Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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

$6.40

Service Code	NDC 50268016211
Hospital Charge Code	1653
Hospital Revenue Code	637
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$5.76
Rate for Payer: Aetna Commercial	$5.44
Rate for Payer: Aetna New Business (MI Preferred)	$4.16
Rate for Payer: Cash Price	$5.12
Rate for Payer: Cofinity Commercial	$4.48
Rate for Payer: Cofinity Commercial	$5.50
Rate for Payer: Cofinity Medicare Advantage	$4.48
Rate for Payer: Encore Health Key Benefits Commercial	$5.12
Rate for Payer: Healthscope Commercial	$5.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.44
Rate for Payer: PHP Commercial	$5.44
Rate for Payer: Priority Health Cigna Priority Health	$4.16
Rate for Payer: Priority Health SBD	$4.03

CHLORPROMAZINE 10 MG TABLET

Facility

$6.40

Service Code	NDC 50268016211
Hospital Charge Code	1653
Hospital Revenue Code	637
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$5.76
Rate for Payer: Aetna Commercial	$5.44
Rate for Payer: Aetna Medicare	$3.20
Rate for Payer: Aetna New Business (MI Preferred)	$4.16
Rate for Payer: BCBS Complete	$2.56
Rate for Payer: Cash Price	$5.12
Rate for Payer: Cofinity Commercial	$4.48
Rate for Payer: Cofinity Commercial	$5.50
Rate for Payer: Cofinity Medicare Advantage	$4.48
Rate for Payer: Encore Health Key Benefits Commercial	$5.12
Rate for Payer: Healthscope Commercial	$5.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.44
Rate for Payer: PHP Commercial	$5.44
Rate for Payer: Priority Health Cigna Priority Health	$4.16
Rate for Payer: Priority Health SBD	$4.03

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 25 MG/ML INJECTION SOLUTION

Facility

$104.80

Service Code	HCPCS J3230
Hospital Charge Code	1649
Hospital Revenue Code	636
Min. Negotiated Rate	$41.92
Max. Negotiated Rate	$94.32
Rate for Payer: Aetna Commercial	$89.08
Rate for Payer: Aetna Commercial	$79.93
Rate for Payer: Aetna Medicare	$47.02
Rate for Payer: Aetna Medicare	$52.40
Rate for Payer: Aetna New Business (MI Preferred)	$68.12
Rate for Payer: Aetna New Business (MI Preferred)	$61.13
Rate for Payer: BCBS Complete	$37.62
Rate for Payer: BCBS Complete	$41.92
Rate for Payer: BCBS Trust/PPO	$78.27
Rate for Payer: BCBS Trust/PPO	$78.27
Rate for Payer: BCN Commercial	$78.27
Rate for Payer: BCN Commercial	$78.27
Rate for Payer: Cash Price	$75.23
Rate for Payer: Cash Price	$83.84
Rate for Payer: Cash Price	$83.84
Rate for Payer: Cash Price	$75.23
Rate for Payer: Cofinity Commercial	$90.13
Rate for Payer: Cofinity Commercial	$73.36
Rate for Payer: Cofinity Commercial	$65.83
Rate for Payer: Cofinity Commercial	$80.87
Rate for Payer: Cofinity Medicare Advantage	$73.36
Rate for Payer: Cofinity Medicare Advantage	$65.83
Rate for Payer: Encore Health Key Benefits Commercial	$83.84
Rate for Payer: Encore Health Key Benefits Commercial	$75.23
Rate for Payer: Healthscope Commercial	$84.64
Rate for Payer: Healthscope Commercial	$94.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$79.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$89.08
Rate for Payer: PHP Commercial	$79.93
Rate for Payer: PHP Commercial	$89.08
Rate for Payer: Priority Health Cigna Priority Health	$61.13
Rate for Payer: Priority Health Cigna Priority Health	$68.12
Rate for Payer: Priority Health SBD	$59.25
Rate for Payer: Priority Health SBD	$66.02

CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION

Facility

$104.80

Service Code	HCPCS J3230
Hospital Charge Code	1649
Hospital Revenue Code	636
Min. Negotiated Rate	$66.02
Max. Negotiated Rate	$94.32
Rate for Payer: Aetna Commercial	$89.08
Rate for Payer: Aetna Commercial	$79.93
Rate for Payer: Aetna New Business (MI Preferred)	$68.12
Rate for Payer: Aetna New Business (MI Preferred)	$61.13
Rate for Payer: Cash Price	$83.84
Rate for Payer: Cash Price	$75.23
Rate for Payer: Cofinity Commercial	$73.36
Rate for Payer: Cofinity Commercial	$65.83
Rate for Payer: Cofinity Commercial	$80.87
Rate for Payer: Cofinity Commercial	$90.13
Rate for Payer: Cofinity Medicare Advantage	$65.83
Rate for Payer: Cofinity Medicare Advantage	$73.36
Rate for Payer: Encore Health Key Benefits Commercial	$83.84
Rate for Payer: Encore Health Key Benefits Commercial	$75.23
Rate for Payer: Healthscope Commercial	$94.32
Rate for Payer: Healthscope Commercial	$84.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$89.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$79.93
Rate for Payer: PHP Commercial	$89.08
Rate for Payer: PHP Commercial	$79.93
Rate for Payer: Priority Health Cigna Priority Health	$61.13
Rate for Payer: Priority Health Cigna Priority Health	$68.12
Rate for Payer: Priority Health SBD	$59.25
Rate for Payer: Priority Health SBD	$66.02

CHLORPROMAZINE 25 MG TABLET

Facility

$1,307.95

Service Code	NDC 00832030100
Hospital Charge Code	1656
Hospital Revenue Code	637
Min. Negotiated Rate	$523.18
Max. Negotiated Rate	$1,177.16
Rate for Payer: Aetna Commercial	$1,111.76
Rate for Payer: Aetna Medicare	$653.98
Rate for Payer: Aetna New Business (MI Preferred)	$850.17
Rate for Payer: BCBS Complete	$523.18
Rate for Payer: Cash Price	$1,046.36
Rate for Payer: Cofinity Commercial	$1,124.84
Rate for Payer: Cofinity Commercial	$915.56
Rate for Payer: Cofinity Medicare Advantage	$915.56
Rate for Payer: Encore Health Key Benefits Commercial	$1,046.36
Rate for Payer: Healthscope Commercial	$1,177.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,111.76
Rate for Payer: PHP Commercial	$1,111.76
Rate for Payer: Priority Health Cigna Priority Health	$850.17
Rate for Payer: Priority Health SBD	$824.01

CHLORPROMAZINE 25 MG TABLET

Facility

$15.24

Service Code	NDC 51079051901
Hospital Charge Code	1656
Hospital Revenue Code	637
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$13.72
Rate for Payer: Aetna Commercial	$12.95
Rate for Payer: Aetna Medicare	$7.62
Rate for Payer: Aetna New Business (MI Preferred)	$9.91
Rate for Payer: BCBS Complete	$6.10
Rate for Payer: Cash Price	$12.19
Rate for Payer: Cofinity Commercial	$10.67
Rate for Payer: Cofinity Commercial	$13.11
Rate for Payer: Cofinity Medicare Advantage	$10.67
Rate for Payer: Encore Health Key Benefits Commercial	$12.19
Rate for Payer: Healthscope Commercial	$13.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.95
Rate for Payer: PHP Commercial	$12.95
Rate for Payer: Priority Health Cigna Priority Health	$9.91
Rate for Payer: Priority Health SBD	$9.60

CHLORPROMAZINE 25 MG TABLET

Facility

$1,177.71

Service Code	NDC 00904713061
Hospital Charge Code	1656
Hospital Revenue Code	637
Min. Negotiated Rate	$741.96
Max. Negotiated Rate	$1,059.94
Rate for Payer: Aetna Commercial	$1,001.05
Rate for Payer: Aetna New Business (MI Preferred)	$765.51
Rate for Payer: Cash Price	$942.17
Rate for Payer: Cofinity Commercial	$1,012.83
Rate for Payer: Cofinity Commercial	$824.40
Rate for Payer: Cofinity Medicare Advantage	$824.40
Rate for Payer: Encore Health Key Benefits Commercial	$942.17
Rate for Payer: Healthscope Commercial	$1,059.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,001.05
Rate for Payer: PHP Commercial	$1,001.05
Rate for Payer: Priority Health Cigna Priority Health	$765.51
Rate for Payer: Priority Health SBD	$741.96

CHLORPROMAZINE 25 MG TABLET

Facility

$1,177.71

Service Code	NDC 00904713061
Hospital Charge Code	1656
Hospital Revenue Code	637
Min. Negotiated Rate	$471.08
Max. Negotiated Rate	$1,059.94
Rate for Payer: Aetna Commercial	$1,001.05
Rate for Payer: Aetna Medicare	$588.86
Rate for Payer: Aetna New Business (MI Preferred)	$765.51
Rate for Payer: BCBS Complete	$471.08
Rate for Payer: Cash Price	$942.17
Rate for Payer: Cofinity Commercial	$1,012.83
Rate for Payer: Cofinity Commercial	$824.40
Rate for Payer: Cofinity Medicare Advantage	$824.40
Rate for Payer: Encore Health Key Benefits Commercial	$942.17
Rate for Payer: Healthscope Commercial	$1,059.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,001.05
Rate for Payer: PHP Commercial	$1,001.05
Rate for Payer: Priority Health Cigna Priority Health	$765.51
Rate for Payer: Priority Health SBD	$741.96

CHLORPROMAZINE 25 MG TABLET

Facility

$1,523.29

Service Code	NDC 51079051920
Hospital Charge Code	1656
Hospital Revenue Code	637
Min. Negotiated Rate	$609.32
Max. Negotiated Rate	$1,370.96
Rate for Payer: Aetna Commercial	$1,294.80
Rate for Payer: Aetna Medicare	$761.64
Rate for Payer: Aetna New Business (MI Preferred)	$990.14
Rate for Payer: BCBS Complete	$609.32
Rate for Payer: Cash Price	$1,218.63
Rate for Payer: Cofinity Commercial	$1,066.30
Rate for Payer: Cofinity Commercial	$1,310.03
Rate for Payer: Cofinity Medicare Advantage	$1,066.30
Rate for Payer: Encore Health Key Benefits Commercial	$1,218.63
Rate for Payer: Healthscope Commercial	$1,370.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,294.80
Rate for Payer: PHP Commercial	$1,294.80
Rate for Payer: Priority Health Cigna Priority Health	$990.14
Rate for Payer: Priority Health SBD	$959.67

CHLORPROMAZINE 25 MG TABLET

Facility

$1,307.95

Service Code	NDC 00832030100
Hospital Charge Code	1656
Hospital Revenue Code	637
Min. Negotiated Rate	$824.01
Max. Negotiated Rate	$1,177.16
Rate for Payer: Aetna Commercial	$1,111.76
Rate for Payer: Aetna New Business (MI Preferred)	$850.17
Rate for Payer: Cash Price	$1,046.36
Rate for Payer: Cofinity Commercial	$1,124.84
Rate for Payer: Cofinity Commercial	$915.56
Rate for Payer: Cofinity Medicare Advantage	$915.56
Rate for Payer: Encore Health Key Benefits Commercial	$1,046.36
Rate for Payer: Healthscope Commercial	$1,177.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,111.76
Rate for Payer: PHP Commercial	$1,111.76
Rate for Payer: Priority Health Cigna Priority Health	$850.17
Rate for Payer: Priority Health SBD	$824.01

CHLORPROMAZINE 25 MG TABLET

Facility

$15.24

Service Code	NDC 51079051901
Hospital Charge Code	1656
Hospital Revenue Code	637
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$13.72
Rate for Payer: Aetna Commercial	$12.95
Rate for Payer: Aetna New Business (MI Preferred)	$9.91
Rate for Payer: Cash Price	$12.19
Rate for Payer: Cofinity Commercial	$10.67
Rate for Payer: Cofinity Commercial	$13.11
Rate for Payer: Cofinity Medicare Advantage	$10.67
Rate for Payer: Encore Health Key Benefits Commercial	$12.19
Rate for Payer: Healthscope Commercial	$13.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.95
Rate for Payer: PHP Commercial	$12.95
Rate for Payer: Priority Health Cigna Priority Health	$9.91
Rate for Payer: Priority Health SBD	$9.60

CHLORPROMAZINE 25 MG TABLET

Facility

$1,523.29

Service Code	NDC 51079051920
Hospital Charge Code	1656
Hospital Revenue Code	637
Min. Negotiated Rate	$959.67
Max. Negotiated Rate	$1,370.96
Rate for Payer: Aetna Commercial	$1,294.80
Rate for Payer: Aetna New Business (MI Preferred)	$990.14
Rate for Payer: Cash Price	$1,218.63
Rate for Payer: Cofinity Commercial	$1,066.30
Rate for Payer: Cofinity Commercial	$1,310.03
Rate for Payer: Cofinity Medicare Advantage	$1,066.30
Rate for Payer: Encore Health Key Benefits Commercial	$1,218.63
Rate for Payer: Healthscope Commercial	$1,370.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,294.80
Rate for Payer: PHP Commercial	$1,294.80
Rate for Payer: Priority Health Cigna Priority Health	$990.14
Rate for Payer: Priority Health SBD	$959.67

CHLORTHALIDONE 25 MG TABLET

Facility

$868.80

Service Code	NDC 51079005820
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$347.52
Max. Negotiated Rate	$781.92
Rate for Payer: Aetna Commercial	$738.48
Rate for Payer: Aetna Medicare	$434.40
Rate for Payer: Aetna New Business (MI Preferred)	$564.72
Rate for Payer: BCBS Complete	$347.52
Rate for Payer: Cash Price	$695.04
Rate for Payer: Cofinity Commercial	$608.16
Rate for Payer: Cofinity Commercial	$747.17
Rate for Payer: Cofinity Medicare Advantage	$608.16
Rate for Payer: Encore Health Key Benefits Commercial	$695.04
Rate for Payer: Healthscope Commercial	$781.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$738.48
Rate for Payer: PHP Commercial	$738.48
Rate for Payer: Priority Health Cigna Priority Health	$564.72
Rate for Payer: Priority Health SBD	$547.34

CHLORTHALIDONE 25 MG TABLET

Facility

$226.66

Service Code	NDC 60687031725
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$203.99
Rate for Payer: Aetna Commercial	$192.66
Rate for Payer: Aetna New Business (MI Preferred)	$147.33
Rate for Payer: Cash Price	$181.33
Rate for Payer: Cofinity Commercial	$158.66
Rate for Payer: Cofinity Commercial	$194.93
Rate for Payer: Cofinity Medicare Advantage	$158.66
Rate for Payer: Encore Health Key Benefits Commercial	$181.33
Rate for Payer: Healthscope Commercial	$203.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$192.66
Rate for Payer: PHP Commercial	$192.66
Rate for Payer: Priority Health Cigna Priority Health	$147.33
Rate for Payer: Priority Health SBD	$142.80

CHLORTHALIDONE 25 MG TABLET

Facility

$8.69

Service Code	NDC 51079005801
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$7.82
Rate for Payer: Aetna Commercial	$7.39
Rate for Payer: Aetna Medicare	$4.34
Rate for Payer: Aetna New Business (MI Preferred)	$5.65
Rate for Payer: BCBS Complete	$3.48
Rate for Payer: Cash Price	$6.95
Rate for Payer: Cofinity Commercial	$6.08
Rate for Payer: Cofinity Commercial	$7.47
Rate for Payer: Cofinity Medicare Advantage	$6.08
Rate for Payer: Encore Health Key Benefits Commercial	$6.95
Rate for Payer: Healthscope Commercial	$7.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.39
Rate for Payer: PHP Commercial	$7.39
Rate for Payer: Priority Health Cigna Priority Health	$5.65
Rate for Payer: Priority Health SBD	$5.47

CHLORTHALIDONE 25 MG TABLET

Facility

$206.07

Service Code	NDC 00904690004
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$129.82
Max. Negotiated Rate	$185.46
Rate for Payer: Aetna Commercial	$175.16
Rate for Payer: Aetna New Business (MI Preferred)	$133.95
Rate for Payer: Cash Price	$164.86
Rate for Payer: Cofinity Commercial	$144.25
Rate for Payer: Cofinity Commercial	$177.22
Rate for Payer: Cofinity Medicare Advantage	$144.25
Rate for Payer: Encore Health Key Benefits Commercial	$164.86
Rate for Payer: Healthscope Commercial	$185.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.16
Rate for Payer: PHP Commercial	$175.16
Rate for Payer: Priority Health Cigna Priority Health	$133.95
Rate for Payer: Priority Health SBD	$129.82

CHLORTHALIDONE 25 MG TABLET

Facility

$7.56

Service Code	NDC 60687031795
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$6.80
Rate for Payer: Aetna Commercial	$6.43
Rate for Payer: Aetna New Business (MI Preferred)	$4.91
Rate for Payer: Cash Price	$6.05
Rate for Payer: Cofinity Commercial	$5.29
Rate for Payer: Cofinity Commercial	$6.50
Rate for Payer: Cofinity Medicare Advantage	$5.29
Rate for Payer: Encore Health Key Benefits Commercial	$6.05
Rate for Payer: Healthscope Commercial	$6.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.43
Rate for Payer: PHP Commercial	$6.43
Rate for Payer: Priority Health Cigna Priority Health	$4.91
Rate for Payer: Priority Health SBD	$4.76

CHLORTHALIDONE 25 MG TABLET

Facility

$7.56

Service Code	NDC 60687031795
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$6.80
Rate for Payer: Aetna Commercial	$6.43
Rate for Payer: Aetna Medicare	$3.78
Rate for Payer: Aetna New Business (MI Preferred)	$4.91
Rate for Payer: BCBS Complete	$3.02
Rate for Payer: Cash Price	$6.05
Rate for Payer: Cofinity Commercial	$5.29
Rate for Payer: Cofinity Commercial	$6.50
Rate for Payer: Cofinity Medicare Advantage	$5.29
Rate for Payer: Encore Health Key Benefits Commercial	$6.05
Rate for Payer: Healthscope Commercial	$6.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.43
Rate for Payer: PHP Commercial	$6.43
Rate for Payer: Priority Health Cigna Priority Health	$4.91
Rate for Payer: Priority Health SBD	$4.76

CHLORTHALIDONE 25 MG TABLET

Facility

$8.69

Service Code	NDC 51079005801
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$7.82
Rate for Payer: Aetna Commercial	$7.39
Rate for Payer: Aetna New Business (MI Preferred)	$5.65
Rate for Payer: Cash Price	$6.95
Rate for Payer: Cofinity Commercial	$6.08
Rate for Payer: Cofinity Commercial	$7.47
Rate for Payer: Cofinity Medicare Advantage	$6.08
Rate for Payer: Encore Health Key Benefits Commercial	$6.95
Rate for Payer: Healthscope Commercial	$7.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.39
Rate for Payer: PHP Commercial	$7.39
Rate for Payer: Priority Health Cigna Priority Health	$5.65
Rate for Payer: Priority Health SBD	$5.47

CHLORTHALIDONE 25 MG TABLET

Facility

$868.80

Service Code	NDC 51079005820
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$547.34
Max. Negotiated Rate	$781.92
Rate for Payer: Aetna Commercial	$738.48
Rate for Payer: Aetna New Business (MI Preferred)	$564.72
Rate for Payer: Cash Price	$695.04
Rate for Payer: Cofinity Commercial	$608.16
Rate for Payer: Cofinity Commercial	$747.17
Rate for Payer: Cofinity Medicare Advantage	$608.16
Rate for Payer: Encore Health Key Benefits Commercial	$695.04
Rate for Payer: Healthscope Commercial	$781.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$738.48
Rate for Payer: PHP Commercial	$738.48
Rate for Payer: Priority Health Cigna Priority Health	$564.72
Rate for Payer: Priority Health SBD	$547.34

CHLORTHALIDONE 25 MG TABLET

Facility

$206.07

Service Code	NDC 00904690004
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$82.43
Max. Negotiated Rate	$185.46
Rate for Payer: Aetna Commercial	$175.16
Rate for Payer: Aetna Medicare	$103.04
Rate for Payer: Aetna New Business (MI Preferred)	$133.95
Rate for Payer: BCBS Complete	$82.43
Rate for Payer: Cash Price	$164.86
Rate for Payer: Cofinity Commercial	$144.25
Rate for Payer: Cofinity Commercial	$177.22
Rate for Payer: Cofinity Medicare Advantage	$144.25
Rate for Payer: Encore Health Key Benefits Commercial	$164.86
Rate for Payer: Healthscope Commercial	$185.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.16
Rate for Payer: PHP Commercial	$175.16
Rate for Payer: Priority Health Cigna Priority Health	$133.95
Rate for Payer: Priority Health SBD	$129.82

CHLORTHALIDONE 25 MG TABLET

Facility

$226.66

Service Code	NDC 60687031725
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$90.66
Max. Negotiated Rate	$203.99
Rate for Payer: Aetna Commercial	$192.66
Rate for Payer: Aetna Medicare	$113.33
Rate for Payer: Aetna New Business (MI Preferred)	$147.33
Rate for Payer: BCBS Complete	$90.66
Rate for Payer: Cash Price	$181.33
Rate for Payer: Cofinity Commercial	$158.66
Rate for Payer: Cofinity Commercial	$194.93
Rate for Payer: Cofinity Medicare Advantage	$158.66
Rate for Payer: Encore Health Key Benefits Commercial	$181.33
Rate for Payer: Healthscope Commercial	$203.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$192.66
Rate for Payer: PHP Commercial	$192.66
Rate for Payer: Priority Health Cigna Priority Health	$147.33
Rate for Payer: Priority Health SBD	$142.80

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$101.18

Service Code	NDC 50268086315
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$63.74
Max. Negotiated Rate	$91.06
Rate for Payer: Aetna Commercial	$86.00
Rate for Payer: Aetna New Business (MI Preferred)	$65.77
Rate for Payer: Cash Price	$80.94
Rate for Payer: Cofinity Commercial	$70.83
Rate for Payer: Cofinity Commercial	$87.01
Rate for Payer: Cofinity Medicare Advantage	$70.83
Rate for Payer: Encore Health Key Benefits Commercial	$80.94
Rate for Payer: Healthscope Commercial	$91.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.00
Rate for Payer: PHP Commercial	$86.00
Rate for Payer: Priority Health Cigna Priority Health	$65.77
Rate for Payer: Priority Health SBD	$63.74

Know your out-of-pocket cost for care.

All Charges