|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$68.60
|
|
|
Service Code
|
NDC 00067815203
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.18 |
| Max. Negotiated Rate |
$61.74 |
| Rate for Payer: Aetna American Axle |
$44.59
|
| Rate for Payer: Aetna Commercial |
$58.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.59
|
| Rate for Payer: Cash Price |
$54.88
|
| Rate for Payer: Cofinity Advantage |
$48.02
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$48.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$51.45
|
| Rate for Payer: PHP Commercial |
$58.31
|
| Rate for Payer: Priority Health SBD |
$43.22
|
| Rate for Payer: UMR Bronson Commercial |
$30.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.45
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$34.13
|
|
|
Service Code
|
NDC 50580057401
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.63 |
| Max. Negotiated Rate |
$30.72 |
| Rate for Payer: Aetna American Axle |
$22.18
|
| Rate for Payer: Aetna Commercial |
$29.01
|
| Rate for Payer: Aetna Medicare |
$17.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.18
|
| Rate for Payer: BCBS Complete |
$13.65
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cofinity Advantage |
$23.89
|
| Rate for Payer: Cofinity Commercial |
$29.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.30
|
| Rate for Payer: Healthscope Commercial |
$30.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.60
|
| Rate for Payer: PHP Commercial |
$29.01
|
| Rate for Payer: Priority Health SBD |
$21.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.18
|
| Rate for Payer: UHC Core |
$17.78
|
| Rate for Payer: UHC Exchange |
$13.41
|
| Rate for Payer: UMR Bronson Commercial |
$12.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.60
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$39.90
|
|
|
Service Code
|
NDC 45802095301
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.76 |
| Max. Negotiated Rate |
$35.91 |
| Rate for Payer: Aetna American Axle |
$25.93
|
| Rate for Payer: Aetna Commercial |
$33.91
|
| Rate for Payer: Aetna Medicare |
$19.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.93
|
| Rate for Payer: BCBS Complete |
$15.96
|
| Rate for Payer: Cash Price |
$31.92
|
| Rate for Payer: Cofinity Advantage |
$27.93
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$27.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.93
|
| Rate for Payer: PHP Commercial |
$33.91
|
| Rate for Payer: Priority Health SBD |
$25.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.93
|
| Rate for Payer: UHC Core |
$20.79
|
| Rate for Payer: UHC Exchange |
$15.68
|
| Rate for Payer: UMR Bronson Commercial |
$14.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.93
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$20.25
|
|
|
Service Code
|
NDC 09629513974
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.49 |
| Max. Negotiated Rate |
$18.23 |
| Rate for Payer: Aetna American Axle |
$13.16
|
| Rate for Payer: Aetna Commercial |
$17.21
|
| Rate for Payer: Aetna Medicare |
$10.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.16
|
| Rate for Payer: BCBS Complete |
$8.10
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Advantage |
$14.18
|
| Rate for Payer: Cofinity Commercial |
$17.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$18.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.19
|
| Rate for Payer: PHP Commercial |
$17.21
|
| Rate for Payer: Priority Health SBD |
$12.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.16
|
| Rate for Payer: UHC Core |
$10.55
|
| Rate for Payer: UHC Exchange |
$7.96
|
| Rate for Payer: UMR Bronson Commercial |
$7.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.19
|
|
|
DICLOFENAC ER 100 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$774.04
|
|
|
Service Code
|
NDC 00527217037
|
| Hospital Charge Code |
27616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.39 |
| Max. Negotiated Rate |
$696.64 |
| Rate for Payer: Aetna American Axle |
$503.13
|
| Rate for Payer: Aetna Commercial |
$657.93
|
| Rate for Payer: Aetna Medicare |
$387.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.13
|
| Rate for Payer: BCBS Complete |
$309.62
|
| Rate for Payer: Cash Price |
$619.23
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$619.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$657.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$580.53
|
| Rate for Payer: PHP Commercial |
$657.93
|
| Rate for Payer: Priority Health SBD |
$487.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$503.13
|
| Rate for Payer: UHC Core |
$403.27
|
| Rate for Payer: UHC Exchange |
$304.20
|
| Rate for Payer: UMR Bronson Commercial |
$286.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$580.53
|
|
|
DICLOFENAC ER 100 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$774.04
|
|
|
Service Code
|
NDC 00527217037
|
| 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 Advantage |
$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 Commercial |
$657.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$580.53
|
| Rate for Payer: PHP Commercial |
$657.93
|
| 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
|
OP
|
$361.92
|
|
|
Service Code
|
NDC 16571020310
|
| Hospital Charge Code |
15339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.91 |
| Max. Negotiated Rate |
$325.73 |
| Rate for Payer: Aetna American Axle |
$235.25
|
| Rate for Payer: Aetna Commercial |
$307.63
|
| Rate for Payer: Aetna Medicare |
$180.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.25
|
| Rate for Payer: BCBS Complete |
$144.77
|
| Rate for Payer: Cash Price |
$289.54
|
| Rate for Payer: Cofinity Advantage |
$253.34
|
| Rate for Payer: Cofinity Commercial |
$311.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.54
|
| Rate for Payer: Healthscope Commercial |
$325.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$253.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$289.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$271.44
|
| Rate for Payer: PHP Commercial |
$307.63
|
| Rate for Payer: Priority Health SBD |
$228.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$235.25
|
| Rate for Payer: UHC Core |
$188.56
|
| Rate for Payer: UHC Exchange |
$142.23
|
| Rate for Payer: UMR Bronson Commercial |
$133.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.44
|
|
|
DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$361.92
|
|
|
Service Code
|
NDC 16571020310
|
| Hospital Charge Code |
15339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.24 |
| Max. Negotiated Rate |
$325.73 |
| Rate for Payer: Aetna American Axle |
$235.25
|
| Rate for Payer: Aetna Commercial |
$307.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.25
|
| Rate for Payer: Cash Price |
$289.54
|
| Rate for Payer: Cofinity Advantage |
$253.34
|
| Rate for Payer: Cofinity Commercial |
$311.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.54
|
| Rate for Payer: Healthscope Commercial |
$325.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$253.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$271.44
|
| Rate for Payer: PHP Commercial |
$307.63
|
| Rate for Payer: Priority Health SBD |
$228.01
|
| Rate for Payer: UMR Bronson Commercial |
$159.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.44
|
|
|
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 |
$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 Advantage |
$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 Commercial |
$3.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.71
|
| Rate for Payer: PHP Commercial |
$3.07
|
| 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
|
$238.45
|
|
|
Service Code
|
NDC 61442010301
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.92 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Advantage |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UMR Bronson Commercial |
$104.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 00228255111
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.73 |
| Max. Negotiated Rate |
$310.37 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Advantage |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$258.64
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$151.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$344.85
|
|
|
Service Code
|
NDC 00228255111
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.59 |
| Max. Negotiated Rate |
$310.37 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna Medicare |
$172.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: BCBS Complete |
$137.94
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Advantage |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$275.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$258.64
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$224.15
|
| Rate for Payer: UHC Core |
$179.67
|
| Rate for Payer: UHC Exchange |
$135.53
|
| Rate for Payer: UMR Bronson Commercial |
$127.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
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 |
$133.57 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna American Axle |
$234.65
|
| Rate for Payer: Aetna Commercial |
$306.85
|
| Rate for Payer: Aetna Medicare |
$180.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.65
|
| Rate for Payer: BCBS Complete |
$144.40
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$288.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$270.75
|
| Rate for Payer: PHP Commercial |
$306.85
|
| Rate for Payer: Priority Health SBD |
$227.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$234.65
|
| Rate for Payer: UHC Core |
$188.08
|
| Rate for Payer: UHC Exchange |
$141.87
|
| Rate for Payer: UMR Bronson Commercial |
$133.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.75
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$238.45
|
|
|
Service Code
|
NDC 61442010301
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna Medicare |
$119.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: BCBS Complete |
$95.38
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Advantage |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.99
|
| Rate for Payer: UHC Core |
$124.23
|
| Rate for Payer: UHC Exchange |
$93.71
|
| Rate for Payer: UMR Bronson Commercial |
$88.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
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 |
$1.34 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Aetna American Axle |
$2.35
|
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: Aetna Medicare |
$1.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.35
|
| Rate for Payer: BCBS Complete |
$1.44
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$2.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.71
|
| Rate for Payer: PHP Commercial |
$3.07
|
| Rate for Payer: Priority Health SBD |
$2.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.35
|
| Rate for Payer: UHC Core |
$1.88
|
| Rate for Payer: UHC Exchange |
$1.42
|
| Rate for Payer: UMR Bronson Commercial |
$1.34
|
| 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 51079022420
|
| 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 Advantage |
$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 Commercial |
$306.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$270.75
|
| Rate for Payer: PHP Commercial |
$306.85
|
| 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
|
|
|
DICLOXACILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$304.80
|
|
|
Service Code
|
NDC 00093312301
|
| Hospital Charge Code |
2414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.78 |
| Max. Negotiated Rate |
$274.32 |
| Rate for Payer: Aetna American Axle |
$198.12
|
| Rate for Payer: Aetna Commercial |
$259.08
|
| Rate for Payer: Aetna Medicare |
$152.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.12
|
| Rate for Payer: BCBS Complete |
$121.92
|
| Rate for Payer: Cash Price |
$243.84
|
| Rate for Payer: Cofinity Advantage |
$213.36
|
| Rate for Payer: Cofinity Commercial |
$262.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.84
|
| Rate for Payer: Healthscope Commercial |
$274.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$243.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$228.60
|
| Rate for Payer: PHP Commercial |
$259.08
|
| Rate for Payer: Priority Health SBD |
$192.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$198.12
|
| Rate for Payer: UHC Core |
$158.80
|
| Rate for Payer: UHC Exchange |
$119.79
|
| Rate for Payer: UMR Bronson Commercial |
$112.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.60
|
|
|
DICLOXACILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$304.80
|
|
|
Service Code
|
NDC 00093312301
|
| Hospital Charge Code |
2414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.11 |
| Max. Negotiated Rate |
$274.32 |
| Rate for Payer: Aetna American Axle |
$198.12
|
| Rate for Payer: Aetna Commercial |
$259.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.12
|
| Rate for Payer: Cash Price |
$243.84
|
| Rate for Payer: Cofinity Advantage |
$213.36
|
| Rate for Payer: Cofinity Commercial |
$262.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.84
|
| Rate for Payer: Healthscope Commercial |
$274.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$259.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$228.60
|
| Rate for Payer: PHP Commercial |
$259.08
|
| Rate for Payer: Priority Health SBD |
$192.02
|
| Rate for Payer: UMR Bronson Commercial |
$134.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.60
|
|
|
DICYCLOMINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$2,056.37
|
|
|
Service Code
|
NDC 70954026110
|
| Hospital Charge Code |
166822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$904.80 |
| Max. Negotiated Rate |
$1,850.73 |
| Rate for Payer: Aetna American Axle |
$1,336.64
|
| Rate for Payer: Aetna Commercial |
$1,747.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,336.64
|
| Rate for Payer: Cash Price |
$1,645.10
|
| Rate for Payer: Cofinity Advantage |
$1,439.46
|
| Rate for Payer: Cofinity Commercial |
$1,768.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,645.10
|
| Rate for Payer: Healthscope Commercial |
$1,850.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,439.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,542.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,747.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,542.28
|
| Rate for Payer: PHP Commercial |
$1,747.91
|
| Rate for Payer: Priority Health SBD |
$1,295.51
|
| Rate for Payer: UMR Bronson Commercial |
$904.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,542.28
|
|
|
DICYCLOMINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$2,056.37
|
|
|
Service Code
|
NDC 70954026110
|
| Hospital Charge Code |
166822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$760.86 |
| Max. Negotiated Rate |
$1,850.73 |
| Rate for Payer: Aetna American Axle |
$1,336.64
|
| Rate for Payer: Aetna Commercial |
$1,747.91
|
| Rate for Payer: Aetna Medicare |
$1,028.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,336.64
|
| Rate for Payer: BCBS Complete |
$822.55
|
| Rate for Payer: Cash Price |
$1,645.10
|
| Rate for Payer: Cofinity Advantage |
$1,439.46
|
| Rate for Payer: Cofinity Commercial |
$1,768.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,645.10
|
| Rate for Payer: Healthscope Commercial |
$1,850.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,439.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,542.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,645.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,747.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,542.28
|
| Rate for Payer: PHP Commercial |
$1,747.91
|
| Rate for Payer: Priority Health SBD |
$1,295.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,336.64
|
| Rate for Payer: UHC Core |
$1,071.37
|
| Rate for Payer: UHC Exchange |
$808.15
|
| Rate for Payer: UMR Bronson Commercial |
$760.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,542.28
|
|
|
DICYCLOMINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
OP
|
$1,002.06
|
|
|
Service Code
|
NDC 00603116158
|
| Hospital Charge Code |
166822
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$370.76 |
| Max. Negotiated Rate |
$901.85 |
| Rate for Payer: Aetna American Axle |
$651.34
|
| Rate for Payer: Aetna Commercial |
$851.75
|
| Rate for Payer: Aetna Medicare |
$501.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$651.34
|
| Rate for Payer: BCBS Complete |
$400.82
|
| Rate for Payer: Cash Price |
$801.65
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$801.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$851.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$751.54
|
| Rate for Payer: PHP Commercial |
$851.75
|
| Rate for Payer: Priority Health SBD |
$631.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$651.34
|
| Rate for Payer: UHC Core |
$522.07
|
| Rate for Payer: UHC Exchange |
$393.81
|
| Rate for Payer: UMR Bronson Commercial |
$370.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$751.54
|
|
|
DICYCLOMINE 10 MG/5 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,002.06
|
|
|
Service Code
|
NDC 00603116158
|
| 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 Advantage |
$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 Commercial |
$851.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$751.54
|
| Rate for Payer: PHP Commercial |
$851.75
|
| 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
|
$437.10
|
|
|
Service Code
|
NDC 00527058601
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.32 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna American Axle |
$284.12
|
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Advantage |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$305.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$327.82
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health SBD |
$275.37
|
| Rate for Payer: UMR Bronson Commercial |
$192.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$381.90
|
|
|
Service Code
|
NDC 51079011820
|
| 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 Advantage |
$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 |
$286.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$324.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$286.43
|
| Rate for Payer: PHP Commercial |
$324.62
|
| 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 |
$286.43
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 00591079401
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.32 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna American Axle |
$284.12
|
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Advantage |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$393.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$305.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$327.82
|
| Rate for Payer: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health SBD |
$275.37
|
| Rate for Payer: UMR Bronson Commercial |
$192.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
