Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DIABETES WITH MCC

Facility

$23,418.21

Service Code	MSDRG 637
Min. Negotiated Rate	$11,098.03
Max. Negotiated Rate	$23,418.21
Rate for Payer: Aetna Medicare	$12,149.43
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,602.67
Rate for Payer: Amish Plain Church Group Commercial	$14,602.67
Rate for Payer: BCBS MAPPO	$11,682.14
Rate for Payer: BCBS Trust/PPO	$19,367.78
Rate for Payer: BCN Commercial	$19,367.78
Rate for Payer: BCN Medicare Advantage	$11,682.14
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,682.14
Rate for Payer: Mclaren Medicare	$11,682.14
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$12,266.25
Rate for Payer: MI Amish Medical Board Commercial	$13,434.46
Rate for Payer: Molina Medicare/Medicaid	$12,850.35
Rate for Payer: Nomi Health Commercial	$18,533.43
Rate for Payer: PACE Medicare	$11,098.03
Rate for Payer: PACE SWMI	$11,682.14
Rate for Payer: PHP Medicare Advantage	$11,682.14
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$23,162.68
Rate for Payer: Priority Health Medicare	$11,682.14
Rate for Payer: Priority Health Tiered Network	$18,530.14
Rate for Payer: Railroad Medicare Medicare	$11,682.14
Rate for Payer: UHC All Payor (Choice/PPO)	$23,418.21
Rate for Payer: UHC Core	$19,592.28
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$11,682.14
Rate for Payer: UHC Exchange	$16,000.53
Rate for Payer: VA VA	$11,682.14

DIABETES WITHOUT CC/MCC

Facility

$10,125.56

Service Code	MSDRG 639
Min. Negotiated Rate	$5,110.77
Max. Negotiated Rate	$10,125.56
Rate for Payer: Aetna Medicare	$5,594.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,724.70
Rate for Payer: Amish Plain Church Group Commercial	$6,724.70
Rate for Payer: BCBS MAPPO	$5,379.76
Rate for Payer: BCBS Trust/PPO	$9,899.24
Rate for Payer: BCN Commercial	$9,899.24
Rate for Payer: BCN Medicare Advantage	$5,379.76
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,379.76
Rate for Payer: Mclaren Medicare	$5,379.76
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5,648.75
Rate for Payer: MI Amish Medical Board Commercial	$6,186.72
Rate for Payer: Molina Medicare/Medicaid	$5,917.74
Rate for Payer: Nomi Health Commercial	$8,013.48
Rate for Payer: PACE Medicare	$5,110.77
Rate for Payer: PACE SWMI	$5,379.76
Rate for Payer: PHP Medicare Advantage	$5,379.76
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$10,015.07
Rate for Payer: Priority Health Medicare	$5,379.76
Rate for Payer: Priority Health Tiered Network	$8,012.06
Rate for Payer: Railroad Medicare Medicare	$5,379.76
Rate for Payer: UHC All Payor (Choice/PPO)	$10,125.56
Rate for Payer: UHC Core	$8,471.30
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$5,379.76
Rate for Payer: UHC Exchange	$6,918.30
Rate for Payer: VA VA	$5,379.76

DIALYSATE RFP-402 (K-0/CA-3) SOLUTION

Facility

$208.80

Service Code	NDC 09900000035
Hospital Charge Code	150777
Hospital Revenue Code	250
Min. Negotiated Rate	$131.54
Max. Negotiated Rate	$187.92
Rate for Payer: Aetna Commercial	$177.48
Rate for Payer: Aetna New Business (MI Preferred)	$135.72
Rate for Payer: Cash Price	$167.04
Rate for Payer: Cofinity Advantage	$146.16
Rate for Payer: Cofinity Commercial	$179.57
Rate for Payer: Encore Health Key Benefits Commercial	$167.04
Rate for Payer: Healthscope Commercial	$187.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$177.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$156.60
Rate for Payer: PHP Commercial	$177.48
Rate for Payer: Priority Health SBD	$131.54

DIALYSATE RFP-402 (K-0/CA-3) SOLUTION

Facility

$208.80

Service Code	NDC 09900000035
Hospital Charge Code	150777
Hospital Revenue Code	250
Min. Negotiated Rate	$82.06
Max. Negotiated Rate	$187.92
Rate for Payer: Aetna Commercial	$177.48
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: Aetna New Business (MI Preferred)	$135.72
Rate for Payer: BCBS Complete	$83.52
Rate for Payer: Cash Price	$167.04
Rate for Payer: Cofinity Advantage	$146.16
Rate for Payer: Cofinity Commercial	$179.57
Rate for Payer: Encore Health Key Benefits Commercial	$167.04
Rate for Payer: Healthscope Commercial	$187.92
Rate for Payer: MI Amish Medical Board Commercial	$167.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$177.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$156.60
Rate for Payer: PHP Commercial	$177.48
Rate for Payer: Priority Health SBD	$131.54
Rate for Payer: UHC All Payor (Choice/PPO)	$135.72
Rate for Payer: UHC Core	$108.78
Rate for Payer: UHC Exchange	$82.06

DIALYSATE RFP-453 (K-2/CA-0) SOLUTION

Facility

$208.80

Service Code	NDC 099000000036
Hospital Charge Code	150773
Hospital Revenue Code	250
Min. Negotiated Rate	$131.54
Max. Negotiated Rate	$187.92
Rate for Payer: Aetna Commercial	$177.48
Rate for Payer: Aetna New Business (MI Preferred)	$135.72
Rate for Payer: Cash Price	$167.04
Rate for Payer: Cofinity Advantage	$146.16
Rate for Payer: Cofinity Commercial	$179.57
Rate for Payer: Encore Health Key Benefits Commercial	$167.04
Rate for Payer: Healthscope Commercial	$187.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$177.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$156.60
Rate for Payer: PHP Commercial	$177.48
Rate for Payer: Priority Health SBD	$131.54

DIALYSATE RFP-453 (K-2/CA-0) SOLUTION

Facility

$208.80

Service Code	NDC 099000000036
Hospital Charge Code	150773
Hospital Revenue Code	250
Min. Negotiated Rate	$82.06
Max. Negotiated Rate	$187.92
Rate for Payer: Aetna Commercial	$177.48
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: Aetna New Business (MI Preferred)	$135.72
Rate for Payer: BCBS Complete	$83.52
Rate for Payer: Cash Price	$167.04
Rate for Payer: Cofinity Advantage	$146.16
Rate for Payer: Cofinity Commercial	$179.57
Rate for Payer: Encore Health Key Benefits Commercial	$167.04
Rate for Payer: Healthscope Commercial	$187.92
Rate for Payer: MI Amish Medical Board Commercial	$167.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$177.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$156.60
Rate for Payer: PHP Commercial	$177.48
Rate for Payer: Priority Health SBD	$131.54
Rate for Payer: UHC All Payor (Choice/PPO)	$135.72
Rate for Payer: UHC Core	$108.78
Rate for Payer: UHC Exchange	$82.06

DIALYSATE RFP-456 (K-4/CA-0) SOLUTION

Facility

$208.80

Service Code	NDC 09900000849
Hospital Charge Code	180369
Hospital Revenue Code	250
Min. Negotiated Rate	$131.54
Max. Negotiated Rate	$187.92
Rate for Payer: Aetna Commercial	$177.48
Rate for Payer: Aetna New Business (MI Preferred)	$135.72
Rate for Payer: Cash Price	$167.04
Rate for Payer: Cofinity Advantage	$146.16
Rate for Payer: Cofinity Commercial	$179.57
Rate for Payer: Encore Health Key Benefits Commercial	$167.04
Rate for Payer: Healthscope Commercial	$187.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$177.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$156.60
Rate for Payer: PHP Commercial	$177.48
Rate for Payer: Priority Health SBD	$131.54

DIALYSATE RFP-456 (K-4/CA-0) SOLUTION

Facility

$208.80

Service Code	NDC 09900000849
Hospital Charge Code	180369
Hospital Revenue Code	250
Min. Negotiated Rate	$82.06
Max. Negotiated Rate	$187.92
Rate for Payer: Aetna Commercial	$177.48
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: Aetna New Business (MI Preferred)	$135.72
Rate for Payer: BCBS Complete	$83.52
Rate for Payer: Cash Price	$167.04
Rate for Payer: Cofinity Advantage	$146.16
Rate for Payer: Cofinity Commercial	$179.57
Rate for Payer: Encore Health Key Benefits Commercial	$167.04
Rate for Payer: Healthscope Commercial	$187.92
Rate for Payer: MI Amish Medical Board Commercial	$167.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$177.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$156.60
Rate for Payer: PHP Commercial	$177.48
Rate for Payer: Priority Health SBD	$131.54
Rate for Payer: UHC All Payor (Choice/PPO)	$135.72
Rate for Payer: UHC Core	$108.78
Rate for Payer: UHC Exchange	$82.06

DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION

Facility

$90.00

Service Code	HCPCS Q9958
Hospital Charge Code	9823
Hospital Revenue Code	636
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: Aetna New Business (MI Preferred)	$58.50
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cofinity Advantage	$63.00
Rate for Payer: Cofinity Commercial	$77.40
Rate for Payer: Encore Health Key Benefits Commercial	$72.00
Rate for Payer: Healthscope Commercial	$81.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$76.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$67.50
Rate for Payer: PHP Commercial	$76.50
Rate for Payer: Priority Health SBD	$56.70

DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION

Facility

$90.00

Service Code	HCPCS Q9958
Hospital Charge Code	9823
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: Aetna New Business (MI Preferred)	$58.50
Rate for Payer: BCBS Complete	$36.00
Rate for Payer: BCBS Trust/PPO	$0.17
Rate for Payer: BCN Commercial	$0.17
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cofinity Advantage	$63.00
Rate for Payer: Cofinity Commercial	$77.40
Rate for Payer: Encore Health Key Benefits Commercial	$72.00
Rate for Payer: Healthscope Commercial	$81.00
Rate for Payer: MI Amish Medical Board Commercial	$72.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$76.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$67.50
Rate for Payer: PHP Commercial	$76.50
Rate for Payer: Priority Health SBD	$56.70
Rate for Payer: UHC All Payor (Choice/PPO)	$0.12
Rate for Payer: UHC Core	$0.12
Rate for Payer: UHC Exchange	$0.12

DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION

Facility

$182.50

Service Code	HCPCS Q9958
Hospital Charge Code	27735
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$164.25
Rate for Payer: Aetna Commercial	$155.12
Rate for Payer: Aetna Medicare	$91.25
Rate for Payer: Aetna New Business (MI Preferred)	$118.62
Rate for Payer: BCBS Complete	$73.00
Rate for Payer: BCBS Trust/PPO	$0.17
Rate for Payer: BCN Commercial	$0.17
Rate for Payer: Cash Price	$146.00
Rate for Payer: Cash Price	$146.00
Rate for Payer: Cofinity Advantage	$127.75
Rate for Payer: Cofinity Commercial	$156.95
Rate for Payer: Encore Health Key Benefits Commercial	$146.00
Rate for Payer: Healthscope Commercial	$164.25
Rate for Payer: MI Amish Medical Board Commercial	$146.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$136.88
Rate for Payer: PHP Commercial	$155.12
Rate for Payer: Priority Health SBD	$114.97
Rate for Payer: UHC All Payor (Choice/PPO)	$0.12
Rate for Payer: UHC Core	$0.12
Rate for Payer: UHC Exchange	$0.12

DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION

Facility

$182.50

Service Code	HCPCS Q9958
Hospital Charge Code	27735
Hospital Revenue Code	636
Min. Negotiated Rate	$114.97
Max. Negotiated Rate	$164.25
Rate for Payer: Aetna Commercial	$155.12
Rate for Payer: Aetna New Business (MI Preferred)	$118.62
Rate for Payer: Cash Price	$146.00
Rate for Payer: Cofinity Advantage	$127.75
Rate for Payer: Cofinity Commercial	$156.95
Rate for Payer: Encore Health Key Benefits Commercial	$146.00
Rate for Payer: Healthscope Commercial	$164.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$136.88
Rate for Payer: PHP Commercial	$155.12
Rate for Payer: Priority Health SBD	$114.97

DIAZEPAM 2 MG TABLET

Facility

$1.56

Service Code	NDC 51079028401
Hospital Charge Code	2404
Hospital Revenue Code	637
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna Commercial	$1.33
Rate for Payer: Aetna New Business (MI Preferred)	$1.01
Rate for Payer: Cash Price	$1.25
Rate for Payer: Cofinity Advantage	$1.09
Rate for Payer: Cofinity Commercial	$1.34
Rate for Payer: Encore Health Key Benefits Commercial	$1.25
Rate for Payer: Healthscope Commercial	$1.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.33
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.17
Rate for Payer: PHP Commercial	$1.33
Rate for Payer: Priority Health SBD	$0.98

DIAZEPAM 2 MG TABLET

Facility

$155.10

Service Code	NDC 51079028420
Hospital Charge Code	2404
Hospital Revenue Code	637
Min. Negotiated Rate	$97.71
Max. Negotiated Rate	$139.59
Rate for Payer: Aetna Commercial	$131.84
Rate for Payer: Aetna New Business (MI Preferred)	$100.81
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cofinity Advantage	$108.57
Rate for Payer: Cofinity Commercial	$133.39
Rate for Payer: Encore Health Key Benefits Commercial	$124.08
Rate for Payer: Healthscope Commercial	$139.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$131.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$116.33
Rate for Payer: PHP Commercial	$131.84
Rate for Payer: Priority Health SBD	$97.71

DIAZEPAM 2 MG TABLET

Facility

$155.10

Service Code	NDC 51079028420
Hospital Charge Code	2404
Hospital Revenue Code	637
Min. Negotiated Rate	$60.95
Max. Negotiated Rate	$139.59
Rate for Payer: Aetna Commercial	$131.84
Rate for Payer: Aetna Medicare	$77.55
Rate for Payer: Aetna New Business (MI Preferred)	$100.81
Rate for Payer: BCBS Complete	$62.04
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cofinity Advantage	$108.57
Rate for Payer: Cofinity Commercial	$133.39
Rate for Payer: Encore Health Key Benefits Commercial	$124.08
Rate for Payer: Healthscope Commercial	$139.59
Rate for Payer: MI Amish Medical Board Commercial	$124.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$131.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$116.33
Rate for Payer: PHP Commercial	$131.84
Rate for Payer: Priority Health SBD	$97.71
Rate for Payer: UHC All Payor (Choice/PPO)	$100.81
Rate for Payer: UHC Core	$80.81
Rate for Payer: UHC Exchange	$60.95

DIAZEPAM 2 MG TABLET

Facility

$56.40

Service Code	NDC 00172392560
Hospital Charge Code	2404
Hospital Revenue Code	637
Min. Negotiated Rate	$35.53
Max. Negotiated Rate	$50.76
Rate for Payer: Aetna Commercial	$47.94
Rate for Payer: Aetna New Business (MI Preferred)	$36.66
Rate for Payer: Cash Price	$45.12
Rate for Payer: Cofinity Advantage	$39.48
Rate for Payer: Cofinity Commercial	$48.50
Rate for Payer: Encore Health Key Benefits Commercial	$45.12
Rate for Payer: Healthscope Commercial	$50.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.94
Rate for Payer: Opus (Opus Packaging Group) HMA	$42.30
Rate for Payer: PHP Commercial	$47.94
Rate for Payer: Priority Health SBD	$35.53

DIAZEPAM 2 MG TABLET

Facility

$56.40

Service Code	NDC 00172392560
Hospital Charge Code	2404
Hospital Revenue Code	637
Min. Negotiated Rate	$22.17
Max. Negotiated Rate	$50.76
Rate for Payer: Aetna Commercial	$47.94
Rate for Payer: Aetna Medicare	$28.20
Rate for Payer: Aetna New Business (MI Preferred)	$36.66
Rate for Payer: BCBS Complete	$22.56
Rate for Payer: Cash Price	$45.12
Rate for Payer: Cofinity Advantage	$39.48
Rate for Payer: Cofinity Commercial	$48.50
Rate for Payer: Encore Health Key Benefits Commercial	$45.12
Rate for Payer: Healthscope Commercial	$50.76
Rate for Payer: MI Amish Medical Board Commercial	$45.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.94
Rate for Payer: Opus (Opus Packaging Group) HMA	$42.30
Rate for Payer: PHP Commercial	$47.94
Rate for Payer: Priority Health SBD	$35.53
Rate for Payer: UHC All Payor (Choice/PPO)	$36.66
Rate for Payer: UHC Core	$29.38
Rate for Payer: UHC Exchange	$22.17

DIAZEPAM 2 MG TABLET

Facility

$1.56

Service Code	NDC 51079028401
Hospital Charge Code	2404
Hospital Revenue Code	637
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna Commercial	$1.33
Rate for Payer: Aetna Medicare	$0.78
Rate for Payer: Aetna New Business (MI Preferred)	$1.01
Rate for Payer: BCBS Complete	$0.62
Rate for Payer: Cash Price	$1.25
Rate for Payer: Cofinity Advantage	$1.09
Rate for Payer: Cofinity Commercial	$1.34
Rate for Payer: Encore Health Key Benefits Commercial	$1.25
Rate for Payer: Healthscope Commercial	$1.40
Rate for Payer: MI Amish Medical Board Commercial	$1.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.33
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.17
Rate for Payer: PHP Commercial	$1.33
Rate for Payer: Priority Health SBD	$0.98
Rate for Payer: UHC All Payor (Choice/PPO)	$1.01
Rate for Payer: UHC Core	$0.81
Rate for Payer: UHC Exchange	$0.61

DIAZEPAM 5 MG TABLET

Facility

$77.55

Service Code	NDC 00172392660
Hospital Charge Code	2405
Hospital Revenue Code	637
Min. Negotiated Rate	$30.48
Max. Negotiated Rate	$69.80
Rate for Payer: Aetna Commercial	$65.92
Rate for Payer: Aetna Medicare	$38.77
Rate for Payer: Aetna New Business (MI Preferred)	$50.41
Rate for Payer: BCBS Complete	$31.02
Rate for Payer: Cash Price	$62.04
Rate for Payer: Cofinity Advantage	$54.28
Rate for Payer: Cofinity Commercial	$66.69
Rate for Payer: Encore Health Key Benefits Commercial	$62.04
Rate for Payer: Healthscope Commercial	$69.80
Rate for Payer: MI Amish Medical Board Commercial	$62.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$58.16
Rate for Payer: PHP Commercial	$65.92
Rate for Payer: Priority Health SBD	$48.86
Rate for Payer: UHC All Payor (Choice/PPO)	$50.41
Rate for Payer: UHC Core	$40.40
Rate for Payer: UHC Exchange	$30.48

DIAZEPAM 5 MG TABLET

Facility

$145.70

Service Code	NDC 51079028520
Hospital Charge Code	2405
Hospital Revenue Code	637
Min. Negotiated Rate	$57.26
Max. Negotiated Rate	$131.13
Rate for Payer: Aetna Commercial	$123.84
Rate for Payer: Aetna Medicare	$72.85
Rate for Payer: Aetna New Business (MI Preferred)	$94.70
Rate for Payer: BCBS Complete	$58.28
Rate for Payer: Cash Price	$116.56
Rate for Payer: Cofinity Advantage	$101.99
Rate for Payer: Cofinity Commercial	$125.30
Rate for Payer: Encore Health Key Benefits Commercial	$116.56
Rate for Payer: Healthscope Commercial	$131.13
Rate for Payer: MI Amish Medical Board Commercial	$116.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$123.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$109.28
Rate for Payer: PHP Commercial	$123.84
Rate for Payer: Priority Health SBD	$91.79
Rate for Payer: UHC All Payor (Choice/PPO)	$94.70
Rate for Payer: UHC Core	$75.91
Rate for Payer: UHC Exchange	$57.26

DIAZEPAM 5 MG TABLET

Facility

$1.46

Service Code	NDC 51079028501
Hospital Charge Code	2405
Hospital Revenue Code	637
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna Commercial	$1.24
Rate for Payer: Aetna New Business (MI Preferred)	$0.95
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cofinity Advantage	$1.02
Rate for Payer: Cofinity Commercial	$1.26
Rate for Payer: Encore Health Key Benefits Commercial	$1.17
Rate for Payer: Healthscope Commercial	$1.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.09
Rate for Payer: PHP Commercial	$1.24
Rate for Payer: Priority Health SBD	$0.92

DIAZEPAM 5 MG TABLET

Facility

$1.46

Service Code	NDC 51079028501
Hospital Charge Code	2405
Hospital Revenue Code	637
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna Commercial	$1.24
Rate for Payer: Aetna Medicare	$0.73
Rate for Payer: Aetna New Business (MI Preferred)	$0.95
Rate for Payer: BCBS Complete	$0.58
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cofinity Advantage	$1.02
Rate for Payer: Cofinity Commercial	$1.26
Rate for Payer: Encore Health Key Benefits Commercial	$1.17
Rate for Payer: Healthscope Commercial	$1.31
Rate for Payer: MI Amish Medical Board Commercial	$1.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.09
Rate for Payer: PHP Commercial	$1.24
Rate for Payer: Priority Health SBD	$0.92
Rate for Payer: UHC All Payor (Choice/PPO)	$0.95
Rate for Payer: UHC Core	$0.76
Rate for Payer: UHC Exchange	$0.57

DIAZEPAM 5 MG TABLET

Facility

$77.55

Service Code	NDC 00172392660
Hospital Charge Code	2405
Hospital Revenue Code	637
Min. Negotiated Rate	$48.86
Max. Negotiated Rate	$69.80
Rate for Payer: Aetna Commercial	$65.92
Rate for Payer: Aetna New Business (MI Preferred)	$50.41
Rate for Payer: Cash Price	$62.04
Rate for Payer: Cofinity Advantage	$54.28
Rate for Payer: Cofinity Commercial	$66.69
Rate for Payer: Encore Health Key Benefits Commercial	$62.04
Rate for Payer: Healthscope Commercial	$69.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$58.16
Rate for Payer: PHP Commercial	$65.92
Rate for Payer: Priority Health SBD	$48.86

DIAZEPAM 5 MG TABLET

Facility

$145.70

Service Code	NDC 51079028520
Hospital Charge Code	2405
Hospital Revenue Code	637
Min. Negotiated Rate	$91.79
Max. Negotiated Rate	$131.13
Rate for Payer: Aetna Commercial	$123.84
Rate for Payer: Aetna New Business (MI Preferred)	$94.70
Rate for Payer: Cash Price	$116.56
Rate for Payer: Cofinity Advantage	$101.99
Rate for Payer: Cofinity Commercial	$125.30
Rate for Payer: Encore Health Key Benefits Commercial	$116.56
Rate for Payer: Healthscope Commercial	$131.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$123.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$109.28
Rate for Payer: PHP Commercial	$123.84
Rate for Payer: Priority Health SBD	$91.79

DICLOFENAC 1 % TOPICAL GEL

Facility

$26.95

Service Code	NDC 70000055502
Hospital Charge Code	100611
Hospital Revenue Code	637
Min. Negotiated Rate	$16.98
Max. Negotiated Rate	$24.25
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 Advantage	$18.86
Rate for Payer: Cofinity Commercial	$23.18
Rate for Payer: Encore Health Key Benefits Commercial	$21.56
Rate for Payer: Healthscope Commercial	$24.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$20.21
Rate for Payer: PHP Commercial	$22.91
Rate for Payer: Priority Health SBD	$16.98

Know your out-of-pocket cost for care.

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