|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION
|
Facility
|
OP
|
$63.72
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.49 |
| Max. Negotiated Rate |
$63.72 |
| Rate for Payer: Aetna Commercial |
$57.35
|
| Rate for Payer: Aetna Medicare |
$31.86
|
| Rate for Payer: ASR ASR |
$61.81
|
| Rate for Payer: ASR Commercial |
$61.81
|
| Rate for Payer: BCBS Complete |
$25.49
|
| Rate for Payer: BCBS Trust/PPO |
$52.18
|
| Rate for Payer: BCN Commercial |
$49.40
|
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: Cofinity Commercial |
$59.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.98
|
| Rate for Payer: Healthscope Commercial |
$63.72
|
| Rate for Payer: Healthscope Whirlpool |
$61.81
|
| Rate for Payer: Mclaren Commercial |
$57.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.16
|
| Rate for Payer: Nomi Health Commercial |
$52.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.83
|
| Rate for Payer: Priority Health Narrow Network |
$44.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.07
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION
|
Facility
|
IP
|
$63.72
|
|
|
Service Code
|
HCPCS Q9963
|
| Hospital Charge Code |
9828
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.42 |
| Max. Negotiated Rate |
$63.72 |
| Rate for Payer: Aetna Commercial |
$57.35
|
| Rate for Payer: ASR ASR |
$61.81
|
| Rate for Payer: ASR Commercial |
$61.81
|
| Rate for Payer: BCBS Trust/PPO |
$51.93
|
| Rate for Payer: BCN Commercial |
$49.40
|
| Rate for Payer: Cash Price |
$50.98
|
| Rate for Payer: Cofinity Commercial |
$59.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.98
|
| Rate for Payer: Healthscope Commercial |
$63.72
|
| Rate for Payer: Healthscope Whirlpool |
$61.81
|
| Rate for Payer: Mclaren Commercial |
$57.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$54.16
|
| Rate for Payer: Nomi Health Commercial |
$52.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$56.07
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$1.41
|
|
|
Service Code
|
NDC 51079028401
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: ASR ASR |
$1.37
|
| Rate for Payer: ASR Commercial |
$1.37
|
| Rate for Payer: BCBS Trust/PPO |
$1.15
|
| Rate for Payer: BCN Commercial |
$1.09
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$1.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.13
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Healthscope Whirlpool |
$1.37
|
| Rate for Payer: Mclaren Commercial |
$1.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.20
|
| Rate for Payer: Nomi Health Commercial |
$1.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.24
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.65 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: ASR ASR |
$136.77
|
| Rate for Payer: ASR Commercial |
$136.77
|
| Rate for Payer: BCBS Trust/PPO |
$114.90
|
| Rate for Payer: BCN Commercial |
$109.32
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$132.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$141.00
|
| Rate for Payer: Healthscope Whirlpool |
$136.77
|
| Rate for Payer: Mclaren Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: Nomi Health Commercial |
$115.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.08
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$1.41
|
|
|
Service Code
|
NDC 51079028401
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna Medicare |
$0.71
|
| Rate for Payer: ASR ASR |
$1.37
|
| Rate for Payer: ASR Commercial |
$1.37
|
| Rate for Payer: BCBS Complete |
$0.56
|
| Rate for Payer: BCBS Trust/PPO |
$1.15
|
| Rate for Payer: BCN Commercial |
$1.09
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$1.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.13
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Healthscope Whirlpool |
$1.37
|
| Rate for Payer: Mclaren Commercial |
$1.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.20
|
| Rate for Payer: Nomi Health Commercial |
$1.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.24
|
| Rate for Payer: Priority Health Narrow Network |
$0.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.24
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.40 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Aetna Medicare |
$70.50
|
| Rate for Payer: ASR ASR |
$136.77
|
| Rate for Payer: ASR Commercial |
$136.77
|
| Rate for Payer: BCBS Complete |
$56.40
|
| Rate for Payer: BCBS Trust/PPO |
$115.46
|
| Rate for Payer: BCN Commercial |
$109.32
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$132.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$141.00
|
| Rate for Payer: Healthscope Whirlpool |
$136.77
|
| Rate for Payer: Mclaren Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: Nomi Health Commercial |
$115.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$123.54
|
| Rate for Payer: Priority Health Narrow Network |
$98.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.08
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$1.48
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna Medicare |
$0.74
|
| Rate for Payer: ASR ASR |
$1.44
|
| Rate for Payer: ASR Commercial |
$1.44
|
| Rate for Payer: BCBS Complete |
$0.59
|
| Rate for Payer: BCBS Trust/PPO |
$1.21
|
| Rate for Payer: BCN Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.18
|
| Rate for Payer: Healthscope Commercial |
$1.48
|
| Rate for Payer: Healthscope Whirlpool |
$1.44
|
| Rate for Payer: Mclaren Commercial |
$1.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.26
|
| Rate for Payer: Nomi Health Commercial |
$1.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.30
|
| Rate for Payer: Priority Health Narrow Network |
$1.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.30
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.22 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.24
|
| Rate for Payer: Aetna Medicare |
$74.02
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: ASR Commercial |
$143.61
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: BCBS Trust/PPO |
$121.24
|
| Rate for Payer: BCN Commercial |
$114.78
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.61
|
| Rate for Payer: Mclaren Commercial |
$133.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$129.72
|
| Rate for Payer: Priority Health Narrow Network |
$103.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.28
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$1.48
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: ASR ASR |
$1.44
|
| Rate for Payer: ASR Commercial |
$1.44
|
| Rate for Payer: BCBS Trust/PPO |
$1.21
|
| Rate for Payer: BCN Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.18
|
| Rate for Payer: Healthscope Commercial |
$1.48
|
| Rate for Payer: Healthscope Whirlpool |
$1.44
|
| Rate for Payer: Mclaren Commercial |
$1.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.26
|
| Rate for Payer: Nomi Health Commercial |
$1.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.30
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.23 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$133.24
|
| Rate for Payer: ASR ASR |
$143.61
|
| Rate for Payer: ASR Commercial |
$143.61
|
| Rate for Payer: BCBS Trust/PPO |
$120.65
|
| Rate for Payer: BCN Commercial |
$114.78
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Healthscope Whirlpool |
$143.61
|
| Rate for Payer: Mclaren Commercial |
$133.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: Nomi Health Commercial |
$121.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$130.28
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$21.66
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$21.66 |
| Rate for Payer: Aetna Commercial |
$19.49
|
| Rate for Payer: ASR ASR |
$21.01
|
| Rate for Payer: ASR Commercial |
$21.01
|
| Rate for Payer: BCBS Trust/PPO |
$17.65
|
| Rate for Payer: BCN Commercial |
$16.79
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$21.66
|
| Rate for Payer: Healthscope Whirlpool |
$21.01
|
| Rate for Payer: Mclaren Commercial |
$19.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.41
|
| Rate for Payer: Nomi Health Commercial |
$17.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.06
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
OP
|
$21.66
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$21.66 |
| Rate for Payer: Aetna Commercial |
$19.49
|
| Rate for Payer: Aetna Medicare |
$10.83
|
| Rate for Payer: ASR ASR |
$21.01
|
| Rate for Payer: ASR Commercial |
$21.01
|
| Rate for Payer: BCBS Complete |
$8.66
|
| Rate for Payer: BCBS Trust/PPO |
$17.74
|
| Rate for Payer: BCN Commercial |
$16.79
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Commercial |
$20.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$21.66
|
| Rate for Payer: Healthscope Whirlpool |
$21.01
|
| Rate for Payer: Mclaren Commercial |
$19.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.41
|
| Rate for Payer: Nomi Health Commercial |
$17.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.98
|
| Rate for Payer: Priority Health Narrow Network |
$15.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.06
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$34.20
|
|
|
Service Code
|
NDC 61314001425
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna Commercial |
$30.78
|
| Rate for Payer: Aetna Medicare |
$17.10
|
| Rate for Payer: ASR ASR |
$33.17
|
| Rate for Payer: ASR Commercial |
$33.17
|
| Rate for Payer: BCBS Complete |
$13.68
|
| Rate for Payer: BCBS Trust/PPO |
$28.01
|
| Rate for Payer: BCN Commercial |
$26.52
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$32.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.36
|
| Rate for Payer: Healthscope Commercial |
$34.20
|
| Rate for Payer: Healthscope Whirlpool |
$33.17
|
| Rate for Payer: Mclaren Commercial |
$30.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.07
|
| Rate for Payer: Nomi Health Commercial |
$28.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$29.97
|
| Rate for Payer: Priority Health Narrow Network |
$23.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.10
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$23.22
|
|
|
Service Code
|
NDC 17478089210
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.29 |
| Max. Negotiated Rate |
$23.22 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: Aetna Medicare |
$11.61
|
| Rate for Payer: ASR ASR |
$22.52
|
| Rate for Payer: ASR Commercial |
$22.52
|
| Rate for Payer: BCBS Complete |
$9.29
|
| Rate for Payer: BCBS Trust/PPO |
$19.01
|
| Rate for Payer: BCN Commercial |
$18.00
|
| Rate for Payer: Cash Price |
$18.58
|
| Rate for Payer: Cofinity Commercial |
$21.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.58
|
| Rate for Payer: Healthscope Commercial |
$23.22
|
| Rate for Payer: Healthscope Whirlpool |
$22.52
|
| Rate for Payer: Mclaren Commercial |
$20.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.74
|
| Rate for Payer: Nomi Health Commercial |
$19.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.35
|
| Rate for Payer: Priority Health Narrow Network |
$16.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.43
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$26.77
|
|
|
Service Code
|
NDC 24208045705
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.40 |
| Max. Negotiated Rate |
$26.77 |
| Rate for Payer: Aetna Commercial |
$24.09
|
| Rate for Payer: ASR ASR |
$25.97
|
| Rate for Payer: ASR Commercial |
$25.97
|
| Rate for Payer: BCBS Trust/PPO |
$21.81
|
| Rate for Payer: BCN Commercial |
$20.75
|
| Rate for Payer: Cash Price |
$21.42
|
| Rate for Payer: Cofinity Commercial |
$25.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.42
|
| Rate for Payer: Healthscope Commercial |
$26.77
|
| Rate for Payer: Healthscope Whirlpool |
$25.97
|
| Rate for Payer: Mclaren Commercial |
$24.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.75
|
| Rate for Payer: Nomi Health Commercial |
$21.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.56
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$26.77
|
|
|
Service Code
|
NDC 24208045705
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$26.77 |
| Rate for Payer: Aetna Commercial |
$24.09
|
| Rate for Payer: Aetna Medicare |
$13.38
|
| Rate for Payer: ASR ASR |
$25.97
|
| Rate for Payer: ASR Commercial |
$25.97
|
| Rate for Payer: BCBS Complete |
$10.71
|
| Rate for Payer: BCBS Trust/PPO |
$21.92
|
| Rate for Payer: BCN Commercial |
$20.75
|
| Rate for Payer: Cash Price |
$21.42
|
| Rate for Payer: Cofinity Commercial |
$25.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.42
|
| Rate for Payer: Healthscope Commercial |
$26.77
|
| Rate for Payer: Healthscope Whirlpool |
$25.97
|
| Rate for Payer: Mclaren Commercial |
$24.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.75
|
| Rate for Payer: Nomi Health Commercial |
$21.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.46
|
| Rate for Payer: Priority Health Narrow Network |
$18.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.56
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$34.20
|
|
|
Service Code
|
NDC 61314001425
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.23 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna Commercial |
$30.78
|
| Rate for Payer: ASR ASR |
$33.17
|
| Rate for Payer: ASR Commercial |
$33.17
|
| Rate for Payer: BCBS Trust/PPO |
$27.87
|
| Rate for Payer: BCN Commercial |
$26.52
|
| Rate for Payer: Cash Price |
$27.36
|
| Rate for Payer: Cofinity Commercial |
$32.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.36
|
| Rate for Payer: Healthscope Commercial |
$34.20
|
| Rate for Payer: Healthscope Whirlpool |
$33.17
|
| Rate for Payer: Mclaren Commercial |
$30.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.07
|
| Rate for Payer: Nomi Health Commercial |
$28.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$30.10
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
IP
|
$23.22
|
|
|
Service Code
|
NDC 17478089210
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.09 |
| Max. Negotiated Rate |
$23.22 |
| Rate for Payer: Aetna Commercial |
$20.90
|
| Rate for Payer: ASR ASR |
$22.52
|
| Rate for Payer: ASR Commercial |
$22.52
|
| Rate for Payer: BCBS Trust/PPO |
$18.92
|
| Rate for Payer: BCN Commercial |
$18.00
|
| Rate for Payer: Cash Price |
$18.58
|
| Rate for Payer: Cofinity Commercial |
$21.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.58
|
| Rate for Payer: Healthscope Commercial |
$23.22
|
| Rate for Payer: Healthscope Whirlpool |
$22.52
|
| Rate for Payer: Mclaren Commercial |
$20.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.74
|
| Rate for Payer: Nomi Health Commercial |
$19.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.43
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$20.25
|
|
|
Service Code
|
NDC 09629513974
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$20.25 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Medicare |
$10.12
|
| Rate for Payer: ASR ASR |
$19.64
|
| Rate for Payer: ASR Commercial |
$19.64
|
| Rate for Payer: BCBS Complete |
$8.10
|
| Rate for Payer: BCBS Trust/PPO |
$16.58
|
| Rate for Payer: BCN Commercial |
$15.70
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$19.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$20.25
|
| Rate for Payer: Healthscope Whirlpool |
$19.64
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.21
|
| Rate for Payer: Nomi Health Commercial |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.74
|
| Rate for Payer: Priority Health Narrow Network |
$14.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.82
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 00536129434
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.66 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$25.83
|
| Rate for Payer: ASR ASR |
$27.84
|
| Rate for Payer: ASR Commercial |
$27.84
|
| Rate for Payer: BCBS Trust/PPO |
$23.39
|
| Rate for Payer: BCN Commercial |
$22.25
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$26.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Healthscope Commercial |
$28.70
|
| Rate for Payer: Healthscope Whirlpool |
$27.84
|
| Rate for Payer: Mclaren Commercial |
$25.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: Nomi Health Commercial |
$23.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$25.26
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$39.73
|
|
|
Service Code
|
NDC 00067815202
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.89 |
| Max. Negotiated Rate |
$39.73 |
| Rate for Payer: Aetna Commercial |
$35.76
|
| Rate for Payer: Aetna Medicare |
$19.86
|
| Rate for Payer: ASR ASR |
$38.54
|
| Rate for Payer: ASR Commercial |
$38.54
|
| Rate for Payer: BCBS Complete |
$15.89
|
| Rate for Payer: BCBS Trust/PPO |
$32.53
|
| Rate for Payer: BCN Commercial |
$30.80
|
| Rate for Payer: Cash Price |
$31.78
|
| Rate for Payer: Cofinity Commercial |
$37.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.78
|
| Rate for Payer: Healthscope Commercial |
$39.73
|
| Rate for Payer: Healthscope Whirlpool |
$38.54
|
| Rate for Payer: Mclaren Commercial |
$35.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.77
|
| Rate for Payer: Nomi Health Commercial |
$32.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$34.81
|
| Rate for Payer: Priority Health Narrow Network |
$27.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$34.96
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$39.73
|
|
|
Service Code
|
NDC 00067815202
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.82 |
| Max. Negotiated Rate |
$39.73 |
| Rate for Payer: Aetna Commercial |
$35.76
|
| Rate for Payer: ASR ASR |
$38.54
|
| Rate for Payer: ASR Commercial |
$38.54
|
| Rate for Payer: BCBS Trust/PPO |
$32.38
|
| Rate for Payer: BCN Commercial |
$30.80
|
| Rate for Payer: Cash Price |
$31.78
|
| Rate for Payer: Cofinity Commercial |
$37.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.78
|
| Rate for Payer: Healthscope Commercial |
$39.73
|
| Rate for Payer: Healthscope Whirlpool |
$38.54
|
| Rate for Payer: Mclaren Commercial |
$35.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.77
|
| Rate for Payer: Nomi Health Commercial |
$32.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$34.96
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 00536129434
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.48 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$25.83
|
| Rate for Payer: Aetna Medicare |
$14.35
|
| Rate for Payer: ASR ASR |
$27.84
|
| Rate for Payer: ASR Commercial |
$27.84
|
| Rate for Payer: BCBS Complete |
$11.48
|
| Rate for Payer: BCBS Trust/PPO |
$23.50
|
| Rate for Payer: BCN Commercial |
$22.25
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$26.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Healthscope Commercial |
$28.70
|
| Rate for Payer: Healthscope Whirlpool |
$27.84
|
| Rate for Payer: Mclaren Commercial |
$25.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: Nomi Health Commercial |
$23.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25.15
|
| Rate for Payer: Priority Health Narrow Network |
$20.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$25.26
|
|
|
DICLOFENAC 1 % TOPICAL GEL
|
Facility
|
IP
|
$20.25
|
|
|
Service Code
|
NDC 09629513974
|
| Hospital Charge Code |
100611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$20.25 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.64
|
| Rate for Payer: ASR Commercial |
$19.64
|
| Rate for Payer: BCBS Trust/PPO |
$16.50
|
| Rate for Payer: BCN Commercial |
$15.70
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cofinity Commercial |
$19.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.20
|
| Rate for Payer: Healthscope Commercial |
$20.25
|
| Rate for Payer: Healthscope Whirlpool |
$19.64
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.21
|
| Rate for Payer: Nomi Health Commercial |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.82
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$437.10
|
|
|
Service Code
|
NDC 00591079401
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.84 |
| Max. Negotiated Rate |
$437.10 |
| Rate for Payer: Aetna Commercial |
$393.39
|
| Rate for Payer: Aetna Medicare |
$218.55
|
| Rate for Payer: ASR ASR |
$423.99
|
| Rate for Payer: ASR Commercial |
$423.99
|
| Rate for Payer: BCBS Complete |
$174.84
|
| Rate for Payer: BCBS Trust/PPO |
$357.94
|
| Rate for Payer: BCN Commercial |
$338.88
|
| Rate for Payer: Cash Price |
$349.68
|
| Rate for Payer: Cofinity Commercial |
$410.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.68
|
| Rate for Payer: Healthscope Commercial |
$437.10
|
| Rate for Payer: Healthscope Whirlpool |
$423.99
|
| Rate for Payer: Mclaren Commercial |
$393.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$371.54
|
| Rate for Payer: Nomi Health Commercial |
$358.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$382.99
|
| Rate for Payer: Priority Health Narrow Network |
$306.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$384.65
|
|
