|
DIALYSATE RFP-402 (K-0/CA-3) SOLUTION
|
Facility
|
IP
|
$208.80
|
|
|
Service Code
|
NDC 09900000035
|
| Hospital Charge Code |
150777
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.87 |
| Max. Negotiated Rate |
$187.92 |
| Rate for Payer: Aetna American Axle |
$135.72
|
| 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 Commercial |
$146.16
|
| Rate for Payer: Cofinity Commercial |
$179.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.04
|
| Rate for Payer: Healthscope Commercial |
$187.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.48
|
| Rate for Payer: PHP Commercial |
$177.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.72
|
| Rate for Payer: Priority Health SBD |
$131.54
|
| Rate for Payer: UMR Bronson Commercial |
$91.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.60
|
|
|
DIALYSATE RFP-453 (K-2/CA-0) SOLUTION
|
Facility
|
OP
|
$208.80
|
|
|
Service Code
|
NDC 99000000036
|
| Hospital Charge Code |
150773
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.26 |
| Max. Negotiated Rate |
$187.92 |
| Rate for Payer: Aetna American Axle |
$135.72
|
| 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 Commercial |
$146.16
|
| Rate for Payer: Cofinity Commercial |
$179.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.04
|
| Rate for Payer: Healthscope Commercial |
$187.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.48
|
| Rate for Payer: PHP Commercial |
$177.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.72
|
| Rate for Payer: Priority Health SBD |
$131.54
|
| Rate for Payer: UMR Bronson Commercial |
$77.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.60
|
|
|
DIALYSATE RFP-453 (K-2/CA-0) SOLUTION
|
Facility
|
IP
|
$208.80
|
|
|
Service Code
|
NDC 99000000036
|
| Hospital Charge Code |
150773
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.87 |
| Max. Negotiated Rate |
$187.92 |
| Rate for Payer: Aetna American Axle |
$135.72
|
| 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 Commercial |
$146.16
|
| Rate for Payer: Cofinity Commercial |
$179.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.04
|
| Rate for Payer: Healthscope Commercial |
$187.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.48
|
| Rate for Payer: PHP Commercial |
$177.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.72
|
| Rate for Payer: Priority Health SBD |
$131.54
|
| Rate for Payer: UMR Bronson Commercial |
$91.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.60
|
|
|
DIALYSATE RFP-456 (K-4/CA-0) SOLUTION
|
Facility
|
OP
|
$208.80
|
|
|
Service Code
|
NDC 09900000849
|
| Hospital Charge Code |
180369
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.26 |
| Max. Negotiated Rate |
$187.92 |
| Rate for Payer: Aetna American Axle |
$135.72
|
| 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 Commercial |
$146.16
|
| Rate for Payer: Cofinity Commercial |
$179.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.04
|
| Rate for Payer: Healthscope Commercial |
$187.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.48
|
| Rate for Payer: PHP Commercial |
$177.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.72
|
| Rate for Payer: Priority Health SBD |
$131.54
|
| Rate for Payer: UMR Bronson Commercial |
$77.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.60
|
|
|
DIALYSATE RFP-456 (K-4/CA-0) SOLUTION
|
Facility
|
IP
|
$208.80
|
|
|
Service Code
|
NDC 09900000849
|
| Hospital Charge Code |
180369
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.87 |
| Max. Negotiated Rate |
$187.92 |
| Rate for Payer: Aetna American Axle |
$135.72
|
| 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 Commercial |
$146.16
|
| Rate for Payer: Cofinity Commercial |
$179.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.04
|
| Rate for Payer: Healthscope Commercial |
$187.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.48
|
| Rate for Payer: PHP Commercial |
$177.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.72
|
| Rate for Payer: Priority Health SBD |
$131.54
|
| Rate for Payer: UMR Bronson Commercial |
$91.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.60
|
|
|
DIALYSIS CIRCUIT PERMANENT VASCULAR EMBOLIZATION OR OCCLUSION (INCLUDING MAIN CIRCUIT OR ANY ACCESSORY VEINS), ENDOVASCULAR, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO COMPLETE THE INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$6,989.54
|
|
|
Service Code
|
CPT 36909
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$192.26 |
| Max. Negotiated Rate |
$6,989.54 |
| Rate for Payer: BCBS Trust/PPO |
$6,989.54
|
| Rate for Payer: BCN Commercial |
$6,989.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$211.49
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Exchange |
$192.26
|
|
|
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
|
|
|
DIATRIZOATE MEGLUMINE 18 % URETHRAL SOLUTION
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
9823
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna American Axle |
$58.50
|
| 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 |
$0.09
|
| Rate for Payer: BCN Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$72.00
|
| 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: 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 |
$33.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.50
|
|
|
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
|
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
|
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 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 |
$153.92
|
| 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
|
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
|
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 Medicare |
$0.71
|
| 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: 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
|
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 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 |
$155.30
|
| 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 |
$155.30
|
|
|
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
|
$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 |
$155.30
|
| 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 |
$155.30
|
|
|
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
|
$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/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 |
$1.52
|
| 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 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 |
$31.72
|
| 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 |
$44.42
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.42
|
| 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 |
$44.42
|
| 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
|
$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: Cofinity Commercial |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.04
|
| 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: 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
|
IP
|
$321.95
|
|
|
Service Code
|
NDC 51862094201
|
| Hospital Charge Code |
2405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.66 |
| Max. Negotiated Rate |
$289.76 |
| 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 |
$225.36
|
| Rate for Payer: Cofinity Commercial |
$276.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$225.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.56
|
| Rate for Payer: Healthscope Commercial |
$289.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.36
|
| 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
|
|
