|
CHLORPHENIRAMINE 4 MG TABLET
|
Facility
|
IP
|
$68.15
|
|
|
Service Code
|
NDC 0904-0012-61
|
| Hospital Charge Code |
1645
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.99 |
| Max. Negotiated Rate |
$61.34 |
| Rate for Payer: Aetna American Axle |
$44.30
|
| Rate for Payer: Aetna Commercial |
$57.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.30
|
| Rate for Payer: Cash Price |
$54.52
|
| Rate for Payer: Cofinity Commercial |
$47.70
|
| Rate for Payer: Cofinity Commercial |
$58.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.52
|
| Rate for Payer: Healthscope Commercial |
$61.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.93
|
| Rate for Payer: PHP Commercial |
$57.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.70
|
| Rate for Payer: Priority Health SBD |
$42.93
|
| Rate for Payer: UMR Bronson Commercial |
$29.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.11
|
|
|
CHLORPHENIRAMINE 4 MG TABLET
|
Facility
|
IP
|
$28.20
|
|
|
Service Code
|
NDC 0536-1006-01
|
| 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: 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 Multiplan/Beech St/PHCS |
$23.97
|
| Rate for Payer: PHP Commercial |
$23.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.74
|
| 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 8 MG HYDROCODONE 10 MG/5 ML ORAL SUSP EXTEND.REL 12HR
|
Facility
|
IP
|
$43.65
|
|
|
Service Code
|
NDC 9900-0000-25
|
| Hospital Charge Code |
9582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$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 |
$30.56
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$30.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$37.10
|
| Rate for Payer: PHP Commercial |
$37.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.56
|
| Rate for Payer: Priority Health SBD |
$27.50
|
| Rate for Payer: UMR Bronson Commercial |
$19.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.74
|
|
|
CHLORPROMAZINE 100 MG TABLET
|
Facility
|
IP
|
$584.64
|
|
|
Service Code
|
NDC 0832-6020-00
|
| Hospital Charge Code |
1654
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.24 |
| Max. Negotiated Rate |
$526.18 |
| Rate for Payer: Aetna American Axle |
$380.02
|
| Rate for Payer: Aetna Commercial |
$496.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$380.02
|
| Rate for Payer: Cash Price |
$467.71
|
| Rate for Payer: Cofinity Commercial |
$409.25
|
| Rate for Payer: Cofinity Commercial |
$502.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$467.71
|
| Rate for Payer: Healthscope Commercial |
$526.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$409.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$438.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$496.94
|
| Rate for Payer: PHP Commercial |
$496.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$409.25
|
| Rate for Payer: Priority Health SBD |
$368.32
|
| Rate for Payer: UMR Bronson Commercial |
$257.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$438.48
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
IP
|
$296.40
|
|
|
Service Code
|
NDC 0832-6017-00
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.42 |
| Max. Negotiated Rate |
$266.76 |
| Rate for Payer: Aetna American Axle |
$192.66
|
| Rate for Payer: Aetna Commercial |
$251.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.66
|
| Rate for Payer: Cash Price |
$237.12
|
| Rate for Payer: Cofinity Commercial |
$207.48
|
| Rate for Payer: Cofinity Commercial |
$254.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$237.12
|
| Rate for Payer: Healthscope Commercial |
$266.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$207.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$222.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$251.94
|
| Rate for Payer: PHP Commercial |
$251.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.48
|
| Rate for Payer: Priority Health SBD |
$186.73
|
| Rate for Payer: UMR Bronson Commercial |
$130.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$222.30
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
IP
|
$1,116.66
|
|
|
Service Code
|
NDC 0904-7129-61
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$491.33 |
| Max. Negotiated Rate |
$1,004.99 |
| Rate for Payer: Aetna American Axle |
$725.83
|
| Rate for Payer: Aetna Commercial |
$949.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$725.83
|
| Rate for Payer: Cash Price |
$893.33
|
| Rate for Payer: Cofinity Commercial |
$781.66
|
| Rate for Payer: Cofinity Commercial |
$960.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$893.33
|
| Rate for Payer: Healthscope Commercial |
$1,004.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$781.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$837.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$949.16
|
| Rate for Payer: PHP Commercial |
$949.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$781.66
|
| Rate for Payer: Priority Health SBD |
$703.50
|
| Rate for Payer: UMR Bronson Commercial |
$491.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$837.50
|
|
|
CHLORPROMAZINE 10 MG TABLET
|
Facility
|
IP
|
$912.79
|
|
|
Service Code
|
NDC 0832-0300-00
|
| 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: 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 Multiplan/Beech St/PHCS |
$775.87
|
| Rate for Payer: PHP Commercial |
$775.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$638.95
|
| 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
|
$927.96
|
|
|
Service Code
|
NDC 0781-5913-01
|
| Hospital Charge Code |
1653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$408.30 |
| Max. Negotiated Rate |
$835.16 |
| Rate for Payer: Aetna American Axle |
$603.17
|
| Rate for Payer: Aetna Commercial |
$788.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$603.17
|
| Rate for Payer: Cash Price |
$742.37
|
| Rate for Payer: Cofinity Commercial |
$649.57
|
| Rate for Payer: Cofinity Commercial |
$798.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$742.37
|
| Rate for Payer: Healthscope Commercial |
$835.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$649.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$695.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$788.77
|
| Rate for Payer: PHP Commercial |
$788.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$649.57
|
| Rate for Payer: Priority Health SBD |
$584.61
|
| Rate for Payer: UMR Bronson Commercial |
$408.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$695.97
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$94.04
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.79 |
| Max. Negotiated Rate |
$96.23 |
| Rate for Payer: Aetna American Axle |
$61.13
|
| Rate for Payer: Aetna American Axle |
$46.86
|
| Rate for Payer: Aetna Commercial |
$79.93
|
| Rate for Payer: Aetna Commercial |
$61.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.86
|
| 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: BCBS Trust/PPO |
$96.23
|
| Rate for Payer: BCBS Trust/PPO |
$96.23
|
| Rate for Payer: Cash Price |
$57.68
|
| Rate for Payer: Cash Price |
$57.68
|
| Rate for Payer: Cash Price |
$75.23
|
| 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 |
$65.83
|
| Rate for Payer: Cofinity Commercial |
$80.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.23
|
| Rate for Payer: Healthscope Commercial |
$84.64
|
| Rate for Payer: Healthscope Commercial |
$64.89
|
| 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 Multiplan/Beech St/PHCS |
$61.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.93
|
| Rate for Payer: PHP Commercial |
$79.93
|
| Rate for Payer: PHP Commercial |
$61.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.47
|
| 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: 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 Multiplan/Beech St/PHCS |
$79.93
|
| Rate for Payer: PHP Commercial |
$79.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.83
|
| 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
|
$380.64
|
|
|
Service Code
|
NDC 69238-1056-1
|
| 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: 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 Multiplan/Beech St/PHCS |
$323.54
|
| Rate for Payer: PHP Commercial |
$323.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.45
|
| 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
|
IP
|
$447.84
|
|
|
Service Code
|
NDC 70710-1130-1
|
| 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: 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 Multiplan/Beech St/PHCS |
$380.66
|
| Rate for Payer: PHP Commercial |
$380.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$313.49
|
| 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
|
$274.08
|
|
|
Service Code
|
NDC 0832-6018-00
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.60 |
| Max. Negotiated Rate |
$246.67 |
| Rate for Payer: Aetna American Axle |
$178.15
|
| Rate for Payer: Aetna Commercial |
$232.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.15
|
| Rate for Payer: Cash Price |
$219.26
|
| Rate for Payer: Cofinity Commercial |
$191.86
|
| Rate for Payer: Cofinity Commercial |
$235.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.26
|
| Rate for Payer: Healthscope Commercial |
$246.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$232.97
|
| Rate for Payer: PHP Commercial |
$232.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.86
|
| Rate for Payer: Priority Health SBD |
$172.67
|
| Rate for Payer: UMR Bronson Commercial |
$120.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.56
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$1,307.95
|
|
|
Service Code
|
NDC 0832-0301-00
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$575.50 |
| Max. Negotiated Rate |
$1,177.16 |
| 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 |
$915.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,046.36
|
| Rate for Payer: Healthscope Commercial |
$1,177.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$915.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$980.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,111.76
|
| Rate for Payer: PHP Commercial |
$1,111.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$915.56
|
| Rate for Payer: Priority Health SBD |
$824.01
|
| Rate for Payer: UMR Bronson Commercial |
$575.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$980.96
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
IP
|
$752.16
|
|
|
Service Code
|
NDC 0904-6900-61
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$330.95 |
| Max. Negotiated Rate |
$676.94 |
| Rate for Payer: Aetna American Axle |
$488.90
|
| Rate for Payer: Aetna Commercial |
$639.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$488.90
|
| Rate for Payer: Cash Price |
$601.73
|
| Rate for Payer: Cofinity Commercial |
$526.51
|
| Rate for Payer: Cofinity Commercial |
$646.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$601.73
|
| Rate for Payer: Healthscope Commercial |
$676.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$526.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$564.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$639.34
|
| Rate for Payer: PHP Commercial |
$639.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$526.51
|
| Rate for Payer: Priority Health SBD |
$473.86
|
| Rate for Payer: UMR Bronson Commercial |
$330.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$564.12
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
IP
|
$8.69
|
|
|
Service Code
|
NDC 51079-058-01
|
| 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: 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 Multiplan/Beech St/PHCS |
$7.39
|
| Rate for Payer: PHP Commercial |
$7.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.08
|
| 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
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
IP
|
$868.80
|
|
|
Service Code
|
NDC 51079-058-20
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$382.27 |
| Max. Negotiated Rate |
$781.92 |
| Rate for Payer: Aetna American Axle |
$564.72
|
| Rate for Payer: Aetna Commercial |
$738.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$564.72
|
| Rate for Payer: Cash Price |
$695.04
|
| Rate for Payer: Cofinity Commercial |
$608.16
|
| Rate for Payer: Cofinity Commercial |
$747.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$695.04
|
| Rate for Payer: Healthscope Commercial |
$781.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$608.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$651.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$738.48
|
| Rate for Payer: PHP Commercial |
$738.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$608.16
|
| Rate for Payer: Priority Health SBD |
$547.34
|
| Rate for Payer: UMR Bronson Commercial |
$382.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$651.60
|
|
|
CHLORZOXAZONE 500 MG TABLET
|
Facility
|
IP
|
$257.45
|
|
|
Service Code
|
NDC 0591-2520-01
|
| Hospital Charge Code |
1664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.28 |
| Max. Negotiated Rate |
$231.70 |
| Rate for Payer: Aetna American Axle |
$167.34
|
| Rate for Payer: Aetna Commercial |
$218.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.34
|
| Rate for Payer: Cash Price |
$205.96
|
| Rate for Payer: Cofinity Commercial |
$180.22
|
| Rate for Payer: Cofinity Commercial |
$221.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.96
|
| Rate for Payer: Healthscope Commercial |
$231.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$218.83
|
| Rate for Payer: PHP Commercial |
$218.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.22
|
| Rate for Payer: Priority Health SBD |
$162.19
|
| Rate for Payer: UMR Bronson Commercial |
$113.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.09
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET
|
Facility
|
IP
|
$30.55
|
|
|
Service Code
|
NDC 904582360
|
| Hospital Charge Code |
109842
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$27.50 |
| Rate for Payer: Aetna American Axle |
$19.86
|
| Rate for Payer: Aetna Commercial |
$25.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.86
|
| Rate for Payer: Cash Price |
$24.44
|
| Rate for Payer: Cofinity Commercial |
$21.38
|
| Rate for Payer: Cofinity Commercial |
$26.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.44
|
| Rate for Payer: Healthscope Commercial |
$27.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.97
|
| Rate for Payer: PHP Commercial |
$25.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.38
|
| Rate for Payer: Priority Health SBD |
$19.25
|
| Rate for Payer: UMR Bronson Commercial |
$13.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.91
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET
|
Facility
|
IP
|
$331.35
|
|
|
Service Code
|
NDC 7733394810
|
| Hospital Charge Code |
109842
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.79 |
| Max. Negotiated Rate |
$298.22 |
| Rate for Payer: Aetna American Axle |
$215.38
|
| Rate for Payer: Aetna Commercial |
$281.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.38
|
| Rate for Payer: Cash Price |
$265.08
|
| Rate for Payer: Cofinity Commercial |
$284.96
|
| Rate for Payer: Cofinity Commercial |
$231.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.08
|
| Rate for Payer: Healthscope Commercial |
$298.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.65
|
| Rate for Payer: PHP Commercial |
$281.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$231.94
|
| Rate for Payer: Priority Health SBD |
$208.75
|
| Rate for Payer: UMR Bronson Commercial |
$145.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.51
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 7733394825
|
| Hospital Charge Code |
109842
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna American Axle |
$2.16
|
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.16
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.66
|
| Rate for Payer: Healthscope Commercial |
$2.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.82
|
| Rate for Payer: PHP Commercial |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.32
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.49
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE
|
Facility
|
IP
|
$159.80
|
|
|
Service Code
|
NDC 7985409098
|
| Hospital Charge Code |
15636
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.31 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna American Axle |
$103.87
|
| Rate for Payer: Aetna Commercial |
$135.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.87
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$111.86
|
| Rate for Payer: Cofinity Commercial |
$137.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$143.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.83
|
| Rate for Payer: PHP Commercial |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.86
|
| Rate for Payer: Priority Health SBD |
$100.67
|
| Rate for Payer: UMR Bronson Commercial |
$70.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.85
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE
|
Facility
|
IP
|
$133.95
|
|
|
Service Code
|
NDC 5026886815
|
| Hospital Charge Code |
15636
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.94 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna American Axle |
$87.07
|
| Rate for Payer: Aetna Commercial |
$113.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.07
|
| Rate for Payer: Cash Price |
$107.16
|
| Rate for Payer: Cofinity Commercial |
$115.20
|
| Rate for Payer: Cofinity Commercial |
$93.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.16
|
| Rate for Payer: Healthscope Commercial |
$120.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.86
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.76
|
| Rate for Payer: Priority Health SBD |
$84.39
|
| Rate for Payer: UMR Bronson Commercial |
$58.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.46
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE
|
Facility
|
IP
|
$61.10
|
|
|
Service Code
|
NDC 8068113100
|
| Hospital Charge Code |
15636
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.88 |
| Max. Negotiated Rate |
$54.99 |
| Rate for Payer: Aetna American Axle |
$39.72
|
| Rate for Payer: Aetna Commercial |
$51.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$39.72
|
| Rate for Payer: Cash Price |
$48.88
|
| Rate for Payer: Cofinity Commercial |
$42.77
|
| Rate for Payer: Cofinity Commercial |
$52.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.88
|
| Rate for Payer: Healthscope Commercial |
$54.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$42.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$45.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$51.94
|
| Rate for Payer: PHP Commercial |
$51.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.77
|
| Rate for Payer: Priority Health SBD |
$38.49
|
| Rate for Payer: UMR Bronson Commercial |
$26.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$45.82
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE
|
Facility
|
IP
|
$344.75
|
|
|
Service Code
|
NDC 3160402621
|
| Hospital Charge Code |
15636
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.69 |
| Max. Negotiated Rate |
$310.28 |
| Rate for Payer: Aetna American Axle |
$224.09
|
| Rate for Payer: Aetna Commercial |
$293.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.09
|
| Rate for Payer: Cash Price |
$275.80
|
| Rate for Payer: Cofinity Commercial |
$241.32
|
| Rate for Payer: Cofinity Commercial |
$296.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.80
|
| Rate for Payer: Healthscope Commercial |
$310.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.04
|
| Rate for Payer: PHP Commercial |
$293.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.32
|
| Rate for Payer: Priority Health SBD |
$217.19
|
| Rate for Payer: UMR Bronson Commercial |
$151.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.56
|
|
