|
PROGESTERONE MICRONIZED 8 % VAGINAL GEL
|
Facility
|
IP
|
$97.27
|
|
|
Service Code
|
NDC 0023-6151-09
|
| Hospital Charge Code |
21321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.80 |
| Max. Negotiated Rate |
$87.54 |
| Rate for Payer: Aetna American Axle |
$63.23
|
| Rate for Payer: Aetna Commercial |
$82.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.23
|
| Rate for Payer: Cash Price |
$77.82
|
| Rate for Payer: Cofinity Commercial |
$68.09
|
| Rate for Payer: Cofinity Commercial |
$83.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.82
|
| Rate for Payer: Healthscope Commercial |
$87.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.68
|
| Rate for Payer: PHP Commercial |
$82.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.09
|
| Rate for Payer: Priority Health SBD |
$61.28
|
| Rate for Payer: UMR Bronson Commercial |
$42.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.95
|
|
|
PROGESTERONE MICRONIZED 8 % VAGINAL GEL
|
Facility
|
IP
|
$97.27
|
|
|
Service Code
|
NDC 0023-6151-08
|
| Hospital Charge Code |
21321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.80 |
| Max. Negotiated Rate |
$87.54 |
| Rate for Payer: Aetna American Axle |
$63.23
|
| Rate for Payer: Aetna Commercial |
$82.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.23
|
| Rate for Payer: Cash Price |
$77.82
|
| Rate for Payer: Cofinity Commercial |
$68.09
|
| Rate for Payer: Cofinity Commercial |
$83.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.82
|
| Rate for Payer: Healthscope Commercial |
$87.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.68
|
| Rate for Payer: PHP Commercial |
$82.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.09
|
| Rate for Payer: Priority Health SBD |
$61.28
|
| Rate for Payer: UMR Bronson Commercial |
$42.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.95
|
|
|
PROLASTIN/ARALAST (ALPHA-1 PROTEINASE INHIBITOR) 1,000 MG IV SOLUTION
|
Facility
|
IP
|
$1.57
|
|
|
Service Code
|
HCPCS J0256
|
| Hospital Charge Code |
36577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: Aetna American Axle |
$1.02
|
| Rate for Payer: Aetna Commercial |
$1.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.02
|
| Rate for Payer: Cash Price |
$1.26
|
| Rate for Payer: Cofinity Commercial |
$1.10
|
| Rate for Payer: Cofinity Commercial |
$1.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.26
|
| Rate for Payer: Healthscope Commercial |
$1.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.33
|
| Rate for Payer: PHP Commercial |
$1.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.10
|
| Rate for Payer: Priority Health SBD |
$0.99
|
| Rate for Payer: UMR Bronson Commercial |
$0.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.18
|
|
|
PR OMALIZUMAB INJECTION
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS J2357
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$40.64 |
| Rate for Payer: Aetna Commercial |
$40.64
|
| Rate for Payer: BCBS Complete |
$12.00
|
| Rate for Payer: BCBS Trust/PPO |
$40.20
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.00
|
| Rate for Payer: UMR Bronson Commercial |
$13.80
|
|
|
PR OMENTAL FLAP INTRA-ABDOMINAL
|
Professional
|
Both
|
$629.00
|
|
|
Service Code
|
HCPCS 49905
|
| Min. Negotiated Rate |
$223.01 |
| Max. Negotiated Rate |
$4,973.94 |
| Rate for Payer: Aetna Commercial |
$477.01
|
| Rate for Payer: BCBS Complete |
$234.16
|
| Rate for Payer: BCBS Trust/PPO |
$4,973.94
|
| Rate for Payer: Cash Price |
$503.20
|
| Rate for Payer: Cash Price |
$503.20
|
| Rate for Payer: Meridian Medicaid |
$234.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$223.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$440.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$614.43
|
| Rate for Payer: Priority Health Narrow Network |
$614.43
|
| Rate for Payer: Priority Health SBD |
$614.43
|
| Rate for Payer: UMR Bronson Commercial |
$289.34
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$15.09
|
|
|
Service Code
|
NDC 0713-0536-06
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.64 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Aetna American Axle |
$9.81
|
| Rate for Payer: Aetna Commercial |
$12.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.81
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: Cofinity Commercial |
$10.56
|
| Rate for Payer: Cofinity Commercial |
$12.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.07
|
| Rate for Payer: Healthscope Commercial |
$13.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.83
|
| Rate for Payer: PHP Commercial |
$12.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.56
|
| Rate for Payer: Priority Health SBD |
$9.51
|
| Rate for Payer: UMR Bronson Commercial |
$6.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.32
|
|
|
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$181.02
|
|
|
Service Code
|
NDC 0713-0536-12
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.65 |
| Max. Negotiated Rate |
$162.92 |
| Rate for Payer: Aetna American Axle |
$117.66
|
| Rate for Payer: Aetna Commercial |
$153.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.66
|
| Rate for Payer: Cash Price |
$144.82
|
| Rate for Payer: Cofinity Commercial |
$126.71
|
| Rate for Payer: Cofinity Commercial |
$155.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$144.82
|
| Rate for Payer: Healthscope Commercial |
$162.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$126.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$135.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$153.87
|
| Rate for Payer: PHP Commercial |
$153.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.71
|
| Rate for Payer: Priority Health SBD |
$114.04
|
| Rate for Payer: UMR Bronson Commercial |
$79.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.76
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 53746-745-01
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$48.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$3.98
|
|
|
Service Code
|
NDC 60687-660-11
|
| 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: 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 Multiplan/Beech St/PHCS |
$3.38
|
| Rate for Payer: PHP Commercial |
$3.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.79
|
| 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
|
IP
|
$346.75
|
|
|
Service Code
|
NDC 68084-154-11
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.57 |
| Max. Negotiated Rate |
$312.08 |
| 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: Encore Health Key Benefits Commercial |
$277.40
|
| Rate for Payer: Healthscope Commercial |
$312.08
|
| 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 Multiplan/Beech St/PHCS |
$294.74
|
| Rate for Payer: PHP Commercial |
$294.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.72
|
| 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
|
IP
|
$152.75
|
|
|
Service Code
|
NDC 68382-040-01
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.21 |
| Max. Negotiated Rate |
$137.48 |
| Rate for Payer: Aetna American Axle |
$99.29
|
| Rate for Payer: Aetna Commercial |
$129.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.29
|
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Cofinity Commercial |
$106.92
|
| Rate for Payer: Cofinity Commercial |
$131.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.20
|
| Rate for Payer: Healthscope Commercial |
$137.48
|
| 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 Multiplan/Beech St/PHCS |
$129.84
|
| Rate for Payer: PHP Commercial |
$129.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.92
|
| Rate for Payer: Priority Health SBD |
$96.23
|
| Rate for Payer: UMR Bronson Commercial |
$67.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.56
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 65162-745-10
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.52 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna American Axle |
$113.04
|
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| 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 |
$130.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.73
|
| 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 |
$130.42
|
|
|
PROMETHAZINE 12.5 MG TABLET
|
Facility
|
IP
|
$397.10
|
|
|
Service Code
|
NDC 60687-660-01
|
| 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: 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 Multiplan/Beech St/PHCS |
$337.54
|
| Rate for Payer: PHP Commercial |
$337.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.97
|
| 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
|
IP
|
$346.75
|
|
|
Service Code
|
NDC 68084-154-01
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.57 |
| Max. Negotiated Rate |
$312.08 |
| 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: Encore Health Key Benefits Commercial |
$277.40
|
| Rate for Payer: Healthscope Commercial |
$312.08
|
| 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 Multiplan/Beech St/PHCS |
$294.74
|
| Rate for Payer: PHP Commercial |
$294.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.72
|
| 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
|
IP
|
$136.30
|
|
|
Service Code
|
NDC 10702-002-01
|
| Hospital Charge Code |
6621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.97 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.60
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.60
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Cofinity Commercial |
$95.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.86
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$95.41
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UMR Bronson Commercial |
$59.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
PROMETHAZINE 25 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$20.02 |
| Rate for Payer: Aetna American Axle |
$14.46
|
| Rate for Payer: Aetna American Axle |
$10.95
|
| Rate for Payer: Aetna American Axle |
$14.33
|
| Rate for Payer: Aetna American Axle |
$14.45
|
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna Commercial |
$14.32
|
| Rate for Payer: Aetna Commercial |
$18.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Cash Price |
$13.48
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$15.58
|
| Rate for Payer: Cofinity Commercial |
$11.80
|
| Rate for Payer: Cofinity Commercial |
$15.56
|
| Rate for Payer: Cofinity Commercial |
$14.49
|
| 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 |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Healthscope Commercial |
$15.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.32
|
| Rate for Payer: PHP Commercial |
$18.74
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: PHP Commercial |
$14.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.44
|
| 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: Priority Health SBD |
$14.02
|
| Rate for Payer: UMR Bronson Commercial |
$7.41
|
| 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: Van Buren County Sheriff Dept. Commercial |
$16.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.69
|
|
|
PROMETHAZINE 25 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$22.23
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$20.01 |
| Rate for Payer: Aetna American Axle |
$14.45
|
| Rate for Payer: Aetna American Axle |
$14.46
|
| Rate for Payer: Aetna American Axle |
$14.33
|
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$18.74
|
| Rate for Payer: Aetna Commercial |
$18.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.45
|
| Rate for Payer: BCBS Complete |
$8.90
|
| Rate for Payer: BCBS Complete |
$8.89
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: BCBS Trust/PPO |
$11.58
|
| Rate for Payer: BCBS Trust/PPO |
$11.58
|
| Rate for Payer: BCBS Trust/PPO |
$11.58
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$17.64
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cofinity Commercial |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Commercial |
$15.56
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$15.58
|
| Rate for Payer: Cofinity Commercial |
$18.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Healthscope Commercial |
$20.02
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| 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 |
$15.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.90
|
| Rate for Payer: PHP Commercial |
$18.74
|
| Rate for Payer: PHP Commercial |
$18.91
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.44
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: Priority Health SBD |
$13.89
|
| Rate for Payer: Priority Health SBD |
$14.00
|
| Rate for Payer: UMR Bronson Commercial |
$8.16
|
| Rate for Payer: UMR Bronson Commercial |
$8.23
|
| Rate for Payer: UMR Bronson Commercial |
$8.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.69
|
|
|
PROMETHAZINE 25 MG RECTAL SUPPOSITORY
|
Facility
|
IP
|
$153.98
|
|
|
Service Code
|
NDC 0713-0526-12
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.75 |
| Max. Negotiated Rate |
$138.58 |
| Rate for Payer: Aetna American Axle |
$100.09
|
| Rate for Payer: Aetna Commercial |
$130.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.09
|
| Rate for Payer: Cash Price |
$123.18
|
| Rate for Payer: Cofinity Commercial |
$107.79
|
| Rate for Payer: Cofinity Commercial |
$132.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$123.18
|
| Rate for Payer: Healthscope Commercial |
$138.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$107.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$115.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.88
|
| Rate for Payer: PHP Commercial |
$130.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.79
|
| Rate for Payer: Priority Health SBD |
$97.01
|
| Rate for Payer: UMR Bronson Commercial |
$67.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$115.48
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 0904-6461-61
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.64 |
| Max. Negotiated Rate |
$226.30 |
| 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 |
$176.02
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.02
|
| 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
|
$448.85
|
|
|
Service Code
|
NDC 68084-155-01
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.49 |
| Max. Negotiated Rate |
$403.96 |
| Rate for Payer: Aetna American Axle |
$291.75
|
| Rate for Payer: Aetna Commercial |
$381.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.75
|
| Rate for Payer: Cash Price |
$359.08
|
| Rate for Payer: Cofinity Commercial |
$314.20
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.08
|
| Rate for Payer: Healthscope Commercial |
$403.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$336.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$381.52
|
| Rate for Payer: PHP Commercial |
$381.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$314.20
|
| Rate for Payer: Priority Health SBD |
$282.78
|
| Rate for Payer: UMR Bronson Commercial |
$197.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$336.64
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
OP
|
$448.85
|
|
|
Service Code
|
NDC 68084-155-01
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.07 |
| Max. Negotiated Rate |
$403.96 |
| Rate for Payer: Aetna American Axle |
$291.75
|
| Rate for Payer: Aetna Commercial |
$381.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.75
|
| Rate for Payer: BCBS Complete |
$179.54
|
| Rate for Payer: Cash Price |
$359.08
|
| Rate for Payer: Cofinity Commercial |
$314.20
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.08
|
| Rate for Payer: Healthscope Commercial |
$403.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$336.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$381.52
|
| Rate for Payer: PHP Commercial |
$381.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$314.20
|
| Rate for Payer: Priority Health SBD |
$282.78
|
| Rate for Payer: UMR Bronson Commercial |
$166.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$336.64
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$86.95
|
|
|
Service Code
|
NDC 53746-521-01
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.26 |
| Max. Negotiated Rate |
$78.26 |
| Rate for Payer: Aetna American Axle |
$56.52
|
| Rate for Payer: Aetna Commercial |
$73.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.52
|
| Rate for Payer: Cash Price |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$60.86
|
| Rate for Payer: Cofinity Commercial |
$74.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.56
|
| Rate for Payer: Healthscope Commercial |
$78.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$73.91
|
| Rate for Payer: PHP Commercial |
$73.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.86
|
| Rate for Payer: Priority Health SBD |
$54.78
|
| Rate for Payer: UMR Bronson Commercial |
$38.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.21
|
|
|
PROMETHAZINE 25 MG TABLET
|
Facility
|
IP
|
$448.85
|
|
|
Service Code
|
NDC 68084-155-11
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.49 |
| Max. Negotiated Rate |
$403.96 |
| Rate for Payer: Aetna American Axle |
$291.75
|
| Rate for Payer: Aetna Commercial |
$381.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.75
|
| Rate for Payer: Cash Price |
$359.08
|
| Rate for Payer: Cofinity Commercial |
$314.20
|
| Rate for Payer: Cofinity Commercial |
$386.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$359.08
|
| Rate for Payer: Healthscope Commercial |
$403.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$314.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$336.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$381.52
|
| Rate for Payer: PHP Commercial |
$381.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$314.20
|
| Rate for Payer: Priority Health SBD |
$282.78
|
| Rate for Payer: UMR Bronson Commercial |
$197.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$336.64
|
|
|
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 |
$21.74 |
| 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 |
$16.90
|
| Rate for Payer: Cofinity Commercial |
$20.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.32
|
| Rate for Payer: Healthscope Commercial |
$21.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.53
|
| Rate for Payer: PHP Commercial |
$20.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.90
|
| 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
|
IP
|
$988.70
|
|
|
Service Code
|
NDC 0713-0132-12
|
| Hospital Charge Code |
6624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$435.03 |
| Max. Negotiated Rate |
$889.83 |
| Rate for Payer: Aetna American Axle |
$642.66
|
| Rate for Payer: Aetna Commercial |
$840.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$642.66
|
| Rate for Payer: Cash Price |
$790.96
|
| Rate for Payer: Cofinity Commercial |
$692.09
|
| Rate for Payer: Cofinity Commercial |
$850.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$790.96
|
| Rate for Payer: Healthscope Commercial |
$889.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$692.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$741.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$840.40
|
| Rate for Payer: PHP Commercial |
$840.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$692.09
|
| Rate for Payer: Priority Health SBD |
$622.88
|
| Rate for Payer: UMR Bronson Commercial |
$435.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$741.52
|
|
