|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 65162083366
|
| 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
|
$33.08
|
|
|
Service Code
|
NDC 41167057302
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.24 |
| Max. Negotiated Rate |
$29.77 |
| Rate for Payer: Aetna American Axle |
$21.50
|
| Rate for Payer: Aetna Commercial |
$28.12
|
| Rate for Payer: Aetna Medicare |
$16.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.50
|
| Rate for Payer: BCBS Complete |
$13.23
|
| Rate for Payer: Cash Price |
$26.46
|
| Rate for Payer: Cofinity Commercial |
$23.16
|
| Rate for Payer: Cofinity Commercial |
$28.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.46
|
| Rate for Payer: Healthscope Commercial |
$29.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.12
|
| Rate for Payer: PHP Commercial |
$28.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.50
|
| Rate for Payer: Priority Health SBD |
$20.84
|
| Rate for Payer: UMR Bronson Commercial |
$12.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.81
|
|
|
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 |
$24.26 |
| Rate for Payer: Aetna American Axle |
$17.52
|
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Aetna Medicare |
$13.48
|
| 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 |
$24.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.21
|
| Rate for Payer: Multiplan/Beech St/PHCS 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
|
$39.73
|
|
|
Service Code
|
NDC 00067815202
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.48 |
| Max. Negotiated Rate |
$35.76 |
| Rate for Payer: Aetna American Axle |
$25.82
|
| Rate for Payer: Aetna Commercial |
$33.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.82
|
| Rate for Payer: Cash Price |
$31.78
|
| Rate for Payer: Cofinity Commercial |
$27.81
|
| Rate for Payer: Cofinity Commercial |
$34.17
|
| Rate for Payer: 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 |
$17.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.80
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 09629513974
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$18.22 |
| Rate for Payer: Aetna American Axle |
$13.16
|
| Rate for Payer: Aetna Commercial |
$17.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.16
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$14.18
|
| Rate for Payer: Cofinity Commercial |
$17.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$18.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.19
|
| Rate for Payer: Multiplan/Beech St/PHCS 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 |
$8.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.19
|
|
|
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 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
|
IP
|
$33.08
|
|
|
Service Code
|
NDC 41167057302
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$29.77 |
| Rate for Payer: Aetna American Axle |
$21.50
|
| Rate for Payer: Aetna Commercial |
$28.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.50
|
| Rate for Payer: Cash Price |
$26.46
|
| Rate for Payer: Cofinity Commercial |
$23.16
|
| Rate for Payer: Cofinity Commercial |
$28.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.46
|
| Rate for Payer: Healthscope Commercial |
$29.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.12
|
| Rate for Payer: PHP Commercial |
$28.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.50
|
| Rate for Payer: Priority Health SBD |
$20.84
|
| Rate for Payer: UMR Bronson Commercial |
$14.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.81
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
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 |
$25.94
|
| Rate for Payer: Aetna Commercial |
$33.92
|
| Rate for Payer: Aetna Medicare |
$19.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.94
|
| 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 |
$29.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.92
|
| Rate for Payer: PHP Commercial |
$33.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.94
|
| 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 |
$29.92
|
|
|
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 |
$24.40
|
| 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 |
$24.40
|
| 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 |
$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 |
$24.40
|
| 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
|
|
|
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
|
$49.00
|
|
|
Service Code
|
NDC 69097052444
|
| 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
|
$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
|
IP
|
$26.95
|
|
|
Service Code
|
NDC 70000055502
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.86 |
| Max. Negotiated Rate |
$24.26 |
| Rate for Payer: Aetna American Axle |
$17.52
|
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.52
|
| Rate for Payer: Cash Price |
$21.56
|
| Rate for Payer: Cofinity Commercial |
$18.86
|
| Rate for Payer: Cofinity Commercial |
$23.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.56
|
| Rate for Payer: Healthscope Commercial |
$24.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.21
|
| Rate for Payer: Multiplan/Beech St/PHCS 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 |
$11.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.21
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$34.13
|
|
|
Service Code
|
NDC 50580057401
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$30.72 |
| Rate for Payer: Aetna American Axle |
$22.18
|
| Rate for Payer: Aetna Commercial |
$29.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.18
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cofinity Commercial |
$23.89
|
| Rate for Payer: Cofinity Commercial |
$29.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.30
|
| Rate for Payer: Healthscope Commercial |
$30.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.01
|
| Rate for Payer: PHP Commercial |
$29.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.18
|
| Rate for Payer: Priority Health SBD |
$21.50
|
| Rate for Payer: UMR Bronson Commercial |
$15.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.60
|
|
|
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 |
$18.22 |
| 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 |
$17.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$18.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.19
|
| Rate for Payer: Multiplan/Beech St/PHCS 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
|
$34.13
|
|
|
Service Code
|
NDC 50580057401
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.63 |
| Max. Negotiated Rate |
$30.72 |
| Rate for Payer: Aetna American Axle |
$22.18
|
| Rate for Payer: Aetna Commercial |
$29.01
|
| Rate for Payer: Aetna Medicare |
$17.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.18
|
| Rate for Payer: BCBS Complete |
$13.65
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: Cofinity Commercial |
$23.89
|
| Rate for Payer: Cofinity Commercial |
$29.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.30
|
| Rate for Payer: Healthscope Commercial |
$30.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.01
|
| Rate for Payer: PHP Commercial |
$29.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.18
|
| Rate for Payer: Priority Health SBD |
$21.50
|
| Rate for Payer: UMR Bronson Commercial |
$12.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.60
|
|
|
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
|
$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
|
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 |
$291.66
|
| 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 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 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: Healthscope Commercial |
$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: 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
|
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
|
|
