|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$33.08
|
|
|
Service Code
|
NDC 41167-0573-2
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$29.77 |
| Rate for Payer: Aetna American Axle |
$21.50
|
| Rate for Payer: Aetna Commercial |
$28.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.50
|
| Rate for Payer: Cash Price |
$26.46
|
| Rate for Payer: Cofinity Commercial |
$23.16
|
| Rate for Payer: Cofinity Commercial |
$28.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.46
|
| Rate for Payer: Healthscope Commercial |
$29.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.12
|
| Rate for Payer: PHP Commercial |
$28.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.16
|
| Rate for Payer: Priority Health SBD |
$20.84
|
| Rate for Payer: UMR Bronson Commercial |
$14.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.81
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$63.35
|
|
|
Service Code
|
NDC 0067-8152-03
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.87 |
| Max. Negotiated Rate |
$57.02 |
| Rate for Payer: Aetna American Axle |
$41.18
|
| Rate for Payer: Aetna Commercial |
$53.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.18
|
| Rate for Payer: Cash Price |
$50.68
|
| Rate for Payer: Cofinity Commercial |
$44.34
|
| Rate for Payer: Cofinity Commercial |
$54.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.68
|
| Rate for Payer: Healthscope Commercial |
$57.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.85
|
| Rate for Payer: PHP Commercial |
$53.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.34
|
| Rate for Payer: Priority Health SBD |
$39.91
|
| Rate for Payer: UMR Bronson Commercial |
$27.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.51
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$39.73
|
|
|
Service Code
|
NDC 0067-8152-02
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.48 |
| Max. Negotiated Rate |
$35.76 |
| Rate for Payer: Aetna American Axle |
$25.82
|
| Rate for Payer: Aetna Commercial |
$33.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.82
|
| Rate for Payer: Cash Price |
$31.78
|
| Rate for Payer: Cofinity Commercial |
$27.81
|
| Rate for Payer: Cofinity Commercial |
$34.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.78
|
| Rate for Payer: Healthscope Commercial |
$35.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.77
|
| Rate for Payer: PHP Commercial |
$33.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.81
|
| Rate for Payer: Priority Health SBD |
$25.03
|
| Rate for Payer: UMR Bronson Commercial |
$17.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.80
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$23.98
|
|
|
Service Code
|
NDC 0536-1294-34
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.55 |
| Max. Negotiated Rate |
$21.58 |
| Rate for Payer: Aetna American Axle |
$15.59
|
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.59
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cofinity Commercial |
$16.79
|
| Rate for Payer: Cofinity Commercial |
$20.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.18
|
| Rate for Payer: Healthscope Commercial |
$21.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.38
|
| Rate for Payer: PHP Commercial |
$20.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.79
|
| Rate for Payer: Priority Health SBD |
$15.11
|
| Rate for Payer: UMR Bronson Commercial |
$10.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.98
|
|
|
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 |
$14.48 |
| Max. Negotiated Rate |
$29.61 |
| Rate for Payer: Aetna American Axle |
$21.38
|
| Rate for Payer: Aetna Commercial |
$27.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.38
|
| Rate for Payer: Cash Price |
$26.32
|
| Rate for Payer: Cofinity Commercial |
$23.03
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$23.03
|
| 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 SBD |
$20.73
|
| Rate for Payer: UMR Bronson Commercial |
$14.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.68
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 96295-13974
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna American Axle |
$13.16
|
| Rate for Payer: Aetna Commercial |
$17.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.16
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$18.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.21
|
| Rate for Payer: PHP Commercial |
$17.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.18
|
| Rate for Payer: Priority Health SBD |
$12.76
|
| Rate for Payer: UMR Bronson Commercial |
$8.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.19
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$26.95
|
|
|
Service Code
|
NDC 70000-0555-2
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$24.26 |
| Rate for Payer: Aetna American Axle |
$17.52
|
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.52
|
| Rate for Payer: Cash Price |
$21.56
|
| Rate for Payer: Cofinity Commercial |
$18.86
|
| Rate for Payer: Cofinity Commercial |
$23.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.56
|
| Rate for Payer: Healthscope Commercial |
$24.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.91
|
| Rate for Payer: PHP Commercial |
$22.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.86
|
| Rate for Payer: Priority Health SBD |
$16.98
|
| Rate for Payer: UMR Bronson Commercial |
$11.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.21
|
|
|
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 |
$21.56 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna American Axle |
$31.85
|
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.85
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$42.14
|
| Rate for Payer: Cofinity Commercial |
$34.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.20
|
| Rate for Payer: Healthscope Commercial |
$44.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.30
|
| 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 SBD |
$30.87
|
| Rate for Payer: UMR Bronson Commercial |
$21.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.75
|
|
|
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 |
$16.63 |
| Max. Negotiated Rate |
$34.02 |
| Rate for Payer: Aetna American Axle |
$24.57
|
| Rate for Payer: Aetna Commercial |
$32.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.57
|
| Rate for Payer: Cash Price |
$30.24
|
| Rate for Payer: Cofinity Commercial |
$26.46
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$26.46
|
| 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 SBD |
$23.81
|
| Rate for Payer: UMR Bronson Commercial |
$16.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.35
|
|
|
DICLOFENAC EPOLAMINE 1.3 % TRANSDERMAL 12 HOUR PATCH
|
Facility
|
IP
|
$97.22
|
|
|
Service Code
|
NDC 59762-0707-1
|
| Hospital Charge Code |
100614
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.78 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna American Axle |
$63.19
|
| Rate for Payer: Aetna Commercial |
$82.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.19
|
| Rate for Payer: Cash Price |
$77.78
|
| Rate for Payer: Cofinity Commercial |
$68.05
|
| Rate for Payer: Cofinity Commercial |
$83.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.78
|
| Rate for Payer: Healthscope Commercial |
$87.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.64
|
| Rate for Payer: PHP Commercial |
$82.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.05
|
| Rate for Payer: Priority Health SBD |
$61.25
|
| Rate for Payer: UMR Bronson Commercial |
$42.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.92
|
|
|
DICLOFENAC EPOLAMINE 1.3 % TRANSDERMAL 12 HOUR PATCH
|
Facility
|
IP
|
$583.31
|
|
|
Service Code
|
NDC 59762-0707-2
|
| Hospital Charge Code |
100614
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$256.66 |
| Max. Negotiated Rate |
$524.98 |
| Rate for Payer: Aetna American Axle |
$379.15
|
| Rate for Payer: Aetna Commercial |
$495.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$379.15
|
| Rate for Payer: Cash Price |
$466.65
|
| Rate for Payer: Cofinity Commercial |
$408.32
|
| Rate for Payer: Cofinity Commercial |
$501.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$466.65
|
| Rate for Payer: Healthscope Commercial |
$524.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$408.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$437.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$495.81
|
| Rate for Payer: PHP Commercial |
$495.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$408.32
|
| Rate for Payer: Priority Health SBD |
$367.49
|
| Rate for Payer: UMR Bronson Commercial |
$256.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$437.48
|
|
|
DICLOFENAC ER 100 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$774.04
|
|
|
Service Code
|
NDC 0527-2170-37
|
| Hospital Charge Code |
27616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$340.58 |
| Max. Negotiated Rate |
$696.64 |
| Rate for Payer: Aetna American Axle |
$503.13
|
| Rate for Payer: Aetna Commercial |
$657.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.13
|
| Rate for Payer: Cash Price |
$619.23
|
| Rate for Payer: Cofinity Commercial |
$541.83
|
| Rate for Payer: Cofinity Commercial |
$665.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.23
|
| Rate for Payer: Healthscope Commercial |
$696.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$541.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$580.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$657.93
|
| Rate for Payer: PHP Commercial |
$657.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$541.83
|
| Rate for Payer: Priority Health SBD |
$487.65
|
| Rate for Payer: UMR Bronson Commercial |
$340.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$580.53
|
|
|
DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$417.60
|
|
|
Service Code
|
NDC 16571-203-10
|
| Hospital Charge Code |
15339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.74 |
| Max. Negotiated Rate |
$375.84 |
| Rate for Payer: Aetna American Axle |
$271.44
|
| Rate for Payer: Aetna Commercial |
$354.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.44
|
| Rate for Payer: Cash Price |
$334.08
|
| Rate for Payer: Cofinity Commercial |
$292.32
|
| Rate for Payer: Cofinity Commercial |
$359.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.08
|
| Rate for Payer: Healthscope Commercial |
$375.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$354.96
|
| Rate for Payer: PHP Commercial |
$354.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.32
|
| Rate for Payer: Priority Health SBD |
$263.09
|
| Rate for Payer: UMR Bronson Commercial |
$183.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.20
|
|
|
DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$479.04
|
|
|
Service Code
|
NDC 0781-1785-01
|
| Hospital Charge Code |
15339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.78 |
| Max. Negotiated Rate |
$431.14 |
| Rate for Payer: Aetna American Axle |
$311.38
|
| Rate for Payer: Aetna Commercial |
$407.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$311.38
|
| Rate for Payer: Cash Price |
$383.23
|
| Rate for Payer: Cofinity Commercial |
$411.97
|
| Rate for Payer: Cofinity Commercial |
$335.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$383.23
|
| Rate for Payer: Healthscope Commercial |
$431.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$335.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$359.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$407.18
|
| Rate for Payer: PHP Commercial |
$407.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$335.33
|
| Rate for Payer: Priority Health SBD |
$301.80
|
| Rate for Payer: UMR Bronson Commercial |
$210.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$359.28
|
|
|
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 |
$98.64 |
| Max. Negotiated Rate |
$201.77 |
| Rate for Payer: Aetna American Axle |
$145.72
|
| Rate for Payer: Aetna Commercial |
$190.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.72
|
| Rate for Payer: Cash Price |
$179.35
|
| Rate for Payer: Cofinity Commercial |
$156.93
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$156.93
|
| 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 SBD |
$141.24
|
| Rate for Payer: UMR Bronson Commercial |
$98.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.14
|
|
|
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 |
$158.84 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna American Axle |
$234.65
|
| Rate for Payer: Aetna Commercial |
$306.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.65
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cofinity Commercial |
$252.70
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$252.70
|
| 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 SBD |
$227.43
|
| Rate for Payer: UMR Bronson Commercial |
$158.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.75
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 61442-103-01
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.88 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna American Axle |
$174.14
|
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.14
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.72
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.53
|
| Rate for Payer: Priority Health SBD |
$168.78
|
| Rate for Payer: UMR Bronson Commercial |
$117.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.92
|
|
|
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 |
$1.98 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna American Axle |
$2.93
|
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.93
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$3.16
|
| 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 SBD |
$2.84
|
| Rate for Payer: UMR Bronson Commercial |
$1.98
|
| 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 |
$1.59 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Aetna American Axle |
$2.35
|
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.35
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$2.53
|
| 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 SBD |
$2.27
|
| Rate for Payer: UMR Bronson Commercial |
$1.59
|
| 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 68084-333-01
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.13 |
| Max. Negotiated Rate |
$405.27 |
| Rate for Payer: Aetna American Axle |
$292.70
|
| Rate for Payer: Aetna Commercial |
$382.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.70
|
| Rate for Payer: Cash Price |
$360.24
|
| Rate for Payer: Cofinity Commercial |
$315.21
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$315.21
|
| 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 SBD |
$283.69
|
| Rate for Payer: UMR Bronson Commercial |
$198.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.72
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$341.05
|
|
|
Service Code
|
NDC 0228-2551-11
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.06 |
| Max. Negotiated Rate |
$306.94 |
| Rate for Payer: Aetna American Axle |
$221.68
|
| Rate for Payer: Aetna Commercial |
$289.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.68
|
| Rate for Payer: Cash Price |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$238.74
|
| Rate for Payer: Cofinity Commercial |
$293.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.84
|
| Rate for Payer: Healthscope Commercial |
$306.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$238.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$289.89
|
| Rate for Payer: PHP Commercial |
$289.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.74
|
| Rate for Payer: Priority Health SBD |
$214.86
|
| Rate for Payer: UMR Bronson Commercial |
$150.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.79
|
|
|
DICLOXACILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$412.30
|
|
|
Service Code
|
NDC 0093-3123-01
|
| Hospital Charge Code |
2414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$181.41 |
| Max. Negotiated Rate |
$371.07 |
| Rate for Payer: Aetna American Axle |
$268.00
|
| Rate for Payer: Aetna Commercial |
$350.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$268.00
|
| Rate for Payer: Cash Price |
$329.84
|
| Rate for Payer: Cofinity Commercial |
$288.61
|
| Rate for Payer: Cofinity Commercial |
$354.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.84
|
| Rate for Payer: Healthscope Commercial |
$371.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$288.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$309.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$350.46
|
| Rate for Payer: PHP Commercial |
$350.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.61
|
| Rate for Payer: Priority Health SBD |
$259.75
|
| Rate for Payer: UMR Bronson Commercial |
$181.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$309.22
|
|
|
DICLOXACILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$266.00
|
|
|
Service Code
|
NDC 0781-2248-01
|
| Hospital Charge Code |
2414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.04 |
| Max. Negotiated Rate |
$239.40 |
| Rate for Payer: Aetna American Axle |
$172.90
|
| Rate for Payer: Aetna Commercial |
$226.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.90
|
| Rate for Payer: Cash Price |
$212.80
|
| Rate for Payer: Cofinity Commercial |
$186.20
|
| Rate for Payer: Cofinity Commercial |
$228.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.80
|
| Rate for Payer: Healthscope Commercial |
$239.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$226.10
|
| Rate for Payer: PHP Commercial |
$226.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.20
|
| Rate for Payer: Priority Health SBD |
$167.58
|
| Rate for Payer: UMR Bronson Commercial |
$117.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.50
|
|
|
DICYCLOMINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,002.06
|
|
|
Service Code
|
NDC 0603-1161-58
|
| Hospital Charge Code |
166822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$440.91 |
| Max. Negotiated Rate |
$901.85 |
| Rate for Payer: Aetna American Axle |
$651.34
|
| Rate for Payer: Aetna Commercial |
$851.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$651.34
|
| Rate for Payer: Cash Price |
$801.65
|
| Rate for Payer: Cofinity Commercial |
$701.44
|
| Rate for Payer: Cofinity Commercial |
$861.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$801.65
|
| Rate for Payer: Healthscope Commercial |
$901.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$701.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$751.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$851.75
|
| Rate for Payer: PHP Commercial |
$851.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$701.44
|
| Rate for Payer: Priority Health SBD |
$631.30
|
| Rate for Payer: UMR Bronson Commercial |
$440.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$751.54
|
|
|
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 |
$168.04 |
| Max. Negotiated Rate |
$343.71 |
| Rate for Payer: Aetna American Axle |
$248.24
|
| Rate for Payer: Aetna Commercial |
$324.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.24
|
| Rate for Payer: Cash Price |
$305.52
|
| Rate for Payer: Cofinity Commercial |
$267.33
|
| Rate for Payer: Cofinity Commercial |
$328.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$305.52
|
| Rate for Payer: Healthscope Commercial |
$343.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$267.33
|
| 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 SBD |
$240.60
|
| Rate for Payer: UMR Bronson Commercial |
$168.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$286.42
|
|
