|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$55.99
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
2364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.27 |
| Max. Negotiated Rate |
$50.39 |
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV ADDITIONAL SOLUTION
|
Facility
|
OP
|
$58.23
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
180629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.29 |
| Max. Negotiated Rate |
$52.41 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Medicare |
$29.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5 % IN WATER (D5W) IV ADDITIONAL SOLUTION
|
Facility
|
IP
|
$58.23
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
180629
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.68 |
| Max. Negotiated Rate |
$52.41 |
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health SBD |
$36.68
|
|
|
DEXTROSE 5% IN WATER INTRAVENOUS SOLUTION (DOSE, ADMIN OVER & INDICATION REQUIRED)
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
301087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.97 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5% IN WATER INTRAVENOUS SOLUTION (DOSE, ADMIN OVER & INDICATION REQUIRED)
|
Facility
|
OP
|
$55.99
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
301087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$50.39 |
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$49.50
|
| Rate for Payer: Aetna Medicare |
$33.59
|
| Rate for Payer: Aetna Medicare |
$28.00
|
| Rate for Payer: Aetna Medicare |
$29.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.85
|
| Rate for Payer: BCBS Complete |
$23.29
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$46.58
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$50.08
|
| Rate for Payer: Cofinity Commercial |
$40.76
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Healthscope Commercial |
$52.41
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$49.50
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.85
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$36.68
|
| Rate for Payer: Priority Health SBD |
$35.27
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$67.19
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.33 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$35.27
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
OP
|
$67.19
|
|
|
Service Code
|
HCPCS J7060
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.88 |
| Max. Negotiated Rate |
$60.47 |
| Rate for Payer: Aetna Commercial |
$57.11
|
| Rate for Payer: Aetna Commercial |
$47.59
|
| Rate for Payer: Aetna Medicare |
$28.00
|
| Rate for Payer: Aetna Medicare |
$33.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.67
|
| Rate for Payer: BCBS Complete |
$26.88
|
| Rate for Payer: BCBS Complete |
$22.40
|
| Rate for Payer: Cash Price |
$44.79
|
| Rate for Payer: Cash Price |
$53.75
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$47.03
|
| Rate for Payer: Cofinity Commercial |
$57.78
|
| Rate for Payer: Cofinity Commercial |
$48.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.75
|
| Rate for Payer: Healthscope Commercial |
$50.39
|
| Rate for Payer: Healthscope Commercial |
$60.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$57.11
|
| Rate for Payer: PHP Commercial |
$47.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.67
|
| Rate for Payer: Priority Health SBD |
$42.33
|
| Rate for Payer: Priority Health SBD |
$35.27
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
IP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.05 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 5 % IV BOLUS
|
Facility
|
OP
|
$69.92
|
|
|
Service Code
|
HCPCS J7070
|
| Hospital Charge Code |
400293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.97 |
| Max. Negotiated Rate |
$62.93 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Aetna Medicare |
$34.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.45
|
| Rate for Payer: BCBS Complete |
$27.97
|
| Rate for Payer: Cash Price |
$55.94
|
| Rate for Payer: Cofinity Commercial |
$48.94
|
| Rate for Payer: Cofinity Commercial |
$60.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.94
|
| Rate for Payer: Healthscope Commercial |
$62.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.43
|
| Rate for Payer: PHP Commercial |
$59.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.45
|
| Rate for Payer: Priority Health SBD |
$44.05
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$110.16
|
|
|
Service Code
|
NDC 00338071906
|
| Hospital Charge Code |
2367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.06 |
| Max. Negotiated Rate |
$99.14 |
| Rate for Payer: Aetna Commercial |
$93.64
|
| Rate for Payer: Aetna Medicare |
$55.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.60
|
| Rate for Payer: BCBS Complete |
$44.06
|
| Rate for Payer: Cash Price |
$88.13
|
| Rate for Payer: Cofinity Commercial |
$77.11
|
| Rate for Payer: Cofinity Commercial |
$94.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.13
|
| Rate for Payer: Healthscope Commercial |
$99.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.64
|
| Rate for Payer: PHP Commercial |
$93.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.60
|
| Rate for Payer: Priority Health SBD |
$69.40
|
|
|
DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$110.16
|
|
|
Service Code
|
NDC 00338071906
|
| Hospital Charge Code |
2367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.40 |
| Max. Negotiated Rate |
$99.14 |
| Rate for Payer: Aetna Commercial |
$93.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.60
|
| Rate for Payer: Cash Price |
$88.13
|
| Rate for Payer: Cofinity Commercial |
$77.11
|
| Rate for Payer: Cofinity Commercial |
$94.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.13
|
| Rate for Payer: Healthscope Commercial |
$99.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.64
|
| Rate for Payer: PHP Commercial |
$93.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.60
|
| Rate for Payer: Priority Health SBD |
$69.40
|
|
|
DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION
|
Facility
|
IP
|
$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 Commercial |
$63.00
|
| Rate for Payer: Cofinity Commercial |
$77.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.00
|
| 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: PHP Commercial |
$76.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.50
|
| Rate for Payer: Priority Health SBD |
$56.70
|
|
|
DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.00 |
| 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: Cash Price |
$72.00
|
| Rate for Payer: Cofinity Commercial |
$63.00
|
| Rate for Payer: Cofinity Commercial |
$77.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.00
|
| 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: PHP Commercial |
$76.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.50
|
| Rate for Payer: Priority Health SBD |
$56.70
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION
|
Facility
|
OP
|
$182.50
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
27735
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.00 |
| 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: Cash Price |
$146.00
|
| Rate for Payer: Cofinity Commercial |
$127.75
|
| Rate for Payer: Cofinity Commercial |
$156.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.75
|
| 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: PHP Commercial |
$155.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.62
|
| Rate for Payer: Priority Health SBD |
$114.97
|
|
|
DIATRIZOATE MEGLUMINE 30 % URETHRAL SOLUTION
|
Facility
|
IP
|
$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 Commercial |
$127.75
|
| Rate for Payer: Cofinity Commercial |
$156.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.75
|
| 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: PHP Commercial |
$155.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.62
|
| Rate for Payer: Priority Health SBD |
$114.97
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
IP
|
$157.45
|
|
|
Service Code
|
NDC 51079028620
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$141.71 |
| Rate for Payer: Aetna Commercial |
$133.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.34
|
| Rate for Payer: Cash Price |
$125.96
|
| Rate for Payer: Cofinity Commercial |
$110.22
|
| Rate for Payer: Cofinity Commercial |
$135.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$110.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.96
|
| Rate for Payer: Healthscope Commercial |
$141.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$133.83
|
| Rate for Payer: PHP Commercial |
$133.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.34
|
| Rate for Payer: Priority Health SBD |
$99.19
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
OP
|
$58.75
|
|
|
Service Code
|
NDC 00172392760
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna Medicare |
$29.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: BCBS Complete |
$23.50
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.19
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
IP
|
$1.58
|
|
|
Service Code
|
NDC 51079028601
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.03
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Commercial |
$1.11
|
| Rate for Payer: Cofinity Commercial |
$1.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.34
|
| Rate for Payer: PHP Commercial |
$1.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.03
|
| Rate for Payer: Priority Health SBD |
$1.00
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 00172392760
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.01 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.19
|
| Rate for Payer: Priority Health SBD |
$37.01
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
OP
|
$157.45
|
|
|
Service Code
|
NDC 51079028620
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.98 |
| Max. Negotiated Rate |
$141.71 |
| Rate for Payer: Aetna Commercial |
$133.83
|
| Rate for Payer: Aetna Medicare |
$78.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.34
|
| Rate for Payer: BCBS Complete |
$62.98
|
| Rate for Payer: Cash Price |
$125.96
|
| Rate for Payer: Cofinity Commercial |
$110.22
|
| Rate for Payer: Cofinity Commercial |
$135.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$110.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.96
|
| Rate for Payer: Healthscope Commercial |
$141.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$133.83
|
| Rate for Payer: PHP Commercial |
$133.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.34
|
| Rate for Payer: Priority Health SBD |
$99.19
|
|
|
DIAZEPAM 10 MG TABLET
|
Facility
|
OP
|
$1.58
|
|
|
Service Code
|
NDC 51079028601
|
| Hospital Charge Code |
2403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna Commercial |
$1.34
|
| Rate for Payer: Aetna Medicare |
$0.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.03
|
| Rate for Payer: BCBS Complete |
$0.63
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Commercial |
$1.11
|
| Rate for Payer: Cofinity Commercial |
$1.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.34
|
| Rate for Payer: PHP Commercial |
$1.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.03
|
| Rate for Payer: Priority Health SBD |
$1.00
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$56.40
|
|
|
Service Code
|
NDC 00172392560
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.56 |
| 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 Commercial |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.48
|
| 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: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.66
|
| Rate for Payer: Priority Health SBD |
$35.53
|
|
|
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 |
$1.27 |
| Rate for Payer: Aetna Commercial |
$1.20
|
| Rate for Payer: Aetna Medicare |
$0.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.92
|
| Rate for Payer: BCBS Complete |
$0.56
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$0.99
|
| Rate for Payer: Cofinity Commercial |
$1.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.13
|
| Rate for Payer: Healthscope Commercial |
$1.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.20
|
| Rate for Payer: PHP Commercial |
$1.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.92
|
| Rate for Payer: Priority Health SBD |
$0.89
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$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 Commercial |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.48
|
| 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: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.66
|
| Rate for Payer: Priority Health SBD |
$35.53
|
|
|
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 |
$126.90 |
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna Medicare |
$70.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: BCBS Complete |
$56.40
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: Priority Health SBD |
$88.83
|
|
