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 |
$5.77
|
| Rate for Payer: BCBS MAPPO |
$7.79
|
| Rate for Payer: BCBS Trust/PPO |
$25.61
|
| Rate for Payer: BCN Commercial |
$25.61
|
| 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: Mclaren Medicaid |
$5.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.18
|
| Rate for Payer: Meridian Medicaid |
$5.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.96
|
| Rate for Payer: Molina Medicare/Medicaid |
$8.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.48
|
| Rate for Payer: Nomi Health Commercial |
$25.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$23.36
|
| 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 Choice Medicaid |
$5.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$27.10
|
| Rate for Payer: Priority Health Medicare |
$7.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.68
|
| 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 Exchange |
$7.79
|
| Rate for Payer: UHC Medicaid |
$5.49
|
| Rate for Payer: UHC Medicare Advantage |
$7.79
|
| Rate for Payer: UHCCP Medicaid |
$5.49
|
| Rate for Payer: VA VA |
$7.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.36
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$68.60
|
|
|
Service Code
|
NDC 00067815203
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$61.74 |
| Rate for Payer: Aetna Commercial |
$58.31
|
| Rate for Payer: Aetna Medicare |
$17.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.44
|
| Rate for Payer: BCBS Complete |
$12.70
|
| Rate for Payer: BCBS MAPPO |
$17.15
|
| Rate for Payer: BCBS Trust/PPO |
$56.40
|
| Rate for Payer: BCN Commercial |
$56.40
|
| Rate for Payer: BCN Medicare Advantage |
$17.15
|
| Rate for Payer: Cash Price |
$54.88
|
| Rate for Payer: Cofinity Commercial |
$59.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.15
|
| Rate for Payer: Healthscope Commercial |
$61.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.45
|
| Rate for Payer: Mclaren Medicaid |
$12.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.01
|
| Rate for Payer: Meridian Medicaid |
$12.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.72
|
| Rate for Payer: Molina Medicare/Medicaid |
$18.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.31
|
| Rate for Payer: Nomi Health Commercial |
$56.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$51.45
|
| Rate for Payer: PACE Senior Care Partners |
$16.29
|
| Rate for Payer: PACE SWMI |
$17.15
|
| Rate for Payer: PHP Commercial |
$58.31
|
| Rate for Payer: PHP Medicare Advantage |
$17.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$12.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$59.68
|
| Rate for Payer: Priority Health Medicare |
$17.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.75
|
| Rate for Payer: Railroad Medicare Medicare |
$17.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.37
|
| Rate for Payer: UHC Core |
$57.28
|
| Rate for Payer: UHC Exchange |
$17.15
|
| Rate for Payer: UHC Medicaid |
$12.09
|
| Rate for Payer: UHC Medicare Advantage |
$17.15
|
| Rate for Payer: UHCCP Medicaid |
$12.09
|
| Rate for Payer: VA VA |
$17.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.45
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$26.95
|
|
|
Service Code
|
NDC 09629513975
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.76 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: BCBS Trust/PPO |
$22.26
|
| Rate for Payer: BCN Commercial |
$22.26
|
| 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: Opus (Opus Packaging Group) HMA |
$20.21
|
| Rate for Payer: PHP Commercial |
$22.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$23.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.76
|
| 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
|
$31.15
|
|
|
Service Code
|
NDC 43598097710
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.68 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Aetna Commercial |
$26.48
|
| Rate for Payer: BCBS Trust/PPO |
$25.73
|
| Rate for Payer: BCN Commercial |
$25.73
|
| 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: Opus (Opus Packaging Group) HMA |
$23.36
|
| Rate for Payer: PHP Commercial |
$26.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$27.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.68
|
| 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
|
$56.00
|
|
|
Service Code
|
NDC 25866059361
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.98 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna Commercial |
$47.60
|
| Rate for Payer: BCBS Trust/PPO |
$46.25
|
| Rate for Payer: BCN Commercial |
$46.25
|
| 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: Opus (Opus Packaging Group) HMA |
$42.00
|
| Rate for Payer: PHP Commercial |
$47.60
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$48.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.98
|
| 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
|
$26.95
|
|
|
Service Code
|
NDC 09629513975
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Aetna Medicare |
$7.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.42
|
| Rate for Payer: BCBS Complete |
$4.99
|
| Rate for Payer: BCBS MAPPO |
$6.74
|
| Rate for Payer: BCBS Trust/PPO |
$22.16
|
| Rate for Payer: BCN Commercial |
$22.16
|
| Rate for Payer: BCN Medicare Advantage |
$6.74
|
| 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: Health Alliance Plan Medicare Advantage |
$6.74
|
| Rate for Payer: Healthscope Commercial |
$24.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.21
|
| Rate for Payer: Mclaren Medicaid |
$4.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.07
|
| Rate for Payer: Meridian Medicaid |
$4.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.75
|
| Rate for Payer: Molina Medicare/Medicaid |
$7.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.91
|
| Rate for Payer: Nomi Health Commercial |
$22.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.21
|
| Rate for Payer: PACE Senior Care Partners |
$6.40
|
| Rate for Payer: PACE SWMI |
$6.74
|
| Rate for Payer: PHP Commercial |
$22.91
|
| Rate for Payer: PHP Medicare Advantage |
$6.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$23.45
|
| Rate for Payer: Priority Health Medicare |
$6.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.76
|
| Rate for Payer: Railroad Medicare Medicare |
$6.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.72
|
| Rate for Payer: UHC Core |
$22.50
|
| Rate for Payer: UHC Exchange |
$6.74
|
| Rate for Payer: UHC Medicaid |
$4.75
|
| Rate for Payer: UHC Medicare Advantage |
$6.74
|
| Rate for Payer: UHCCP Medicaid |
$4.75
|
| Rate for Payer: VA VA |
$6.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.21
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$145.92
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.56 |
| Max. Negotiated Rate |
$131.33 |
| Rate for Payer: Aetna Commercial |
$124.03
|
| Rate for Payer: BCBS Trust/PPO |
$120.52
|
| Rate for Payer: BCN Commercial |
$120.52
|
| Rate for Payer: Cash Price |
$116.74
|
| Rate for Payer: Cofinity Commercial |
$125.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.74
|
| Rate for Payer: Healthscope Commercial |
$131.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.03
|
| Rate for Payer: Nomi Health Commercial |
$119.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.44
|
| Rate for Payer: PHP Commercial |
$124.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$126.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$101.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.41
|
| Rate for Payer: UHC Core |
$121.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.44
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$145.92
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.73 |
| Max. Negotiated Rate |
$131.33 |
| Rate for Payer: Aetna Commercial |
$124.03
|
| Rate for Payer: Aetna Medicare |
$37.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$45.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$45.60
|
| Rate for Payer: BCBS Complete |
$27.01
|
| Rate for Payer: BCBS MAPPO |
$36.48
|
| Rate for Payer: BCBS Trust/PPO |
$119.96
|
| Rate for Payer: BCN Commercial |
$119.96
|
| Rate for Payer: BCN Medicare Advantage |
$36.48
|
| Rate for Payer: Cash Price |
$116.74
|
| Rate for Payer: Cofinity Commercial |
$125.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$36.48
|
| Rate for Payer: Healthscope Commercial |
$131.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.44
|
| Rate for Payer: Mclaren Medicaid |
$25.73
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$38.30
|
| Rate for Payer: Meridian Medicaid |
$27.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.95
|
| Rate for Payer: Molina Medicare/Medicaid |
$40.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.03
|
| Rate for Payer: Nomi Health Commercial |
$119.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.44
|
| Rate for Payer: PACE Senior Care Partners |
$34.66
|
| Rate for Payer: PACE SWMI |
$36.48
|
| Rate for Payer: PHP Commercial |
$124.03
|
| Rate for Payer: PHP Medicare Advantage |
$36.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$25.73
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$126.95
|
| Rate for Payer: Priority Health Medicare |
$36.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$101.56
|
| Rate for Payer: Railroad Medicare Medicare |
$36.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.41
|
| Rate for Payer: UHC Core |
$121.84
|
| Rate for Payer: UHC Exchange |
$36.48
|
| Rate for Payer: UHC Medicaid |
$25.73
|
| Rate for Payer: UHC Medicare Advantage |
$36.48
|
| Rate for Payer: UHCCP Medicaid |
$25.73
|
| Rate for Payer: VA VA |
$36.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.44
|
|
|
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 |
$251.26 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna Commercial |
$306.85
|
| Rate for Payer: BCBS Trust/PPO |
$298.15
|
| Rate for Payer: BCN Commercial |
$298.15
|
| 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: Opus (Opus Packaging Group) HMA |
$270.75
|
| Rate for Payer: PHP Commercial |
$306.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$314.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$251.26
|
| 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
|
$150.48
|
|
|
Service Code
|
NDC 61442010360
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.73 |
| Max. Negotiated Rate |
$135.43 |
| Rate for Payer: Aetna Commercial |
$127.91
|
| Rate for Payer: BCBS Trust/PPO |
$124.28
|
| Rate for Payer: BCN Commercial |
$124.28
|
| Rate for Payer: Cash Price |
$120.38
|
| Rate for Payer: Cofinity Commercial |
$129.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.38
|
| Rate for Payer: Healthscope Commercial |
$135.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.91
|
| Rate for Payer: Nomi Health Commercial |
$123.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$112.86
|
| Rate for Payer: PHP Commercial |
$127.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$130.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$104.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$132.42
|
| Rate for Payer: UHC Core |
$125.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.86
|
|
|
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 |
$63.64 |
| 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 |
$66.82
|
| Rate for Payer: BCBS MAPPO |
$90.25
|
| Rate for Payer: BCBS Trust/PPO |
$296.78
|
| Rate for Payer: BCN Commercial |
$296.78
|
| 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: Mclaren Medicaid |
$63.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$94.76
|
| Rate for Payer: Meridian Medicaid |
$66.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$103.79
|
| Rate for Payer: Molina Medicare/Medicaid |
$99.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.85
|
| Rate for Payer: Nomi Health Commercial |
$296.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$270.75
|
| 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 Choice Medicaid |
$63.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$314.07
|
| Rate for Payer: Priority Health Medicare |
$91.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$251.26
|
| 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 Exchange |
$90.25
|
| Rate for Payer: UHC Medicaid |
$63.64
|
| Rate for Payer: UHC Medicare Advantage |
$90.25
|
| Rate for Payer: UHCCP Medicaid |
$63.64
|
| 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
|
$3.61
|
|
|
Service Code
|
NDC 51079022401
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| 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 |
$0.67
|
| Rate for Payer: BCBS MAPPO |
$0.90
|
| Rate for Payer: BCBS Trust/PPO |
$2.97
|
| Rate for Payer: BCN Commercial |
$2.97
|
| 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: Mclaren Medicaid |
$0.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.95
|
| Rate for Payer: Meridian Medicaid |
$0.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.04
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.07
|
| Rate for Payer: Nomi Health Commercial |
$2.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.71
|
| 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 Choice Medicaid |
$0.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.14
|
| Rate for Payer: Priority Health Medicare |
$0.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.51
|
| 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 Exchange |
$0.90
|
| Rate for Payer: UHC Medicaid |
$0.64
|
| Rate for Payer: UHC Medicare Advantage |
$0.90
|
| Rate for Payer: UHCCP Medicaid |
$0.64
|
| 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
|
OP
|
$150.48
|
|
|
Service Code
|
NDC 61442010360
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.53 |
| Max. Negotiated Rate |
$135.43 |
| Rate for Payer: Aetna Commercial |
$127.91
|
| Rate for Payer: Aetna Medicare |
$39.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$47.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$47.02
|
| Rate for Payer: BCBS Complete |
$27.85
|
| Rate for Payer: BCBS MAPPO |
$37.62
|
| Rate for Payer: BCBS Trust/PPO |
$123.71
|
| Rate for Payer: BCN Commercial |
$123.71
|
| Rate for Payer: BCN Medicare Advantage |
$37.62
|
| Rate for Payer: Cash Price |
$120.38
|
| Rate for Payer: Cofinity Commercial |
$129.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.62
|
| Rate for Payer: Healthscope Commercial |
$135.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.86
|
| Rate for Payer: Mclaren Medicaid |
$26.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.50
|
| Rate for Payer: Meridian Medicaid |
$27.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$43.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$41.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.91
|
| Rate for Payer: Nomi Health Commercial |
$123.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$112.86
|
| Rate for Payer: PACE Senior Care Partners |
$35.74
|
| Rate for Payer: PACE SWMI |
$37.62
|
| Rate for Payer: PHP Commercial |
$127.91
|
| Rate for Payer: PHP Medicare Advantage |
$37.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.53
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$130.92
|
| Rate for Payer: Priority Health Medicare |
$38.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$104.73
|
| Rate for Payer: Railroad Medicare Medicare |
$37.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$132.42
|
| Rate for Payer: UHC Core |
$125.65
|
| Rate for Payer: UHC Exchange |
$37.62
|
| Rate for Payer: UHC Medicaid |
$26.53
|
| Rate for Payer: UHC Medicare Advantage |
$37.62
|
| Rate for Payer: UHCCP Medicaid |
$26.53
|
| Rate for Payer: VA VA |
$37.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.86
|
|
|
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 |
$2.51 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: BCBS Trust/PPO |
$2.98
|
| Rate for Payer: BCN Commercial |
$2.98
|
| 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: Opus (Opus Packaging Group) HMA |
$2.71
|
| Rate for Payer: PHP Commercial |
$3.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.51
|
| 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
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$417.05
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$290.27 |
| Max. Negotiated Rate |
$375.35 |
| Rate for Payer: Aetna Commercial |
$354.49
|
| Rate for Payer: BCBS Trust/PPO |
$344.44
|
| Rate for Payer: BCN Commercial |
$344.44
|
| Rate for Payer: Cash Price |
$333.64
|
| Rate for Payer: Cofinity Commercial |
$358.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$333.64
|
| Rate for Payer: Healthscope Commercial |
$375.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$312.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$354.49
|
| Rate for Payer: Nomi Health Commercial |
$341.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$312.79
|
| Rate for Payer: PHP Commercial |
$354.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$362.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$290.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$367.00
|
| Rate for Payer: UHC Core |
$348.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$312.79
|
|
