|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$39.90
|
|
|
Service Code
|
NDC 45802095301
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.56 |
| Max. Negotiated Rate |
$35.91 |
| Rate for Payer: Aetna American Axle |
$25.93
|
| Rate for Payer: Aetna Commercial |
$33.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.93
|
| Rate for Payer: Cash Price |
$31.92
|
| Rate for Payer: Cofinity Commercial |
$27.93
|
| Rate for Payer: Cofinity Commercial |
$34.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.93
|
| 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: Multiplan/Beech St/PHCS Commercial |
$33.91
|
| Rate for Payer: PHP Commercial |
$33.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.93
|
| Rate for Payer: Priority Health SBD |
$25.14
|
| Rate for Payer: UMR Bronson Commercial |
$17.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.93
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$26.95
|
|
|
Service Code
|
NDC 70000055502
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Aetna American Axle |
$17.52
|
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Aetna Medicare |
$13.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.52
|
| Rate for Payer: BCBS Complete |
$10.78
|
| Rate for Payer: Cash Price |
$21.56
|
| Rate for Payer: Cofinity Commercial |
$18.86
|
| Rate for Payer: Cofinity Commercial |
$23.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.56
|
| Rate for Payer: Healthscope Commercial |
$24.25
|
| 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 Commercial |
$22.91
|
| Rate for Payer: PHP Commercial |
$22.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.52
|
| Rate for Payer: Priority Health SBD |
$16.98
|
| Rate for Payer: UMR Bronson Commercial |
$9.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.21
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$63.35
|
|
|
Service Code
|
NDC 00067815203
|
| 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: Cofinity Medicare Advantage |
$44.34
|
| 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 Commercial |
$53.85
|
| Rate for Payer: PHP Commercial |
$53.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.18
|
| 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
|
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 Commercial |
$14.18
|
| Rate for Payer: Cofinity Commercial |
$17.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.18
|
| 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: Multiplan/Beech St/PHCS Commercial |
$17.21
|
| Rate for Payer: PHP Commercial |
$17.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health SBD |
$12.76
|
| Rate for Payer: UMR Bronson Commercial |
$7.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.19
|
|
|
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
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 00536129434
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.63 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna American Axle |
$18.66
|
| Rate for Payer: Aetna Commercial |
$24.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.66
|
| 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 |
$24.39
|
| Rate for Payer: PHP Commercial |
$24.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health SBD |
$18.08
|
| Rate for Payer: UMR Bronson Commercial |
$12.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.52
|
|
|
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 |
$24.39
|
| 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 |
$24.39
|
| Rate for Payer: PHP Commercial |
$24.39
|
| 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
|
|
|
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 Commercial |
$27.93
|
| Rate for Payer: Cofinity Commercial |
$34.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.93
|
| 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: Multiplan/Beech St/PHCS Commercial |
$33.91
|
| Rate for Payer: PHP Commercial |
$33.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.93
|
| Rate for Payer: Priority Health SBD |
$25.14
|
| Rate for Payer: UMR Bronson Commercial |
$14.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.93
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 69097052444
|
| 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 |
$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 |
$21.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.75
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$63.35
|
|
|
Service Code
|
NDC 00067815203
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.44 |
| Max. Negotiated Rate |
$57.02 |
| Rate for Payer: Aetna American Axle |
$41.18
|
| Rate for Payer: Aetna Commercial |
$53.85
|
| Rate for Payer: Aetna Medicare |
$31.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.18
|
| Rate for Payer: BCBS Complete |
$25.34
|
| Rate for Payer: Cash Price |
$50.68
|
| Rate for Payer: Cofinity Commercial |
$44.34
|
| Rate for Payer: Cofinity Commercial |
$54.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.34
|
| 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 Commercial |
$53.85
|
| Rate for Payer: PHP Commercial |
$53.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.18
|
| Rate for Payer: Priority Health SBD |
$39.91
|
| Rate for Payer: UMR Bronson Commercial |
$23.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.51
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$39.73
|
|
|
Service Code
|
NDC 00067815202
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$35.76 |
| Rate for Payer: Aetna American Axle |
$25.82
|
| Rate for Payer: Aetna Commercial |
$33.77
|
| Rate for Payer: Aetna Medicare |
$19.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.82
|
| Rate for Payer: BCBS Complete |
$15.89
|
| Rate for Payer: Cash Price |
$31.78
|
| Rate for Payer: Cofinity Commercial |
$27.81
|
| Rate for Payer: Cofinity Commercial |
$34.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.81
|
| 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 Commercial |
$33.77
|
| Rate for Payer: PHP Commercial |
$33.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.82
|
| Rate for Payer: Priority Health SBD |
$25.03
|
| Rate for Payer: UMR Bronson Commercial |
$14.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.80
|
|
|
DICLOFENAC EPOLAMINE 1.3 % TRANSDERMAL 12 HOUR PATCH
|
Facility
|
OP
|
$97.22
|
|
|
Service Code
|
NDC 59762070701
|
| Hospital Charge Code |
100614
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.97 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna American Axle |
$63.19
|
| Rate for Payer: Aetna Commercial |
$82.64
|
| Rate for Payer: Aetna Medicare |
$48.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.19
|
| Rate for Payer: BCBS Complete |
$38.89
|
| Rate for Payer: Cash Price |
$77.78
|
| Rate for Payer: Cofinity Commercial |
$68.05
|
| Rate for Payer: Cofinity Commercial |
$83.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.05
|
| 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 Commercial |
$82.64
|
| Rate for Payer: PHP Commercial |
$82.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.19
|
| Rate for Payer: Priority Health SBD |
$61.25
|
| Rate for Payer: UMR Bronson Commercial |
$35.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.92
|
|
|
DICLOFENAC EPOLAMINE 1.3 % TRANSDERMAL 12 HOUR PATCH
|
Facility
|
IP
|
$97.22
|
|
|
Service Code
|
NDC 59762070701
|
| 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: Cofinity Medicare Advantage |
$68.05
|
| 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 Commercial |
$82.64
|
| Rate for Payer: PHP Commercial |
$82.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.19
|
| 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 59762070702
|
| 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: Cofinity Medicare Advantage |
$408.32
|
| 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 Commercial |
$495.81
|
| Rate for Payer: PHP Commercial |
$495.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$379.15
|
| 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 EPOLAMINE 1.3 % TRANSDERMAL 12 HOUR PATCH
|
Facility
|
OP
|
$583.31
|
|
|
Service Code
|
NDC 59762070702
|
| Hospital Charge Code |
100614
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$215.82 |
| Max. Negotiated Rate |
$524.98 |
| Rate for Payer: Aetna American Axle |
$379.15
|
| Rate for Payer: Aetna Commercial |
$495.81
|
| Rate for Payer: Aetna Medicare |
$291.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$379.15
|
| Rate for Payer: BCBS Complete |
$233.32
|
| Rate for Payer: Cash Price |
$466.65
|
| Rate for Payer: Cofinity Commercial |
$408.32
|
| Rate for Payer: Cofinity Commercial |
$501.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$408.32
|
| 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 Commercial |
$495.81
|
| Rate for Payer: PHP Commercial |
$495.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$379.15
|
| Rate for Payer: Priority Health SBD |
$367.49
|
| Rate for Payer: UMR Bronson Commercial |
$215.82
|
| 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 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 Commercial |
$541.83
|
| Rate for Payer: Cofinity Commercial |
$665.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$541.83
|
| 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: PHP Commercial |
$657.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.13
|
| 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 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 Commercial |
$541.83
|
| Rate for Payer: Cofinity Commercial |
$665.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$541.83
|
| 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: PHP Commercial |
$657.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.13
|
| Rate for Payer: Priority Health SBD |
$487.65
|
| Rate for Payer: UMR Bronson Commercial |
$286.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$580.53
|
|
|
DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$361.44
|
|
|
Service Code
|
NDC 16571020310
|
| Hospital Charge Code |
15339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.73 |
| Max. Negotiated Rate |
$325.30 |
| Rate for Payer: Aetna American Axle |
$234.94
|
| Rate for Payer: Aetna Commercial |
$307.22
|
| Rate for Payer: Aetna Medicare |
$180.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.94
|
| Rate for Payer: BCBS Complete |
$144.58
|
| Rate for Payer: Cash Price |
$289.15
|
| Rate for Payer: Cofinity Commercial |
$253.01
|
| Rate for Payer: Cofinity Commercial |
$310.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$253.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.15
|
| Rate for Payer: Healthscope Commercial |
$325.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$253.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.22
|
| Rate for Payer: PHP Commercial |
$307.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.94
|
| Rate for Payer: Priority Health SBD |
$227.71
|
| Rate for Payer: UMR Bronson Commercial |
$133.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.08
|
|
|
DICLOFENAC SODIUM 25 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$361.44
|
|
|
Service Code
|
NDC 16571020310
|
| Hospital Charge Code |
15339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.03 |
| Max. Negotiated Rate |
$325.30 |
| Rate for Payer: Aetna American Axle |
$234.94
|
| Rate for Payer: Aetna Commercial |
$307.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.94
|
| Rate for Payer: Cash Price |
$289.15
|
| Rate for Payer: Cofinity Commercial |
$253.01
|
| Rate for Payer: Cofinity Commercial |
$310.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$253.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.15
|
| Rate for Payer: Healthscope Commercial |
$325.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$253.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.22
|
| Rate for Payer: PHP Commercial |
$307.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.94
|
| Rate for Payer: Priority Health SBD |
$227.71
|
| Rate for Payer: UMR Bronson Commercial |
$159.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.08
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$258.03
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.47 |
| Max. Negotiated Rate |
$232.23 |
| Rate for Payer: Aetna American Axle |
$167.72
|
| Rate for Payer: Aetna Commercial |
$219.33
|
| Rate for Payer: Aetna Medicare |
$129.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.72
|
| Rate for Payer: BCBS Complete |
$103.21
|
| Rate for Payer: Cash Price |
$206.42
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Commercial |
$221.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.42
|
| Rate for Payer: Healthscope Commercial |
$232.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.33
|
| Rate for Payer: PHP Commercial |
$219.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.72
|
| Rate for Payer: Priority Health SBD |
$162.56
|
| Rate for Payer: UMR Bronson Commercial |
$95.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.52
|
|
|
DICLOFENAC SODIUM 50 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$258.03
|
|
|
Service Code
|
NDC 61442010260
|
| Hospital Charge Code |
15340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.53 |
| Max. Negotiated Rate |
$232.23 |
| Rate for Payer: Aetna American Axle |
$167.72
|
| Rate for Payer: Aetna Commercial |
$219.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.72
|
| Rate for Payer: Cash Price |
$206.42
|
| Rate for Payer: Cofinity Commercial |
$180.62
|
| Rate for Payer: Cofinity Commercial |
$221.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.42
|
| Rate for Payer: Healthscope Commercial |
$232.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.33
|
| Rate for Payer: PHP Commercial |
$219.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.72
|
| Rate for Payer: Priority Health SBD |
$162.56
|
| Rate for Payer: UMR Bronson Commercial |
$113.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.52
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$267.90
|
|
|
Service Code
|
NDC 61442010301
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.12 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna American Axle |
$174.13
|
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna Medicare |
$133.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.13
|
| Rate for Payer: BCBS Complete |
$107.16
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$187.53
|
| 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 |
$200.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.72
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.13
|
| Rate for Payer: Priority Health SBD |
$168.78
|
| Rate for Payer: UMR Bronson Commercial |
$99.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.93
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$450.30
|
|
|
Service Code
|
NDC 68084033301
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.61 |
| Max. Negotiated Rate |
$405.27 |
| Rate for Payer: Aetna American Axle |
$292.69
|
| Rate for Payer: Aetna Commercial |
$382.75
|
| Rate for Payer: Aetna Medicare |
$225.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.69
|
| Rate for Payer: BCBS Complete |
$180.12
|
| Rate for Payer: Cash Price |
$360.24
|
| Rate for Payer: Cofinity Commercial |
$315.21
|
| Rate for Payer: Cofinity Commercial |
$387.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$315.21
|
| 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 |
$337.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$382.75
|
| Rate for Payer: PHP Commercial |
$382.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.69
|
| Rate for Payer: Priority Health SBD |
$283.69
|
| Rate for Payer: UMR Bronson Commercial |
$166.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.73
|
|
|
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 Commercial |
$252.70
|
| Rate for Payer: Cofinity Commercial |
$310.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$252.70
|
| 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: PHP Commercial |
$306.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.65
|
| Rate for Payer: Priority Health SBD |
$227.43
|
| 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
|
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 Commercial |
$252.70
|
| Rate for Payer: Cofinity Commercial |
$310.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$252.70
|
| 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: PHP Commercial |
$306.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.65
|
| 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
|
|
