|
CHLORPHENIRAMINE 4 MG TABLET
|
Facility
|
OP
|
$28.20
|
|
|
Service Code
|
NDC 00536100601
|
| Hospital Charge Code |
1645
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$25.38 |
| Rate for Payer: Aetna American Axle |
$18.33
|
| Rate for Payer: Aetna Commercial |
$23.97
|
| Rate for Payer: Aetna Medicare |
$14.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.33
|
| Rate for Payer: BCBS Complete |
$11.28
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cofinity Commercial |
$19.74
|
| Rate for Payer: Cofinity Commercial |
$24.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.56
|
| Rate for Payer: Healthscope Commercial |
$25.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.97
|
| Rate for Payer: PHP Commercial |
$23.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.33
|
| Rate for Payer: Priority Health SBD |
$17.77
|
| Rate for Payer: UMR Bronson Commercial |
$10.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.15
|
|
|
CHLORPHENIRAMINE 4 MG TABLET
|
Facility
|
IP
|
$28.20
|
|
|
Service Code
|
NDC 00536100601
|
| Hospital Charge Code |
1645
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.41 |
| Max. Negotiated Rate |
$25.38 |
| Rate for Payer: Aetna American Axle |
$18.33
|
| Rate for Payer: Aetna Commercial |
$23.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.33
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cofinity Commercial |
$19.74
|
| Rate for Payer: Cofinity Commercial |
$24.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.56
|
| Rate for Payer: Healthscope Commercial |
$25.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.97
|
| Rate for Payer: PHP Commercial |
$23.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.33
|
| Rate for Payer: Priority Health SBD |
$17.77
|
| Rate for Payer: UMR Bronson Commercial |
$12.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.15
|
|
|
CHLORPHENIRAMINE 4 MG TABLET
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 00904001261
|
| Hospital Charge Code |
1645
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.01 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Cofinity Commercial |
$97.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.12
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UMR Bronson Commercial |
$61.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
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 |
$19.21 |
| Max. Negotiated Rate |
$39.28 |
| Rate for Payer: Aetna American Axle |
$28.37
|
| Rate for Payer: Aetna Commercial |
$37.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.37
|
| Rate for Payer: Cash Price |
$34.92
|
| Rate for Payer: Cofinity Commercial |
$30.55
|
| Rate for Payer: Cofinity Commercial |
$37.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.92
|
| Rate for Payer: Healthscope Commercial |
$39.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.10
|
| Rate for Payer: PHP Commercial |
$37.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.37
|
| Rate for Payer: Priority Health SBD |
$27.50
|
| Rate for Payer: UMR Bronson Commercial |
$19.21
|
| 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
|
$43.65
|
|
|
Service Code
|
NDC 09900000025
|
| Hospital Charge Code |
9582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$39.28 |
| Rate for Payer: Aetna American Axle |
$28.37
|
| Rate for Payer: Aetna Commercial |
$37.10
|
| Rate for Payer: Aetna Medicare |
$21.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.37
|
| Rate for Payer: BCBS Complete |
$17.46
|
| Rate for Payer: Cash Price |
$34.92
|
| Rate for Payer: Cofinity Commercial |
$30.55
|
| Rate for Payer: Cofinity Commercial |
$37.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.92
|
| Rate for Payer: Healthscope Commercial |
$39.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.10
|
| Rate for Payer: PHP Commercial |
$37.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.37
|
| Rate for Payer: Priority Health SBD |
$27.50
|
| Rate for Payer: UMR Bronson Commercial |
$16.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.74
|
|
|
CHLORPROMAZINE 100 MG TABLET
|
Facility
|
IP
|
$637.92
|
|
|
Service Code
|
NDC 00832602000
|
| Hospital Charge Code |
1654
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$280.68 |
| Max. Negotiated Rate |
$574.13 |
| Rate for Payer: Aetna American Axle |
$414.65
|
| Rate for Payer: Aetna Commercial |
$542.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$414.65
|
| Rate for Payer: Cash Price |
$510.34
|
| Rate for Payer: Cofinity Commercial |
$446.54
|
| Rate for Payer: Cofinity Commercial |
$548.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$446.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$510.34
|
| Rate for Payer: Healthscope Commercial |
$574.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$446.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$478.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$542.23
|
| Rate for Payer: PHP Commercial |
$542.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$414.65
|
| Rate for Payer: Priority Health SBD |
$401.89
|
| Rate for Payer: UMR Bronson Commercial |
$280.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$478.44
|
|
|
CHLORPROMAZINE 100 MG TABLET
|
Facility
|
OP
|
$637.92
|
|
|
Service Code
|
NDC 00832602000
|
| Hospital Charge Code |
1654
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$236.03 |
| Max. Negotiated Rate |
$574.13 |
| Rate for Payer: Aetna American Axle |
$414.65
|
| Rate for Payer: Aetna Commercial |
$542.23
|
| Rate for Payer: Aetna Medicare |
$318.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$414.65
|
| Rate for Payer: BCBS Complete |
$255.17
|
| Rate for Payer: Cash Price |
$510.34
|
| Rate for Payer: Cofinity Commercial |
$446.54
|
| Rate for Payer: Cofinity Commercial |
$548.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$446.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$510.34
|
| Rate for Payer: Healthscope Commercial |
$574.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$446.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$478.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$542.23
|
| Rate for Payer: PHP Commercial |
$542.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$414.65
|
| Rate for Payer: Priority Health SBD |
$401.89
|
| Rate for Payer: UMR Bronson Commercial |
$236.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$478.44
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
IP
|
$353.40
|
|
|
Service Code
|
NDC 00832601700
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.50 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna American Axle |
$229.71
|
| Rate for Payer: Aetna Commercial |
$300.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.71
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Commercial |
$247.38
|
| Rate for Payer: Cofinity Commercial |
$303.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$247.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$318.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$247.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$265.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.39
|
| Rate for Payer: PHP Commercial |
$300.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.71
|
| Rate for Payer: Priority Health SBD |
$222.64
|
| Rate for Payer: UMR Bronson Commercial |
$155.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$265.05
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
OP
|
$353.40
|
|
|
Service Code
|
NDC 00832601700
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.76 |
| Max. Negotiated Rate |
$318.06 |
| Rate for Payer: Aetna American Axle |
$229.71
|
| Rate for Payer: Aetna Commercial |
$300.39
|
| Rate for Payer: Aetna Medicare |
$176.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.71
|
| Rate for Payer: BCBS Complete |
$141.36
|
| Rate for Payer: Cash Price |
$282.72
|
| Rate for Payer: Cofinity Commercial |
$247.38
|
| Rate for Payer: Cofinity Commercial |
$303.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$247.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.72
|
| Rate for Payer: Healthscope Commercial |
$318.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$247.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$265.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.39
|
| Rate for Payer: PHP Commercial |
$300.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.71
|
| Rate for Payer: Priority Health SBD |
$222.64
|
| Rate for Payer: UMR Bronson Commercial |
$130.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$265.05
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
OP
|
$912.79
|
|
|
Service Code
|
NDC 00832030000
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$337.73 |
| Max. Negotiated Rate |
$821.51 |
| Rate for Payer: Aetna American Axle |
$593.31
|
| Rate for Payer: Aetna Commercial |
$775.87
|
| Rate for Payer: Aetna Medicare |
$456.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$593.31
|
| Rate for Payer: BCBS Complete |
$365.12
|
| Rate for Payer: Cash Price |
$730.23
|
| Rate for Payer: Cofinity Commercial |
$638.95
|
| Rate for Payer: Cofinity Commercial |
$785.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$638.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$730.23
|
| Rate for Payer: Healthscope Commercial |
$821.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$638.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$684.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$775.87
|
| Rate for Payer: PHP Commercial |
$775.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$593.31
|
| Rate for Payer: Priority Health SBD |
$575.06
|
| Rate for Payer: UMR Bronson Commercial |
$337.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$684.59
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
IP
|
$912.79
|
|
|
Service Code
|
NDC 00832030000
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$401.63 |
| Max. Negotiated Rate |
$821.51 |
| Rate for Payer: Aetna American Axle |
$593.31
|
| Rate for Payer: Aetna Commercial |
$775.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$593.31
|
| Rate for Payer: Cash Price |
$730.23
|
| Rate for Payer: Cofinity Commercial |
$638.95
|
| Rate for Payer: Cofinity Commercial |
$785.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$638.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$730.23
|
| Rate for Payer: Healthscope Commercial |
$821.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$638.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$684.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$775.87
|
| Rate for Payer: PHP Commercial |
$775.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$593.31
|
| Rate for Payer: Priority Health SBD |
$575.06
|
| Rate for Payer: UMR Bronson Commercial |
$401.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$684.59
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
IP
|
$1,152.55
|
|
|
Service Code
|
NDC 00904712961
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$507.12 |
| Max. Negotiated Rate |
$1,037.30 |
| Rate for Payer: Aetna American Axle |
$749.16
|
| Rate for Payer: Aetna Commercial |
$979.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$749.16
|
| Rate for Payer: Cash Price |
$922.04
|
| Rate for Payer: Cofinity Commercial |
$806.78
|
| Rate for Payer: Cofinity Commercial |
$991.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$806.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$922.04
|
| Rate for Payer: Healthscope Commercial |
$1,037.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$806.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$864.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$979.67
|
| Rate for Payer: PHP Commercial |
$979.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$749.16
|
| Rate for Payer: Priority Health SBD |
$726.11
|
| Rate for Payer: UMR Bronson Commercial |
$507.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$864.41
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
OP
|
$1,152.55
|
|
|
Service Code
|
NDC 00904712961
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$426.44 |
| Max. Negotiated Rate |
$1,037.30 |
| Rate for Payer: Aetna American Axle |
$749.16
|
| Rate for Payer: Aetna Commercial |
$979.67
|
| Rate for Payer: Aetna Medicare |
$576.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$749.16
|
| Rate for Payer: BCBS Complete |
$461.02
|
| Rate for Payer: Cash Price |
$922.04
|
| Rate for Payer: Cofinity Commercial |
$806.78
|
| Rate for Payer: Cofinity Commercial |
$991.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$806.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$922.04
|
| Rate for Payer: Healthscope Commercial |
$1,037.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$806.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$864.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$979.67
|
| Rate for Payer: PHP Commercial |
$979.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$749.16
|
| Rate for Payer: Priority Health SBD |
$726.11
|
| Rate for Payer: UMR Bronson Commercial |
$426.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$864.41
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$72.10
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.68 |
| Max. Negotiated Rate |
$64.89 |
| Rate for Payer: Aetna American Axle |
$46.87
|
| Rate for Payer: Aetna American Axle |
$61.13
|
| Rate for Payer: Aetna Commercial |
$61.28
|
| Rate for Payer: Aetna Commercial |
$79.93
|
| Rate for Payer: Aetna Medicare |
$36.05
|
| Rate for Payer: Aetna Medicare |
$47.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.13
|
| Rate for Payer: BCBS Complete |
$28.84
|
| Rate for Payer: BCBS Complete |
$37.62
|
| Rate for Payer: Cash Price |
$57.68
|
| Rate for Payer: Cash Price |
$75.23
|
| Rate for Payer: Cofinity Commercial |
$62.01
|
| Rate for Payer: Cofinity Commercial |
$50.47
|
| Rate for Payer: Cofinity Commercial |
$80.87
|
| Rate for Payer: Cofinity Commercial |
$65.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$50.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.68
|
| Rate for Payer: Healthscope Commercial |
$64.89
|
| Rate for Payer: Healthscope Commercial |
$84.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.28
|
| Rate for Payer: PHP Commercial |
$79.93
|
| Rate for Payer: PHP Commercial |
$61.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.13
|
| Rate for Payer: Priority Health SBD |
$59.25
|
| Rate for Payer: Priority Health SBD |
$45.42
|
| Rate for Payer: UMR Bronson Commercial |
$26.68
|
| Rate for Payer: UMR Bronson Commercial |
$34.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.53
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$94.04
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.38 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna American Axle |
$61.13
|
| Rate for Payer: Aetna Commercial |
$79.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.13
|
| Rate for Payer: Cash Price |
$75.23
|
| Rate for Payer: Cofinity Commercial |
$65.83
|
| Rate for Payer: Cofinity Commercial |
$80.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.23
|
| Rate for Payer: Healthscope Commercial |
$84.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.93
|
| Rate for Payer: PHP Commercial |
$79.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.13
|
| Rate for Payer: Priority Health SBD |
$59.25
|
| Rate for Payer: UMR Bronson Commercial |
$41.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.53
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$306.24
|
|
|
Service Code
|
NDC 00832601800
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.75 |
| Max. Negotiated Rate |
$275.62 |
| Rate for Payer: Aetna American Axle |
$199.06
|
| Rate for Payer: Aetna Commercial |
$260.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.06
|
| Rate for Payer: Cash Price |
$244.99
|
| Rate for Payer: Cofinity Commercial |
$214.37
|
| Rate for Payer: Cofinity Commercial |
$263.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$214.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.99
|
| Rate for Payer: Healthscope Commercial |
$275.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$214.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$229.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.30
|
| Rate for Payer: PHP Commercial |
$260.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.06
|
| Rate for Payer: Priority Health SBD |
$192.93
|
| Rate for Payer: UMR Bronson Commercial |
$134.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$229.68
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$1,307.95
|
|
|
Service Code
|
NDC 00832030100
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$483.94 |
| Max. Negotiated Rate |
$1,177.15 |
| Rate for Payer: Aetna American Axle |
$850.17
|
| Rate for Payer: Aetna Commercial |
$1,111.76
|
| Rate for Payer: Aetna Medicare |
$653.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$850.17
|
| Rate for Payer: BCBS Complete |
$523.18
|
| Rate for Payer: Cash Price |
$1,046.36
|
| Rate for Payer: Cofinity Commercial |
$1,124.84
|
| Rate for Payer: Cofinity Commercial |
$915.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$915.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,046.36
|
| Rate for Payer: Healthscope Commercial |
$1,177.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$915.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$980.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,111.76
|
| Rate for Payer: PHP Commercial |
$1,111.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$850.17
|
| Rate for Payer: Priority Health SBD |
$824.01
|
| Rate for Payer: UMR Bronson Commercial |
$483.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$980.96
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$306.24
|
|
|
Service Code
|
NDC 00832601800
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.31 |
| Max. Negotiated Rate |
$275.62 |
| Rate for Payer: Aetna American Axle |
$199.06
|
| Rate for Payer: Aetna Commercial |
$260.30
|
| Rate for Payer: Aetna Medicare |
$153.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$199.06
|
| Rate for Payer: BCBS Complete |
$122.50
|
| Rate for Payer: Cash Price |
$244.99
|
| Rate for Payer: Cofinity Commercial |
$214.37
|
| Rate for Payer: Cofinity Commercial |
$263.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$214.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$244.99
|
| Rate for Payer: Healthscope Commercial |
$275.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$214.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$229.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$260.30
|
| Rate for Payer: PHP Commercial |
$260.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.06
|
| Rate for Payer: Priority Health SBD |
$192.93
|
| Rate for Payer: UMR Bronson Commercial |
$113.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$229.68
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$380.64
|
|
|
Service Code
|
NDC 69238105601
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.48 |
| Max. Negotiated Rate |
$342.58 |
| Rate for Payer: Aetna American Axle |
$247.42
|
| Rate for Payer: Aetna Commercial |
$323.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$247.42
|
| Rate for Payer: Cash Price |
$304.51
|
| Rate for Payer: Cofinity Commercial |
$266.45
|
| Rate for Payer: Cofinity Commercial |
$327.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$266.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.51
|
| Rate for Payer: Healthscope Commercial |
$342.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$266.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$323.54
|
| Rate for Payer: PHP Commercial |
$323.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$247.42
|
| Rate for Payer: Priority Health SBD |
$239.80
|
| Rate for Payer: UMR Bronson Commercial |
$167.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.48
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$380.64
|
|
|
Service Code
|
NDC 69238105601
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.84 |
| Max. Negotiated Rate |
$342.58 |
| Rate for Payer: Aetna American Axle |
$247.42
|
| Rate for Payer: Aetna Commercial |
$323.54
|
| Rate for Payer: Aetna Medicare |
$190.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$247.42
|
| Rate for Payer: BCBS Complete |
$152.26
|
| Rate for Payer: Cash Price |
$304.51
|
| Rate for Payer: Cofinity Commercial |
$266.45
|
| Rate for Payer: Cofinity Commercial |
$327.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$266.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.51
|
| Rate for Payer: Healthscope Commercial |
$342.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$266.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$323.54
|
| Rate for Payer: PHP Commercial |
$323.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$247.42
|
| Rate for Payer: Priority Health SBD |
$239.80
|
| Rate for Payer: UMR Bronson Commercial |
$140.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.48
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$447.84
|
|
|
Service Code
|
NDC 70710113001
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.05 |
| Max. Negotiated Rate |
$403.06 |
| Rate for Payer: Aetna American Axle |
$291.10
|
| Rate for Payer: Aetna Commercial |
$380.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.10
|
| Rate for Payer: Cash Price |
$358.27
|
| Rate for Payer: Cofinity Commercial |
$313.49
|
| Rate for Payer: Cofinity Commercial |
$385.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$313.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$358.27
|
| Rate for Payer: Healthscope Commercial |
$403.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$313.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$335.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$380.66
|
| Rate for Payer: PHP Commercial |
$380.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.10
|
| Rate for Payer: Priority Health SBD |
$282.14
|
| Rate for Payer: UMR Bronson Commercial |
$197.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$335.88
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$1,307.95
|
|
|
Service Code
|
NDC 00832030100
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$575.50 |
| Max. Negotiated Rate |
$1,177.15 |
| Rate for Payer: Aetna American Axle |
$850.17
|
| Rate for Payer: Aetna Commercial |
$1,111.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$850.17
|
| Rate for Payer: Cash Price |
$1,046.36
|
| Rate for Payer: Cofinity Commercial |
$1,124.84
|
| Rate for Payer: Cofinity Commercial |
$915.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$915.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,046.36
|
| Rate for Payer: Healthscope Commercial |
$1,177.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$915.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$980.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,111.76
|
| Rate for Payer: PHP Commercial |
$1,111.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$850.17
|
| Rate for Payer: Priority Health SBD |
$824.01
|
| Rate for Payer: UMR Bronson Commercial |
$575.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$980.96
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$447.84
|
|
|
Service Code
|
NDC 70710113001
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.70 |
| Max. Negotiated Rate |
$403.06 |
| Rate for Payer: Aetna American Axle |
$291.10
|
| Rate for Payer: Aetna Commercial |
$380.66
|
| Rate for Payer: Aetna Medicare |
$223.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.10
|
| Rate for Payer: BCBS Complete |
$179.14
|
| Rate for Payer: Cash Price |
$358.27
|
| Rate for Payer: Cofinity Commercial |
$313.49
|
| Rate for Payer: Cofinity Commercial |
$385.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$313.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$358.27
|
| Rate for Payer: Healthscope Commercial |
$403.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$313.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$335.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$380.66
|
| Rate for Payer: PHP Commercial |
$380.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.10
|
| Rate for Payer: Priority Health SBD |
$282.14
|
| Rate for Payer: UMR Bronson Commercial |
$165.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$335.88
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
OP
|
$772.32
|
|
|
Service Code
|
NDC 00904690061
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.76 |
| Max. Negotiated Rate |
$695.09 |
| Rate for Payer: Aetna American Axle |
$502.01
|
| Rate for Payer: Aetna Commercial |
$656.47
|
| Rate for Payer: Aetna Medicare |
$386.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$502.01
|
| Rate for Payer: BCBS Complete |
$308.93
|
| Rate for Payer: Cash Price |
$617.86
|
| Rate for Payer: Cofinity Commercial |
$540.62
|
| Rate for Payer: Cofinity Commercial |
$664.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$540.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$617.86
|
| Rate for Payer: Healthscope Commercial |
$695.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$540.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$579.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$656.47
|
| Rate for Payer: PHP Commercial |
$656.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$502.01
|
| Rate for Payer: Priority Health SBD |
$486.56
|
| Rate for Payer: UMR Bronson Commercial |
$285.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$579.24
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
IP
|
$8.69
|
|
|
Service Code
|
NDC 51079005801
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$7.82 |
| Rate for Payer: Aetna American Axle |
$5.65
|
| Rate for Payer: Aetna Commercial |
$7.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.65
|
| Rate for Payer: Cash Price |
$6.95
|
| Rate for Payer: Cofinity Commercial |
$6.08
|
| Rate for Payer: Cofinity Commercial |
$7.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.95
|
| Rate for Payer: Healthscope Commercial |
$7.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.39
|
| Rate for Payer: PHP Commercial |
$7.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.65
|
| Rate for Payer: Priority Health SBD |
$5.47
|
| Rate for Payer: UMR Bronson Commercial |
$3.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.52
|
|
