Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$66.70

Service Code	NDC 00116200116
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$42.02
Max. Negotiated Rate	$60.03
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Aetna New Business (MI Preferred)	$43.36
Rate for Payer: Cash Price	$53.36
Rate for Payer: Cofinity Commercial	$46.69
Rate for Payer: Cofinity Commercial	$57.36
Rate for Payer: Cofinity Medicare Advantage	$46.69
Rate for Payer: Encore Health Key Benefits Commercial	$53.36
Rate for Payer: Healthscope Commercial	$60.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$56.70
Rate for Payer: PHP Commercial	$56.70
Rate for Payer: Priority Health Cigna Priority Health	$43.36
Rate for Payer: Priority Health SBD	$42.02

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$222.31

Service Code	NDC 48878062001
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$88.92
Max. Negotiated Rate	$200.08
Rate for Payer: Aetna Commercial	$188.96
Rate for Payer: Aetna Medicare	$111.16
Rate for Payer: Aetna New Business (MI Preferred)	$144.50
Rate for Payer: BCBS Complete	$88.92
Rate for Payer: Cash Price	$177.85
Rate for Payer: Cofinity Commercial	$155.62
Rate for Payer: Cofinity Commercial	$191.19
Rate for Payer: Cofinity Medicare Advantage	$155.62
Rate for Payer: Encore Health Key Benefits Commercial	$177.85
Rate for Payer: Healthscope Commercial	$200.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.96
Rate for Payer: PHP Commercial	$188.96
Rate for Payer: Priority Health Cigna Priority Health	$144.50
Rate for Payer: Priority Health SBD	$140.06

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$3.88

Service Code	NDC 09900000023
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$3.49
Rate for Payer: Aetna Commercial	$3.30
Rate for Payer: Aetna Medicare	$1.94
Rate for Payer: Aetna New Business (MI Preferred)	$2.52
Rate for Payer: BCBS Complete	$1.55
Rate for Payer: Cash Price	$3.10
Rate for Payer: Cofinity Commercial	$2.72
Rate for Payer: Cofinity Commercial	$3.34
Rate for Payer: Cofinity Medicare Advantage	$2.72
Rate for Payer: Encore Health Key Benefits Commercial	$3.10
Rate for Payer: Healthscope Commercial	$3.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.30
Rate for Payer: PHP Commercial	$3.30
Rate for Payer: Priority Health Cigna Priority Health	$2.52
Rate for Payer: Priority Health SBD	$2.44

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$3.88

Service Code	NDC 09900000023
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$3.49
Rate for Payer: Aetna Commercial	$3.30
Rate for Payer: Aetna New Business (MI Preferred)	$2.52
Rate for Payer: Cash Price	$3.10
Rate for Payer: Cofinity Commercial	$2.72
Rate for Payer: Cofinity Commercial	$3.34
Rate for Payer: Cofinity Medicare Advantage	$2.72
Rate for Payer: Encore Health Key Benefits Commercial	$3.10
Rate for Payer: Healthscope Commercial	$3.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.30
Rate for Payer: PHP Commercial	$3.30
Rate for Payer: Priority Health Cigna Priority Health	$2.52
Rate for Payer: Priority Health SBD	$2.44

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$27.15

Service Code	NDC 69339013817
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$10.86
Max. Negotiated Rate	$24.44
Rate for Payer: Aetna Commercial	$23.08
Rate for Payer: Aetna Medicare	$13.58
Rate for Payer: Aetna New Business (MI Preferred)	$17.65
Rate for Payer: BCBS Complete	$10.86
Rate for Payer: Cash Price	$21.72
Rate for Payer: Cofinity Commercial	$19.00
Rate for Payer: Cofinity Commercial	$23.35
Rate for Payer: Cofinity Medicare Advantage	$19.00
Rate for Payer: Encore Health Key Benefits Commercial	$21.72
Rate for Payer: Healthscope Commercial	$24.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.08
Rate for Payer: PHP Commercial	$23.08
Rate for Payer: Priority Health Cigna Priority Health	$17.65
Rate for Payer: Priority Health SBD	$17.10

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$27.15

Service Code	NDC 69339013815
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$24.44
Rate for Payer: Aetna Commercial	$23.08
Rate for Payer: Aetna New Business (MI Preferred)	$17.65
Rate for Payer: Cash Price	$21.72
Rate for Payer: Cofinity Commercial	$19.00
Rate for Payer: Cofinity Commercial	$23.35
Rate for Payer: Cofinity Medicare Advantage	$19.00
Rate for Payer: Encore Health Key Benefits Commercial	$21.72
Rate for Payer: Healthscope Commercial	$24.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.08
Rate for Payer: PHP Commercial	$23.08
Rate for Payer: Priority Health Cigna Priority Health	$17.65
Rate for Payer: Priority Health SBD	$17.10

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$66.70

Service Code	NDC 00116200116
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$26.68
Max. Negotiated Rate	$60.03
Rate for Payer: Aetna Commercial	$56.70
Rate for Payer: Aetna Medicare	$33.35
Rate for Payer: Aetna New Business (MI Preferred)	$43.36
Rate for Payer: BCBS Complete	$26.68
Rate for Payer: Cash Price	$53.36
Rate for Payer: Cofinity Commercial	$46.69
Rate for Payer: Cofinity Commercial	$57.36
Rate for Payer: Cofinity Medicare Advantage	$46.69
Rate for Payer: Encore Health Key Benefits Commercial	$53.36
Rate for Payer: Healthscope Commercial	$60.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$56.70
Rate for Payer: PHP Commercial	$56.70
Rate for Payer: Priority Health Cigna Priority Health	$43.36
Rate for Payer: Priority Health SBD	$42.02

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$222.31

Service Code	NDC 48878062001
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$140.06
Max. Negotiated Rate	$200.08
Rate for Payer: Aetna Commercial	$188.96
Rate for Payer: Aetna New Business (MI Preferred)	$144.50
Rate for Payer: Cash Price	$177.85
Rate for Payer: Cofinity Commercial	$155.62
Rate for Payer: Cofinity Commercial	$191.19
Rate for Payer: Cofinity Medicare Advantage	$155.62
Rate for Payer: Encore Health Key Benefits Commercial	$177.85
Rate for Payer: Healthscope Commercial	$200.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.96
Rate for Payer: PHP Commercial	$188.96
Rate for Payer: Priority Health Cigna Priority Health	$144.50
Rate for Payer: Priority Health SBD	$140.06

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$23.27

Service Code	NDC 63739005274
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$20.94
Rate for Payer: Aetna Commercial	$19.78
Rate for Payer: Aetna New Business (MI Preferred)	$15.13
Rate for Payer: Cash Price	$18.62
Rate for Payer: Cofinity Commercial	$16.29
Rate for Payer: Cofinity Commercial	$20.01
Rate for Payer: Cofinity Medicare Advantage	$16.29
Rate for Payer: Encore Health Key Benefits Commercial	$18.62
Rate for Payer: Healthscope Commercial	$20.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.78
Rate for Payer: PHP Commercial	$19.78
Rate for Payer: Priority Health Cigna Priority Health	$15.13
Rate for Payer: Priority Health SBD	$14.66

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$25.03

Service Code	NDC 63739005269
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$15.77
Max. Negotiated Rate	$22.53
Rate for Payer: Aetna Commercial	$21.28
Rate for Payer: Aetna New Business (MI Preferred)	$16.27
Rate for Payer: Cash Price	$20.02
Rate for Payer: Cofinity Commercial	$17.52
Rate for Payer: Cofinity Commercial	$21.53
Rate for Payer: Cofinity Medicare Advantage	$17.52
Rate for Payer: Encore Health Key Benefits Commercial	$20.02
Rate for Payer: Healthscope Commercial	$22.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.28
Rate for Payer: PHP Commercial	$21.28
Rate for Payer: Priority Health Cigna Priority Health	$16.27
Rate for Payer: Priority Health SBD	$15.77

CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH

Facility

$27.15

Service Code	NDC 69339013817
Hospital Charge Code	9516
Hospital Revenue Code	637
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$24.44
Rate for Payer: Aetna Commercial	$23.08
Rate for Payer: Aetna New Business (MI Preferred)	$17.65
Rate for Payer: Cash Price	$21.72
Rate for Payer: Cofinity Commercial	$19.00
Rate for Payer: Cofinity Commercial	$23.35
Rate for Payer: Cofinity Medicare Advantage	$19.00
Rate for Payer: Encore Health Key Benefits Commercial	$21.72
Rate for Payer: Healthscope Commercial	$24.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.08
Rate for Payer: PHP Commercial	$23.08
Rate for Payer: Priority Health Cigna Priority Health	$17.65
Rate for Payer: Priority Health SBD	$17.10

CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$82.86

Service Code	HCPCS J2401
Hospital Charge Code	150549
Hospital Revenue Code	636
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$74.57
Rate for Payer: Aetna Commercial	$70.43
Rate for Payer: Aetna Commercial	$66.12
Rate for Payer: Aetna New Business (MI Preferred)	$50.56
Rate for Payer: Aetna New Business (MI Preferred)	$53.86
Rate for Payer: Cash Price	$62.23
Rate for Payer: Cash Price	$66.29
Rate for Payer: Cofinity Commercial	$71.26
Rate for Payer: Cofinity Commercial	$58.00
Rate for Payer: Cofinity Commercial	$54.45
Rate for Payer: Cofinity Commercial	$66.90
Rate for Payer: Cofinity Medicare Advantage	$54.45
Rate for Payer: Cofinity Medicare Advantage	$58.00
Rate for Payer: Encore Health Key Benefits Commercial	$62.23
Rate for Payer: Encore Health Key Benefits Commercial	$66.29
Rate for Payer: Healthscope Commercial	$74.57
Rate for Payer: Healthscope Commercial	$70.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$66.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$70.43
Rate for Payer: PHP Commercial	$70.43
Rate for Payer: PHP Commercial	$66.12
Rate for Payer: Priority Health Cigna Priority Health	$50.56
Rate for Payer: Priority Health Cigna Priority Health	$53.86
Rate for Payer: Priority Health SBD	$49.01
Rate for Payer: Priority Health SBD	$52.20

CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$82.86

Service Code	HCPCS J2401
Hospital Charge Code	150549
Hospital Revenue Code	636
Min. Negotiated Rate	$33.14
Max. Negotiated Rate	$74.57
Rate for Payer: Aetna Commercial	$70.43
Rate for Payer: Aetna Commercial	$66.12
Rate for Payer: Aetna Medicare	$38.90
Rate for Payer: Aetna Medicare	$41.43
Rate for Payer: Aetna New Business (MI Preferred)	$53.86
Rate for Payer: Aetna New Business (MI Preferred)	$50.56
Rate for Payer: BCBS Complete	$33.14
Rate for Payer: BCBS Complete	$31.12
Rate for Payer: Cash Price	$66.29
Rate for Payer: Cash Price	$62.23
Rate for Payer: Cofinity Commercial	$71.26
Rate for Payer: Cofinity Commercial	$54.45
Rate for Payer: Cofinity Commercial	$66.90
Rate for Payer: Cofinity Commercial	$58.00
Rate for Payer: Cofinity Medicare Advantage	$54.45
Rate for Payer: Cofinity Medicare Advantage	$58.00
Rate for Payer: Encore Health Key Benefits Commercial	$62.23
Rate for Payer: Encore Health Key Benefits Commercial	$66.29
Rate for Payer: Healthscope Commercial	$74.57
Rate for Payer: Healthscope Commercial	$70.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$70.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$66.12
Rate for Payer: PHP Commercial	$70.43
Rate for Payer: PHP Commercial	$66.12
Rate for Payer: Priority Health Cigna Priority Health	$50.56
Rate for Payer: Priority Health Cigna Priority Health	$53.86
Rate for Payer: Priority Health SBD	$49.01
Rate for Payer: Priority Health SBD	$52.20

CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION

Facility

$87.05

Service Code	HCPCS J2401
Hospital Charge Code	1635
Hospital Revenue Code	636
Min. Negotiated Rate	$34.82
Max. Negotiated Rate	$78.34
Rate for Payer: Aetna Commercial	$73.99
Rate for Payer: Aetna Commercial	$69.45
Rate for Payer: Aetna Medicare	$40.86
Rate for Payer: Aetna Medicare	$43.52
Rate for Payer: Aetna New Business (MI Preferred)	$53.11
Rate for Payer: Aetna New Business (MI Preferred)	$56.58
Rate for Payer: BCBS Complete	$34.82
Rate for Payer: BCBS Complete	$32.68
Rate for Payer: Cash Price	$65.37
Rate for Payer: Cash Price	$69.64
Rate for Payer: Cofinity Commercial	$57.20
Rate for Payer: Cofinity Commercial	$60.94
Rate for Payer: Cofinity Commercial	$74.86
Rate for Payer: Cofinity Commercial	$70.27
Rate for Payer: Cofinity Medicare Advantage	$60.94
Rate for Payer: Cofinity Medicare Advantage	$57.20
Rate for Payer: Encore Health Key Benefits Commercial	$65.37
Rate for Payer: Encore Health Key Benefits Commercial	$69.64
Rate for Payer: Healthscope Commercial	$73.54
Rate for Payer: Healthscope Commercial	$78.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$73.99
Rate for Payer: PHP Commercial	$73.99
Rate for Payer: PHP Commercial	$69.45
Rate for Payer: Priority Health Cigna Priority Health	$53.11
Rate for Payer: Priority Health Cigna Priority Health	$56.58
Rate for Payer: Priority Health SBD	$54.84
Rate for Payer: Priority Health SBD	$51.48

CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION

Facility

$87.05

Service Code	HCPCS J2401
Hospital Charge Code	1635
Hospital Revenue Code	636
Min. Negotiated Rate	$54.84
Max. Negotiated Rate	$78.34
Rate for Payer: Aetna Commercial	$73.99
Rate for Payer: Aetna Commercial	$69.45
Rate for Payer: Aetna New Business (MI Preferred)	$53.11
Rate for Payer: Aetna New Business (MI Preferred)	$56.58
Rate for Payer: Cash Price	$65.37
Rate for Payer: Cash Price	$69.64
Rate for Payer: Cofinity Commercial	$57.20
Rate for Payer: Cofinity Commercial	$60.94
Rate for Payer: Cofinity Commercial	$74.86
Rate for Payer: Cofinity Commercial	$70.27
Rate for Payer: Cofinity Medicare Advantage	$60.94
Rate for Payer: Cofinity Medicare Advantage	$57.20
Rate for Payer: Encore Health Key Benefits Commercial	$65.37
Rate for Payer: Encore Health Key Benefits Commercial	$69.64
Rate for Payer: Healthscope Commercial	$73.54
Rate for Payer: Healthscope Commercial	$78.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$73.99
Rate for Payer: PHP Commercial	$69.45
Rate for Payer: PHP Commercial	$73.99
Rate for Payer: Priority Health Cigna Priority Health	$56.58
Rate for Payer: Priority Health Cigna Priority Health	$53.11
Rate for Payer: Priority Health SBD	$54.84
Rate for Payer: Priority Health SBD	$51.48

CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION

Facility

$130.83

Service Code	HCPCS J1205
Hospital Charge Code	9526
Hospital Revenue Code	636
Min. Negotiated Rate	$52.33
Max. Negotiated Rate	$117.75
Rate for Payer: Aetna Commercial	$111.21
Rate for Payer: Aetna Commercial	$149.52
Rate for Payer: Aetna Medicare	$87.96
Rate for Payer: Aetna Medicare	$65.42
Rate for Payer: Aetna New Business (MI Preferred)	$85.04
Rate for Payer: Aetna New Business (MI Preferred)	$114.34
Rate for Payer: BCBS Complete	$70.36
Rate for Payer: BCBS Complete	$52.33
Rate for Payer: BCBS Trust/PPO	$112.67
Rate for Payer: BCBS Trust/PPO	$112.67
Rate for Payer: BCN Commercial	$112.67
Rate for Payer: BCN Commercial	$112.67
Rate for Payer: Cash Price	$140.73
Rate for Payer: Cash Price	$104.66
Rate for Payer: Cash Price	$104.66
Rate for Payer: Cash Price	$140.73
Rate for Payer: Cofinity Commercial	$91.58
Rate for Payer: Cofinity Commercial	$112.51
Rate for Payer: Cofinity Commercial	$123.14
Rate for Payer: Cofinity Commercial	$151.28
Rate for Payer: Cofinity Medicare Advantage	$91.58
Rate for Payer: Cofinity Medicare Advantage	$123.14
Rate for Payer: Encore Health Key Benefits Commercial	$104.66
Rate for Payer: Encore Health Key Benefits Commercial	$140.73
Rate for Payer: Healthscope Commercial	$158.32
Rate for Payer: Healthscope Commercial	$117.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$149.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$111.21
Rate for Payer: PHP Commercial	$149.52
Rate for Payer: PHP Commercial	$111.21
Rate for Payer: Priority Health Cigna Priority Health	$114.34
Rate for Payer: Priority Health Cigna Priority Health	$85.04
Rate for Payer: Priority Health SBD	$110.82
Rate for Payer: Priority Health SBD	$82.42

CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION

Facility

$175.91

Service Code	HCPCS J1205
Hospital Charge Code	9526
Hospital Revenue Code	636
Min. Negotiated Rate	$110.82
Max. Negotiated Rate	$158.32
Rate for Payer: Aetna Commercial	$149.52
Rate for Payer: Aetna Commercial	$111.21
Rate for Payer: Aetna New Business (MI Preferred)	$85.04
Rate for Payer: Aetna New Business (MI Preferred)	$114.34
Rate for Payer: Cash Price	$104.66
Rate for Payer: Cash Price	$140.73
Rate for Payer: Cofinity Commercial	$151.28
Rate for Payer: Cofinity Commercial	$123.14
Rate for Payer: Cofinity Commercial	$112.51
Rate for Payer: Cofinity Commercial	$91.58
Rate for Payer: Cofinity Medicare Advantage	$91.58
Rate for Payer: Cofinity Medicare Advantage	$123.14
Rate for Payer: Encore Health Key Benefits Commercial	$104.66
Rate for Payer: Encore Health Key Benefits Commercial	$140.73
Rate for Payer: Healthscope Commercial	$158.32
Rate for Payer: Healthscope Commercial	$117.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$111.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$149.52
Rate for Payer: PHP Commercial	$149.52
Rate for Payer: PHP Commercial	$111.21
Rate for Payer: Priority Health Cigna Priority Health	$85.04
Rate for Payer: Priority Health Cigna Priority Health	$114.34
Rate for Payer: Priority Health SBD	$82.42
Rate for Payer: Priority Health SBD	$110.82

CHLOROTHIAZIDE SODIUM 500 MG SOLUTION FOR SOLID FORM MIXTURE CUSTOM

Facility

$329.48

Service Code	HCPCS J1205
Hospital Charge Code	301757
Hospital Revenue Code	636
Min. Negotiated Rate	$207.57
Max. Negotiated Rate	$296.53
Rate for Payer: Aetna Commercial	$280.06
Rate for Payer: Aetna New Business (MI Preferred)	$214.16
Rate for Payer: Cash Price	$263.58
Rate for Payer: Cofinity Commercial	$230.64
Rate for Payer: Cofinity Commercial	$283.35
Rate for Payer: Cofinity Medicare Advantage	$230.64
Rate for Payer: Encore Health Key Benefits Commercial	$263.58
Rate for Payer: Healthscope Commercial	$296.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$280.06
Rate for Payer: PHP Commercial	$280.06
Rate for Payer: Priority Health Cigna Priority Health	$214.16
Rate for Payer: Priority Health SBD	$207.57

CHLOROTHIAZIDE SODIUM 500 MG SOLUTION FOR SOLID FORM MIXTURE CUSTOM

Facility

$329.48

Service Code	HCPCS J1205
Hospital Charge Code	301757
Hospital Revenue Code	636
Min. Negotiated Rate	$112.67
Max. Negotiated Rate	$296.53
Rate for Payer: Aetna Commercial	$280.06
Rate for Payer: Aetna Medicare	$164.74
Rate for Payer: Aetna New Business (MI Preferred)	$214.16
Rate for Payer: BCBS Complete	$131.79
Rate for Payer: BCBS Trust/PPO	$112.67
Rate for Payer: BCN Commercial	$112.67
Rate for Payer: Cash Price	$263.58
Rate for Payer: Cash Price	$263.58
Rate for Payer: Cofinity Commercial	$283.35
Rate for Payer: Cofinity Commercial	$230.64
Rate for Payer: Cofinity Medicare Advantage	$230.64
Rate for Payer: Encore Health Key Benefits Commercial	$263.58
Rate for Payer: Healthscope Commercial	$296.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$280.06
Rate for Payer: PHP Commercial	$280.06
Rate for Payer: Priority Health Cigna Priority Health	$214.16
Rate for Payer: Priority Health SBD	$207.57

CHLORPROMAZINE 10 MG TABLET

Facility

$12.19

Service Code	NDC 51079051801
Hospital Charge Code	1653
Hospital Revenue Code	637
Min. Negotiated Rate	$7.68
Max. Negotiated Rate	$10.97
Rate for Payer: Aetna Commercial	$10.36
Rate for Payer: Aetna New Business (MI Preferred)	$7.92
Rate for Payer: Cash Price	$9.75
Rate for Payer: Cofinity Commercial	$10.48
Rate for Payer: Cofinity Commercial	$8.53
Rate for Payer: Cofinity Medicare Advantage	$8.53
Rate for Payer: Encore Health Key Benefits Commercial	$9.75
Rate for Payer: Healthscope Commercial	$10.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.36
Rate for Payer: PHP Commercial	$10.36
Rate for Payer: Priority Health Cigna Priority Health	$7.92
Rate for Payer: Priority Health SBD	$7.68

CHLORPROMAZINE 10 MG TABLET

Facility

$912.79

Service Code	NDC 00832030000
Hospital Charge Code	1653
Hospital Revenue Code	637
Min. Negotiated Rate	$365.12
Max. Negotiated Rate	$821.51
Rate for Payer: Aetna Commercial	$775.87
Rate for Payer: Aetna Medicare	$456.40
Rate for Payer: Aetna New Business (MI Preferred)	$593.31
Rate for Payer: BCBS Complete	$365.12
Rate for Payer: Cash Price	$730.23
Rate for Payer: Cofinity Commercial	$638.95
Rate for Payer: Cofinity Commercial	$785.00
Rate for Payer: Cofinity Medicare Advantage	$638.95
Rate for Payer: Encore Health Key Benefits Commercial	$730.23
Rate for Payer: Healthscope Commercial	$821.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$775.87
Rate for Payer: PHP Commercial	$775.87
Rate for Payer: Priority Health Cigna Priority Health	$593.31
Rate for Payer: Priority Health SBD	$575.06

CHLORPROMAZINE 10 MG TABLET

Facility

$1,218.78

Service Code	NDC 51079051820
Hospital Charge Code	1653
Hospital Revenue Code	637
Min. Negotiated Rate	$767.83
Max. Negotiated Rate	$1,096.90
Rate for Payer: Aetna Commercial	$1,035.96
Rate for Payer: Aetna New Business (MI Preferred)	$792.21
Rate for Payer: Cash Price	$975.02
Rate for Payer: Cofinity Commercial	$1,048.15
Rate for Payer: Cofinity Commercial	$853.15
Rate for Payer: Cofinity Medicare Advantage	$853.15
Rate for Payer: Encore Health Key Benefits Commercial	$975.02
Rate for Payer: Healthscope Commercial	$1,096.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,035.96
Rate for Payer: PHP Commercial	$1,035.96
Rate for Payer: Priority Health Cigna Priority Health	$792.21
Rate for Payer: Priority Health SBD	$767.83

CHLORPROMAZINE 10 MG TABLET

Facility

$12.19

Service Code	NDC 51079051801
Hospital Charge Code	1653
Hospital Revenue Code	637
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$10.97
Rate for Payer: Aetna Commercial	$10.36
Rate for Payer: Aetna Medicare	$6.10
Rate for Payer: Aetna New Business (MI Preferred)	$7.92
Rate for Payer: BCBS Complete	$4.88
Rate for Payer: Cash Price	$9.75
Rate for Payer: Cofinity Commercial	$10.48
Rate for Payer: Cofinity Commercial	$8.53
Rate for Payer: Cofinity Medicare Advantage	$8.53
Rate for Payer: Encore Health Key Benefits Commercial	$9.75
Rate for Payer: Healthscope Commercial	$10.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.36
Rate for Payer: PHP Commercial	$10.36
Rate for Payer: Priority Health Cigna Priority Health	$7.92
Rate for Payer: Priority Health SBD	$7.68

CHLORPROMAZINE 10 MG TABLET

Facility

$319.92

Service Code	NDC 50268016215
Hospital Charge Code	1653
Hospital Revenue Code	637
Min. Negotiated Rate	$201.55
Max. Negotiated Rate	$287.93
Rate for Payer: Aetna Commercial	$271.93
Rate for Payer: Aetna New Business (MI Preferred)	$207.95
Rate for Payer: Cash Price	$255.94
Rate for Payer: Cofinity Commercial	$223.94
Rate for Payer: Cofinity Commercial	$275.13
Rate for Payer: Cofinity Medicare Advantage	$223.94
Rate for Payer: Encore Health Key Benefits Commercial	$255.94
Rate for Payer: Healthscope Commercial	$287.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$271.93
Rate for Payer: PHP Commercial	$271.93
Rate for Payer: Priority Health Cigna Priority Health	$207.95
Rate for Payer: Priority Health SBD	$201.55

CHLORPROMAZINE 10 MG TABLET

Facility

$1,218.78

Service Code	NDC 51079051820
Hospital Charge Code	1653
Hospital Revenue Code	637
Min. Negotiated Rate	$487.51
Max. Negotiated Rate	$1,096.90
Rate for Payer: Aetna Commercial	$1,035.96
Rate for Payer: Aetna Medicare	$609.39
Rate for Payer: Aetna New Business (MI Preferred)	$792.21
Rate for Payer: BCBS Complete	$487.51
Rate for Payer: Cash Price	$975.02
Rate for Payer: Cofinity Commercial	$1,048.15
Rate for Payer: Cofinity Commercial	$853.15
Rate for Payer: Cofinity Medicare Advantage	$853.15
Rate for Payer: Encore Health Key Benefits Commercial	$975.02
Rate for Payer: Healthscope Commercial	$1,096.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,035.96
Rate for Payer: PHP Commercial	$1,035.96
Rate for Payer: Priority Health Cigna Priority Health	$792.21
Rate for Payer: Priority Health SBD	$767.83

Know your out-of-pocket cost for care.

All Charges