|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$346.75
|
|
|
Service Code
|
NDC 68084015401
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.57 |
| Max. Negotiated Rate |
$312.07 |
| Rate for Payer: Aetna American Axle |
$225.39
|
| Rate for Payer: Aetna Commercial |
$294.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$225.39
|
| Rate for Payer: Cash Price |
$277.40
|
| Rate for Payer: Cofinity Commercial |
$242.72
|
| Rate for Payer: Cofinity Commercial |
$298.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$242.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$277.40
|
| Rate for Payer: Healthscope Commercial |
$312.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$242.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$260.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$294.74
|
| Rate for Payer: PHP Commercial |
$294.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.39
|
| Rate for Payer: Priority Health SBD |
$218.45
|
| Rate for Payer: UMR Bronson Commercial |
$152.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$260.06
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$152.75
|
|
|
Service Code
|
NDC 68382004001
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.52 |
| Max. Negotiated Rate |
$137.47 |
| Rate for Payer: Aetna American Axle |
$99.29
|
| Rate for Payer: Aetna Commercial |
$129.84
|
| Rate for Payer: Aetna Medicare |
$76.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.29
|
| Rate for Payer: BCBS Complete |
$61.10
|
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Cofinity Commercial |
$106.92
|
| Rate for Payer: Cofinity Commercial |
$131.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$106.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.20
|
| Rate for Payer: Healthscope Commercial |
$137.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$106.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.84
|
| Rate for Payer: PHP Commercial |
$129.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.29
|
| Rate for Payer: Priority Health SBD |
$96.23
|
| Rate for Payer: UMR Bronson Commercial |
$56.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.56
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$397.10
|
|
|
Service Code
|
NDC 60687066001
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.93 |
| Max. Negotiated Rate |
$357.39 |
| Rate for Payer: Aetna American Axle |
$258.12
|
| Rate for Payer: Aetna Commercial |
$337.54
|
| Rate for Payer: Aetna Medicare |
$198.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.12
|
| Rate for Payer: BCBS Complete |
$158.84
|
| Rate for Payer: Cash Price |
$317.68
|
| Rate for Payer: Cofinity Commercial |
$277.97
|
| Rate for Payer: Cofinity Commercial |
$341.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$317.68
|
| Rate for Payer: Healthscope Commercial |
$357.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$337.54
|
| Rate for Payer: PHP Commercial |
$337.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.12
|
| Rate for Payer: Priority Health SBD |
$250.17
|
| Rate for Payer: UMR Bronson Commercial |
$146.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.82
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$397.10
|
|
|
Service Code
|
NDC 60687066001
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.72 |
| Max. Negotiated Rate |
$357.39 |
| Rate for Payer: Aetna American Axle |
$258.12
|
| Rate for Payer: Aetna Commercial |
$337.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.12
|
| Rate for Payer: Cash Price |
$317.68
|
| Rate for Payer: Cofinity Commercial |
$277.97
|
| Rate for Payer: Cofinity Commercial |
$341.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$317.68
|
| Rate for Payer: Healthscope Commercial |
$357.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$337.54
|
| Rate for Payer: PHP Commercial |
$337.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.12
|
| Rate for Payer: Priority Health SBD |
$250.17
|
| Rate for Payer: UMR Bronson Commercial |
$174.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.82
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$346.75
|
|
|
Service Code
|
NDC 68084015401
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.30 |
| Max. Negotiated Rate |
$312.07 |
| Rate for Payer: Aetna American Axle |
$225.39
|
| Rate for Payer: Aetna Commercial |
$294.74
|
| Rate for Payer: Aetna Medicare |
$173.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$225.39
|
| Rate for Payer: BCBS Complete |
$138.70
|
| Rate for Payer: Cash Price |
$277.40
|
| Rate for Payer: Cofinity Commercial |
$242.72
|
| Rate for Payer: Cofinity Commercial |
$298.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$242.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$277.40
|
| Rate for Payer: Healthscope Commercial |
$312.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$242.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$260.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$294.74
|
| Rate for Payer: PHP Commercial |
$294.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.39
|
| Rate for Payer: Priority Health SBD |
$218.45
|
| Rate for Payer: UMR Bronson Commercial |
$128.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$260.06
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 65162074510
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna American Axle |
$113.03
|
| Rate for Payer: Aetna Commercial |
$147.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.03
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$121.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.12
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$121.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$130.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$147.81
|
| Rate for Payer: PHP Commercial |
$147.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$113.03
|
| Rate for Payer: Priority Health SBD |
$109.56
|
| Rate for Payer: UMR Bronson Commercial |
$76.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.43
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$3.98
|
|
|
Service Code
|
NDC 60687066011
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$3.58 |
| Rate for Payer: Aetna American Axle |
$2.59
|
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.59
|
| Rate for Payer: Cash Price |
$3.18
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Commercial |
$3.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.18
|
| Rate for Payer: Healthscope Commercial |
$3.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.38
|
| Rate for Payer: PHP Commercial |
$3.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.59
|
| Rate for Payer: Priority Health SBD |
$2.51
|
| Rate for Payer: UMR Bronson Commercial |
$1.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.98
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
OP
|
$150.40
|
|
|
Service Code
|
NDC 53746074501
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.65 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna American Axle |
$97.76
|
| Rate for Payer: Aetna Commercial |
$127.84
|
| Rate for Payer: Aetna Medicare |
$75.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.76
|
| Rate for Payer: BCBS Complete |
$60.16
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$129.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$105.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$105.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.84
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.76
|
| Rate for Payer: Priority Health SBD |
$94.75
|
| Rate for Payer: UMR Bronson Commercial |
$55.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.80
|
|
|
PROMETHAZINE 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$22.23
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$20.01 |
| Rate for Payer: Aetna American Axle |
$14.45
|
| Rate for Payer: Aetna American Axle |
$14.33
|
| Rate for Payer: Aetna American Axle |
$10.95
|
| Rate for Payer: Aetna American Axle |
$14.46
|
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$18.74
|
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.45
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$11.79
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Commercial |
$15.57
|
| Rate for Payer: Cofinity Commercial |
$15.56
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$14.32
|
| Rate for Payer: PHP Commercial |
$18.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.95
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: Priority Health SBD |
$10.62
|
| Rate for Payer: Priority Health SBD |
$13.89
|
| Rate for Payer: Priority Health SBD |
$14.00
|
| Rate for Payer: UMR Bronson Commercial |
$9.78
|
| Rate for Payer: UMR Bronson Commercial |
$9.79
|
| Rate for Payer: UMR Bronson Commercial |
$9.70
|
| Rate for Payer: UMR Bronson Commercial |
$7.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.67
|
|
|
PROMETHAZINE 25 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$22.05
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$19.84 |
| Rate for Payer: Aetna American Axle |
$14.33
|
| Rate for Payer: Aetna American Axle |
$14.46
|
| Rate for Payer: Aetna American Axle |
$10.95
|
| Rate for Payer: Aetna American Axle |
$14.45
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$18.74
|
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Aetna Medicare |
$8.43
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Aetna Medicare |
$11.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.95
|
| Rate for Payer: BCBS Complete |
$6.74
|
| Rate for Payer: BCBS Complete |
$8.90
|
| Rate for Payer: BCBS Complete |
$8.89
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Commercial |
$11.79
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$15.56
|
| Rate for Payer: Cofinity Commercial |
$15.57
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$18.74
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.95
|
| Rate for Payer: Priority Health SBD |
$14.00
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: Priority Health SBD |
$13.89
|
| Rate for Payer: Priority Health SBD |
$10.62
|
| Rate for Payer: UMR Bronson Commercial |
$8.23
|
| Rate for Payer: UMR Bronson Commercial |
$8.16
|
| Rate for Payer: UMR Bronson Commercial |
$8.23
|
| Rate for Payer: UMR Bronson Commercial |
$6.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.54
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$159.00
|
|
|
Service Code
|
NDC 00713052612
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.96 |
| Max. Negotiated Rate |
$143.10 |
| Rate for Payer: Aetna American Axle |
$103.35
|
| Rate for Payer: Aetna Commercial |
$135.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.35
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cofinity Commercial |
$111.30
|
| Rate for Payer: Cofinity Commercial |
$136.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.20
|
| Rate for Payer: Healthscope Commercial |
$143.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.15
|
| Rate for Payer: PHP Commercial |
$135.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.35
|
| Rate for Payer: Priority Health SBD |
$100.17
|
| Rate for Payer: UMR Bronson Commercial |
$69.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.25
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$159.00
|
|
|
Service Code
|
NDC 00713052612
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.83 |
| Max. Negotiated Rate |
$143.10 |
| Rate for Payer: Aetna American Axle |
$103.35
|
| Rate for Payer: Aetna Commercial |
$135.15
|
| Rate for Payer: Aetna Medicare |
$79.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.35
|
| Rate for Payer: BCBS Complete |
$63.60
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cofinity Commercial |
$111.30
|
| Rate for Payer: Cofinity Commercial |
$136.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$111.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.20
|
| Rate for Payer: Healthscope Commercial |
$143.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$135.15
|
| Rate for Payer: PHP Commercial |
$135.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.35
|
| Rate for Payer: Priority Health SBD |
$100.17
|
| Rate for Payer: UMR Bronson Commercial |
$58.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.25
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$89.30
|
|
|
Service Code
|
NDC 53746052101
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.04 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna American Axle |
$58.05
|
| Rate for Payer: Aetna Commercial |
$75.91
|
| Rate for Payer: Aetna Medicare |
$44.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.05
|
| Rate for Payer: BCBS Complete |
$35.72
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.91
|
| Rate for Payer: PHP Commercial |
$75.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.05
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UMR Bronson Commercial |
$33.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.97
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$251.45
|
|
|
Service Code
|
NDC 00904646161
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.04 |
| Max. Negotiated Rate |
$226.31 |
| Rate for Payer: Aetna American Axle |
$163.44
|
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna Medicare |
$125.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: BCBS Complete |
$100.58
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.01
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$176.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: Priority Health SBD |
$158.41
|
| Rate for Payer: UMR Bronson Commercial |
$93.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$89.30
|
|
|
Service Code
|
NDC 53746052101
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.29 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna American Axle |
$58.05
|
| Rate for Payer: Aetna Commercial |
$75.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.05
|
| Rate for Payer: Cash Price |
$71.44
|
| Rate for Payer: Cofinity Commercial |
$62.51
|
| Rate for Payer: Cofinity Commercial |
$76.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.44
|
| Rate for Payer: Healthscope Commercial |
$80.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.91
|
| Rate for Payer: PHP Commercial |
$75.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.05
|
| Rate for Payer: Priority Health SBD |
$56.26
|
| Rate for Payer: UMR Bronson Commercial |
$39.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.97
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$192.85
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.85 |
| Max. Negotiated Rate |
$173.56 |
| Rate for Payer: Aetna American Axle |
$125.35
|
| Rate for Payer: Aetna Commercial |
$163.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.35
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$135.00
|
| Rate for Payer: Cofinity Commercial |
$165.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$173.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$135.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$144.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: PHP Commercial |
$163.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health SBD |
$121.50
|
| Rate for Payer: UMR Bronson Commercial |
$84.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$144.64
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$192.85
|
|
|
Service Code
|
NDC 68084015501
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.35 |
| Max. Negotiated Rate |
$173.56 |
| Rate for Payer: Aetna American Axle |
$125.35
|
| Rate for Payer: Aetna Commercial |
$163.92
|
| Rate for Payer: Aetna Medicare |
$96.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.35
|
| Rate for Payer: BCBS Complete |
$77.14
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$135.00
|
| Rate for Payer: Cofinity Commercial |
$165.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$173.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$135.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$144.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: PHP Commercial |
$163.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health SBD |
$121.50
|
| Rate for Payer: UMR Bronson Commercial |
$71.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$144.64
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
NDC 68084015511
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna American Axle |
$1.25
|
| Rate for Payer: Aetna Commercial |
$1.64
|
| Rate for Payer: Aetna Medicare |
$0.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.25
|
| Rate for Payer: BCBS Complete |
$0.77
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Cofinity Commercial |
$1.35
|
| Rate for Payer: Cofinity Commercial |
$1.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.54
|
| Rate for Payer: Healthscope Commercial |
$1.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.64
|
| Rate for Payer: PHP Commercial |
$1.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.25
|
| Rate for Payer: Priority Health SBD |
$1.22
|
| Rate for Payer: UMR Bronson Commercial |
$0.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.45
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 00904646161
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.64 |
| Max. Negotiated Rate |
$226.31 |
| Rate for Payer: Aetna American Axle |
$163.44
|
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.01
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$176.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$163.44
|
| Rate for Payer: Priority Health SBD |
$158.41
|
| Rate for Payer: UMR Bronson Commercial |
$110.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
NDC 68084015511
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna American Axle |
$1.25
|
| Rate for Payer: Aetna Commercial |
$1.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.25
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Cofinity Commercial |
$1.35
|
| Rate for Payer: Cofinity Commercial |
$1.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.54
|
| Rate for Payer: Healthscope Commercial |
$1.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.64
|
| Rate for Payer: PHP Commercial |
$1.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.25
|
| Rate for Payer: Priority Health SBD |
$1.22
|
| Rate for Payer: UMR Bronson Commercial |
$0.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.45
|
|
|
PROMETHAZINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$24.15
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.94 |
| Max. Negotiated Rate |
$21.73 |
| Rate for Payer: Aetna American Axle |
$15.70
|
| Rate for Payer: Aetna Commercial |
$20.53
|
| Rate for Payer: Aetna Medicare |
$12.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.70
|
| Rate for Payer: BCBS Complete |
$9.66
|
| Rate for Payer: Cash Price |
$19.32
|
| Rate for Payer: Cofinity Commercial |
$16.91
|
| Rate for Payer: Cofinity Commercial |
$20.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.32
|
| Rate for Payer: Healthscope Commercial |
$21.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.53
|
| Rate for Payer: PHP Commercial |
$20.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.70
|
| Rate for Payer: Priority Health SBD |
$15.21
|
| Rate for Payer: UMR Bronson Commercial |
$8.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.11
|
|
|
PROMETHAZINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$24.15
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$21.73 |
| Rate for Payer: Aetna American Axle |
$15.70
|
| Rate for Payer: Aetna Commercial |
$20.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.70
|
| Rate for Payer: Cash Price |
$19.32
|
| Rate for Payer: Cofinity Commercial |
$16.91
|
| Rate for Payer: Cofinity Commercial |
$20.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.32
|
| Rate for Payer: Healthscope Commercial |
$21.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.53
|
| Rate for Payer: PHP Commercial |
$20.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.70
|
| Rate for Payer: Priority Health SBD |
$15.21
|
| Rate for Payer: UMR Bronson Commercial |
$10.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.11
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY
|
Facility
|
OP
|
$1,107.61
|
|
|
Service Code
|
NDC 00713013212
|
| Hospital Charge Code |
6624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$409.82 |
| Max. Negotiated Rate |
$996.85 |
| Rate for Payer: Aetna American Axle |
$719.95
|
| Rate for Payer: Aetna Commercial |
$941.47
|
| Rate for Payer: Aetna Medicare |
$553.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$719.95
|
| Rate for Payer: BCBS Complete |
$443.04
|
| Rate for Payer: Cash Price |
$886.09
|
| Rate for Payer: Cofinity Commercial |
$775.33
|
| Rate for Payer: Cofinity Commercial |
$952.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$775.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$886.09
|
| Rate for Payer: Healthscope Commercial |
$996.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$775.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$830.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$941.47
|
| Rate for Payer: PHP Commercial |
$941.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$719.95
|
| Rate for Payer: Priority Health SBD |
$697.79
|
| Rate for Payer: UMR Bronson Commercial |
$409.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$830.71
|
|
|
PROMETHAZINE 50 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$1,107.61
|
|
|
Service Code
|
NDC 00713013212
|
| Hospital Charge Code |
6624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$487.35 |
| Max. Negotiated Rate |
$996.85 |
| Rate for Payer: Aetna American Axle |
$719.95
|
| Rate for Payer: Aetna Commercial |
$941.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$719.95
|
| Rate for Payer: Cash Price |
$886.09
|
| Rate for Payer: Cofinity Commercial |
$775.33
|
| Rate for Payer: Cofinity Commercial |
$952.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$775.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$886.09
|
| Rate for Payer: Healthscope Commercial |
$996.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$775.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$830.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$941.47
|
| Rate for Payer: PHP Commercial |
$941.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$719.95
|
| Rate for Payer: Priority Health SBD |
$697.79
|
| Rate for Payer: UMR Bronson Commercial |
$487.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$830.71
|
|
|
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP
|
Facility
|
IP
|
$389.05
|
|
|
Service Code
|
NDC 60432060816
|
| Hospital Charge Code |
6620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.18 |
| Max. Negotiated Rate |
$350.14 |
| Rate for Payer: Aetna American Axle |
$252.88
|
| Rate for Payer: Aetna Commercial |
$330.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.88
|
| Rate for Payer: Cash Price |
$311.24
|
| Rate for Payer: Cofinity Commercial |
$272.33
|
| Rate for Payer: Cofinity Commercial |
$334.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$272.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.24
|
| Rate for Payer: Healthscope Commercial |
$350.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$272.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$291.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$330.69
|
| Rate for Payer: PHP Commercial |
$330.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.88
|
| Rate for Payer: Priority Health SBD |
$245.10
|
| Rate for Payer: UMR Bronson Commercial |
$171.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$291.79
|
|
