|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 51862094201
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.66 |
| Max. Negotiated Rate |
$289.76 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.36
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$141.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 00378034501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.87 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna Medicare |
$55.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: BCBS Complete |
$44.18
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$40.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$1.49
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna American Axle |
$0.97
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.97
|
| Rate for Payer: BCBS Complete |
$0.60
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health SBD |
$0.94
|
| Rate for Payer: UMR Bronson Commercial |
$0.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 00378034501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$48.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.24 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$63.45
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna American Axle |
$41.24
|
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.42
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| Rate for Payer: Priority Health SBD |
$39.97
|
| Rate for Payer: UMR Bronson Commercial |
$27.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$321.95
|
|
|
Service Code
|
NDC 51862094201
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.12 |
| Max. Negotiated Rate |
$289.76 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna Medicare |
$160.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Commercial |
$225.36
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$119.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$655.02
|
|
|
Service Code
|
NDC 00254101019
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$288.21 |
| Max. Negotiated Rate |
$589.52 |
| Rate for Payer: Aetna American Axle |
$425.76
|
| Rate for Payer: Aetna Commercial |
$556.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.76
|
| Rate for Payer: Cash Price |
$524.02
|
| Rate for Payer: Cofinity Commercial |
$458.51
|
| Rate for Payer: Cofinity Commercial |
$563.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$458.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$524.02
|
| Rate for Payer: Healthscope Commercial |
$589.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$491.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$556.77
|
| Rate for Payer: PHP Commercial |
$556.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$425.76
|
| Rate for Payer: Priority Health SBD |
$412.66
|
| Rate for Payer: UMR Bronson Commercial |
$288.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$491.26
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$1,667.67
|
|
|
Service Code
|
NDC 00575620030
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$617.04 |
| Max. Negotiated Rate |
$1,500.90 |
| Rate for Payer: Aetna American Axle |
$1,083.99
|
| Rate for Payer: Aetna Commercial |
$1,417.52
|
| Rate for Payer: Aetna Medicare |
$833.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,083.99
|
| Rate for Payer: BCBS Complete |
$667.07
|
| Rate for Payer: Cash Price |
$1,334.14
|
| Rate for Payer: Cofinity Commercial |
$1,167.37
|
| Rate for Payer: Cofinity Commercial |
$1,434.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,167.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.14
|
| Rate for Payer: Healthscope Commercial |
$1,500.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,167.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,250.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,417.52
|
| Rate for Payer: PHP Commercial |
$1,417.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,083.99
|
| Rate for Payer: Priority Health SBD |
$1,050.63
|
| Rate for Payer: UMR Bronson Commercial |
$617.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,250.75
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,667.67
|
|
|
Service Code
|
NDC 00575620030
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$733.77 |
| Max. Negotiated Rate |
$1,500.90 |
| Rate for Payer: Cash Price |
$1,334.14
|
| Rate for Payer: Cofinity Commercial |
$1,167.37
|
| Rate for Payer: Cofinity Commercial |
$1,434.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,167.37
|
| Rate for Payer: Aetna American Axle |
$1,083.99
|
| Rate for Payer: Aetna Commercial |
$1,417.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,083.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.14
|
| Rate for Payer: Healthscope Commercial |
$1,500.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,167.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,250.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,417.52
|
| Rate for Payer: PHP Commercial |
$1,417.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,083.99
|
| Rate for Payer: Priority Health SBD |
$1,050.63
|
| Rate for Payer: UMR Bronson Commercial |
$733.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,250.75
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$655.02
|
|
|
Service Code
|
NDC 00254101019
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.36 |
| Max. Negotiated Rate |
$589.52 |
| Rate for Payer: Aetna American Axle |
$425.76
|
| Rate for Payer: Aetna Commercial |
$556.77
|
| Rate for Payer: Aetna Medicare |
$327.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.76
|
| Rate for Payer: BCBS Complete |
$262.01
|
| Rate for Payer: Cash Price |
$524.02
|
| Rate for Payer: Cofinity Commercial |
$458.51
|
| Rate for Payer: Cofinity Commercial |
$563.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$458.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$524.02
|
| Rate for Payer: Healthscope Commercial |
$589.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$491.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$556.77
|
| Rate for Payer: PHP Commercial |
$556.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$425.76
|
| Rate for Payer: Priority Health SBD |
$412.66
|
| Rate for Payer: UMR Bronson Commercial |
$242.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$491.26
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$21.66
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$19.49 |
| Rate for Payer: Aetna American Axle |
$14.08
|
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.08
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Commercial |
$15.16
|
| Rate for Payer: Cofinity Commercial |
$18.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$19.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.41
|
| Rate for Payer: PHP Commercial |
$18.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.08
|
| Rate for Payer: Priority Health SBD |
$13.65
|
| Rate for Payer: UMR Bronson Commercial |
$9.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.24
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
OP
|
$21.66
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.01 |
| Max. Negotiated Rate |
$19.49 |
| Rate for Payer: Aetna American Axle |
$14.08
|
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Aetna Medicare |
$10.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.08
|
| Rate for Payer: BCBS Complete |
$8.66
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Commercial |
$15.16
|
| Rate for Payer: Cofinity Commercial |
$18.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$19.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.41
|
| Rate for Payer: PHP Commercial |
$18.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.08
|
| Rate for Payer: Priority Health SBD |
$13.65
|
| Rate for Payer: UMR Bronson Commercial |
$8.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.24
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$26.78
|
|
|
Service Code
|
NDC 24208045705
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$24.10 |
| Rate for Payer: Aetna American Axle |
$17.41
|
| Rate for Payer: Aetna Commercial |
$22.76
|
| Rate for Payer: Aetna Medicare |
$13.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.41
|
| Rate for Payer: BCBS Complete |
$10.71
|
| Rate for Payer: Cash Price |
$21.42
|
| Rate for Payer: Cofinity Commercial |
$18.75
|
| Rate for Payer: Cofinity Commercial |
$23.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.42
|
| Rate for Payer: Healthscope Commercial |
$24.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.76
|
| Rate for Payer: PHP Commercial |
$22.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.41
|
| Rate for Payer: Priority Health SBD |
$16.87
|
| Rate for Payer: UMR Bronson Commercial |
$9.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.08
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$34.20
|
|
|
Service Code
|
NDC 61314001425
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.65 |
| Max. Negotiated Rate |
$30.78 |
| Rate for Payer: Aetna American Axle |
$22.23
|
| Rate for Payer: Aetna Commercial |
$29.07
|
| Rate for Payer: Aetna Medicare |
$17.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.23
|
| Rate for Payer: BCBS Complete |
$13.68
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$29.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.36
|
| Rate for Payer: Healthscope Commercial |
$30.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.07
|
| Rate for Payer: PHP Commercial |
$29.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.23
|
| Rate for Payer: Priority Health SBD |
$21.55
|
| Rate for Payer: UMR Bronson Commercial |
$12.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.65
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$45.57
|
|
|
Service Code
|
NDC 61314001405
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$41.01 |
| Rate for Payer: Aetna American Axle |
$29.62
|
| Rate for Payer: Aetna Commercial |
$38.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.62
|
| Rate for Payer: Cash Price |
$36.46
|
| Rate for Payer: Cofinity Commercial |
$31.90
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.46
|
| Rate for Payer: Healthscope Commercial |
$41.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.73
|
| Rate for Payer: PHP Commercial |
$38.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.62
|
| Rate for Payer: Priority Health SBD |
$28.71
|
| Rate for Payer: UMR Bronson Commercial |
$20.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.18
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$34.20
|
|
|
Service Code
|
NDC 61314001425
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$30.78 |
| Rate for Payer: Aetna American Axle |
$22.23
|
| Rate for Payer: Aetna Commercial |
$29.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.23
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$29.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.36
|
| Rate for Payer: Healthscope Commercial |
$30.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.07
|
| Rate for Payer: PHP Commercial |
$29.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.23
|
| Rate for Payer: Priority Health SBD |
$21.55
|
| Rate for Payer: UMR Bronson Commercial |
$15.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.65
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$45.57
|
|
|
Service Code
|
NDC 61314001405
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.86 |
| Max. Negotiated Rate |
$41.01 |
| Rate for Payer: Aetna American Axle |
$29.62
|
| Rate for Payer: Aetna Commercial |
$38.73
|
| Rate for Payer: Aetna Medicare |
$22.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.62
|
| Rate for Payer: BCBS Complete |
$18.23
|
| Rate for Payer: Cash Price |
$36.46
|
| Rate for Payer: Cofinity Commercial |
$31.90
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.46
|
| Rate for Payer: Healthscope Commercial |
$41.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.73
|
| Rate for Payer: PHP Commercial |
$38.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.62
|
| Rate for Payer: Priority Health SBD |
$28.71
|
| Rate for Payer: UMR Bronson Commercial |
$16.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.18
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$23.18
|
|
|
Service Code
|
NDC 17478089210
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$20.86 |
| Rate for Payer: Aetna American Axle |
$15.07
|
| Rate for Payer: Aetna Commercial |
$19.70
|
| Rate for Payer: Aetna Medicare |
$11.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.07
|
| Rate for Payer: BCBS Complete |
$9.27
|
| Rate for Payer: Cash Price |
$18.54
|
| Rate for Payer: Cofinity Commercial |
$16.23
|
| Rate for Payer: Cofinity Commercial |
$19.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.54
|
| Rate for Payer: Healthscope Commercial |
$20.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.70
|
| Rate for Payer: PHP Commercial |
$19.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.07
|
| Rate for Payer: Priority Health SBD |
$14.60
|
| Rate for Payer: UMR Bronson Commercial |
$8.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.38
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$26.78
|
|
|
Service Code
|
NDC 24208045705
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.78 |
| Max. Negotiated Rate |
$24.10 |
| Rate for Payer: Aetna American Axle |
$17.41
|
| Rate for Payer: Aetna Commercial |
$22.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.41
|
| Rate for Payer: Cash Price |
$21.42
|
| Rate for Payer: Cofinity Commercial |
$18.75
|
| Rate for Payer: Cofinity Commercial |
$23.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.42
|
| Rate for Payer: Healthscope Commercial |
$24.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.76
|
| Rate for Payer: PHP Commercial |
$22.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.41
|
| Rate for Payer: Priority Health SBD |
$16.87
|
| Rate for Payer: UMR Bronson Commercial |
$11.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.08
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$15.57
|
|
|
Service Code
|
NDC 17478089225
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.85 |
| Max. Negotiated Rate |
$14.01 |
| Rate for Payer: Aetna American Axle |
$10.12
|
| Rate for Payer: Aetna Commercial |
$13.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.12
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cofinity Commercial |
$10.90
|
| Rate for Payer: Cofinity Commercial |
$13.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.46
|
| Rate for Payer: Healthscope Commercial |
$14.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.23
|
| Rate for Payer: PHP Commercial |
$13.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.12
|
| Rate for Payer: Priority Health SBD |
$9.81
|
| Rate for Payer: UMR Bronson Commercial |
$6.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.68
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$23.18
|
|
|
Service Code
|
NDC 17478089210
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$20.86 |
| Rate for Payer: Aetna American Axle |
$15.07
|
| Rate for Payer: Aetna Commercial |
$19.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.07
|
| Rate for Payer: Cash Price |
$18.54
|
| Rate for Payer: Cofinity Commercial |
$16.23
|
| Rate for Payer: Cofinity Commercial |
$19.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.54
|
| Rate for Payer: Healthscope Commercial |
$20.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.70
|
| Rate for Payer: PHP Commercial |
$19.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.07
|
| Rate for Payer: Priority Health SBD |
$14.60
|
| Rate for Payer: UMR Bronson Commercial |
$10.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.38
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$15.57
|
|
|
Service Code
|
NDC 17478089225
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$14.01 |
| Rate for Payer: Aetna American Axle |
$10.12
|
| Rate for Payer: Aetna Commercial |
$13.23
|
| Rate for Payer: Aetna Medicare |
$7.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.12
|
| Rate for Payer: BCBS Complete |
$6.23
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cofinity Commercial |
$10.90
|
| Rate for Payer: Cofinity Commercial |
$13.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.46
|
| Rate for Payer: Healthscope Commercial |
$14.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.23
|
| Rate for Payer: PHP Commercial |
$13.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.12
|
| Rate for Payer: Priority Health SBD |
$9.81
|
| Rate for Payer: UMR Bronson Commercial |
$5.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.68
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 65162083366
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna American Axle |
$31.85
|
| Rate for Payer: Aetna Commercial |
$41.65
|
| Rate for Payer: Aetna Medicare |
$24.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.85
|
| Rate for Payer: BCBS Complete |
$19.60
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cofinity Commercial |
$34.30
|
| Rate for Payer: Cofinity Commercial |
$42.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$41.65
|
| Rate for Payer: PHP Commercial |
$41.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.85
|
| Rate for Payer: Priority Health SBD |
$30.87
|
| Rate for Payer: UMR Bronson Commercial |
$18.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.75
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 00536129434
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.62 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna American Axle |
$18.66
|
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: Aetna Medicare |
$14.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.66
|
| Rate for Payer: BCBS Complete |
$11.48
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$20.09
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Healthscope Commercial |
$25.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: PHP Commercial |
$24.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health SBD |
$18.08
|
| Rate for Payer: UMR Bronson Commercial |
$10.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.52
|
|
