|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH
|
Facility
|
OP
|
$25.03
|
|
|
Service Code
|
NDC 00904703588
|
| Hospital Charge Code |
9516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$22.53 |
| Rate for Payer: Aetna Commercial |
$21.28
|
| Rate for Payer: Aetna Medicare |
$6.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.82
|
| Rate for Payer: BCBS Complete |
$4.63
|
| Rate for Payer: BCBS MAPPO |
$6.26
|
| Rate for Payer: BCBS Trust/PPO |
$20.58
|
| Rate for Payer: BCN Commercial |
$20.58
|
| Rate for Payer: BCN Medicare Advantage |
$6.26
|
| Rate for Payer: Cash Price |
$20.02
|
| Rate for Payer: Cofinity Commercial |
$21.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.26
|
| Rate for Payer: Healthscope Commercial |
$22.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.77
|
| Rate for Payer: Mclaren Medicaid |
$4.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.57
|
| Rate for Payer: Meridian Medicaid |
$4.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.20
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.28
|
| Rate for Payer: Nomi Health Commercial |
$20.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.77
|
| Rate for Payer: PACE Senior Care Partners |
$5.94
|
| Rate for Payer: PACE SWMI |
$6.26
|
| Rate for Payer: PHP Commercial |
$21.28
|
| Rate for Payer: PHP Medicare Advantage |
$6.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.41
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$21.78
|
| Rate for Payer: Priority Health Medicare |
$6.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.42
|
| Rate for Payer: Railroad Medicare Medicare |
$6.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.03
|
| Rate for Payer: UHC Core |
$20.90
|
| Rate for Payer: UHC Exchange |
$6.26
|
| Rate for Payer: UHC Medicaid |
$4.41
|
| Rate for Payer: UHC Medicare Advantage |
$6.26
|
| Rate for Payer: UHCCP Medicaid |
$4.41
|
| Rate for Payer: VA VA |
$6.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.77
|
|
|
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 |
$57.67 |
| Max. Negotiated Rate |
$74.57 |
| Rate for Payer: Aetna Commercial |
$70.43
|
| Rate for Payer: BCBS Trust/PPO |
$68.43
|
| Rate for Payer: BCN Commercial |
$68.43
|
| 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 |
$62.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.43
|
| Rate for Payer: Nomi Health Commercial |
$67.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$62.15
|
| Rate for Payer: PHP Commercial |
$70.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$72.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$57.67
|
| 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 |
$62.15
|
|
|
CHLOROPROCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
OP
|
$82.86
|
|
|
Service Code
|
HCPCS J2401
|
| Hospital Charge Code |
150549
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.61 |
| Max. Negotiated Rate |
$74.57 |
| Rate for Payer: Aetna Commercial |
$70.43
|
| Rate for Payer: Aetna Medicare |
$21.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25.89
|
| Rate for Payer: BCBS Complete |
$15.34
|
| Rate for Payer: BCBS MAPPO |
$20.71
|
| Rate for Payer: BCBS Trust/PPO |
$68.12
|
| Rate for Payer: BCN Commercial |
$68.12
|
| Rate for Payer: BCN Medicare Advantage |
$20.71
|
| 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: Health Alliance Plan Medicare Advantage |
$20.71
|
| Rate for Payer: Healthscope Commercial |
$74.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$62.15
|
| Rate for Payer: Mclaren Medicaid |
$14.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$21.75
|
| Rate for Payer: Meridian Medicaid |
$15.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.82
|
| Rate for Payer: Molina Medicare/Medicaid |
$22.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.43
|
| Rate for Payer: Nomi Health Commercial |
$67.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$62.15
|
| Rate for Payer: PACE Senior Care Partners |
$19.68
|
| Rate for Payer: PACE SWMI |
$20.71
|
| Rate for Payer: PHP Commercial |
$70.43
|
| Rate for Payer: PHP Medicare Advantage |
$20.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$14.61
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$72.09
|
| Rate for Payer: Priority Health Medicare |
$20.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$57.67
|
| Rate for Payer: Railroad Medicare Medicare |
$20.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$72.92
|
| Rate for Payer: UHC Core |
$69.19
|
| Rate for Payer: UHC Exchange |
$20.71
|
| Rate for Payer: UHC Medicaid |
$14.61
|
| Rate for Payer: UHC Medicare Advantage |
$20.71
|
| Rate for Payer: UHCCP Medicaid |
$14.61
|
| Rate for Payer: VA VA |
$20.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$62.15
|
|
|
CHLORPHENIRAMINE 8 MG HYDROCODONE 10 MG/5 ML ORAL SUSP EXTEND.REL 12HR
|
Facility
|
OP
|
$43.65
|
|
|
Service Code
|
NDC 09900000025
|
| Hospital Charge Code |
9582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$39.28 |
| Rate for Payer: Aetna Commercial |
$37.10
|
| Rate for Payer: Aetna Medicare |
$11.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13.64
|
| Rate for Payer: BCBS Complete |
$8.08
|
| Rate for Payer: BCBS MAPPO |
$10.91
|
| Rate for Payer: BCBS Trust/PPO |
$35.88
|
| Rate for Payer: BCN Commercial |
$35.88
|
| Rate for Payer: BCN Medicare Advantage |
$10.91
|
| 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: Health Alliance Plan Medicare Advantage |
$10.91
|
| Rate for Payer: Healthscope Commercial |
$39.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.74
|
| Rate for Payer: Mclaren Medicaid |
$7.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11.46
|
| Rate for Payer: Meridian Medicaid |
$8.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.55
|
| Rate for Payer: Molina Medicare/Medicaid |
$12.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.10
|
| Rate for Payer: Nomi Health Commercial |
$35.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.74
|
| Rate for Payer: PACE Senior Care Partners |
$10.37
|
| Rate for Payer: PACE SWMI |
$10.91
|
| Rate for Payer: PHP Commercial |
$37.10
|
| Rate for Payer: PHP Medicare Advantage |
$10.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.70
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$37.98
|
| Rate for Payer: Priority Health Medicare |
$11.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$30.38
|
| Rate for Payer: Railroad Medicare Medicare |
$10.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.41
|
| Rate for Payer: UHC Core |
$36.45
|
| Rate for Payer: UHC Exchange |
$10.91
|
| Rate for Payer: UHC Medicaid |
$7.70
|
| Rate for Payer: UHC Medicare Advantage |
$10.91
|
| Rate for Payer: UHCCP Medicaid |
$7.70
|
| Rate for Payer: VA VA |
$10.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.74
|
|
|
CHLORPHENIRAMINE 8 MG HYDROCODONE 10 MG/5 ML ORAL SUSP EXTEND.REL 12HR
|
Facility
|
OP
|
$927.77
|
|
|
Service Code
|
NDC 27808008601
|
| Hospital Charge Code |
9582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.57 |
| Max. Negotiated Rate |
$834.99 |
| Rate for Payer: Aetna Commercial |
$788.60
|
| Rate for Payer: Aetna Medicare |
$241.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$289.93
|
| Rate for Payer: Amish Plain Church Group Commercial |
$289.93
|
| Rate for Payer: BCBS Complete |
$171.73
|
| Rate for Payer: BCBS MAPPO |
$231.94
|
| Rate for Payer: BCBS Trust/PPO |
$762.72
|
| Rate for Payer: BCN Commercial |
$762.72
|
| Rate for Payer: BCN Medicare Advantage |
$231.94
|
| Rate for Payer: Cash Price |
$742.22
|
| Rate for Payer: Cofinity Commercial |
$797.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$742.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$231.94
|
| Rate for Payer: Healthscope Commercial |
$834.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$695.83
|
| Rate for Payer: Mclaren Medicaid |
$163.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$243.54
|
| Rate for Payer: Meridian Medicaid |
$171.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$266.73
|
| Rate for Payer: Molina Medicare/Medicaid |
$255.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$788.60
|
| Rate for Payer: Nomi Health Commercial |
$760.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$695.83
|
| Rate for Payer: PACE Senior Care Partners |
$220.35
|
| Rate for Payer: PACE SWMI |
$231.94
|
| Rate for Payer: PHP Commercial |
$788.60
|
| Rate for Payer: PHP Medicare Advantage |
$231.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$163.57
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$807.16
|
| Rate for Payer: Priority Health Medicare |
$234.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$645.73
|
| Rate for Payer: Railroad Medicare Medicare |
$231.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$816.44
|
| Rate for Payer: UHC Core |
$774.69
|
| Rate for Payer: UHC Exchange |
$231.94
|
| Rate for Payer: UHC Medicaid |
$163.57
|
| Rate for Payer: UHC Medicare Advantage |
$231.94
|
| Rate for Payer: UHCCP Medicaid |
$163.57
|
| Rate for Payer: VA VA |
$231.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$695.83
|
|
|
CHLORPHENIRAMINE 8 MG HYDROCODONE 10 MG/5 ML ORAL SUSP EXTEND.REL 12HR
|
Facility
|
IP
|
$43.65
|
|
|
Service Code
|
NDC 09900000025
|
| Hospital Charge Code |
9582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$39.28 |
| Rate for Payer: Aetna Commercial |
$37.10
|
| Rate for Payer: BCBS Trust/PPO |
$36.05
|
| Rate for Payer: BCN Commercial |
$36.05
|
| 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 Commercial |
$37.10
|
| Rate for Payer: Nomi Health Commercial |
$35.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.74
|
| Rate for Payer: PHP Commercial |
$37.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$37.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$30.38
|
| 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
|
|
|
CHLORPHENIRAMINE 8 MG HYDROCODONE 10 MG/5 ML ORAL SUSP EXTEND.REL 12HR
|
Facility
|
IP
|
$927.77
|
|
|
Service Code
|
NDC 27808008601
|
| Hospital Charge Code |
9582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$645.73 |
| Max. Negotiated Rate |
$834.99 |
| Rate for Payer: Aetna Commercial |
$788.60
|
| Rate for Payer: BCBS Trust/PPO |
$766.25
|
| Rate for Payer: BCN Commercial |
$766.25
|
| Rate for Payer: Cash Price |
$742.22
|
| Rate for Payer: Cofinity Commercial |
$797.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$742.22
|
| Rate for Payer: Healthscope Commercial |
$834.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$695.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$788.60
|
| Rate for Payer: Nomi Health Commercial |
$760.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$695.83
|
| Rate for Payer: PHP Commercial |
$788.60
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$807.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$645.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$816.44
|
| Rate for Payer: UHC Core |
$774.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$695.83
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$17.65
|
|
|
Service Code
|
NDC 00832030189
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna Commercial |
$15.00
|
| Rate for Payer: Aetna Medicare |
$4.59
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.52
|
| Rate for Payer: BCBS Complete |
$3.27
|
| Rate for Payer: BCBS MAPPO |
$4.41
|
| Rate for Payer: BCBS Trust/PPO |
$14.51
|
| Rate for Payer: BCN Commercial |
$14.51
|
| Rate for Payer: BCN Medicare Advantage |
$4.41
|
| 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: Health Alliance Plan Medicare Advantage |
$4.41
|
| Rate for Payer: Healthscope Commercial |
$15.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.24
|
| Rate for Payer: Mclaren Medicaid |
$3.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.63
|
| Rate for Payer: Meridian Medicaid |
$3.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.07
|
| Rate for Payer: Molina Medicare/Medicaid |
$4.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.00
|
| Rate for Payer: Nomi Health Commercial |
$14.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.24
|
| Rate for Payer: PACE Senior Care Partners |
$4.19
|
| Rate for Payer: PACE SWMI |
$4.41
|
| Rate for Payer: PHP Commercial |
$15.00
|
| Rate for Payer: PHP Medicare Advantage |
$4.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$15.36
|
| Rate for Payer: Priority Health Medicare |
$4.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.28
|
| Rate for Payer: Railroad Medicare Medicare |
$4.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.53
|
| Rate for Payer: UHC Core |
$14.74
|
| Rate for Payer: UHC Exchange |
$4.41
|
| Rate for Payer: UHC Medicaid |
$3.11
|
| Rate for Payer: UHC Medicare Advantage |
$4.41
|
| Rate for Payer: UHCCP Medicaid |
$3.11
|
| Rate for Payer: VA VA |
$4.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.24
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$429.20
|
|
|
Service Code
|
NDC 50268016315
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.67 |
| Max. Negotiated Rate |
$386.28 |
| Rate for Payer: Aetna Commercial |
$364.82
|
| Rate for Payer: Aetna Medicare |
$111.59
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$134.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$134.12
|
| Rate for Payer: BCBS Complete |
$79.44
|
| Rate for Payer: BCBS MAPPO |
$107.30
|
| Rate for Payer: BCBS Trust/PPO |
$352.85
|
| Rate for Payer: BCN Commercial |
$352.85
|
| Rate for Payer: BCN Medicare Advantage |
$107.30
|
| Rate for Payer: Cash Price |
$343.36
|
| Rate for Payer: Cofinity Commercial |
$369.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$107.30
|
| Rate for Payer: Healthscope Commercial |
$386.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.90
|
| Rate for Payer: Mclaren Medicaid |
$75.67
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$112.67
|
| Rate for Payer: Meridian Medicaid |
$79.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$123.39
|
| Rate for Payer: Molina Medicare/Medicaid |
$118.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.82
|
| Rate for Payer: Nomi Health Commercial |
$351.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$321.90
|
| Rate for Payer: PACE Senior Care Partners |
$101.94
|
| Rate for Payer: PACE SWMI |
$107.30
|
| Rate for Payer: PHP Commercial |
$364.82
|
| Rate for Payer: PHP Medicare Advantage |
$107.30
|
| Rate for Payer: Priority Health Choice Medicaid |
$75.67
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$373.40
|
| Rate for Payer: Priority Health Medicare |
$108.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$298.72
|
| Rate for Payer: Railroad Medicare Medicare |
$107.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$377.70
|
| Rate for Payer: UHC Core |
$358.38
|
| Rate for Payer: UHC Exchange |
$107.30
|
| Rate for Payer: UHC Medicaid |
$75.67
|
| Rate for Payer: UHC Medicare Advantage |
$107.30
|
| Rate for Payer: UHCCP Medicaid |
$75.67
|
| Rate for Payer: VA VA |
$107.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.90
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$1,764.16
|
|
|
Service Code
|
NDC 00832030101
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$311.02 |
| Max. Negotiated Rate |
$1,587.74 |
| Rate for Payer: Aetna Commercial |
$1,499.54
|
| Rate for Payer: Aetna Medicare |
$458.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$551.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$551.30
|
| Rate for Payer: BCBS Complete |
$326.55
|
| Rate for Payer: BCBS MAPPO |
$441.04
|
| Rate for Payer: BCBS Trust/PPO |
$1,450.32
|
| Rate for Payer: BCN Commercial |
$1,450.32
|
| Rate for Payer: BCN Medicare Advantage |
$441.04
|
| 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: Health Alliance Plan Medicare Advantage |
$441.04
|
| Rate for Payer: Healthscope Commercial |
$1,587.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,323.12
|
| Rate for Payer: Mclaren Medicaid |
$311.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$463.09
|
| Rate for Payer: Meridian Medicaid |
$326.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$507.20
|
| Rate for Payer: Molina Medicare/Medicaid |
$485.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,499.54
|
| Rate for Payer: Nomi Health Commercial |
$1,446.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,323.12
|
| Rate for Payer: PACE Senior Care Partners |
$418.99
|
| Rate for Payer: PACE SWMI |
$441.04
|
| Rate for Payer: PHP Commercial |
$1,499.54
|
| Rate for Payer: PHP Medicare Advantage |
$441.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$311.02
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,534.82
|
| Rate for Payer: Priority Health Medicare |
$445.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,227.86
|
| Rate for Payer: Railroad Medicare Medicare |
$441.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,552.46
|
| Rate for Payer: UHC Core |
$1,473.07
|
| Rate for Payer: UHC Exchange |
$441.04
|
| Rate for Payer: UHC Medicaid |
$311.02
|
| Rate for Payer: UHC Medicare Advantage |
$441.04
|
| Rate for Payer: UHCCP Medicaid |
$311.02
|
| Rate for Payer: VA VA |
$441.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,323.12
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$1,307.95
|
|
|
Service Code
|
NDC 00832030100
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.59 |
| Max. Negotiated Rate |
$1,177.15 |
| Rate for Payer: Aetna Commercial |
$1,111.76
|
| Rate for Payer: Aetna Medicare |
$340.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$408.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$408.73
|
| Rate for Payer: BCBS Complete |
$242.10
|
| Rate for Payer: BCBS MAPPO |
$326.99
|
| Rate for Payer: BCBS Trust/PPO |
$1,075.27
|
| Rate for Payer: BCN Commercial |
$1,075.27
|
| Rate for Payer: BCN Medicare Advantage |
$326.99
|
| 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: Health Alliance Plan Medicare Advantage |
$326.99
|
| Rate for Payer: Healthscope Commercial |
$1,177.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$980.96
|
| Rate for Payer: Mclaren Medicaid |
$230.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$343.34
|
| Rate for Payer: Meridian Medicaid |
$242.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$376.04
|
| Rate for Payer: Molina Medicare/Medicaid |
$359.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,111.76
|
| Rate for Payer: Nomi Health Commercial |
$1,072.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$980.96
|
| Rate for Payer: PACE Senior Care Partners |
$310.64
|
| Rate for Payer: PACE SWMI |
$326.99
|
| Rate for Payer: PHP Commercial |
$1,111.76
|
| Rate for Payer: PHP Medicare Advantage |
$326.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$230.59
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,137.92
|
| Rate for Payer: Priority Health Medicare |
$330.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$910.33
|
| Rate for Payer: Railroad Medicare Medicare |
$326.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,151.00
|
| Rate for Payer: UHC Core |
$1,092.14
|
| Rate for Payer: UHC Exchange |
$326.99
|
| Rate for Payer: UHC Medicaid |
$230.59
|
| Rate for Payer: UHC Medicare Advantage |
$326.99
|
| Rate for Payer: UHCCP Medicaid |
$230.59
|
| Rate for Payer: VA VA |
$326.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$980.96
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$8.59
|
|
|
Service Code
|
NDC 50268016311
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$7.73 |
| Rate for Payer: Aetna Commercial |
$7.30
|
| Rate for Payer: Aetna Medicare |
$2.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.68
|
| Rate for Payer: BCBS Complete |
$1.59
|
| Rate for Payer: BCBS MAPPO |
$2.15
|
| Rate for Payer: BCBS Trust/PPO |
$7.06
|
| Rate for Payer: BCN Commercial |
$7.06
|
| Rate for Payer: BCN Medicare Advantage |
$2.15
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cofinity Commercial |
$7.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.15
|
| Rate for Payer: Healthscope Commercial |
$7.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.44
|
| Rate for Payer: Mclaren Medicaid |
$1.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.25
|
| Rate for Payer: Meridian Medicaid |
$1.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.47
|
| Rate for Payer: Molina Medicare/Medicaid |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.30
|
| Rate for Payer: Nomi Health Commercial |
$7.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.44
|
| Rate for Payer: PACE Senior Care Partners |
$2.04
|
| Rate for Payer: PACE SWMI |
$2.15
|
| Rate for Payer: PHP Commercial |
$7.30
|
| Rate for Payer: PHP Medicare Advantage |
$2.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$7.47
|
| Rate for Payer: Priority Health Medicare |
$2.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.98
|
| Rate for Payer: Railroad Medicare Medicare |
$2.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.56
|
| Rate for Payer: UHC Core |
$7.17
|
| Rate for Payer: UHC Exchange |
$2.15
|
| Rate for Payer: UHC Medicaid |
$1.51
|
| Rate for Payer: UHC Medicare Advantage |
$2.15
|
| Rate for Payer: UHCCP Medicaid |
$1.51
|
| Rate for Payer: VA VA |
$2.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.44
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$249.12
|
|
|
Service Code
|
NDC 00832601800
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.92 |
| Max. Negotiated Rate |
$224.21 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Aetna Medicare |
$64.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$77.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$77.85
|
| Rate for Payer: BCBS Complete |
$46.11
|
| Rate for Payer: BCBS MAPPO |
$62.28
|
| Rate for Payer: BCBS Trust/PPO |
$204.80
|
| Rate for Payer: BCN Commercial |
$204.80
|
| Rate for Payer: BCN Medicare Advantage |
$62.28
|
| Rate for Payer: Cash Price |
$199.30
|
| Rate for Payer: Cofinity Commercial |
$214.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.28
|
| Rate for Payer: Healthscope Commercial |
$224.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.84
|
| Rate for Payer: Mclaren Medicaid |
$43.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$65.39
|
| Rate for Payer: Meridian Medicaid |
$46.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.62
|
| Rate for Payer: Molina Medicare/Medicaid |
$68.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.75
|
| Rate for Payer: Nomi Health Commercial |
$204.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$186.84
|
| Rate for Payer: PACE Senior Care Partners |
$59.17
|
| Rate for Payer: PACE SWMI |
$62.28
|
| Rate for Payer: PHP Commercial |
$211.75
|
| Rate for Payer: PHP Medicare Advantage |
$62.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$43.92
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$216.73
|
| Rate for Payer: Priority Health Medicare |
$62.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$173.39
|
| Rate for Payer: Railroad Medicare Medicare |
$62.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$219.23
|
| Rate for Payer: UHC Core |
$208.02
|
| Rate for Payer: UHC Exchange |
$62.28
|
| Rate for Payer: UHC Medicaid |
$43.92
|
| Rate for Payer: UHC Medicare Advantage |
$62.28
|
| Rate for Payer: UHCCP Medicaid |
$43.92
|
| Rate for Payer: VA VA |
$62.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.84
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$1,307.95
|
|
|
Service Code
|
NDC 00832030100
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$910.33 |
| Max. Negotiated Rate |
$1,177.15 |
| Rate for Payer: Aetna Commercial |
$1,111.76
|
| Rate for Payer: BCBS Trust/PPO |
$1,080.24
|
| Rate for Payer: BCN Commercial |
$1,080.24
|
| 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 |
$1,177.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$980.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,111.76
|
| Rate for Payer: Nomi Health Commercial |
$1,072.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$980.96
|
| Rate for Payer: PHP Commercial |
$1,111.76
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,137.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$910.33
|
| 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
|
$249.12
|
|
|
Service Code
|
NDC 00832601800
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.39 |
| Max. Negotiated Rate |
$224.21 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: BCBS Trust/PPO |
$205.75
|
| Rate for Payer: BCN Commercial |
$205.75
|
| Rate for Payer: Cash Price |
$199.30
|
| Rate for Payer: Cofinity Commercial |
$214.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.30
|
| Rate for Payer: Healthscope Commercial |
$224.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$211.75
|
| Rate for Payer: Nomi Health Commercial |
$204.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$186.84
|
| Rate for Payer: PHP Commercial |
$211.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$216.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$173.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$219.23
|
| Rate for Payer: UHC Core |
$208.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.84
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$1,276.87
|
|
|
Service Code
|
NDC 00904713061
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$888.70 |
| Max. Negotiated Rate |
$1,149.18 |
| Rate for Payer: Aetna Commercial |
$1,085.34
|
| Rate for Payer: BCBS Trust/PPO |
$1,054.57
|
| Rate for Payer: BCN Commercial |
$1,054.57
|
| Rate for Payer: Cash Price |
$1,021.50
|
| Rate for Payer: Cofinity Commercial |
$1,098.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,021.50
|
| Rate for Payer: Healthscope Commercial |
$1,149.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$957.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,085.34
|
| Rate for Payer: Nomi Health Commercial |
$1,047.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$957.65
|
| Rate for Payer: PHP Commercial |
$1,085.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,110.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$888.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,123.65
|
| Rate for Payer: UHC Core |
$1,066.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$957.65
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$8.59
|
|
|
Service Code
|
NDC 50268016311
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.98 |
| Max. Negotiated Rate |
$7.73 |
| Rate for Payer: Aetna Commercial |
$7.30
|
| Rate for Payer: BCBS Trust/PPO |
$7.09
|
| Rate for Payer: BCN Commercial |
$7.09
|
| Rate for Payer: Cash Price |
$6.87
|
| Rate for Payer: Cofinity Commercial |
$7.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.87
|
| Rate for Payer: Healthscope Commercial |
$7.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.30
|
| Rate for Payer: Nomi Health Commercial |
$7.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.44
|
| Rate for Payer: PHP Commercial |
$7.30
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$7.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.56
|
| Rate for Payer: UHC Core |
$7.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.44
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$429.20
|
|
|
Service Code
|
NDC 50268016315
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$298.72 |
| Max. Negotiated Rate |
$386.28 |
| Rate for Payer: Aetna Commercial |
$364.82
|
| Rate for Payer: BCBS Trust/PPO |
$354.48
|
| Rate for Payer: BCN Commercial |
$354.48
|
| Rate for Payer: Cash Price |
$343.36
|
| Rate for Payer: Cofinity Commercial |
$369.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.36
|
| Rate for Payer: Healthscope Commercial |
$386.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.82
|
| Rate for Payer: Nomi Health Commercial |
$351.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$321.90
|
| Rate for Payer: PHP Commercial |
$364.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$373.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$298.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$377.70
|
| Rate for Payer: UHC Core |
$358.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.90
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$17.65
|
|
|
Service Code
|
NDC 00832030189
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.28 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna Commercial |
$15.00
|
| Rate for Payer: BCBS Trust/PPO |
$14.58
|
| Rate for Payer: BCN Commercial |
$14.58
|
| 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 Commercial |
$15.00
|
| Rate for Payer: Nomi Health Commercial |
$14.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.24
|
| Rate for Payer: PHP Commercial |
$15.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$15.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.28
|
| 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 25 MG TABLET
|
Facility
|
IP
|
$1,764.16
|
|
|
Service Code
|
NDC 00832030101
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,227.86 |
| Max. Negotiated Rate |
$1,587.74 |
| Rate for Payer: Aetna Commercial |
$1,499.54
|
| Rate for Payer: BCBS Trust/PPO |
$1,457.02
|
| Rate for Payer: BCN Commercial |
$1,457.02
|
| 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 Commercial |
$1,499.54
|
| Rate for Payer: Nomi Health Commercial |
$1,446.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,323.12
|
| Rate for Payer: PHP Commercial |
$1,499.54
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,534.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,227.86
|
| 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
|
OP
|
$1,276.87
|
|
|
Service Code
|
NDC 00904713061
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.11 |
| Max. Negotiated Rate |
$1,149.18 |
| Rate for Payer: Aetna Commercial |
$1,085.34
|
| Rate for Payer: Aetna Medicare |
$331.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$399.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$399.02
|
| Rate for Payer: BCBS Complete |
$236.35
|
| Rate for Payer: BCBS MAPPO |
$319.22
|
| Rate for Payer: BCBS Trust/PPO |
$1,049.71
|
| Rate for Payer: BCN Commercial |
$1,049.71
|
| Rate for Payer: BCN Medicare Advantage |
$319.22
|
| Rate for Payer: Cash Price |
$1,021.50
|
| Rate for Payer: Cofinity Commercial |
$1,098.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,021.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$319.22
|
| Rate for Payer: Healthscope Commercial |
$1,149.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$957.65
|
| Rate for Payer: Mclaren Medicaid |
$225.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$335.18
|
| Rate for Payer: Meridian Medicaid |
$236.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$367.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$351.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,085.34
|
| Rate for Payer: Nomi Health Commercial |
$1,047.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$957.65
|
| Rate for Payer: PACE Senior Care Partners |
$303.26
|
| Rate for Payer: PACE SWMI |
$319.22
|
| Rate for Payer: PHP Commercial |
$1,085.34
|
| Rate for Payer: PHP Medicare Advantage |
$319.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$225.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$1,110.88
|
| Rate for Payer: Priority Health Medicare |
$322.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$888.70
|
| Rate for Payer: Railroad Medicare Medicare |
$319.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,123.65
|
| Rate for Payer: UHC Core |
$1,066.19
|
| Rate for Payer: UHC Exchange |
$319.22
|
| Rate for Payer: UHC Medicaid |
$225.11
|
| Rate for Payer: UHC Medicare Advantage |
$319.22
|
| Rate for Payer: UHCCP Medicaid |
$225.11
|
| Rate for Payer: VA VA |
$319.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$957.65
|
|
|
CHLORPROMAZINE (BULK) 100 % POWDER
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
NDC 38779042304
|
| Hospital Charge Code |
12309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.34 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna Commercial |
$183.60
|
| Rate for Payer: BCBS Trust/PPO |
$178.39
|
| Rate for Payer: BCN Commercial |
$178.39
|
| Rate for Payer: Cash Price |
$172.80
|
| Rate for Payer: Cofinity Commercial |
$185.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.80
|
| Rate for Payer: Healthscope Commercial |
$194.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$183.60
|
| Rate for Payer: Nomi Health Commercial |
$177.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.00
|
| Rate for Payer: PHP Commercial |
$183.60
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$187.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$150.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$190.08
|
| Rate for Payer: UHC Core |
$180.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.00
|
|
|
CHLORPROMAZINE (BULK) 100 % POWDER
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
NDC 38779042304
|
| Hospital Charge Code |
12309
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.08 |
| Max. Negotiated Rate |
$194.40 |
| Rate for Payer: Aetna Commercial |
$183.60
|
| Rate for Payer: Aetna Medicare |
$56.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$67.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$67.50
|
| Rate for Payer: BCBS Complete |
$39.98
|
| Rate for Payer: BCBS MAPPO |
$54.00
|
| Rate for Payer: BCBS Trust/PPO |
$177.57
|
| Rate for Payer: BCN Commercial |
$177.57
|
| Rate for Payer: BCN Medicare Advantage |
$54.00
|
| Rate for Payer: Cash Price |
$172.80
|
| Rate for Payer: Cofinity Commercial |
$185.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$54.00
|
| Rate for Payer: Healthscope Commercial |
$194.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.00
|
| Rate for Payer: Mclaren Medicaid |
$38.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$56.70
|
| Rate for Payer: Meridian Medicaid |
$39.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$59.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$183.60
|
| Rate for Payer: Nomi Health Commercial |
$177.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.00
|
| Rate for Payer: PACE Senior Care Partners |
$51.30
|
| Rate for Payer: PACE SWMI |
$54.00
|
| Rate for Payer: PHP Commercial |
$183.60
|
| Rate for Payer: PHP Medicare Advantage |
$54.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$38.08
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$187.92
|
| Rate for Payer: Priority Health Medicare |
$54.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$150.34
|
| Rate for Payer: Railroad Medicare Medicare |
$54.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$190.08
|
| Rate for Payer: UHC Core |
$180.36
|
| Rate for Payer: UHC Exchange |
$54.00
|
| Rate for Payer: UHC Medicaid |
$38.08
|
| Rate for Payer: UHC Medicare Advantage |
$54.00
|
| Rate for Payer: UHCCP Medicaid |
$38.08
|
| Rate for Payer: VA VA |
$54.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.00
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
OP
|
$341.05
|
|
|
Service Code
|
NDC 43598071901
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.13 |
| Max. Negotiated Rate |
$306.94 |
| Rate for Payer: Aetna Commercial |
$289.89
|
| Rate for Payer: Aetna Medicare |
$88.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$106.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$106.58
|
| Rate for Payer: BCBS Complete |
$63.13
|
| Rate for Payer: BCBS MAPPO |
$85.26
|
| Rate for Payer: BCBS Trust/PPO |
$280.38
|
| Rate for Payer: BCN Commercial |
$280.38
|
| Rate for Payer: BCN Medicare Advantage |
$85.26
|
| Rate for Payer: Cash Price |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$293.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$85.26
|
| Rate for Payer: Healthscope Commercial |
$306.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.79
|
| Rate for Payer: Mclaren Medicaid |
$60.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$89.53
|
| Rate for Payer: Meridian Medicaid |
$63.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$98.05
|
| Rate for Payer: Molina Medicare/Medicaid |
$93.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.89
|
| Rate for Payer: Nomi Health Commercial |
$279.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$255.79
|
| Rate for Payer: PACE Senior Care Partners |
$81.00
|
| Rate for Payer: PACE SWMI |
$85.26
|
| Rate for Payer: PHP Commercial |
$289.89
|
| Rate for Payer: PHP Medicare Advantage |
$85.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$60.13
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$296.71
|
| Rate for Payer: Priority Health Medicare |
$86.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$237.37
|
| Rate for Payer: Railroad Medicare Medicare |
$85.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$300.12
|
| Rate for Payer: UHC Core |
$284.78
|
| Rate for Payer: UHC Exchange |
$85.26
|
| Rate for Payer: UHC Medicaid |
$60.13
|
| Rate for Payer: UHC Medicare Advantage |
$85.26
|
| Rate for Payer: UHCCP Medicaid |
$60.13
|
| Rate for Payer: VA VA |
$85.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.79
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
IP
|
$341.05
|
|
|
Service Code
|
NDC 43598071901
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$237.37 |
| Max. Negotiated Rate |
$306.94 |
| Rate for Payer: Aetna Commercial |
$289.89
|
| Rate for Payer: BCBS Trust/PPO |
$281.67
|
| Rate for Payer: BCN Commercial |
$281.67
|
| Rate for Payer: Cash Price |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$293.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.84
|
| Rate for Payer: Healthscope Commercial |
$306.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.89
|
| Rate for Payer: Nomi Health Commercial |
$279.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$255.79
|
| Rate for Payer: PHP Commercial |
$289.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$296.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$237.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$300.12
|
| Rate for Payer: UHC Core |
$284.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.79
|
|
