|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$307.85
|
|
|
Service Code
|
NDC 51862094101
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.90 |
| Max. Negotiated Rate |
$277.06 |
| Rate for Payer: Aetna American Axle |
$200.10
|
| Rate for Payer: Aetna Commercial |
$261.67
|
| Rate for Payer: Aetna Medicare |
$153.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.10
|
| Rate for Payer: BCBS Complete |
$123.14
|
| Rate for Payer: Cash Price |
$246.28
|
| Rate for Payer: Cofinity Advantage |
$215.50
|
| Rate for Payer: Cofinity Commercial |
$264.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.28
|
| Rate for Payer: Healthscope Commercial |
$277.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$215.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$230.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$246.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$261.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$230.89
|
| Rate for Payer: PHP Commercial |
$261.67
|
| Rate for Payer: Priority Health SBD |
$193.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$200.10
|
| Rate for Payer: UHC Core |
$160.39
|
| Rate for Payer: UHC Exchange |
$120.99
|
| Rate for Payer: UMR Bronson Commercial |
$113.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.89
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$155.10
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.39 |
| Max. Negotiated Rate |
$139.59 |
| Rate for Payer: Aetna American Axle |
$100.81
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$108.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.33
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$57.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.33
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$180.60
|
|
|
Service Code
|
NDC 00527176836
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.46 |
| Max. Negotiated Rate |
$162.54 |
| Rate for Payer: Aetna American Axle |
$117.39
|
| Rate for Payer: Aetna Commercial |
$153.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.39
|
| Rate for Payer: Cash Price |
$144.48
|
| Rate for Payer: Cofinity Advantage |
$126.42
|
| Rate for Payer: Cofinity Commercial |
$155.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$144.48
|
| Rate for Payer: Healthscope Commercial |
$162.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$126.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$135.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$153.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$135.45
|
| Rate for Payer: PHP Commercial |
$153.51
|
| Rate for Payer: Priority Health SBD |
$113.78
|
| Rate for Payer: UMR Bronson Commercial |
$79.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.45
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
OP
|
$180.60
|
|
|
Service Code
|
NDC 00527176836
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.82 |
| Max. Negotiated Rate |
$162.54 |
| Rate for Payer: Aetna American Axle |
$117.39
|
| Rate for Payer: Aetna Commercial |
$153.51
|
| Rate for Payer: Aetna Medicare |
$90.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.39
|
| Rate for Payer: BCBS Complete |
$72.24
|
| Rate for Payer: Cash Price |
$144.48
|
| Rate for Payer: Cofinity Advantage |
$126.42
|
| Rate for Payer: Cofinity Commercial |
$155.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$144.48
|
| Rate for Payer: Healthscope Commercial |
$162.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$126.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$135.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$153.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$135.45
|
| Rate for Payer: PHP Commercial |
$153.51
|
| Rate for Payer: Priority Health SBD |
$113.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$117.39
|
| Rate for Payer: UHC Core |
$94.09
|
| Rate for Payer: UHC Exchange |
$70.98
|
| Rate for Payer: UMR Bronson Commercial |
$66.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.45
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
OP
|
$207.69
|
|
|
Service Code
|
NDC 00054318544
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.85 |
| Max. Negotiated Rate |
$186.92 |
| Rate for Payer: Aetna American Axle |
$135.00
|
| Rate for Payer: Aetna Commercial |
$176.54
|
| Rate for Payer: Aetna Medicare |
$103.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.00
|
| Rate for Payer: BCBS Complete |
$83.08
|
| Rate for Payer: Cash Price |
$166.15
|
| Rate for Payer: Cofinity Advantage |
$145.38
|
| Rate for Payer: Cofinity Commercial |
$178.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.15
|
| Rate for Payer: Healthscope Commercial |
$186.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$145.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$166.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$155.77
|
| Rate for Payer: PHP Commercial |
$176.54
|
| Rate for Payer: Priority Health SBD |
$130.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$135.00
|
| Rate for Payer: UHC Core |
$108.21
|
| Rate for Payer: UHC Exchange |
$81.62
|
| Rate for Payer: UMR Bronson Commercial |
$76.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.77
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$207.69
|
|
|
Service Code
|
NDC 00054318544
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.38 |
| Max. Negotiated Rate |
$186.92 |
| Rate for Payer: Aetna American Axle |
$135.00
|
| Rate for Payer: Aetna Commercial |
$176.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.00
|
| Rate for Payer: Cash Price |
$166.15
|
| Rate for Payer: Cofinity Advantage |
$145.38
|
| Rate for Payer: Cofinity Commercial |
$178.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.15
|
| Rate for Payer: Healthscope Commercial |
$186.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$145.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$155.77
|
| Rate for Payer: PHP Commercial |
$176.54
|
| Rate for Payer: Priority Health SBD |
$130.84
|
| Rate for Payer: UMR Bronson Commercial |
$91.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.77
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$3.03
|
|
|
Service Code
|
NDC 09900000596
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna American Axle |
$1.97
|
| Rate for Payer: Aetna Commercial |
$2.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.97
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cofinity Advantage |
$2.12
|
| Rate for Payer: Cofinity Commercial |
$2.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.42
|
| Rate for Payer: Healthscope Commercial |
$2.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.27
|
| Rate for Payer: PHP Commercial |
$2.58
|
| Rate for Payer: Priority Health SBD |
$1.91
|
| Rate for Payer: UMR Bronson Commercial |
$1.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.27
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
OP
|
$3.03
|
|
|
Service Code
|
NDC 09900000596
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna American Axle |
$1.97
|
| Rate for Payer: Aetna Commercial |
$2.58
|
| Rate for Payer: Aetna Medicare |
$1.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.97
|
| Rate for Payer: BCBS Complete |
$1.21
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cofinity Advantage |
$2.12
|
| Rate for Payer: Cofinity Commercial |
$2.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.42
|
| Rate for Payer: Healthscope Commercial |
$2.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.27
|
| Rate for Payer: PHP Commercial |
$2.58
|
| Rate for Payer: Priority Health SBD |
$1.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.97
|
| Rate for Payer: UHC Core |
$1.58
|
| Rate for Payer: UHC Exchange |
$1.19
|
| Rate for Payer: UMR Bronson Commercial |
$1.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.27
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$1.46
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna American Axle |
$0.95
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.09
|
| 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: UMR Bronson Commercial |
$0.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.09
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$145.70
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.91 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna American Axle |
$94.70
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$101.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.28
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$53.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.28
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 00378034501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Advantage |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.84
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$48.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$1.46
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Aetna American Axle |
$0.95
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.09
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$0.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.09
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$145.70
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.11 |
| Max. Negotiated Rate |
$131.13 |
| Rate for Payer: Aetna American Axle |
$94.70
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$101.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.28
|
| 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: UMR Bronson Commercial |
$64.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.28
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 51862094201
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.66 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Advantage |
$225.37
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.46
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$141.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$321.95
|
|
|
Service Code
|
NDC 51862094201
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.12 |
| Max. Negotiated Rate |
$289.75 |
| Rate for Payer: Aetna American Axle |
$209.27
|
| Rate for Payer: Aetna Commercial |
$273.66
|
| Rate for Payer: Aetna Medicare |
$160.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.27
|
| Rate for Payer: BCBS Complete |
$128.78
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cofinity Advantage |
$225.37
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$257.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.46
|
| Rate for Payer: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.27
|
| Rate for Payer: UHC Core |
$167.74
|
| Rate for Payer: UHC Exchange |
$126.53
|
| Rate for Payer: UMR Bronson Commercial |
$119.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.69 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$28.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 00378034501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.87 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna Medicare |
$55.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: BCBS Complete |
$44.18
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Advantage |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$88.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.84
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.79
|
| Rate for Payer: UHC Core |
$57.54
|
| Rate for Payer: UHC Exchange |
$43.41
|
| Rate for Payer: UMR Bronson Commercial |
$40.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| 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: UMR Bronson Commercial |
$34.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$753.25
|
|
|
Service Code
|
NDC 00254101019
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.70 |
| Max. Negotiated Rate |
$677.92 |
| Rate for Payer: Aetna American Axle |
$489.61
|
| Rate for Payer: Aetna Commercial |
$640.26
|
| Rate for Payer: Aetna Medicare |
$376.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$489.61
|
| Rate for Payer: BCBS Complete |
$301.30
|
| Rate for Payer: Cash Price |
$602.60
|
| Rate for Payer: Cofinity Advantage |
$527.27
|
| Rate for Payer: Cofinity Commercial |
$647.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.60
|
| Rate for Payer: Healthscope Commercial |
$677.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$527.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$564.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$602.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$640.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$564.94
|
| Rate for Payer: PHP Commercial |
$640.26
|
| Rate for Payer: Priority Health SBD |
$474.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$489.61
|
| Rate for Payer: UHC Core |
$392.44
|
| Rate for Payer: UHC Exchange |
$296.03
|
| Rate for Payer: UMR Bronson Commercial |
$278.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$564.94
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
OP
|
$1,824.40
|
|
|
Service Code
|
NDC 00575620030
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$675.03 |
| Max. Negotiated Rate |
$1,641.96 |
| Rate for Payer: Aetna American Axle |
$1,185.86
|
| Rate for Payer: Aetna Commercial |
$1,550.74
|
| Rate for Payer: Aetna Medicare |
$912.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,185.86
|
| Rate for Payer: BCBS Complete |
$729.76
|
| Rate for Payer: Cash Price |
$1,459.52
|
| Rate for Payer: Cofinity Advantage |
$1,277.08
|
| Rate for Payer: Cofinity Commercial |
$1,568.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,459.52
|
| Rate for Payer: Healthscope Commercial |
$1,641.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,277.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,368.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,459.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,550.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,368.30
|
| Rate for Payer: PHP Commercial |
$1,550.74
|
| Rate for Payer: Priority Health SBD |
$1,149.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,185.86
|
| Rate for Payer: UHC Core |
$950.51
|
| Rate for Payer: UHC Exchange |
$716.99
|
| Rate for Payer: UMR Bronson Commercial |
$675.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,368.30
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$1,824.40
|
|
|
Service Code
|
NDC 00575620030
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$802.74 |
| Max. Negotiated Rate |
$1,641.96 |
| Rate for Payer: Aetna American Axle |
$1,185.86
|
| Rate for Payer: Aetna Commercial |
$1,550.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,185.86
|
| Rate for Payer: Cash Price |
$1,459.52
|
| Rate for Payer: Cofinity Advantage |
$1,277.08
|
| Rate for Payer: Cofinity Commercial |
$1,568.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,459.52
|
| Rate for Payer: Healthscope Commercial |
$1,641.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,277.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,368.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,550.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,368.30
|
| Rate for Payer: PHP Commercial |
$1,550.74
|
| Rate for Payer: Priority Health SBD |
$1,149.37
|
| Rate for Payer: UMR Bronson Commercial |
$802.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,368.30
|
|
|
DIAZOXIDE 50 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$753.25
|
|
|
Service Code
|
NDC 00254101019
|
| Hospital Charge Code |
19713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.43 |
| Max. Negotiated Rate |
$677.92 |
| Rate for Payer: Aetna American Axle |
$489.61
|
| Rate for Payer: Aetna Commercial |
$640.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$489.61
|
| Rate for Payer: Cash Price |
$602.60
|
| Rate for Payer: Cofinity Advantage |
$527.27
|
| Rate for Payer: Cofinity Commercial |
$647.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$602.60
|
| Rate for Payer: Healthscope Commercial |
$677.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$527.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$564.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$640.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$564.94
|
| Rate for Payer: PHP Commercial |
$640.26
|
| Rate for Payer: Priority Health SBD |
$474.55
|
| Rate for Payer: UMR Bronson Commercial |
$331.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$564.94
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
OP
|
$21.66
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.01 |
| Max. Negotiated Rate |
$19.49 |
| Rate for Payer: Aetna American Axle |
$14.08
|
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Aetna Medicare |
$10.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.08
|
| Rate for Payer: BCBS Complete |
$8.66
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Advantage |
$15.16
|
| Rate for Payer: Cofinity Commercial |
$18.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$19.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.25
|
| Rate for Payer: PHP Commercial |
$18.41
|
| Rate for Payer: Priority Health SBD |
$13.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.08
|
| Rate for Payer: UHC Core |
$11.28
|
| Rate for Payer: UHC Exchange |
$8.51
|
| Rate for Payer: UMR Bronson Commercial |
$8.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.25
|
|
|
DIBUCAINE 1 % TOPICAL OINTMENT
|
Facility
|
IP
|
$21.66
|
|
|
Service Code
|
NDC 45802005003
|
| Hospital Charge Code |
2412
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$19.49 |
| Rate for Payer: Aetna American Axle |
$14.08
|
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.08
|
| Rate for Payer: Cash Price |
$17.33
|
| Rate for Payer: Cofinity Advantage |
$15.16
|
| Rate for Payer: Cofinity Commercial |
$18.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.33
|
| Rate for Payer: Healthscope Commercial |
$19.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.25
|
| Rate for Payer: PHP Commercial |
$18.41
|
| Rate for Payer: Priority Health SBD |
$13.65
|
| Rate for Payer: UMR Bronson Commercial |
$9.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.25
|
|
|
DICLOFENAC 0.1 % EYE DROPS
|
Facility
|
OP
|
$15.57
|
|
|
Service Code
|
NDC 17478089225
|
| Hospital Charge Code |
19714
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$14.01 |
| Rate for Payer: Aetna American Axle |
$10.12
|
| Rate for Payer: Aetna Commercial |
$13.23
|
| Rate for Payer: Aetna Medicare |
$7.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.12
|
| Rate for Payer: BCBS Complete |
$6.23
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cofinity Advantage |
$10.90
|
| Rate for Payer: Cofinity Commercial |
$13.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.46
|
| Rate for Payer: Healthscope Commercial |
$14.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.68
|
| Rate for Payer: PHP Commercial |
$13.23
|
| Rate for Payer: Priority Health SBD |
$9.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.12
|
| Rate for Payer: UHC Core |
$8.11
|
| Rate for Payer: UHC Exchange |
$6.12
|
| Rate for Payer: UMR Bronson Commercial |
$5.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.68
|
|
