|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$31.38
|
|
|
Service Code
|
NDC 66689-106-50
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$28.24 |
| Rate for Payer: Aetna Commercial |
$26.67
|
| Rate for Payer: BCBS Trust/PPO |
$24.25
|
| Rate for Payer: BCN Commercial |
$24.25
|
| Rate for Payer: Cash Price |
$25.10
|
| Rate for Payer: Cofinity Commercial |
$26.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.10
|
| Rate for Payer: Healthscope Commercial |
$28.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.67
|
| Rate for Payer: PHP Commercial |
$26.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.61
|
| Rate for Payer: UHC Core |
$26.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.54
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$31.38
|
|
|
Service Code
|
NDC 66689-106-01
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$28.24 |
| Rate for Payer: Aetna Commercial |
$26.67
|
| Rate for Payer: BCBS Trust/PPO |
$24.25
|
| Rate for Payer: BCN Commercial |
$24.25
|
| Rate for Payer: Cash Price |
$25.10
|
| Rate for Payer: Cofinity Commercial |
$26.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.10
|
| Rate for Payer: Healthscope Commercial |
$28.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.67
|
| Rate for Payer: PHP Commercial |
$26.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$27.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$27.61
|
| Rate for Payer: UHC Core |
$26.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.54
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
IP
|
$3.88
|
|
|
Service Code
|
NDC 9900-0000-23
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: BCBS Trust/PPO |
$3.00
|
| Rate for Payer: BCN Commercial |
$3.00
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.30
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.41
|
| Rate for Payer: UHC Core |
$3.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$82.86
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
150549
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.54 |
| Max. Negotiated Rate |
$74.57 |
| Rate for Payer: Aetna Commercial |
$70.43
|
| Rate for Payer: BCBS Trust/PPO |
$64.03
|
| Rate for Payer: BCN Commercial |
$64.03
|
| Rate for Payer: Cash Price |
$66.29
|
| Rate for Payer: Cofinity Commercial |
$71.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.29
|
| Rate for Payer: Healthscope Commercial |
$74.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$70.43
|
| Rate for Payer: PHP Commercial |
$70.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$72.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$50.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$72.92
|
| Rate for Payer: UHC Core |
$69.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62.14
|
|
|
CHLORPHENIRAMINE 8 MG HYDROCODONE 10 MG/5 ML ORAL SUSP EXTEND.REL 12HR
|
Facility
|
IP
|
$843.24
|
|
|
Service Code
|
NDC 27808-086-01
|
| Hospital Charge Code |
9582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$514.29 |
| Max. Negotiated Rate |
$758.92 |
| Rate for Payer: Aetna Commercial |
$716.75
|
| Rate for Payer: BCBS Trust/PPO |
$651.66
|
| Rate for Payer: BCN Commercial |
$651.66
|
| Rate for Payer: Cash Price |
$674.59
|
| Rate for Payer: Cofinity Commercial |
$725.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$674.59
|
| Rate for Payer: Healthscope Commercial |
$758.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$632.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$716.75
|
| Rate for Payer: PHP Commercial |
$716.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$590.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$733.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$514.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$742.05
|
| Rate for Payer: UHC Core |
$704.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$632.43
|
|
|
CHLORPHENIRAMINE 8 MG HYDROCODONE 10 MG/5 ML ORAL SUSP EXTEND.REL 12HR
|
Facility
|
IP
|
$43.65
|
|
|
Service Code
|
NDC 9900-0000-25
|
| Hospital Charge Code |
9582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.62 |
| Max. Negotiated Rate |
$39.28 |
| Rate for Payer: Aetna Commercial |
$37.10
|
| Rate for Payer: BCBS Trust/PPO |
$33.73
|
| Rate for Payer: BCN Commercial |
$33.73
|
| Rate for Payer: Cash Price |
$34.92
|
| Rate for Payer: Cofinity Commercial |
$37.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.92
|
| Rate for Payer: Healthscope Commercial |
$39.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.10
|
| Rate for Payer: PHP Commercial |
$37.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$37.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.41
|
| Rate for Payer: UHC Core |
$36.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.74
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
IP
|
$6.32
|
|
|
Service Code
|
NDC 50268-162-11
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$5.69 |
| Rate for Payer: Aetna Commercial |
$5.37
|
| Rate for Payer: BCBS Trust/PPO |
$4.88
|
| Rate for Payer: BCN Commercial |
$4.88
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Cofinity Commercial |
$5.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.06
|
| Rate for Payer: Healthscope Commercial |
$5.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.37
|
| Rate for Payer: PHP Commercial |
$5.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.56
|
| Rate for Payer: UHC Core |
$5.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.74
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
IP
|
$315.60
|
|
|
Service Code
|
NDC 50268-162-15
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.48 |
| Max. Negotiated Rate |
$284.04 |
| Rate for Payer: Aetna Commercial |
$268.26
|
| Rate for Payer: BCBS Trust/PPO |
$243.90
|
| Rate for Payer: BCN Commercial |
$243.90
|
| Rate for Payer: Cash Price |
$252.48
|
| Rate for Payer: Cofinity Commercial |
$271.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$252.48
|
| Rate for Payer: Healthscope Commercial |
$284.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$236.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$268.26
|
| Rate for Payer: PHP Commercial |
$268.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$274.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$192.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$277.73
|
| Rate for Payer: UHC Core |
$263.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$236.70
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$8.48
|
|
|
Service Code
|
NDC 50268-163-11
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$7.63 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: BCBS Trust/PPO |
$6.55
|
| Rate for Payer: BCN Commercial |
$6.55
|
| Rate for Payer: Cash Price |
$6.78
|
| Rate for Payer: Cofinity Commercial |
$7.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.78
|
| Rate for Payer: Healthscope Commercial |
$7.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.21
|
| Rate for Payer: PHP Commercial |
$7.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.46
|
| Rate for Payer: UHC Core |
$7.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.36
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$1,307.95
|
|
|
Service Code
|
NDC 0832-0301-00
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$797.72 |
| Max. Negotiated Rate |
$1,177.16 |
| Rate for Payer: Aetna Commercial |
$1,111.76
|
| Rate for Payer: BCBS Trust/PPO |
$1,010.78
|
| Rate for Payer: BCN Commercial |
$1,010.78
|
| Rate for Payer: Cash Price |
$1,046.36
|
| Rate for Payer: Cofinity Commercial |
$1,124.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,046.36
|
| Rate for Payer: Healthscope Commercial |
$1,177.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$980.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,111.76
|
| Rate for Payer: PHP Commercial |
$1,111.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$915.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,137.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$797.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,151.00
|
| Rate for Payer: UHC Core |
$1,092.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$980.96
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$1,140.71
|
|
|
Service Code
|
NDC 0904-7130-61
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$695.72 |
| Max. Negotiated Rate |
$1,026.64 |
| Rate for Payer: Aetna Commercial |
$969.60
|
| Rate for Payer: BCBS Trust/PPO |
$881.54
|
| Rate for Payer: BCN Commercial |
$881.54
|
| Rate for Payer: Cash Price |
$912.57
|
| Rate for Payer: Cofinity Commercial |
$981.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$912.57
|
| Rate for Payer: Healthscope Commercial |
$1,026.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$855.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$969.60
|
| Rate for Payer: PHP Commercial |
$969.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$798.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$992.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$695.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,003.82
|
| Rate for Payer: UHC Core |
$952.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$855.53
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$423.65
|
|
|
Service Code
|
NDC 50268-163-15
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.38 |
| Max. Negotiated Rate |
$381.28 |
| Rate for Payer: Aetna Commercial |
$360.10
|
| Rate for Payer: BCBS Trust/PPO |
$327.40
|
| Rate for Payer: BCN Commercial |
$327.40
|
| Rate for Payer: Cash Price |
$338.92
|
| Rate for Payer: Cofinity Commercial |
$364.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.92
|
| Rate for Payer: Healthscope Commercial |
$381.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$360.10
|
| Rate for Payer: PHP Commercial |
$360.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$368.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$258.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$372.81
|
| Rate for Payer: UHC Core |
$353.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.74
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$1,764.16
|
|
|
Service Code
|
NDC 0832-0301-01
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,075.96 |
| Max. Negotiated Rate |
$1,587.74 |
| Rate for Payer: Aetna Commercial |
$1,499.54
|
| Rate for Payer: BCBS Trust/PPO |
$1,363.34
|
| Rate for Payer: BCN Commercial |
$1,363.34
|
| Rate for Payer: Cash Price |
$1,411.33
|
| Rate for Payer: Cofinity Commercial |
$1,517.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,411.33
|
| Rate for Payer: Healthscope Commercial |
$1,587.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,323.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,499.54
|
| Rate for Payer: PHP Commercial |
$1,499.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,234.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,534.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,075.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,552.46
|
| Rate for Payer: UHC Core |
$1,473.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,323.12
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$998.26
|
|
|
Service Code
|
NDC 0904-6893-61
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$608.84 |
| Max. Negotiated Rate |
$898.43 |
| Rate for Payer: Aetna Commercial |
$848.52
|
| Rate for Payer: BCBS Trust/PPO |
$771.46
|
| Rate for Payer: BCN Commercial |
$771.46
|
| Rate for Payer: Cash Price |
$798.61
|
| Rate for Payer: Cofinity Commercial |
$858.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$798.61
|
| Rate for Payer: Healthscope Commercial |
$898.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$748.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$848.52
|
| Rate for Payer: PHP Commercial |
$848.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$698.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$868.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$608.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$878.47
|
| Rate for Payer: UHC Core |
$833.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$748.70
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$17.65
|
|
|
Service Code
|
NDC 0832-0301-89
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna Commercial |
$15.00
|
| Rate for Payer: BCBS Trust/PPO |
$13.64
|
| Rate for Payer: BCN Commercial |
$13.64
|
| Rate for Payer: Cash Price |
$14.12
|
| Rate for Payer: Cofinity Commercial |
$15.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.12
|
| Rate for Payer: Healthscope Commercial |
$15.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.00
|
| Rate for Payer: PHP Commercial |
$15.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.53
|
| Rate for Payer: UHC Core |
$14.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.24
|
|
|
CHLORPROMAZINE (BULK) 100 % POWDER
|
Facility
|
IP
|
$194.40
|
|
|
Service Code
|
NDC 38779-0423-4
|
| Hospital Charge Code |
12309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.56 |
| Max. Negotiated Rate |
$174.96 |
| Rate for Payer: Aetna Commercial |
$165.24
|
| Rate for Payer: BCBS Trust/PPO |
$150.23
|
| Rate for Payer: BCN Commercial |
$150.23
|
| Rate for Payer: Cash Price |
$155.52
|
| Rate for Payer: Cofinity Commercial |
$167.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.52
|
| Rate for Payer: Healthscope Commercial |
$174.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.24
|
| Rate for Payer: PHP Commercial |
$165.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$169.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$118.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.07
|
| Rate for Payer: UHC Core |
$162.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.80
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
IP
|
$157.45
|
|
|
Service Code
|
NDC 43598-719-01
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.03 |
| Max. Negotiated Rate |
$141.70 |
| Rate for Payer: Aetna Commercial |
$133.83
|
| Rate for Payer: BCBS Trust/PPO |
$121.68
|
| Rate for Payer: BCN Commercial |
$121.68
|
| Rate for Payer: Cash Price |
$125.96
|
| Rate for Payer: Cofinity Commercial |
$135.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.96
|
| Rate for Payer: Healthscope Commercial |
$141.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$118.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.83
|
| Rate for Payer: PHP Commercial |
$133.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$136.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$96.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$138.56
|
| Rate for Payer: UHC Core |
$131.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$118.09
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
IP
|
$431.04
|
|
|
Service Code
|
NDC 0378-0222-01
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.89 |
| Max. Negotiated Rate |
$387.94 |
| Rate for Payer: Aetna Commercial |
$366.38
|
| Rate for Payer: BCBS Trust/PPO |
$333.11
|
| Rate for Payer: BCN Commercial |
$333.11
|
| Rate for Payer: Cash Price |
$344.83
|
| Rate for Payer: Cofinity Commercial |
$370.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$344.83
|
| Rate for Payer: Healthscope Commercial |
$387.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$323.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$366.38
|
| Rate for Payer: PHP Commercial |
$366.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$301.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$375.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$262.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$379.32
|
| Rate for Payer: UHC Core |
$359.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$323.28
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET
|
Facility
|
IP
|
$30.55
|
|
|
Service Code
|
NDC 904582460
|
| Hospital Charge Code |
82639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.63 |
| Max. Negotiated Rate |
$27.50 |
| Rate for Payer: Aetna Commercial |
$25.97
|
| Rate for Payer: BCBS Trust/PPO |
$23.61
|
| Rate for Payer: BCN Commercial |
$23.61
|
| Rate for Payer: Cash Price |
$24.44
|
| Rate for Payer: Cofinity Commercial |
$26.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.44
|
| Rate for Payer: Healthscope Commercial |
$27.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.97
|
| Rate for Payer: PHP Commercial |
$25.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.88
|
| Rate for Payer: UHC Core |
$25.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.91
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET
|
Facility
|
IP
|
$133.95
|
|
|
Service Code
|
NDC 3160401870
|
| Hospital Charge Code |
82639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.70 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna Commercial |
$113.86
|
| Rate for Payer: BCBS Trust/PPO |
$103.52
|
| Rate for Payer: BCN Commercial |
$103.52
|
| Rate for Payer: Cash Price |
$107.16
|
| Rate for Payer: Cofinity Commercial |
$115.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.16
|
| Rate for Payer: Healthscope Commercial |
$120.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.86
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$116.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$81.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$117.88
|
| Rate for Payer: UHC Core |
$111.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.46
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET
|
Facility
|
IP
|
$84.60
|
|
|
Service Code
|
NDC 2055503300
|
| Hospital Charge Code |
82639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.60 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: BCBS Trust/PPO |
$65.38
|
| Rate for Payer: BCN Commercial |
$65.38
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$71.91
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$73.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$51.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$74.45
|
| Rate for Payer: UHC Core |
$70.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.45
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
NDC 761009840
|
| Hospital Charge Code |
82639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.00 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: BCBS Trust/PPO |
$108.96
|
| Rate for Payer: BCN Commercial |
$108.96
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$122.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$86.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$124.08
|
| Rate for Payer: UHC Core |
$117.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 50 MCG (2,000 UNIT) TABLET
|
Facility
|
IP
|
$4.09
|
|
|
Service Code
|
NDC 5026886511
|
| Hospital Charge Code |
94284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: BCBS Trust/PPO |
$3.16
|
| Rate for Payer: BCN Commercial |
$3.16
|
| Rate for Payer: Cash Price |
$3.27
|
| Rate for Payer: Cofinity Commercial |
$3.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.27
|
| Rate for Payer: Healthscope Commercial |
$3.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.48
|
| Rate for Payer: PHP Commercial |
$3.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.60
|
| Rate for Payer: UHC Core |
$3.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.07
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 50 MCG (2,000 UNIT) TABLET
|
Facility
|
IP
|
$204.45
|
|
|
Service Code
|
NDC 5026886515
|
| Hospital Charge Code |
94284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.69 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$173.78
|
| Rate for Payer: BCBS Trust/PPO |
$158.00
|
| Rate for Payer: BCN Commercial |
$158.00
|
| Rate for Payer: Cash Price |
$163.56
|
| Rate for Payer: Cofinity Commercial |
$175.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.56
|
| Rate for Payer: Healthscope Commercial |
$184.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$173.78
|
| Rate for Payer: PHP Commercial |
$173.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$177.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$124.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$179.92
|
| Rate for Payer: UHC Core |
$170.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.34
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 50 MCG (2,000 UNIT) TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 8068117000
|
| Hospital Charge Code |
94284
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.83 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: BCBS Trust/PPO |
$45.40
|
| Rate for Payer: BCN Commercial |
$45.40
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$51.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.70
|
| Rate for Payer: UHC Core |
$49.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.06
|
|
