|
PERMETHRIN 5 % TOPICAL CREAM
|
Facility
|
IP
|
$322.35
|
|
|
Service Code
|
NDC 0472-0242-60
|
| Hospital Charge Code |
10917
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.08 |
| Max. Negotiated Rate |
$290.12 |
| Rate for Payer: Aetna Commercial |
$274.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.53
|
| Rate for Payer: Cash Price |
$257.88
|
| Rate for Payer: Cofinity Commercial |
$225.64
|
| Rate for Payer: Cofinity Commercial |
$277.22
|
| Rate for Payer: Healthscope Commercial |
$290.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$274.00
|
| Rate for Payer: PHP Commercial |
$274.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.64
|
| Rate for Payer: Priority Health SBD |
$203.08
|
|
|
PERPHENAZINE 4 MG TABLET
|
Facility
|
IP
|
$445.44
|
|
|
Service Code
|
HCPCS Q0175
|
| Hospital Charge Code |
6158
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$280.63 |
| Max. Negotiated Rate |
$400.90 |
| Rate for Payer: Aetna Commercial |
$378.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$289.54
|
| Rate for Payer: Cash Price |
$356.35
|
| Rate for Payer: Cofinity Commercial |
$311.81
|
| Rate for Payer: Cofinity Commercial |
$383.08
|
| Rate for Payer: Healthscope Commercial |
$400.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$378.62
|
| Rate for Payer: PHP Commercial |
$378.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$311.81
|
| Rate for Payer: Priority Health SBD |
$280.63
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$29,305.27
|
|
|
Service Code
|
HCPCS J9306
|
| Hospital Charge Code |
160029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$26,374.74 |
| Rate for Payer: Aetna Commercial |
$24,909.48
|
| Rate for Payer: Aetna Medicare |
$16.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,048.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.28
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.28
|
| Rate for Payer: BCBS Complete |
$8.86
|
| Rate for Payer: BCBS MAPPO |
$15.43
|
| Rate for Payer: BCBS Trust/PPO |
$45.65
|
| Rate for Payer: BCN Medicare Advantage |
$15.43
|
| Rate for Payer: Cash Price |
$23,444.22
|
| Rate for Payer: Cash Price |
$23,444.22
|
| Rate for Payer: Cofinity Commercial |
$25,202.53
|
| Rate for Payer: Cofinity Commercial |
$20,513.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.43
|
| Rate for Payer: Healthscope Commercial |
$26,374.74
|
| Rate for Payer: Mclaren Medicaid |
$8.44
|
| Rate for Payer: Mclaren Medicare |
$15.43
|
| Rate for Payer: Meridian Medicaid |
$8.86
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$16.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24,909.48
|
| Rate for Payer: PACE Medicare |
$14.66
|
| Rate for Payer: PACE SWMI |
$15.43
|
| Rate for Payer: PHP Commercial |
$24,909.48
|
| Rate for Payer: PHP Medicare Advantage |
$15.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,513.69
|
| Rate for Payer: Priority Health Medicare |
$15.43
|
| Rate for Payer: Priority Health SBD |
$18,462.32
|
| Rate for Payer: Railroad Medicare Medicare |
$15.43
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.43
|
| Rate for Payer: UHC Medicare Advantage |
$15.89
|
| Rate for Payer: VA VA |
$15.43
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$29,305.27
|
|
|
Service Code
|
HCPCS J9306
|
| Hospital Charge Code |
160029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18,462.32 |
| Max. Negotiated Rate |
$26,374.74 |
| Rate for Payer: Aetna Commercial |
$24,909.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,048.43
|
| Rate for Payer: Cash Price |
$23,444.22
|
| Rate for Payer: Cofinity Commercial |
$20,513.69
|
| Rate for Payer: Cofinity Commercial |
$25,202.53
|
| Rate for Payer: Healthscope Commercial |
$26,374.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24,909.48
|
| Rate for Payer: PHP Commercial |
$24,909.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,513.69
|
| Rate for Payer: Priority Health SBD |
$18,462.32
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 75826-114-10
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.22 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.92
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health SBD |
$150.22
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
IP
|
$535.68
|
|
|
Service Code
|
NDC 69367-163-04
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$337.48 |
| Max. Negotiated Rate |
$482.11 |
| Rate for Payer: Aetna Commercial |
$455.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$348.19
|
| Rate for Payer: Cash Price |
$428.54
|
| Rate for Payer: Cofinity Commercial |
$374.98
|
| Rate for Payer: Cofinity Commercial |
$460.68
|
| Rate for Payer: Healthscope Commercial |
$482.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$455.33
|
| Rate for Payer: PHP Commercial |
$455.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$374.98
|
| Rate for Payer: Priority Health SBD |
$337.48
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
IP
|
$326.80
|
|
|
Service Code
|
NDC 75826-115-10
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.88 |
| Max. Negotiated Rate |
$294.12 |
| Rate for Payer: Aetna Commercial |
$277.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.42
|
| Rate for Payer: Cash Price |
$261.44
|
| Rate for Payer: Cofinity Commercial |
$228.76
|
| Rate for Payer: Cofinity Commercial |
$281.05
|
| Rate for Payer: Healthscope Commercial |
$294.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.78
|
| Rate for Payer: PHP Commercial |
$277.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.76
|
| Rate for Payer: Priority Health SBD |
$205.88
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$210.73
|
|
|
Service Code
|
NDC 13517-107-16
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.76 |
| Max. Negotiated Rate |
$189.66 |
| Rate for Payer: Aetna Commercial |
$179.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.97
|
| Rate for Payer: Cash Price |
$168.58
|
| Rate for Payer: Cofinity Commercial |
$147.51
|
| Rate for Payer: Cofinity Commercial |
$181.23
|
| Rate for Payer: Healthscope Commercial |
$189.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$179.12
|
| Rate for Payer: PHP Commercial |
$179.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$147.51
|
| Rate for Payer: Priority Health SBD |
$132.76
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$216.97
|
|
|
Service Code
|
NDC 0603-1508-58
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.69 |
| Max. Negotiated Rate |
$195.27 |
| Rate for Payer: Aetna Commercial |
$184.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.03
|
| Rate for Payer: Cash Price |
$173.58
|
| Rate for Payer: Cofinity Commercial |
$151.88
|
| Rate for Payer: Cofinity Commercial |
$186.59
|
| Rate for Payer: Healthscope Commercial |
$195.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$184.42
|
| Rate for Payer: PHP Commercial |
$184.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.88
|
| Rate for Payer: Priority Health SBD |
$136.69
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
IP
|
$274.55
|
|
|
Service Code
|
NDC 0904-6575-61
|
| Hospital Charge Code |
6217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.97 |
| Max. Negotiated Rate |
$247.10 |
| Rate for Payer: Aetna Commercial |
$233.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.46
|
| Rate for Payer: Cash Price |
$219.64
|
| Rate for Payer: Cofinity Commercial |
$192.18
|
| Rate for Payer: Cofinity Commercial |
$236.11
|
| Rate for Payer: Healthscope Commercial |
$247.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$233.37
|
| Rate for Payer: PHP Commercial |
$233.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.18
|
| Rate for Payer: Priority Health SBD |
$172.97
|
|
|
PHENOBARBITAL 97.2 MG TABLET
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
NDC 16571-668-01
|
| Hospital Charge Code |
6220
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.67 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.85
|
| Rate for Payer: Cash Price |
$167.20
|
| Rate for Payer: Cofinity Commercial |
$146.30
|
| Rate for Payer: Cofinity Commercial |
$179.74
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$177.65
|
| Rate for Payer: PHP Commercial |
$177.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.30
|
| Rate for Payer: Priority Health SBD |
$131.67
|
|
|
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$302.15
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
6221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$190.35 |
| Max. Negotiated Rate |
$271.94 |
| Rate for Payer: Aetna Commercial |
$256.83
|
| Rate for Payer: Aetna Commercial |
$110.52
|
| Rate for Payer: Aetna Commercial |
$240.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$196.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.51
|
| Rate for Payer: Cash Price |
$104.02
|
| Rate for Payer: Cash Price |
$226.51
|
| Rate for Payer: Cash Price |
$241.72
|
| Rate for Payer: Cofinity Commercial |
$91.01
|
| Rate for Payer: Cofinity Commercial |
$259.85
|
| Rate for Payer: Cofinity Commercial |
$111.82
|
| Rate for Payer: Cofinity Commercial |
$211.50
|
| Rate for Payer: Cofinity Commercial |
$198.20
|
| Rate for Payer: Cofinity Commercial |
$243.50
|
| Rate for Payer: Healthscope Commercial |
$271.94
|
| Rate for Payer: Healthscope Commercial |
$117.02
|
| Rate for Payer: Healthscope Commercial |
$254.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$240.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$110.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$256.83
|
| Rate for Payer: PHP Commercial |
$240.67
|
| Rate for Payer: PHP Commercial |
$110.52
|
| Rate for Payer: PHP Commercial |
$256.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.50
|
| Rate for Payer: Priority Health SBD |
$178.38
|
| Rate for Payer: Priority Health SBD |
$190.35
|
| Rate for Payer: Priority Health SBD |
$81.91
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$25.49
|
|
|
Service Code
|
NDC 7811201103
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.06 |
| Max. Negotiated Rate |
$22.94 |
| Rate for Payer: Aetna Commercial |
$21.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.57
|
| Rate for Payer: Cash Price |
$20.39
|
| Rate for Payer: Cofinity Commercial |
$17.84
|
| Rate for Payer: Cofinity Commercial |
$21.92
|
| Rate for Payer: Healthscope Commercial |
$22.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.67
|
| Rate for Payer: PHP Commercial |
$21.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.84
|
| Rate for Payer: Priority Health SBD |
$16.06
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$10.62
|
|
|
Service Code
|
NDC 70000-0458-1
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.69 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$9.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.90
|
| Rate for Payer: Cash Price |
$8.50
|
| Rate for Payer: Cofinity Commercial |
$7.43
|
| Rate for Payer: Cofinity Commercial |
$9.13
|
| Rate for Payer: Healthscope Commercial |
$9.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.03
|
| Rate for Payer: PHP Commercial |
$9.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.43
|
| Rate for Payer: Priority Health SBD |
$6.69
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$9.56
|
|
|
Service Code
|
NDC 96295-13644
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.02 |
| Max. Negotiated Rate |
$8.60 |
| Rate for Payer: Aetna Commercial |
$8.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.21
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cofinity Commercial |
$6.69
|
| Rate for Payer: Cofinity Commercial |
$8.22
|
| Rate for Payer: Healthscope Commercial |
$8.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.13
|
| Rate for Payer: PHP Commercial |
$8.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.69
|
| Rate for Payer: Priority Health SBD |
$6.02
|
|
|
PHENTOLAMINE 0.5 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$309.10
|
|
|
Service Code
|
NDC 9900-0019-43
|
| Hospital Charge Code |
150967
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$194.73 |
| Max. Negotiated Rate |
$278.19 |
| Rate for Payer: Aetna Commercial |
$262.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.92
|
| Rate for Payer: Cash Price |
$247.28
|
| Rate for Payer: Cofinity Commercial |
$265.83
|
| Rate for Payer: Cofinity Commercial |
$216.37
|
| Rate for Payer: Healthscope Commercial |
$278.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$262.74
|
| Rate for Payer: PHP Commercial |
$262.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.37
|
| Rate for Payer: Priority Health SBD |
$194.73
|
|
|
PHENTOLAMINE 1 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$1,671.75
|
|
|
Service Code
|
NDC 9900-0019-45
|
| Hospital Charge Code |
301530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,053.20 |
| Max. Negotiated Rate |
$1,504.58 |
| Rate for Payer: Aetna Commercial |
$1,420.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,086.64
|
| Rate for Payer: Cash Price |
$1,337.40
|
| Rate for Payer: Cofinity Commercial |
$1,170.22
|
| Rate for Payer: Cofinity Commercial |
$1,437.70
|
| Rate for Payer: Healthscope Commercial |
$1,504.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,420.99
|
| Rate for Payer: PHP Commercial |
$1,420.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,170.22
|
| Rate for Payer: Priority Health SBD |
$1,053.20
|
|
|
PHENTOLAMINE 1 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$618.20
|
|
|
Service Code
|
NDC 9900-0019-44
|
| Hospital Charge Code |
301530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$389.47 |
| Max. Negotiated Rate |
$556.38 |
| Rate for Payer: Aetna Commercial |
$525.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$401.83
|
| Rate for Payer: Cash Price |
$494.56
|
| Rate for Payer: Cofinity Commercial |
$432.74
|
| Rate for Payer: Cofinity Commercial |
$531.65
|
| Rate for Payer: Healthscope Commercial |
$556.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$525.47
|
| Rate for Payer: PHP Commercial |
$525.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$432.74
|
| Rate for Payer: Priority Health SBD |
$389.47
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION
|
Facility
|
IP
|
$1,385.23
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
10947
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$872.69 |
| Max. Negotiated Rate |
$1,246.71 |
| Rate for Payer: Aetna Commercial |
$1,177.45
|
| Rate for Payer: Aetna Commercial |
$1,177.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$900.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$900.40
|
| Rate for Payer: Cash Price |
$1,108.18
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cofinity Commercial |
$969.66
|
| Rate for Payer: Cofinity Commercial |
$1,191.30
|
| Rate for Payer: Cofinity Commercial |
$1,191.32
|
| Rate for Payer: Cofinity Commercial |
$969.68
|
| Rate for Payer: Healthscope Commercial |
$1,246.71
|
| Rate for Payer: Healthscope Commercial |
$1,246.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,177.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,177.45
|
| Rate for Payer: PHP Commercial |
$1,177.46
|
| Rate for Payer: PHP Commercial |
$1,177.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$969.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$969.68
|
| Rate for Payer: Priority Health SBD |
$872.69
|
| Rate for Payer: Priority Health SBD |
$872.71
|
|
|
PHENYLEPHRINE 0.25 %-PRAMOXINE 1 %-GLYCERIN-WH.PETROLATUM RECTAL CREAM
|
Facility
|
IP
|
$25.94
|
|
|
Service Code
|
NDC 573286893
|
| Hospital Charge Code |
77868
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.34 |
| Max. Negotiated Rate |
$23.35 |
| Rate for Payer: Aetna Commercial |
$22.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.86
|
| Rate for Payer: Cash Price |
$20.75
|
| Rate for Payer: Cofinity Commercial |
$18.16
|
| Rate for Payer: Cofinity Commercial |
$22.31
|
| Rate for Payer: Healthscope Commercial |
$23.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.05
|
| Rate for Payer: PHP Commercial |
$22.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.16
|
| Rate for Payer: Priority Health SBD |
$16.34
|
|
|
PHENYLEPHRINE 0.5 % NASAL SPRAY
|
Facility
|
IP
|
$18.70
|
|
|
Service Code
|
NDC 0225-0805-47
|
| Hospital Charge Code |
6244
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.78 |
| Max. Negotiated Rate |
$16.83 |
| Rate for Payer: Aetna Commercial |
$15.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.16
|
| Rate for Payer: Cash Price |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$13.09
|
| Rate for Payer: Cofinity Commercial |
$16.08
|
| Rate for Payer: Healthscope Commercial |
$16.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.90
|
| Rate for Payer: PHP Commercial |
$15.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.09
|
| Rate for Payer: Priority Health SBD |
$11.78
|
|
|
PHENYLEPHRINE 0.5 % NASAL SPRAY
|
Facility
|
IP
|
$17.96
|
|
|
Service Code
|
NDC 69536-050-15
|
| Hospital Charge Code |
6244
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna Commercial |
$15.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.67
|
| Rate for Payer: Cash Price |
$14.37
|
| Rate for Payer: Cofinity Commercial |
$12.57
|
| Rate for Payer: Cofinity Commercial |
$15.45
|
| Rate for Payer: Healthscope Commercial |
$16.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.27
|
| Rate for Payer: PHP Commercial |
$15.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.57
|
| Rate for Payer: Priority Health SBD |
$11.31
|
|
|
PHENYLEPHRINE 0.5 % NASAL SPRAY
|
Facility
|
IP
|
$17.96
|
|
|
Service Code
|
NDC 5032300603
|
| Hospital Charge Code |
6244
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna Commercial |
$15.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.67
|
| Rate for Payer: Cash Price |
$14.37
|
| Rate for Payer: Cofinity Commercial |
$12.57
|
| Rate for Payer: Cofinity Commercial |
$15.45
|
| Rate for Payer: Healthscope Commercial |
$16.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.27
|
| Rate for Payer: PHP Commercial |
$15.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.57
|
| Rate for Payer: Priority Health SBD |
$11.31
|
|
|
PHENYLEPHRINE 10 MG IN NS 200 ML
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 9900-0002-09
|
| Hospital Charge Code |
155016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.75
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cofinity Commercial |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.75
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.50
|
| Rate for Payer: Priority Health SBD |
$22.05
|
|
|
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$186.04
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
6242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$117.21 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$158.13
|
| Rate for Payer: Aetna Commercial |
$8.90
|
| Rate for Payer: Aetna Commercial |
$14.24
|
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna Commercial |
$13.54
|
| Rate for Payer: Aetna Commercial |
$20.35
|
| Rate for Payer: Aetna Commercial |
$17.65
|
| Rate for Payer: Aetna Commercial |
$13.76
|
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Commercial |
$14.10
|
| Rate for Payer: Aetna Commercial |
$155.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.35
|
| Rate for Payer: Cash Price |
$13.40
|
| Rate for Payer: Cash Price |
$13.32
|
| Rate for Payer: Cash Price |
$16.62
|
| Rate for Payer: Cash Price |
$12.95
|
| Rate for Payer: Cash Price |
$13.27
|
| Rate for Payer: Cash Price |
$12.74
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cash Price |
$8.38
|
| Rate for Payer: Cash Price |
$146.51
|
| Rate for Payer: Cash Price |
$73.32
|
| Rate for Payer: Cash Price |
$19.15
|
| Rate for Payer: Cash Price |
$148.83
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Commercial |
$7.33
|
| Rate for Payer: Cofinity Commercial |
$9.00
|
| Rate for Payer: Cofinity Commercial |
$11.15
|
| Rate for Payer: Cofinity Commercial |
$13.70
|
| Rate for Payer: Cofinity Commercial |
$11.33
|
| Rate for Payer: Cofinity Commercial |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$14.27
|
| Rate for Payer: Cofinity Commercial |
$11.66
|
| Rate for Payer: Cofinity Commercial |
$14.32
|
| Rate for Payer: Cofinity Commercial |
$11.72
|
| Rate for Payer: Cofinity Commercial |
$14.40
|
| Rate for Payer: Cofinity Commercial |
$128.20
|
| Rate for Payer: Cofinity Commercial |
$157.50
|
| Rate for Payer: Cofinity Commercial |
$130.23
|
| Rate for Payer: Cofinity Commercial |
$159.99
|
| Rate for Payer: Cofinity Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$14.54
|
| Rate for Payer: Cofinity Commercial |
$17.86
|
| Rate for Payer: Cofinity Commercial |
$16.76
|
| Rate for Payer: Cofinity Commercial |
$20.59
|
| Rate for Payer: Cofinity Commercial |
$64.16
|
| Rate for Payer: Cofinity Commercial |
$78.82
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Healthscope Commercial |
$164.83
|
| Rate for Payer: Healthscope Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$9.42
|
| Rate for Payer: Healthscope Commercial |
$14.93
|
| Rate for Payer: Healthscope Commercial |
$21.55
|
| Rate for Payer: Healthscope Commercial |
$167.44
|
| Rate for Payer: Healthscope Commercial |
$82.48
|
| Rate for Payer: Healthscope Commercial |
$14.34
|
| Rate for Payer: Healthscope Commercial |
$14.57
|
| Rate for Payer: Healthscope Commercial |
$18.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$155.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$158.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.35
|
| Rate for Payer: PHP Commercial |
$13.76
|
| Rate for Payer: PHP Commercial |
$14.10
|
| Rate for Payer: PHP Commercial |
$155.67
|
| Rate for Payer: PHP Commercial |
$14.24
|
| Rate for Payer: PHP Commercial |
$158.13
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: PHP Commercial |
$13.54
|
| Rate for Payer: PHP Commercial |
$17.65
|
| Rate for Payer: PHP Commercial |
$20.35
|
| Rate for Payer: PHP Commercial |
$8.90
|
| Rate for Payer: PHP Commercial |
$14.15
|
| Rate for Payer: PHP Commercial |
$77.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.15
|
| Rate for Payer: Priority Health SBD |
$10.20
|
| Rate for Payer: Priority Health SBD |
$13.09
|
| Rate for Payer: Priority Health SBD |
$117.21
|
| Rate for Payer: Priority Health SBD |
$6.60
|
| Rate for Payer: Priority Health SBD |
$10.49
|
| Rate for Payer: Priority Health SBD |
$15.08
|
| Rate for Payer: Priority Health SBD |
$115.38
|
| Rate for Payer: Priority Health SBD |
$10.55
|
| Rate for Payer: Priority Health SBD |
$57.74
|
| Rate for Payer: Priority Health SBD |
$11.79
|
| Rate for Payer: Priority Health SBD |
$10.45
|
| Rate for Payer: Priority Health SBD |
$10.04
|
|
