|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$197.75
|
|
|
Service Code
|
NDC 60687-401-01
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.01 |
| Max. Negotiated Rate |
$177.98 |
| Rate for Payer: Aetna American Axle |
$128.54
|
| Rate for Payer: Aetna Commercial |
$168.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.54
|
| Rate for Payer: Cash Price |
$158.20
|
| Rate for Payer: Cofinity Commercial |
$138.42
|
| Rate for Payer: Cofinity Commercial |
$170.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.20
|
| Rate for Payer: Healthscope Commercial |
$177.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$168.09
|
| Rate for Payer: PHP Commercial |
$168.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.42
|
| Rate for Payer: Priority Health SBD |
$124.58
|
| Rate for Payer: UMR Bronson Commercial |
$87.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.31
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$194.25
|
|
|
Service Code
|
NDC 51079-417-20
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.47 |
| Max. Negotiated Rate |
$174.82 |
| Rate for Payer: Aetna American Axle |
$126.26
|
| Rate for Payer: Aetna Commercial |
$165.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.26
|
| Rate for Payer: Cash Price |
$155.40
|
| Rate for Payer: Cofinity Commercial |
$135.98
|
| Rate for Payer: Cofinity Commercial |
$167.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.40
|
| Rate for Payer: Healthscope Commercial |
$174.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$135.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.11
|
| Rate for Payer: PHP Commercial |
$165.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.98
|
| Rate for Payer: Priority Health SBD |
$122.38
|
| Rate for Payer: UMR Bronson Commercial |
$85.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.69
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$227.50
|
|
|
Service Code
|
NDC 69315-904-05
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.10 |
| Max. Negotiated Rate |
$204.75 |
| Rate for Payer: Aetna American Axle |
$147.88
|
| Rate for Payer: Aetna Commercial |
$193.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.88
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cofinity Commercial |
$159.25
|
| Rate for Payer: Cofinity Commercial |
$195.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.00
|
| Rate for Payer: Healthscope Commercial |
$204.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.38
|
| Rate for Payer: PHP Commercial |
$193.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.25
|
| Rate for Payer: Priority Health SBD |
$143.32
|
| Rate for Payer: UMR Bronson Commercial |
$100.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.62
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$71.75
|
|
|
Service Code
|
NDC 69315-904-01
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.57 |
| Max. Negotiated Rate |
$64.58 |
| Rate for Payer: Aetna American Axle |
$46.64
|
| Rate for Payer: Aetna Commercial |
$60.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.64
|
| Rate for Payer: Cash Price |
$57.40
|
| Rate for Payer: Cofinity Commercial |
$50.22
|
| Rate for Payer: Cofinity Commercial |
$61.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.40
|
| Rate for Payer: Healthscope Commercial |
$64.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.99
|
| Rate for Payer: PHP Commercial |
$60.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.22
|
| Rate for Payer: Priority Health SBD |
$45.20
|
| Rate for Payer: UMR Bronson Commercial |
$31.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.81
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 60687-401-11
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.78 |
| Rate for Payer: Aetna American Axle |
$1.29
|
| Rate for Payer: Aetna Commercial |
$1.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.29
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cofinity Commercial |
$1.39
|
| Rate for Payer: Cofinity Commercial |
$1.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.58
|
| Rate for Payer: Healthscope Commercial |
$1.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.68
|
| Rate for Payer: PHP Commercial |
$1.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.39
|
| Rate for Payer: Priority Health SBD |
$1.25
|
| Rate for Payer: UMR Bronson Commercial |
$0.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.48
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
IP
|
$129.50
|
|
|
Service Code
|
NDC 0904-6007-61
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.98 |
| Max. Negotiated Rate |
$116.55 |
| Rate for Payer: Aetna American Axle |
$84.18
|
| Rate for Payer: Aetna Commercial |
$110.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.18
|
| Rate for Payer: Cash Price |
$103.60
|
| Rate for Payer: Cofinity Commercial |
$111.37
|
| Rate for Payer: Cofinity Commercial |
$90.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.60
|
| Rate for Payer: Healthscope Commercial |
$116.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$110.08
|
| Rate for Payer: PHP Commercial |
$110.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.65
|
| Rate for Payer: Priority Health SBD |
$81.58
|
| Rate for Payer: UMR Bronson Commercial |
$56.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.12
|
|
|
LORAZEPAM 0.5 MG TABLET
|
Facility
|
OP
|
$129.50
|
|
|
Service Code
|
NDC 0904-6007-61
|
| Hospital Charge Code |
4572
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.92 |
| Max. Negotiated Rate |
$116.55 |
| Rate for Payer: Aetna American Axle |
$84.18
|
| Rate for Payer: Aetna Commercial |
$110.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.18
|
| Rate for Payer: BCBS Complete |
$51.80
|
| Rate for Payer: Cash Price |
$103.60
|
| Rate for Payer: Cofinity Commercial |
$111.37
|
| Rate for Payer: Cofinity Commercial |
$90.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.60
|
| Rate for Payer: Healthscope Commercial |
$116.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$110.08
|
| Rate for Payer: PHP Commercial |
$110.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.65
|
| Rate for Payer: Priority Health SBD |
$81.58
|
| Rate for Payer: UMR Bronson Commercial |
$47.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.12
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 60687-638-11
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna American Axle |
$1.41
|
| Rate for Payer: Aetna Commercial |
$1.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.41
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cofinity Commercial |
$1.52
|
| Rate for Payer: Cofinity Commercial |
$1.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.74
|
| Rate for Payer: Healthscope Commercial |
$1.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.84
|
| Rate for Payer: PHP Commercial |
$1.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.52
|
| Rate for Payer: Priority Health SBD |
$1.37
|
| Rate for Payer: UMR Bronson Commercial |
$0.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.63
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$113.75
|
|
|
Service Code
|
NDC 51079-386-20
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.05 |
| Max. Negotiated Rate |
$102.38 |
| Rate for Payer: Aetna American Axle |
$73.94
|
| Rate for Payer: Aetna Commercial |
$96.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.94
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cofinity Commercial |
$79.62
|
| Rate for Payer: Cofinity Commercial |
$97.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.00
|
| Rate for Payer: Healthscope Commercial |
$102.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$79.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$85.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$96.69
|
| Rate for Payer: PHP Commercial |
$96.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.62
|
| Rate for Payer: Priority Health SBD |
$71.66
|
| Rate for Payer: UMR Bronson Commercial |
$50.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$85.31
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$402.50
|
|
|
Service Code
|
NDC 13107-084-05
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.10 |
| Max. Negotiated Rate |
$362.25 |
| Rate for Payer: Aetna American Axle |
$261.62
|
| Rate for Payer: Aetna Commercial |
$342.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.62
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: Cofinity Commercial |
$281.75
|
| Rate for Payer: Cofinity Commercial |
$346.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.00
|
| Rate for Payer: Healthscope Commercial |
$362.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$342.12
|
| Rate for Payer: PHP Commercial |
$342.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.75
|
| Rate for Payer: Priority Health SBD |
$253.58
|
| Rate for Payer: UMR Bronson Commercial |
$177.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.88
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
NDC 60687-638-01
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.48 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna American Axle |
$141.05
|
| Rate for Payer: Aetna Commercial |
$184.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.05
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Cofinity Commercial |
$151.90
|
| Rate for Payer: Cofinity Commercial |
$186.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.60
|
| Rate for Payer: Healthscope Commercial |
$195.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$151.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$184.45
|
| Rate for Payer: PHP Commercial |
$184.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.90
|
| Rate for Payer: Priority Health SBD |
$136.71
|
| Rate for Payer: UMR Bronson Commercial |
$95.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.75
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$78.75
|
|
|
Service Code
|
NDC 69315-905-01
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$70.88 |
| Rate for Payer: Aetna American Axle |
$51.19
|
| Rate for Payer: Aetna Commercial |
$66.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.19
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cofinity Commercial |
$55.12
|
| Rate for Payer: Cofinity Commercial |
$67.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.00
|
| Rate for Payer: Healthscope Commercial |
$70.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.94
|
| Rate for Payer: PHP Commercial |
$66.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.12
|
| Rate for Payer: Priority Health SBD |
$49.61
|
| Rate for Payer: UMR Bronson Commercial |
$34.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.06
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$358.75
|
|
|
Service Code
|
NDC 69315-905-05
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.85 |
| Max. Negotiated Rate |
$322.88 |
| Rate for Payer: Aetna American Axle |
$233.19
|
| Rate for Payer: Aetna Commercial |
$304.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.19
|
| Rate for Payer: Cash Price |
$287.00
|
| Rate for Payer: Cofinity Commercial |
$251.12
|
| Rate for Payer: Cofinity Commercial |
$308.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.00
|
| Rate for Payer: Healthscope Commercial |
$322.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$304.94
|
| Rate for Payer: PHP Commercial |
$304.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.12
|
| Rate for Payer: Priority Health SBD |
$226.01
|
| Rate for Payer: UMR Bronson Commercial |
$157.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.06
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$80.50
|
|
|
Service Code
|
NDC 0591-0241-01
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.42 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Aetna American Axle |
$52.32
|
| Rate for Payer: Aetna Commercial |
$68.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.32
|
| Rate for Payer: Cash Price |
$64.40
|
| Rate for Payer: Cofinity Commercial |
$56.35
|
| Rate for Payer: Cofinity Commercial |
$69.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.40
|
| Rate for Payer: Healthscope Commercial |
$72.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.42
|
| Rate for Payer: PHP Commercial |
$68.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.35
|
| Rate for Payer: Priority Health SBD |
$50.72
|
| Rate for Payer: UMR Bronson Commercial |
$35.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.38
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 0093-3426-01
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.19 |
| Max. Negotiated Rate |
$74.02 |
| Rate for Payer: Aetna American Axle |
$53.46
|
| Rate for Payer: Aetna Commercial |
$69.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.46
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$57.58
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$74.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.91
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.58
|
| Rate for Payer: Priority Health SBD |
$51.82
|
| Rate for Payer: UMR Bronson Commercial |
$36.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.69
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$80.50
|
|
|
Service Code
|
NDC 13107-084-01
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.42 |
| Max. Negotiated Rate |
$72.45 |
| Rate for Payer: Aetna American Axle |
$52.32
|
| Rate for Payer: Aetna Commercial |
$68.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.32
|
| Rate for Payer: Cash Price |
$64.40
|
| Rate for Payer: Cofinity Commercial |
$56.35
|
| Rate for Payer: Cofinity Commercial |
$69.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.40
|
| Rate for Payer: Healthscope Commercial |
$72.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.42
|
| Rate for Payer: PHP Commercial |
$68.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.35
|
| Rate for Payer: Priority Health SBD |
$50.72
|
| Rate for Payer: UMR Bronson Commercial |
$35.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.38
|
|
|
LORAZEPAM 1 MG TABLET
|
Facility
|
IP
|
$96.25
|
|
|
Service Code
|
NDC 0904-6008-60
|
| Hospital Charge Code |
4573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.35 |
| Max. Negotiated Rate |
$86.62 |
| Rate for Payer: Aetna American Axle |
$62.56
|
| Rate for Payer: Aetna Commercial |
$81.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.56
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cofinity Commercial |
$67.38
|
| Rate for Payer: Cofinity Commercial |
$82.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.00
|
| Rate for Payer: Healthscope Commercial |
$86.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.81
|
| Rate for Payer: PHP Commercial |
$81.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.38
|
| Rate for Payer: Priority Health SBD |
$60.64
|
| Rate for Payer: UMR Bronson Commercial |
$42.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.19
|
|
|
LORAZEPAM 2 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$161.51
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
10467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$145.36 |
| Rate for Payer: Aetna American Axle |
$104.98
|
| Rate for Payer: Aetna American Axle |
$20.20
|
| Rate for Payer: Aetna American Axle |
$11.62
|
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Commercial |
$26.42
|
| Rate for Payer: Aetna Commercial |
$137.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$104.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.20
|
| Rate for Payer: BCBS Complete |
$64.60
|
| Rate for Payer: BCBS Complete |
$7.15
|
| Rate for Payer: BCBS Complete |
$12.43
|
| Rate for Payer: BCBS Trust/PPO |
$3.62
|
| Rate for Payer: BCBS Trust/PPO |
$3.62
|
| Rate for Payer: BCBS Trust/PPO |
$3.62
|
| Rate for Payer: Cash Price |
$129.21
|
| Rate for Payer: Cash Price |
$14.30
|
| Rate for Payer: Cash Price |
$129.21
|
| Rate for Payer: Cash Price |
$14.30
|
| Rate for Payer: Cash Price |
$24.86
|
| Rate for Payer: Cash Price |
$24.86
|
| Rate for Payer: Cofinity Commercial |
$12.52
|
| Rate for Payer: Cofinity Commercial |
$26.73
|
| Rate for Payer: Cofinity Commercial |
$21.76
|
| Rate for Payer: Cofinity Commercial |
$138.90
|
| Rate for Payer: Cofinity Commercial |
$113.06
|
| Rate for Payer: Cofinity Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.30
|
| Rate for Payer: Healthscope Commercial |
$27.97
|
| Rate for Payer: Healthscope Commercial |
$16.09
|
| Rate for Payer: Healthscope Commercial |
$145.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.28
|
| Rate for Payer: PHP Commercial |
$26.42
|
| Rate for Payer: PHP Commercial |
$137.28
|
| Rate for Payer: PHP Commercial |
$15.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.76
|
| Rate for Payer: Priority Health SBD |
$19.58
|
| Rate for Payer: Priority Health SBD |
$101.75
|
| Rate for Payer: Priority Health SBD |
$11.26
|
| Rate for Payer: UMR Bronson Commercial |
$59.76
|
| Rate for Payer: UMR Bronson Commercial |
$11.50
|
| Rate for Payer: UMR Bronson Commercial |
$6.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.13
|
|
|
LORAZEPAM 2 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$28.48
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
10467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$25.63 |
| Rate for Payer: Aetna American Axle |
$18.51
|
| Rate for Payer: Aetna American Axle |
$20.20
|
| Rate for Payer: Aetna American Axle |
$12.75
|
| Rate for Payer: Aetna American Axle |
$104.98
|
| Rate for Payer: Aetna American Axle |
$11.62
|
| Rate for Payer: Aetna American Axle |
$5.61
|
| Rate for Payer: Aetna Commercial |
$15.20
|
| Rate for Payer: Aetna Commercial |
$137.28
|
| Rate for Payer: Aetna Commercial |
$24.21
|
| Rate for Payer: Aetna Commercial |
$26.42
|
| Rate for Payer: Aetna Commercial |
$16.67
|
| Rate for Payer: Aetna Commercial |
$7.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$104.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.75
|
| Rate for Payer: Cash Price |
$22.78
|
| Rate for Payer: Cash Price |
$129.21
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$14.30
|
| Rate for Payer: Cash Price |
$24.86
|
| Rate for Payer: Cash Price |
$15.69
|
| Rate for Payer: Cofinity Commercial |
$15.38
|
| Rate for Payer: Cofinity Commercial |
$12.52
|
| Rate for Payer: Cofinity Commercial |
$26.73
|
| Rate for Payer: Cofinity Commercial |
$21.76
|
| Rate for Payer: Cofinity Commercial |
$19.94
|
| Rate for Payer: Cofinity Commercial |
$6.04
|
| Rate for Payer: Cofinity Commercial |
$7.42
|
| Rate for Payer: Cofinity Commercial |
$113.06
|
| Rate for Payer: Cofinity Commercial |
$13.73
|
| Rate for Payer: Cofinity Commercial |
$16.86
|
| Rate for Payer: Cofinity Commercial |
$138.90
|
| Rate for Payer: Cofinity Commercial |
$24.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.78
|
| Rate for Payer: Healthscope Commercial |
$25.63
|
| Rate for Payer: Healthscope Commercial |
$16.09
|
| Rate for Payer: Healthscope Commercial |
$27.97
|
| Rate for Payer: Healthscope Commercial |
$17.65
|
| Rate for Payer: Healthscope Commercial |
$145.36
|
| Rate for Payer: Healthscope Commercial |
$7.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.28
|
| Rate for Payer: PHP Commercial |
$26.42
|
| Rate for Payer: PHP Commercial |
$137.28
|
| Rate for Payer: PHP Commercial |
$24.21
|
| Rate for Payer: PHP Commercial |
$7.34
|
| Rate for Payer: PHP Commercial |
$15.20
|
| Rate for Payer: PHP Commercial |
$16.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.04
|
| Rate for Payer: Priority Health SBD |
$11.26
|
| Rate for Payer: Priority Health SBD |
$5.44
|
| Rate for Payer: Priority Health SBD |
$12.35
|
| Rate for Payer: Priority Health SBD |
$17.94
|
| Rate for Payer: Priority Health SBD |
$19.58
|
| Rate for Payer: Priority Health SBD |
$101.75
|
| Rate for Payer: UMR Bronson Commercial |
$13.68
|
| Rate for Payer: UMR Bronson Commercial |
$71.06
|
| Rate for Payer: UMR Bronson Commercial |
$8.63
|
| Rate for Payer: UMR Bronson Commercial |
$7.87
|
| Rate for Payer: UMR Bronson Commercial |
$12.53
|
| Rate for Payer: UMR Bronson Commercial |
$3.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.71
|
|
|
LORAZEPAM 2 MG/ML INJECTION SYRINGE
|
Facility
|
OP
|
$16.54
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
112180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Aetna American Axle |
$10.75
|
| Rate for Payer: Aetna Commercial |
$14.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.75
|
| Rate for Payer: BCBS Complete |
$6.62
|
| Rate for Payer: BCBS Trust/PPO |
$3.62
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cofinity Commercial |
$11.58
|
| Rate for Payer: Cofinity Commercial |
$14.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.23
|
| Rate for Payer: Healthscope Commercial |
$14.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.06
|
| Rate for Payer: PHP Commercial |
$14.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.58
|
| Rate for Payer: Priority Health SBD |
$10.42
|
| Rate for Payer: UMR Bronson Commercial |
$6.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.40
|
|
|
LORAZEPAM 2 MG/ML INJECTION SYRINGE
|
Facility
|
IP
|
$16.54
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
112180
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.28 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Aetna American Axle |
$10.75
|
| Rate for Payer: Aetna Commercial |
$14.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.75
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: Cofinity Commercial |
$11.58
|
| Rate for Payer: Cofinity Commercial |
$14.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.23
|
| Rate for Payer: Healthscope Commercial |
$14.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.06
|
| Rate for Payer: PHP Commercial |
$14.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.58
|
| Rate for Payer: Priority Health SBD |
$10.42
|
| Rate for Payer: UMR Bronson Commercial |
$7.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.40
|
|
|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$244.65
|
|
|
Service Code
|
NDC 0121-0770-01
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.65 |
| Max. Negotiated Rate |
$220.18 |
| Rate for Payer: Aetna American Axle |
$159.02
|
| Rate for Payer: Aetna Commercial |
$207.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.02
|
| Rate for Payer: Cash Price |
$195.72
|
| Rate for Payer: Cofinity Commercial |
$171.26
|
| Rate for Payer: Cofinity Commercial |
$210.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.72
|
| Rate for Payer: Healthscope Commercial |
$220.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.95
|
| Rate for Payer: PHP Commercial |
$207.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.26
|
| Rate for Payer: Priority Health SBD |
$154.13
|
| Rate for Payer: UMR Bronson Commercial |
$107.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.49
|
|
|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$305.03
|
|
|
Service Code
|
NDC 0054-3532-44
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.21 |
| Max. Negotiated Rate |
$274.53 |
| Rate for Payer: Aetna American Axle |
$198.27
|
| Rate for Payer: Aetna Commercial |
$259.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.27
|
| Rate for Payer: Cash Price |
$244.02
|
| Rate for Payer: Cofinity Commercial |
$213.52
|
| Rate for Payer: Cofinity Commercial |
$262.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.02
|
| Rate for Payer: Healthscope Commercial |
$274.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$259.28
|
| Rate for Payer: PHP Commercial |
$259.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.52
|
| Rate for Payer: Priority Health SBD |
$192.17
|
| Rate for Payer: UMR Bronson Commercial |
$134.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.77
|
|
|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$5.09
|
|
|
Service Code
|
NDC 9900-0000-07
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: Aetna American Axle |
$3.31
|
| Rate for Payer: Aetna Commercial |
$4.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.31
|
| Rate for Payer: Cash Price |
$4.07
|
| Rate for Payer: Cofinity Commercial |
$3.56
|
| Rate for Payer: Cofinity Commercial |
$4.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.07
|
| Rate for Payer: Healthscope Commercial |
$4.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.33
|
| Rate for Payer: PHP Commercial |
$4.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.56
|
| Rate for Payer: Priority Health SBD |
$3.21
|
| Rate for Payer: UMR Bronson Commercial |
$2.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.82
|
|
|
LORAZEPAM 2 MG/ML ORAL CONCENTRATE
|
Facility
|
IP
|
$231.84
|
|
|
Service Code
|
NDC 50383-705-30
|
| Hospital Charge Code |
4571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.01 |
| Max. Negotiated Rate |
$208.66 |
| Rate for Payer: Aetna American Axle |
$150.70
|
| Rate for Payer: Aetna Commercial |
$197.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.70
|
| Rate for Payer: Cash Price |
$185.47
|
| Rate for Payer: Cofinity Commercial |
$162.29
|
| Rate for Payer: Cofinity Commercial |
$199.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.47
|
| Rate for Payer: Healthscope Commercial |
$208.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.06
|
| Rate for Payer: PHP Commercial |
$197.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.29
|
| Rate for Payer: Priority Health SBD |
$146.06
|
| Rate for Payer: UMR Bronson Commercial |
$102.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.88
|
|
