|
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 |
$133.25
|
| Rate for Payer: Aetna Medicare |
$74.03
|
| 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 |
$133.25
|
| 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
|
|
|
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
|
|
|
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
|
|
|
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
|
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
|
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
|
$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
|
$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
|
$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
|
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
|
$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
|
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 |
$24.39
|
| 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
|
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 |
$18.23
|
| 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 |
$18.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.21
|
| Rate for Payer: Nomi Health Commercial |
$16.61
|
| 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
|
$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 |
$18.23
|
| 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 |
$18.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.21
|
| Rate for Payer: Nomi Health Commercial |
$16.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| 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 |
$24.39
|
| 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
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$398.05
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.22 |
| Max. Negotiated Rate |
$398.05 |
| Rate for Payer: Aetna Commercial |
$358.25
|
| Rate for Payer: Aetna Medicare |
$199.03
|
| Rate for Payer: ASR ASR |
$386.11
|
| Rate for Payer: ASR Commercial |
$386.11
|
| Rate for Payer: BCBS Complete |
$159.22
|
| Rate for Payer: BCBS Trust/PPO |
$325.96
|
| Rate for Payer: BCN Commercial |
$308.61
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cofinity Commercial |
$374.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Healthscope Commercial |
$398.05
|
| Rate for Payer: Healthscope Whirlpool |
$386.11
|
| Rate for Payer: Mclaren Commercial |
$358.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$338.34
|
| Rate for Payer: Nomi Health Commercial |
$326.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$348.77
|
| Rate for Payer: Priority Health Narrow Network |
$279.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$350.28
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 51079011801
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Aetna Medicare |
$1.91
|
| Rate for Payer: ASR ASR |
$3.71
|
| Rate for Payer: ASR Commercial |
$3.71
|
| Rate for Payer: BCBS Complete |
$1.53
|
| Rate for Payer: BCBS Trust/PPO |
$3.13
|
| Rate for Payer: BCN Commercial |
$2.96
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.82
|
| Rate for Payer: Healthscope Whirlpool |
$3.71
|
| Rate for Payer: Mclaren Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Nomi Health Commercial |
$3.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.35
|
| Rate for Payer: Priority Health Narrow Network |
$2.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.36
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$398.05
|
|
|
Service Code
|
NDC 00904698761
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.73 |
| Max. Negotiated Rate |
$398.05 |
| Rate for Payer: Aetna Commercial |
$358.25
|
| Rate for Payer: ASR ASR |
$386.11
|
| Rate for Payer: ASR Commercial |
$386.11
|
| Rate for Payer: BCBS Trust/PPO |
$324.37
|
| Rate for Payer: BCN Commercial |
$308.61
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cofinity Commercial |
$374.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Healthscope Commercial |
$398.05
|
| Rate for Payer: Healthscope Whirlpool |
$386.11
|
| Rate for Payer: Mclaren Commercial |
$358.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$338.34
|
| Rate for Payer: Nomi Health Commercial |
$326.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$350.28
|
|
|
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
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$437.10
|
|
|
Service Code
|
NDC 00591079401
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.12 |
| Max. Negotiated Rate |
$437.10 |
| Rate for Payer: Aetna Commercial |
$393.39
|
| Rate for Payer: ASR ASR |
$423.99
|
| Rate for Payer: ASR Commercial |
$423.99
|
| Rate for Payer: BCBS Trust/PPO |
$356.19
|
| 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: UHC All Payor (Choice/PPO) + Core |
$384.65
|
|
|
DICYCLOMINE 10 MG CAPSULE
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 51079011801
|
| Hospital Charge Code |
2418
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: ASR ASR |
$3.71
|
| Rate for Payer: ASR Commercial |
$3.71
|
| Rate for Payer: BCBS Trust/PPO |
$3.11
|
| Rate for Payer: BCN Commercial |
$2.96
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.82
|
| Rate for Payer: Healthscope Whirlpool |
$3.71
|
| Rate for Payer: Mclaren Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.25
|
| Rate for Payer: Nomi Health Commercial |
$3.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.36
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$161.40
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.91 |
| Max. Negotiated Rate |
$161.40 |
| Rate for Payer: Aetna Commercial |
$145.26
|
| Rate for Payer: Aetna Commercial |
$64.02
|
| Rate for Payer: Aetna Commercial |
$28.73
|
| Rate for Payer: Aetna Commercial |
$29.23
|
| Rate for Payer: Aetna Commercial |
$29.80
|
| Rate for Payer: Aetna Commercial |
$156.18
|
| Rate for Payer: Aetna Commercial |
$249.77
|
| Rate for Payer: ASR ASR |
$31.51
|
| Rate for Payer: ASR ASR |
$32.12
|
| Rate for Payer: ASR ASR |
$156.56
|
| Rate for Payer: ASR ASR |
$69.00
|
| Rate for Payer: ASR ASR |
$168.32
|
| Rate for Payer: ASR ASR |
$269.19
|
| Rate for Payer: ASR ASR |
$30.96
|
| Rate for Payer: ASR Commercial |
$30.96
|
| Rate for Payer: ASR Commercial |
$269.19
|
| Rate for Payer: ASR Commercial |
$168.32
|
| Rate for Payer: ASR Commercial |
$156.56
|
| Rate for Payer: ASR Commercial |
$69.00
|
| Rate for Payer: ASR Commercial |
$32.12
|
| Rate for Payer: ASR Commercial |
$31.51
|
| Rate for Payer: BCBS Trust/PPO |
$57.96
|
| Rate for Payer: BCBS Trust/PPO |
$226.15
|
| Rate for Payer: BCBS Trust/PPO |
$26.47
|
| Rate for Payer: BCBS Trust/PPO |
$26.01
|
| Rate for Payer: BCBS Trust/PPO |
$141.41
|
| Rate for Payer: BCBS Trust/PPO |
$26.98
|
| Rate for Payer: BCBS Trust/PPO |
$131.52
|
| Rate for Payer: BCN Commercial |
$125.13
|
| Rate for Payer: BCN Commercial |
$134.54
|
| Rate for Payer: BCN Commercial |
$215.16
|
| Rate for Payer: BCN Commercial |
$24.75
|
| Rate for Payer: BCN Commercial |
$25.18
|
| Rate for Payer: BCN Commercial |
$25.67
|
| Rate for Payer: BCN Commercial |
$55.15
|
| Rate for Payer: Cash Price |
$129.12
|
| Rate for Payer: Cash Price |
$56.90
|
| Rate for Payer: Cash Price |
$138.83
|
| Rate for Payer: Cash Price |
$26.49
|
| Rate for Payer: Cash Price |
$25.53
|
| Rate for Payer: Cash Price |
$222.01
|
| Rate for Payer: Cash Price |
$25.99
|
| Rate for Payer: Cofinity Commercial |
$260.87
|
| Rate for Payer: Cofinity Commercial |
$163.12
|
| Rate for Payer: Cofinity Commercial |
$66.86
|
| Rate for Payer: Cofinity Commercial |
$30.53
|
| Rate for Payer: Cofinity Commercial |
$30.00
|
| Rate for Payer: Cofinity Commercial |
$31.12
|
| Rate for Payer: Cofinity Commercial |
$151.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.54
|
| Rate for Payer: Healthscope Commercial |
$173.53
|
| Rate for Payer: Healthscope Commercial |
$71.13
|
| Rate for Payer: Healthscope Commercial |
$31.92
|
| Rate for Payer: Healthscope Commercial |
$161.40
|
| Rate for Payer: Healthscope Commercial |
$277.52
|
| Rate for Payer: Healthscope Commercial |
$32.48
|
| Rate for Payer: Healthscope Commercial |
$33.11
|
| Rate for Payer: Healthscope Whirlpool |
$30.96
|
| Rate for Payer: Healthscope Whirlpool |
$156.56
|
| Rate for Payer: Healthscope Whirlpool |
$168.32
|
| Rate for Payer: Healthscope Whirlpool |
$31.51
|
| Rate for Payer: Healthscope Whirlpool |
$32.12
|
| Rate for Payer: Healthscope Whirlpool |
$69.00
|
| Rate for Payer: Healthscope Whirlpool |
$269.19
|
| Rate for Payer: Mclaren Commercial |
$29.23
|
| Rate for Payer: Mclaren Commercial |
$29.80
|
| Rate for Payer: Mclaren Commercial |
$249.77
|
| Rate for Payer: Mclaren Commercial |
$64.02
|
| Rate for Payer: Mclaren Commercial |
$28.73
|
| Rate for Payer: Mclaren Commercial |
$145.26
|
| Rate for Payer: Mclaren Commercial |
$156.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.50
|
| Rate for Payer: Nomi Health Commercial |
$227.57
|
| Rate for Payer: Nomi Health Commercial |
$26.17
|
| Rate for Payer: Nomi Health Commercial |
$132.35
|
| Rate for Payer: Nomi Health Commercial |
$27.15
|
| Rate for Payer: Nomi Health Commercial |
$58.33
|
| Rate for Payer: Nomi Health Commercial |
$26.63
|
| Rate for Payer: Nomi Health Commercial |
$142.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$152.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.09
|
|
|
DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$71.13
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2417
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.45 |
| Max. Negotiated Rate |
$71.13 |
| Rate for Payer: Aetna Commercial |
$64.02
|
| Rate for Payer: Aetna Commercial |
$156.18
|
| Rate for Payer: Aetna Commercial |
$249.77
|
| Rate for Payer: Aetna Commercial |
$29.23
|
| Rate for Payer: Aetna Commercial |
$28.73
|
| Rate for Payer: Aetna Commercial |
$145.26
|
| Rate for Payer: Aetna Commercial |
$29.80
|
| Rate for Payer: Aetna Medicare |
$35.56
|
| Rate for Payer: Aetna Medicare |
$86.77
|
| Rate for Payer: Aetna Medicare |
$16.55
|
| Rate for Payer: Aetna Medicare |
$80.70
|
| Rate for Payer: Aetna Medicare |
$16.24
|
| Rate for Payer: Aetna Medicare |
$138.76
|
| Rate for Payer: Aetna Medicare |
$15.96
|
| Rate for Payer: ASR ASR |
$269.19
|
| Rate for Payer: ASR ASR |
$32.12
|
| Rate for Payer: ASR ASR |
$69.00
|
| Rate for Payer: ASR ASR |
$31.51
|
| Rate for Payer: ASR ASR |
$168.32
|
| Rate for Payer: ASR ASR |
$30.96
|
| Rate for Payer: ASR ASR |
$156.56
|
| Rate for Payer: ASR Commercial |
$269.19
|
| Rate for Payer: ASR Commercial |
$156.56
|
| Rate for Payer: ASR Commercial |
$31.51
|
| Rate for Payer: ASR Commercial |
$69.00
|
| Rate for Payer: ASR Commercial |
$32.12
|
| Rate for Payer: ASR Commercial |
$168.32
|
| Rate for Payer: ASR Commercial |
$30.96
|
| Rate for Payer: BCBS Complete |
$12.77
|
| Rate for Payer: BCBS Complete |
$64.56
|
| Rate for Payer: BCBS Complete |
$12.99
|
| Rate for Payer: BCBS Complete |
$111.01
|
| Rate for Payer: BCBS Complete |
$69.41
|
| Rate for Payer: BCBS Complete |
$28.45
|
| Rate for Payer: BCBS Complete |
$13.24
|
| Rate for Payer: BCBS Trust/PPO |
$27.11
|
| Rate for Payer: BCBS Trust/PPO |
$26.14
|
| Rate for Payer: BCBS Trust/PPO |
$132.17
|
| Rate for Payer: BCBS Trust/PPO |
$142.10
|
| Rate for Payer: BCBS Trust/PPO |
$227.26
|
| Rate for Payer: BCBS Trust/PPO |
$26.60
|
| Rate for Payer: BCBS Trust/PPO |
$58.25
|
| Rate for Payer: BCN Commercial |
$25.67
|
| Rate for Payer: BCN Commercial |
$25.18
|
| Rate for Payer: BCN Commercial |
$55.15
|
| Rate for Payer: BCN Commercial |
$24.75
|
| Rate for Payer: BCN Commercial |
$134.54
|
| Rate for Payer: BCN Commercial |
$125.13
|
| Rate for Payer: BCN Commercial |
$215.16
|
| Rate for Payer: Cash Price |
$129.12
|
| Rate for Payer: Cash Price |
$25.53
|
| Rate for Payer: Cash Price |
$26.49
|
| Rate for Payer: Cash Price |
$25.99
|
| Rate for Payer: Cash Price |
$138.83
|
| Rate for Payer: Cash Price |
$222.01
|
| Rate for Payer: Cash Price |
$56.90
|
| Rate for Payer: Cofinity Commercial |
$66.86
|
| Rate for Payer: Cofinity Commercial |
$30.53
|
| Rate for Payer: Cofinity Commercial |
$31.12
|
| Rate for Payer: Cofinity Commercial |
$151.72
|
| Rate for Payer: Cofinity Commercial |
$163.12
|
| Rate for Payer: Cofinity Commercial |
$30.00
|
| Rate for Payer: Cofinity Commercial |
$260.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.98
|
| Rate for Payer: Healthscope Commercial |
$161.40
|
| Rate for Payer: Healthscope Commercial |
$71.13
|
| Rate for Payer: Healthscope Commercial |
$33.11
|
| Rate for Payer: Healthscope Commercial |
$31.92
|
| Rate for Payer: Healthscope Commercial |
$173.53
|
| Rate for Payer: Healthscope Commercial |
$32.48
|
| Rate for Payer: Healthscope Commercial |
$277.52
|
| Rate for Payer: Healthscope Whirlpool |
$269.19
|
| Rate for Payer: Healthscope Whirlpool |
$156.56
|
| Rate for Payer: Healthscope Whirlpool |
$30.96
|
| Rate for Payer: Healthscope Whirlpool |
$31.51
|
| Rate for Payer: Healthscope Whirlpool |
$32.12
|
| Rate for Payer: Healthscope Whirlpool |
$69.00
|
| Rate for Payer: Healthscope Whirlpool |
$168.32
|
| Rate for Payer: Mclaren Commercial |
$249.77
|
| Rate for Payer: Mclaren Commercial |
$29.23
|
| Rate for Payer: Mclaren Commercial |
$29.80
|
| Rate for Payer: Mclaren Commercial |
$64.02
|
| Rate for Payer: Mclaren Commercial |
$28.73
|
| Rate for Payer: Mclaren Commercial |
$145.26
|
| Rate for Payer: Mclaren Commercial |
$156.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.46
|
| Rate for Payer: Nomi Health Commercial |
$227.57
|
| Rate for Payer: Nomi Health Commercial |
$27.15
|
| Rate for Payer: Nomi Health Commercial |
$26.63
|
| Rate for Payer: Nomi Health Commercial |
$58.33
|
| Rate for Payer: Nomi Health Commercial |
$142.29
|
| Rate for Payer: Nomi Health Commercial |
$132.35
|
| Rate for Payer: Nomi Health Commercial |
$26.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$62.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$29.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$243.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$141.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$152.05
|
| Rate for Payer: Priority Health Narrow Network |
$121.64
|
| Rate for Payer: Priority Health Narrow Network |
$22.38
|
| Rate for Payer: Priority Health Narrow Network |
$194.54
|
| Rate for Payer: Priority Health Narrow Network |
$113.14
|
| Rate for Payer: Priority Health Narrow Network |
$23.21
|
| Rate for Payer: Priority Health Narrow Network |
$22.77
|
| Rate for Payer: Priority Health Narrow Network |
$49.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$152.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$244.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$142.03
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET
|
Facility
|
IP
|
$601.92
|
|
|
Service Code
|
NDC 42292000320
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$391.25 |
| Max. Negotiated Rate |
$601.92 |
| Rate for Payer: Aetna Commercial |
$541.73
|
| Rate for Payer: ASR ASR |
$583.86
|
| Rate for Payer: ASR Commercial |
$583.86
|
| Rate for Payer: BCBS Trust/PPO |
$490.50
|
| Rate for Payer: BCN Commercial |
$466.67
|
| Rate for Payer: Cash Price |
$481.54
|
| Rate for Payer: Cofinity Commercial |
$565.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$481.54
|
| Rate for Payer: Healthscope Commercial |
$601.92
|
| Rate for Payer: Healthscope Whirlpool |
$583.86
|
| Rate for Payer: Mclaren Commercial |
$541.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$511.63
|
| Rate for Payer: Nomi Health Commercial |
$493.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$391.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$529.69
|
|
|
DIGOXIN 125 MCG (0.125 MG) TABLET
|
Facility
|
OP
|
$601.92
|
|
|
Service Code
|
NDC 42292000320
|
| Hospital Charge Code |
2444
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.77 |
| Max. Negotiated Rate |
$601.92 |
| Rate for Payer: Aetna Commercial |
$541.73
|
| Rate for Payer: Aetna Medicare |
$300.96
|
| Rate for Payer: ASR ASR |
$583.86
|
| Rate for Payer: ASR Commercial |
$583.86
|
| Rate for Payer: BCBS Complete |
$240.77
|
| Rate for Payer: BCBS Trust/PPO |
$492.91
|
| Rate for Payer: BCN Commercial |
$466.67
|
| Rate for Payer: Cash Price |
$481.54
|
| Rate for Payer: Cofinity Commercial |
$565.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$481.54
|
| Rate for Payer: Healthscope Commercial |
$601.92
|
| Rate for Payer: Healthscope Whirlpool |
$583.86
|
| Rate for Payer: Mclaren Commercial |
$541.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$511.63
|
| Rate for Payer: Nomi Health Commercial |
$493.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$391.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$527.40
|
| Rate for Payer: Priority Health Narrow Network |
$421.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$529.69
|
|
