|
DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.60 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna American Axle |
$58.50
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$63.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.50
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$39.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.50
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$98.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$52.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$56.40
|
|
|
Service Code
|
NDC 00172392560
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.82 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna American Axle |
$36.66
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$39.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$24.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$1.41
|
|
|
Service Code
|
NDC 51079028401
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna American Axle |
$0.92
|
| Rate for Payer: Aetna Commercial |
$1.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.92
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$0.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.06
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$0.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.06
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$1.41
|
|
|
Service Code
|
NDC 51079028401
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Aetna American Axle |
$0.92
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$0.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.06
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$0.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.06
|
|
|
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 Commercial |
$215.50
|
| Rate for Payer: Cofinity Commercial |
$264.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.50
|
| 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: Multiplan/Beech St/PHCS Commercial |
$261.67
|
| Rate for Payer: PHP Commercial |
$261.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.10
|
| Rate for Payer: Priority Health SBD |
$193.95
|
| Rate for Payer: UMR Bronson Commercial |
$113.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.89
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.04 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$98.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$62.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
IP
|
$307.85
|
|
|
Service Code
|
NDC 51862094101
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.45 |
| Max. Negotiated Rate |
$277.06 |
| Rate for Payer: Aetna American Axle |
$200.10
|
| Rate for Payer: Aetna Commercial |
$261.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.10
|
| Rate for Payer: Cash Price |
$246.28
|
| Rate for Payer: Cofinity Commercial |
$215.50
|
| Rate for Payer: Cofinity Commercial |
$264.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$215.50
|
| 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: Multiplan/Beech St/PHCS Commercial |
$261.67
|
| Rate for Payer: PHP Commercial |
$261.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.10
|
| Rate for Payer: Priority Health SBD |
$193.95
|
| Rate for Payer: UMR Bronson Commercial |
$135.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$230.89
|
|
|
DIAZEPAM 2 MG TABLET
|
Facility
|
OP
|
$56.40
|
|
|
Service Code
|
NDC 00172392560
|
| Hospital Charge Code |
2404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.87 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna American Axle |
$36.66
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$39.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$20.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$207.06
|
|
|
Service Code
|
NDC 00054318544
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.11 |
| Max. Negotiated Rate |
$186.35 |
| Rate for Payer: Aetna American Axle |
$134.59
|
| Rate for Payer: Aetna Commercial |
$176.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.59
|
| Rate for Payer: Cash Price |
$165.65
|
| Rate for Payer: Cofinity Commercial |
$144.94
|
| Rate for Payer: Cofinity Commercial |
$178.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.65
|
| Rate for Payer: Healthscope Commercial |
$186.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.00
|
| Rate for Payer: PHP Commercial |
$176.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.59
|
| Rate for Payer: Priority Health SBD |
$130.45
|
| Rate for Payer: UMR Bronson Commercial |
$91.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.29
|
|
|
DIAZEPAM 5 MG/ML ORAL CONCENTRATE
|
Facility
|
OP
|
$207.06
|
|
|
Service Code
|
NDC 00054318544
|
| Hospital Charge Code |
109433
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.61 |
| Max. Negotiated Rate |
$186.35 |
| Rate for Payer: Aetna American Axle |
$134.59
|
| Rate for Payer: Aetna Commercial |
$176.00
|
| Rate for Payer: Aetna Medicare |
$103.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.59
|
| Rate for Payer: BCBS Complete |
$82.82
|
| Rate for Payer: Cash Price |
$165.65
|
| Rate for Payer: Cofinity Commercial |
$144.94
|
| Rate for Payer: Cofinity Commercial |
$178.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.65
|
| Rate for Payer: Healthscope Commercial |
$186.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$155.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.00
|
| Rate for Payer: PHP Commercial |
$176.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.59
|
| Rate for Payer: Priority Health SBD |
$130.45
|
| Rate for Payer: UMR Bronson Commercial |
$76.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$155.29
|
|
|
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 Commercial |
$126.42
|
| Rate for Payer: Cofinity Commercial |
$155.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$126.42
|
| 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: PHP Commercial |
$153.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$117.39
|
| 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
|
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 Commercial |
$2.12
|
| Rate for Payer: Cofinity Commercial |
$2.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.12
|
| 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: PHP Commercial |
$2.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.97
|
| 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 Commercial |
$2.12
|
| Rate for Payer: Cofinity Commercial |
$2.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.12
|
| 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: PHP Commercial |
$2.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.97
|
| Rate for Payer: Priority Health SBD |
$1.91
|
| Rate for Payer: UMR Bronson Commercial |
$1.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.27
|
|
|
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 Commercial |
$126.42
|
| Rate for Payer: Cofinity Commercial |
$155.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$126.42
|
| 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: PHP Commercial |
$153.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$117.39
|
| Rate for Payer: Priority Health SBD |
$113.78
|
| Rate for Payer: UMR Bronson Commercial |
$66.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.45
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.78 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna Medicare |
$74.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$54.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$63.45
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna American Axle |
$41.24
|
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.41
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| Rate for Payer: Priority Health SBD |
$39.97
|
| Rate for Payer: UMR Bronson Commercial |
$27.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
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 Commercial |
$225.37
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.37
|
| 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: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| 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
|
$63.45
|
|
|
Service Code
|
NDC 00172392660
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna American Axle |
$41.24
|
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna Medicare |
$31.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: BCBS Complete |
$25.38
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.41
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| Rate for Payer: Priority Health SBD |
$39.97
|
| Rate for Payer: UMR Bronson Commercial |
$23.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
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 Commercial |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.31
|
| 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: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| 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
|
IP
|
$1.49
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna American Axle |
$0.97
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.97
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health SBD |
$0.94
|
| Rate for Payer: UMR Bronson Commercial |
$0.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
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 Commercial |
$225.37
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.37
|
| 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: PHP Commercial |
$273.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.27
|
| Rate for Payer: Priority Health SBD |
$202.83
|
| Rate for Payer: UMR Bronson Commercial |
$119.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.46
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079028520
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.23
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
DIAZEPAM 5 MG TABLET
|
Facility
|
OP
|
$1.49
|
|
|
Service Code
|
NDC 51079028501
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna American Axle |
$0.97
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.97
|
| Rate for Payer: BCBS Complete |
$0.60
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health SBD |
$0.94
|
| Rate for Payer: UMR Bronson Commercial |
$0.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
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 Commercial |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.31
|
| 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: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$40.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
