|
CHG X-RAY TRUNK SPINE SCOLIOSIS
|
Professional
|
Both
|
$46.00
|
|
|
Service Code
|
HCPCS 72069
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$34.50 |
| Rate for Payer: BCBS Complete |
$18.40
|
| Rate for Payer: BCBS Complete |
$24.80
|
| Rate for Payer: Cash Price |
$36.80
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$46.50
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
|
IP
|
$593,279.85
|
|
|
Service Code
|
MSDRG 018
|
| Min. Negotiated Rate |
$297,088.09 |
| Max. Negotiated Rate |
$593,279.85 |
| Rate for Payer: Aetna Medicare |
$312,724.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$390,905.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$390,905.39
|
| Rate for Payer: BCBS MAPPO |
$312,724.31
|
| Rate for Payer: BCN Medicare Advantage |
$312,724.31
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$312,724.31
|
| Rate for Payer: Humana Choice PPO Medicare |
$312,724.31
|
| Rate for Payer: Mclaren Medicare |
$312,724.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$328,360.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$359,632.96
|
| Rate for Payer: Molina Medicare/Medicaid |
$343,996.74
|
| Rate for Payer: PACE Medicare |
$297,088.09
|
| Rate for Payer: PACE SWMI |
$312,724.31
|
| Rate for Payer: PHP Commercial |
$343,996.74
|
| Rate for Payer: PHP Medicare Advantage |
$312,724.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$593,279.85
|
| Rate for Payer: Priority Health Medicare |
$312,724.31
|
| Rate for Payer: Priority Health Narrow Network |
$474,623.88
|
| Rate for Payer: Railroad Medicare Medicare |
$312,724.31
|
| Rate for Payer: UHCCP DNSP |
$312,724.31
|
| Rate for Payer: VA VA |
$312,724.31
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
|
IP
|
$143,354.00
|
|
|
Service Code
|
APR-DRG 0113
|
| Min. Negotiated Rate |
$129,609.17 |
| Max. Negotiated Rate |
$143,354.00 |
| Rate for Payer: BCBS Complete |
$143,354.00
|
| Rate for Payer: Mclaren Medicaid |
$136,527.62
|
| Rate for Payer: Meridian Medicaid |
$143,354.00
|
| Rate for Payer: PHP Medicaid |
$129,609.17
|
| Rate for Payer: Priority Health Choice Medicaid |
$136,527.62
|
| Rate for Payer: UHC Medicaid |
$136,527.62
|
| Rate for Payer: UHCCP Medicaid |
$136,527.62
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
|
IP
|
$56,128.76
|
|
|
Service Code
|
APR-DRG 0111
|
| Min. Negotiated Rate |
$50,747.11 |
| Max. Negotiated Rate |
$56,128.76 |
| Rate for Payer: BCBS Complete |
$56,128.76
|
| Rate for Payer: Mclaren Medicaid |
$53,455.96
|
| Rate for Payer: Meridian Medicaid |
$56,128.76
|
| Rate for Payer: PHP Medicaid |
$50,747.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$53,455.96
|
| Rate for Payer: UHC Medicaid |
$53,455.96
|
| Rate for Payer: UHCCP Medicaid |
$53,455.96
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
|
IP
|
$121,639.38
|
|
|
Service Code
|
APR-DRG 0112
|
| Min. Negotiated Rate |
$109,976.55 |
| Max. Negotiated Rate |
$121,639.38 |
| Rate for Payer: BCBS Complete |
$121,639.38
|
| Rate for Payer: Mclaren Medicaid |
$115,847.03
|
| Rate for Payer: Meridian Medicaid |
$121,639.38
|
| Rate for Payer: PHP Medicaid |
$109,976.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$115,847.03
|
| Rate for Payer: UHC Medicaid |
$115,847.03
|
| Rate for Payer: UHCCP Medicaid |
$115,847.03
|
|
|
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES
|
Facility
|
IP
|
$186,053.01
|
|
|
Service Code
|
APR-DRG 0114
|
| Min. Negotiated Rate |
$168,214.19 |
| Max. Negotiated Rate |
$186,053.01 |
| Rate for Payer: BCBS Complete |
$186,053.01
|
| Rate for Payer: Mclaren Medicaid |
$177,193.35
|
| Rate for Payer: Meridian Medicaid |
$186,053.01
|
| Rate for Payer: PHP Medicaid |
$168,214.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$177,193.35
|
| Rate for Payer: UHC Medicaid |
$177,193.35
|
| Rate for Payer: UHCCP Medicaid |
$177,193.35
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: ASR ASR |
$4.22
|
| Rate for Payer: BCBS Trust/PPO |
$3.57
|
| Rate for Payer: BCN Commercial |
$3.57
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cofinity Commercial |
$4.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.48
|
| Rate for Payer: Healthscope Commercial |
$4.22
|
| Rate for Payer: Healthscope Whirlpool |
$4.35
|
| Rate for Payer: Mclaren Commercial |
$3.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.70
|
| Rate for Payer: Nomi Health Commercial |
$3.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.83
|
|
|
CHLORDIAZEPOXIDE 10 MG CAPSULE
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 51079037501
|
| Hospital Charge Code |
1622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Aetna Medicare |
$1.61
|
| Rate for Payer: ASR ASR |
$4.22
|
| Rate for Payer: BCBS Complete |
$1.74
|
| Rate for Payer: BCBS Trust/PPO |
$3.59
|
| Rate for Payer: BCN Commercial |
$3.59
|
| Rate for Payer: Cash Price |
$3.48
|
| Rate for Payer: Cofinity Commercial |
$4.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.48
|
| Rate for Payer: Healthscope Commercial |
$4.22
|
| Rate for Payer: Healthscope Whirlpool |
$4.35
|
| Rate for Payer: Mclaren Commercial |
$3.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.70
|
| Rate for Payer: Nomi Health Commercial |
$3.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.26
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.81
|
| Rate for Payer: Priority Health Narrow Network |
$3.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.83
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 51079014101
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$4.22
|
| Rate for Payer: ASR ASR |
$4.55
|
| Rate for Payer: BCBS Trust/PPO |
$3.85
|
| Rate for Payer: BCN Commercial |
$3.85
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: Cofinity Commercial |
$4.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.75
|
| Rate for Payer: Healthscope Commercial |
$4.55
|
| Rate for Payer: Healthscope Whirlpool |
$4.69
|
| Rate for Payer: Mclaren Commercial |
$4.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.99
|
| Rate for Payer: Nomi Health Commercial |
$3.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.13
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$385.40
|
|
|
Service Code
|
NDC 555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$289.05 |
| Max. Negotiated Rate |
$385.40 |
| Rate for Payer: Aetna Commercial |
$346.86
|
| Rate for Payer: ASR ASR |
$373.84
|
| Rate for Payer: BCBS Trust/PPO |
$316.49
|
| Rate for Payer: BCN Commercial |
$316.49
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$362.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$373.84
|
| Rate for Payer: Healthscope Whirlpool |
$385.40
|
| Rate for Payer: Mclaren Commercial |
$346.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: Nomi Health Commercial |
$316.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$339.15
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$385.40
|
|
|
Service Code
|
NDC 555015902
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.60 |
| Max. Negotiated Rate |
$385.40 |
| Rate for Payer: Aetna Commercial |
$346.86
|
| Rate for Payer: Aetna Medicare |
$142.60
|
| Rate for Payer: ASR ASR |
$373.84
|
| Rate for Payer: BCBS Complete |
$154.16
|
| Rate for Payer: BCBS Trust/PPO |
$317.76
|
| Rate for Payer: BCN Commercial |
$317.76
|
| Rate for Payer: Cash Price |
$308.32
|
| Rate for Payer: Cofinity Commercial |
$362.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.32
|
| Rate for Payer: Healthscope Commercial |
$373.84
|
| Rate for Payer: Healthscope Whirlpool |
$385.40
|
| Rate for Payer: Mclaren Commercial |
$346.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$308.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.59
|
| Rate for Payer: Nomi Health Commercial |
$316.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$337.69
|
| Rate for Payer: Priority Health Narrow Network |
$270.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$339.15
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$4.69
|
|
|
Service Code
|
NDC 51079014101
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$4.69 |
| Rate for Payer: Aetna Commercial |
$4.22
|
| Rate for Payer: Aetna Medicare |
$1.74
|
| Rate for Payer: ASR ASR |
$4.55
|
| Rate for Payer: BCBS Complete |
$1.88
|
| Rate for Payer: BCBS Trust/PPO |
$3.87
|
| Rate for Payer: BCN Commercial |
$3.87
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: Cofinity Commercial |
$4.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.75
|
| Rate for Payer: Healthscope Commercial |
$4.55
|
| Rate for Payer: Healthscope Whirlpool |
$4.69
|
| Rate for Payer: Mclaren Commercial |
$4.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.99
|
| Rate for Payer: Nomi Health Commercial |
$3.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.11
|
| Rate for Payer: Priority Health Narrow Network |
$3.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.13
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
OP
|
$469.30
|
|
|
Service Code
|
NDC 51079014120
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.64 |
| Max. Negotiated Rate |
$469.30 |
| Rate for Payer: Aetna Commercial |
$422.37
|
| Rate for Payer: Aetna Medicare |
$173.64
|
| Rate for Payer: ASR ASR |
$455.22
|
| Rate for Payer: BCBS Complete |
$187.72
|
| Rate for Payer: BCBS Trust/PPO |
$386.94
|
| Rate for Payer: BCN Commercial |
$386.94
|
| Rate for Payer: Cash Price |
$375.44
|
| Rate for Payer: Cofinity Commercial |
$441.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.44
|
| Rate for Payer: Healthscope Commercial |
$455.22
|
| Rate for Payer: Healthscope Whirlpool |
$469.30
|
| Rate for Payer: Mclaren Commercial |
$422.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$375.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$398.90
|
| Rate for Payer: Nomi Health Commercial |
$384.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$351.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$411.20
|
| Rate for Payer: Priority Health Narrow Network |
$328.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$412.98
|
|
|
CHLORDIAZEPOXIDE 25 MG CAPSULE
|
Facility
|
IP
|
$469.30
|
|
|
Service Code
|
NDC 51079014120
|
| Hospital Charge Code |
1623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$351.98 |
| Max. Negotiated Rate |
$469.30 |
| Rate for Payer: Aetna Commercial |
$422.37
|
| Rate for Payer: ASR ASR |
$455.22
|
| Rate for Payer: BCBS Trust/PPO |
$385.39
|
| Rate for Payer: BCN Commercial |
$385.39
|
| Rate for Payer: Cash Price |
$375.44
|
| Rate for Payer: Cofinity Commercial |
$441.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$375.44
|
| Rate for Payer: Healthscope Commercial |
$455.22
|
| Rate for Payer: Healthscope Whirlpool |
$469.30
|
| Rate for Payer: Mclaren Commercial |
$422.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$398.90
|
| Rate for Payer: Nomi Health Commercial |
$384.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$351.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$412.98
|
|
|
CHLORDIAZEPOXIDE 5 MG CAPSULE
|
Facility
|
OP
|
$465.30
|
|
|
Service Code
|
NDC 555015802
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.16 |
| Max. Negotiated Rate |
$465.30 |
| Rate for Payer: Aetna Commercial |
$418.77
|
| Rate for Payer: Aetna Medicare |
$172.16
|
| Rate for Payer: ASR ASR |
$451.34
|
| Rate for Payer: BCBS Complete |
$186.12
|
| Rate for Payer: BCBS Trust/PPO |
$383.64
|
| Rate for Payer: BCN Commercial |
$383.64
|
| Rate for Payer: Cash Price |
$372.24
|
| Rate for Payer: Cofinity Commercial |
$437.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$372.24
|
| Rate for Payer: Healthscope Commercial |
$451.34
|
| Rate for Payer: Healthscope Whirlpool |
$465.30
|
| Rate for Payer: Mclaren Commercial |
$418.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$372.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.50
|
| Rate for Payer: Nomi Health Commercial |
$381.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$348.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$407.70
|
| Rate for Payer: Priority Health Narrow Network |
$326.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$409.46
|
|
|
CHLORDIAZEPOXIDE 5 MG CAPSULE
|
Facility
|
IP
|
$465.30
|
|
|
Service Code
|
NDC 555015802
|
| Hospital Charge Code |
1624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$348.98 |
| Max. Negotiated Rate |
$465.30 |
| Rate for Payer: Aetna Commercial |
$418.77
|
| Rate for Payer: ASR ASR |
$451.34
|
| Rate for Payer: BCBS Trust/PPO |
$382.10
|
| Rate for Payer: BCN Commercial |
$382.10
|
| Rate for Payer: Cash Price |
$372.24
|
| Rate for Payer: Cofinity Commercial |
$437.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$372.24
|
| Rate for Payer: Healthscope Commercial |
$451.34
|
| Rate for Payer: Healthscope Whirlpool |
$465.30
|
| Rate for Payer: Mclaren Commercial |
$418.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.50
|
| Rate for Payer: Nomi Health Commercial |
$381.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$348.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$409.46
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$95.95
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.73 |
| Max. Negotiated Rate |
$95.95 |
| Rate for Payer: Aetna Commercial |
$86.36
|
| Rate for Payer: Aetna Medicare |
$35.50
|
| Rate for Payer: ASR ASR |
$93.07
|
| Rate for Payer: BCBS Complete |
$38.38
|
| Rate for Payer: BCBS Trust/PPO |
$79.11
|
| Rate for Payer: BCN Commercial |
$79.11
|
| Rate for Payer: Cash Price |
$76.76
|
| Rate for Payer: Cash Price |
$76.76
|
| Rate for Payer: Cofinity Commercial |
$90.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.76
|
| Rate for Payer: Healthscope Commercial |
$93.07
|
| Rate for Payer: Healthscope Whirlpool |
$95.95
|
| Rate for Payer: Mclaren Commercial |
$86.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.56
|
| Rate for Payer: Nomi Health Commercial |
$78.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$24.66
|
| Rate for Payer: Priority Health Narrow Network |
$19.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$84.44
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$95.95
|
|
|
Service Code
|
HCPCS J3230
|
| Hospital Charge Code |
1649
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.96 |
| Max. Negotiated Rate |
$95.95 |
| Rate for Payer: Aetna Commercial |
$86.36
|
| Rate for Payer: ASR ASR |
$93.07
|
| Rate for Payer: BCBS Trust/PPO |
$78.79
|
| Rate for Payer: BCN Commercial |
$78.79
|
| Rate for Payer: Cash Price |
$76.76
|
| Rate for Payer: Cofinity Commercial |
$90.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.76
|
| Rate for Payer: Healthscope Commercial |
$93.07
|
| Rate for Payer: Healthscope Whirlpool |
$95.95
|
| Rate for Payer: Mclaren Commercial |
$86.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.56
|
| Rate for Payer: Nomi Health Commercial |
$78.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$84.44
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
IP
|
$1,307.95
|
|
|
Service Code
|
NDC 832030100
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$980.96 |
| Max. Negotiated Rate |
$1,307.95 |
| Rate for Payer: Aetna Commercial |
$1,177.15
|
| Rate for Payer: ASR ASR |
$1,268.71
|
| Rate for Payer: BCBS Trust/PPO |
$1,074.09
|
| Rate for Payer: BCN Commercial |
$1,074.09
|
| Rate for Payer: Cash Price |
$1,046.36
|
| Rate for Payer: Cofinity Commercial |
$1,229.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,046.36
|
| Rate for Payer: Healthscope Commercial |
$1,268.71
|
| Rate for Payer: Healthscope Whirlpool |
$1,307.95
|
| Rate for Payer: Mclaren Commercial |
$1,177.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,111.76
|
| Rate for Payer: Nomi Health Commercial |
$1,072.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$980.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,151.00
|
|
|
CHLORPROMAZINE 25 MG TABLET
|
Facility
|
OP
|
$1,307.95
|
|
|
Service Code
|
NDC 832030100
|
| Hospital Charge Code |
1656
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$483.94 |
| Max. Negotiated Rate |
$1,307.95 |
| Rate for Payer: Aetna Commercial |
$1,177.15
|
| Rate for Payer: Aetna Medicare |
$483.94
|
| Rate for Payer: ASR ASR |
$1,268.71
|
| Rate for Payer: BCBS Complete |
$523.18
|
| Rate for Payer: BCBS Trust/PPO |
$1,078.40
|
| Rate for Payer: BCN Commercial |
$1,078.40
|
| Rate for Payer: Cash Price |
$1,046.36
|
| Rate for Payer: Cofinity Commercial |
$1,229.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,046.36
|
| Rate for Payer: Healthscope Commercial |
$1,268.71
|
| Rate for Payer: Healthscope Whirlpool |
$1,307.95
|
| Rate for Payer: Mclaren Commercial |
$1,177.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,046.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,111.76
|
| Rate for Payer: Nomi Health Commercial |
$1,072.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$980.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$1,146.03
|
| Rate for Payer: Priority Health Narrow Network |
$916.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,151.00
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
OP
|
$205.34
|
|
|
Service Code
|
NDC 904690004
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.98 |
| Max. Negotiated Rate |
$205.34 |
| Rate for Payer: Aetna Commercial |
$184.81
|
| Rate for Payer: Aetna Medicare |
$75.98
|
| Rate for Payer: ASR ASR |
$199.18
|
| Rate for Payer: BCBS Complete |
$82.14
|
| Rate for Payer: BCBS Trust/PPO |
$169.31
|
| Rate for Payer: BCN Commercial |
$169.31
|
| Rate for Payer: Cash Price |
$164.28
|
| Rate for Payer: Cofinity Commercial |
$193.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.28
|
| Rate for Payer: Healthscope Commercial |
$199.18
|
| Rate for Payer: Healthscope Whirlpool |
$205.34
|
| Rate for Payer: Mclaren Commercial |
$184.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$164.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$174.54
|
| Rate for Payer: Nomi Health Commercial |
$168.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$154.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$179.92
|
| Rate for Payer: Priority Health Narrow Network |
$143.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$180.70
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
OP
|
$3.37
|
|
|
Service Code
|
NDC 50268016711
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna Medicare |
$1.25
|
| Rate for Payer: ASR ASR |
$3.26
|
| Rate for Payer: BCBS Complete |
$1.35
|
| Rate for Payer: BCBS Trust/PPO |
$2.77
|
| Rate for Payer: BCN Commercial |
$2.77
|
| Rate for Payer: Cash Price |
$2.69
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.69
|
| Rate for Payer: Healthscope Commercial |
$3.26
|
| Rate for Payer: Healthscope Whirlpool |
$3.37
|
| Rate for Payer: Mclaren Commercial |
$3.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.86
|
| Rate for Payer: Nomi Health Commercial |
$2.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.95
|
| Rate for Payer: Priority Health Narrow Network |
$2.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.96
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
IP
|
$341.05
|
|
|
Service Code
|
NDC 43598071901
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$255.79 |
| Max. Negotiated Rate |
$341.05 |
| Rate for Payer: Aetna Commercial |
$306.94
|
| Rate for Payer: ASR ASR |
$330.82
|
| Rate for Payer: BCBS Trust/PPO |
$280.07
|
| Rate for Payer: BCN Commercial |
$280.07
|
| Rate for Payer: Cash Price |
$272.84
|
| Rate for Payer: Cofinity Commercial |
$320.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.84
|
| Rate for Payer: Healthscope Commercial |
$330.82
|
| Rate for Payer: Healthscope Whirlpool |
$341.05
|
| Rate for Payer: Mclaren Commercial |
$306.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$289.89
|
| Rate for Payer: Nomi Health Commercial |
$279.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$255.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$300.12
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 51079005801
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$9.37 |
| Rate for Payer: Aetna Commercial |
$8.43
|
| Rate for Payer: Aetna Medicare |
$3.47
|
| Rate for Payer: ASR ASR |
$9.09
|
| Rate for Payer: BCBS Complete |
$3.75
|
| Rate for Payer: BCBS Trust/PPO |
$7.73
|
| Rate for Payer: BCN Commercial |
$7.73
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cofinity Commercial |
$8.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.50
|
| Rate for Payer: Healthscope Commercial |
$9.09
|
| Rate for Payer: Healthscope Whirlpool |
$9.37
|
| Rate for Payer: Mclaren Commercial |
$8.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.96
|
| Rate for Payer: Nomi Health Commercial |
$7.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.21
|
| Rate for Payer: Priority Health Narrow Network |
$6.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.25
|
|
|
CHLORTHALIDONE 25 MG TABLET
|
Facility
|
OP
|
$213.75
|
|
|
Service Code
|
NDC 57664064888
|
| Hospital Charge Code |
1661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.09 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$192.38
|
| Rate for Payer: Aetna Medicare |
$79.09
|
| Rate for Payer: ASR ASR |
$207.34
|
| Rate for Payer: BCBS Complete |
$85.50
|
| Rate for Payer: BCBS Trust/PPO |
$176.24
|
| Rate for Payer: BCN Commercial |
$176.24
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$200.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$207.34
|
| Rate for Payer: Healthscope Whirlpool |
$213.75
|
| Rate for Payer: Mclaren Commercial |
$192.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$171.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$187.29
|
| Rate for Payer: Priority Health Narrow Network |
$149.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$188.10
|
|
