|
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
|
|
|
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 Commercial |
$2.53
|
| Rate for Payer: Cofinity Commercial |
$3.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.53
|
| 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: PHP Commercial |
$3.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.35
|
| Rate for Payer: Priority Health SBD |
$2.27
|
| 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
|
OP
|
$341.05
|
|
|
Service Code
|
NDC 00228255111
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.19 |
| Max. Negotiated Rate |
$306.94 |
| Rate for Payer: Aetna American Axle |
$221.68
|
| Rate for Payer: Aetna Commercial |
$289.89
|
| Rate for Payer: Aetna Medicare |
$170.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.68
|
| Rate for Payer: BCBS Complete |
$136.42
|
| Rate for Payer: Cash Price |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$238.74
|
| Rate for Payer: Cofinity Commercial |
$293.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.84
|
| Rate for Payer: Healthscope Commercial |
$306.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$238.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.89
|
| Rate for Payer: PHP Commercial |
$289.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.68
|
| Rate for Payer: Priority Health SBD |
$214.86
|
| Rate for Payer: UMR Bronson Commercial |
$126.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.79
|
|
|
DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$450.30
|
|
|
Service Code
|
NDC 68084033301
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.13 |
| Max. Negotiated Rate |
$405.27 |
| Rate for Payer: Aetna American Axle |
$292.69
|
| Rate for Payer: Aetna Commercial |
$382.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$292.69
|
| 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 |
$198.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$337.73
|
|
|
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
|
$4.51
|
|
|
Service Code
|
NDC 68084033311
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna American Axle |
$2.93
|
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Aetna Medicare |
$2.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.93
|
| Rate for Payer: BCBS Complete |
$1.80
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Cofinity Commercial |
$3.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.61
|
| Rate for Payer: Healthscope Commercial |
$4.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.83
|
| Rate for Payer: PHP Commercial |
$3.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.93
|
| Rate for Payer: Priority Health SBD |
$2.84
|
| Rate for Payer: UMR Bronson Commercial |
$1.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.38
|
|
|
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
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 68084033311
|
| Hospital Charge Code |
15341
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna American Axle |
$2.93
|
| Rate for Payer: Aetna Commercial |
$3.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.93
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Cofinity Commercial |
$3.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.61
|
| Rate for Payer: Healthscope Commercial |
$4.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.83
|
| Rate for Payer: PHP Commercial |
$3.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.93
|
| Rate for Payer: Priority Health SBD |
$2.84
|
| Rate for Payer: UMR Bronson Commercial |
$1.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.38
|
|
|
DICLOXACILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$266.00
|
|
|
Service Code
|
NDC 00781224801
|
| Hospital Charge Code |
2414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.42 |
| Max. Negotiated Rate |
$239.40 |
| Rate for Payer: Aetna American Axle |
$172.90
|
| Rate for Payer: Aetna Commercial |
$226.10
|
| Rate for Payer: Aetna Medicare |
$133.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.90
|
| Rate for Payer: BCBS Complete |
$106.40
|
| Rate for Payer: Cash Price |
$212.80
|
| Rate for Payer: Cofinity Commercial |
$186.20
|
| Rate for Payer: Cofinity Commercial |
$228.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.80
|
| Rate for Payer: Healthscope Commercial |
$239.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.10
|
| Rate for Payer: PHP Commercial |
$226.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.90
|
| Rate for Payer: Priority Health SBD |
$167.58
|
| Rate for Payer: UMR Bronson Commercial |
$98.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.50
|
|
|
DICLOXACILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$424.65
|
|
|
Service Code
|
NDC 00093312301
|
| Hospital Charge Code |
2414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.85 |
| Max. Negotiated Rate |
$382.19 |
| Rate for Payer: Aetna American Axle |
$276.02
|
| Rate for Payer: Aetna Commercial |
$360.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.02
|
| Rate for Payer: Cash Price |
$339.72
|
| Rate for Payer: Cofinity Commercial |
$297.25
|
| Rate for Payer: Cofinity Commercial |
$365.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$297.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.72
|
| Rate for Payer: Healthscope Commercial |
$382.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$318.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.95
|
| Rate for Payer: PHP Commercial |
$360.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.02
|
| Rate for Payer: Priority Health SBD |
$267.53
|
| Rate for Payer: UMR Bronson Commercial |
$186.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$318.49
|
|
|
DICLOXACILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$266.00
|
|
|
Service Code
|
NDC 00781224801
|
| Hospital Charge Code |
2414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.04 |
| Max. Negotiated Rate |
$239.40 |
| Rate for Payer: Aetna American Axle |
$172.90
|
| Rate for Payer: Aetna Commercial |
$226.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.90
|
| Rate for Payer: Cash Price |
$212.80
|
| Rate for Payer: Cofinity Commercial |
$186.20
|
| Rate for Payer: Cofinity Commercial |
$228.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.80
|
| Rate for Payer: Healthscope Commercial |
$239.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.10
|
| Rate for Payer: PHP Commercial |
$226.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$172.90
|
| Rate for Payer: Priority Health SBD |
$167.58
|
| Rate for Payer: UMR Bronson Commercial |
$117.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.50
|
|
|
DICLOXACILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$424.65
|
|
|
Service Code
|
NDC 00093312301
|
| Hospital Charge Code |
2414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.12 |
| Max. Negotiated Rate |
$382.19 |
| Rate for Payer: Aetna American Axle |
$276.02
|
| Rate for Payer: Aetna Commercial |
$360.95
|
| Rate for Payer: Aetna Medicare |
$212.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.02
|
| Rate for Payer: BCBS Complete |
$169.86
|
| Rate for Payer: Cash Price |
$339.72
|
| Rate for Payer: Cofinity Commercial |
$297.25
|
| Rate for Payer: Cofinity Commercial |
$365.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$297.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$339.72
|
| Rate for Payer: Healthscope Commercial |
$382.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$318.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.95
|
| Rate for Payer: PHP Commercial |
$360.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.02
|
| Rate for Payer: Priority Health SBD |
$267.53
|
| Rate for Payer: UMR Bronson Commercial |
$157.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$318.49
|
|
|
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 Commercial |
$701.44
|
| Rate for Payer: Cofinity Commercial |
$861.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$701.44
|
| 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: PHP Commercial |
$851.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$651.34
|
| 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/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 Commercial |
$701.44
|
| Rate for Payer: Cofinity Commercial |
$861.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$701.44
|
| 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: PHP Commercial |
$851.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$651.34
|
| Rate for Payer: Priority Health SBD |
$631.30
|
| Rate for Payer: UMR Bronson Commercial |
$370.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$751.54
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$178.60
|
|
|
Service Code
|
NDC 00378161001
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.08 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna American Axle |
$116.09
|
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna Medicare |
$89.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
| Rate for Payer: BCBS Complete |
$71.44
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: Priority Health SBD |
$112.52
|
| Rate for Payer: UMR Bronson Commercial |
$66.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$398.05
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.14 |
| Max. Negotiated Rate |
$358.25 |
| Rate for Payer: Aetna American Axle |
$258.73
|
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.73
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cofinity Commercial |
$278.63
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$278.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Healthscope Commercial |
$358.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$278.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$298.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$338.34
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.73
|
| Rate for Payer: Priority Health SBD |
$250.77
|
| Rate for Payer: UMR Bronson Commercial |
$175.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$298.54
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079011801
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna American Axle |
$2.48
|
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UMR Bronson Commercial |
$1.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$446.50
|
|
|
Service Code
|
NDC 00527058601
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.46 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Aetna American Axle |
$290.23
|
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$290.23
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$312.55
|
| Rate for Payer: Cofinity Commercial |
$383.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$312.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$312.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$334.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$379.52
|
| Rate for Payer: PHP Commercial |
$379.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$290.23
|
| Rate for Payer: Priority Health SBD |
$281.30
|
| Rate for Payer: UMR Bronson Commercial |
$196.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$334.88
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 51079011801
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna American Axle |
$2.48
|
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna Medicare |
$1.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: BCBS Complete |
$1.53
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UMR Bronson Commercial |
$1.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.87
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 00143312601
|
| 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 Commercial |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$305.97
|
| 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: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| 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
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 60687036911
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$3.94 |
| Rate for Payer: Aetna American Axle |
$2.85
|
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Aetna Medicare |
$2.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.85
|
| Rate for Payer: BCBS Complete |
$1.75
|
| Rate for Payer: Cash Price |
$3.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Cofinity Commercial |
$3.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.50
|
| Rate for Payer: Healthscope Commercial |
$3.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.72
|
| Rate for Payer: PHP Commercial |
$3.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.85
|
| Rate for Payer: Priority Health SBD |
$2.76
|
| Rate for Payer: UMR Bronson Commercial |
$1.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.29
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$437.95
|
|
|
Service Code
|
NDC 60687036901
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.04 |
| Max. Negotiated Rate |
$394.15 |
| Rate for Payer: Aetna American Axle |
$284.67
|
| Rate for Payer: Aetna Commercial |
$372.26
|
| Rate for Payer: Aetna Medicare |
$218.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.67
|
| Rate for Payer: BCBS Complete |
$175.18
|
| Rate for Payer: Cash Price |
$350.36
|
| Rate for Payer: Cofinity Commercial |
$306.56
|
| Rate for Payer: Cofinity Commercial |
$376.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$306.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$350.36
|
| Rate for Payer: Healthscope Commercial |
$394.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$306.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$328.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$372.26
|
| Rate for Payer: PHP Commercial |
$372.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.67
|
| Rate for Payer: Priority Health SBD |
$275.91
|
| Rate for Payer: UMR Bronson Commercial |
$162.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$328.46
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 00378161001
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.58 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna American Axle |
$116.09
|
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: Priority Health SBD |
$112.52
|
| Rate for Payer: UMR Bronson Commercial |
$78.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$437.10
|
|
|
Service Code
|
NDC 00143312601
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.73 |
| Max. Negotiated Rate |
$393.39 |
| Rate for Payer: Aetna American Axle |
$284.12
|
| Rate for Payer: Aetna Commercial |
$371.54
|
| Rate for Payer: Aetna Medicare |
$218.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.12
|
| Rate for Payer: BCBS Complete |
$174.84
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$305.97
|
| Rate for Payer: Cofinity Commercial |
$375.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$305.97
|
| 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: PHP Commercial |
$371.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: Priority Health SBD |
$275.37
|
| Rate for Payer: UMR Bronson Commercial |
$161.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.82
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$446.50
|
|
|
Service Code
|
NDC 00527058601
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.21 |
| Max. Negotiated Rate |
$401.85 |
| Rate for Payer: Aetna American Axle |
$290.23
|
| Rate for Payer: Aetna Commercial |
$379.52
|
| Rate for Payer: Aetna Medicare |
$223.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$290.23
|
| Rate for Payer: BCBS Complete |
$178.60
|
| Rate for Payer: Cash Price |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$312.55
|
| Rate for Payer: Cofinity Commercial |
$383.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$312.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.20
|
| Rate for Payer: Healthscope Commercial |
$401.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$312.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$334.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$379.52
|
| Rate for Payer: PHP Commercial |
$379.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$290.23
|
| Rate for Payer: Priority Health SBD |
$281.30
|
| Rate for Payer: UMR Bronson Commercial |
$165.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$334.88
|
|
