|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
OP
|
$326.80
|
|
|
Service Code
|
NDC 75826011510
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.72 |
| Max. Negotiated Rate |
$294.12 |
| Rate for Payer: Aetna Commercial |
$277.78
|
| Rate for Payer: Aetna Medicare |
$163.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.42
|
| Rate for Payer: BCBS Complete |
$130.72
|
| Rate for Payer: Cash Price |
$261.44
|
| Rate for Payer: Cofinity Commercial |
$228.76
|
| Rate for Payer: Cofinity Commercial |
$281.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$228.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.44
|
| Rate for Payer: Healthscope Commercial |
$294.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.78
|
| Rate for Payer: PHP Commercial |
$277.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.42
|
| Rate for Payer: Priority Health SBD |
$205.88
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
OP
|
$216.97
|
|
|
Service Code
|
NDC 00603150858
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.79 |
| Max. Negotiated Rate |
$195.27 |
| Rate for Payer: Aetna Commercial |
$184.42
|
| Rate for Payer: Aetna Medicare |
$108.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.03
|
| Rate for Payer: BCBS Complete |
$86.79
|
| Rate for Payer: Cash Price |
$173.58
|
| Rate for Payer: Cofinity Commercial |
$151.88
|
| Rate for Payer: Cofinity Commercial |
$186.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$151.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.58
|
| Rate for Payer: Healthscope Commercial |
$195.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.42
|
| Rate for Payer: PHP Commercial |
$184.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.03
|
| Rate for Payer: Priority Health SBD |
$136.69
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$212.29
|
|
|
Service Code
|
NDC 13517010716
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.74 |
| Max. Negotiated Rate |
$191.06 |
| Rate for Payer: Aetna Commercial |
$180.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.99
|
| Rate for Payer: Cash Price |
$169.83
|
| Rate for Payer: Cofinity Commercial |
$148.60
|
| Rate for Payer: Cofinity Commercial |
$182.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.83
|
| Rate for Payer: Healthscope Commercial |
$191.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.45
|
| Rate for Payer: PHP Commercial |
$180.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.99
|
| Rate for Payer: Priority Health SBD |
$133.74
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
OP
|
$212.29
|
|
|
Service Code
|
NDC 13517010716
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.92 |
| Max. Negotiated Rate |
$191.06 |
| Rate for Payer: Aetna Commercial |
$180.45
|
| Rate for Payer: Aetna Medicare |
$106.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.99
|
| Rate for Payer: BCBS Complete |
$84.92
|
| Rate for Payer: Cash Price |
$169.83
|
| Rate for Payer: Cofinity Commercial |
$148.60
|
| Rate for Payer: Cofinity Commercial |
$182.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.83
|
| Rate for Payer: Healthscope Commercial |
$191.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.45
|
| Rate for Payer: PHP Commercial |
$180.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.99
|
| Rate for Payer: Priority Health SBD |
$133.74
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$216.97
|
|
|
Service Code
|
NDC 00603150858
|
| 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: Cofinity Medicare Advantage |
$151.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.58
|
| Rate for Payer: Healthscope Commercial |
$195.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.42
|
| Rate for Payer: PHP Commercial |
$184.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.03
|
| Rate for Payer: Priority Health SBD |
$136.69
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
OP
|
$279.30
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
6217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.72 |
| Max. Negotiated Rate |
$251.37 |
| Rate for Payer: Aetna Commercial |
$237.41
|
| Rate for Payer: Aetna Medicare |
$139.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.54
|
| Rate for Payer: BCBS Complete |
$111.72
|
| Rate for Payer: Cash Price |
$223.44
|
| Rate for Payer: Cofinity Commercial |
$195.51
|
| Rate for Payer: Cofinity Commercial |
$240.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$195.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.44
|
| Rate for Payer: Healthscope Commercial |
$251.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.41
|
| Rate for Payer: PHP Commercial |
$237.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.54
|
| Rate for Payer: Priority Health SBD |
$175.96
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
IP
|
$279.30
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
6217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.96 |
| Max. Negotiated Rate |
$251.37 |
| Rate for Payer: Aetna Commercial |
$237.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.54
|
| Rate for Payer: Cash Price |
$223.44
|
| Rate for Payer: Cofinity Commercial |
$195.51
|
| Rate for Payer: Cofinity Commercial |
$240.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$195.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.44
|
| Rate for Payer: Healthscope Commercial |
$251.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.41
|
| Rate for Payer: PHP Commercial |
$237.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.54
|
| Rate for Payer: Priority Health SBD |
$175.96
|
|
|
PHENOBARBITAL 97.2 MG TABLET
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
NDC 16571066801
|
| Hospital Charge Code |
6220
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.60 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna Medicare |
$104.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.85
|
| Rate for Payer: BCBS Complete |
$83.60
|
| Rate for Payer: Cash Price |
$167.20
|
| Rate for Payer: Cofinity Commercial |
$146.30
|
| Rate for Payer: Cofinity Commercial |
$179.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.20
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.65
|
| Rate for Payer: PHP Commercial |
$177.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.85
|
| Rate for Payer: Priority Health SBD |
$131.67
|
|
|
PHENOBARBITAL 97.2 MG TABLET
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
NDC 16571066801
|
| 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: Cofinity Medicare Advantage |
$146.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.20
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.65
|
| Rate for Payer: PHP Commercial |
$177.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.85
|
| Rate for Payer: Priority Health SBD |
$131.67
|
|
|
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$182.28
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
6221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.91 |
| Max. Negotiated Rate |
$164.05 |
| Rate for Payer: Aetna Commercial |
$154.94
|
| Rate for Payer: Aetna Commercial |
$110.52
|
| Rate for Payer: Aetna Medicare |
$65.01
|
| Rate for Payer: Aetna Medicare |
$91.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.51
|
| Rate for Payer: BCBS Complete |
$72.91
|
| Rate for Payer: BCBS Complete |
$52.01
|
| Rate for Payer: Cash Price |
$145.82
|
| Rate for Payer: Cash Price |
$104.02
|
| Rate for Payer: Cofinity Commercial |
$156.76
|
| Rate for Payer: Cofinity Commercial |
$111.82
|
| Rate for Payer: Cofinity Commercial |
$91.01
|
| Rate for Payer: Cofinity Commercial |
$127.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.82
|
| Rate for Payer: Healthscope Commercial |
$164.05
|
| Rate for Payer: Healthscope Commercial |
$117.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$154.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.52
|
| Rate for Payer: PHP Commercial |
$154.94
|
| Rate for Payer: PHP Commercial |
$110.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.48
|
| Rate for Payer: Priority Health SBD |
$81.91
|
| Rate for Payer: Priority Health SBD |
$114.84
|
|
|
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$130.02
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
6221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.91 |
| Max. Negotiated Rate |
$117.02 |
| Rate for Payer: Aetna Commercial |
$110.52
|
| Rate for Payer: Aetna Commercial |
$154.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.48
|
| Rate for Payer: Cash Price |
$104.02
|
| Rate for Payer: Cash Price |
$145.82
|
| Rate for Payer: Cofinity Commercial |
$111.82
|
| Rate for Payer: Cofinity Commercial |
$127.60
|
| Rate for Payer: Cofinity Commercial |
$156.76
|
| Rate for Payer: Cofinity Commercial |
$91.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$91.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.82
|
| Rate for Payer: Healthscope Commercial |
$117.02
|
| Rate for Payer: Healthscope Commercial |
$164.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$154.94
|
| Rate for Payer: PHP Commercial |
$110.52
|
| Rate for Payer: PHP Commercial |
$154.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.51
|
| Rate for Payer: Priority Health SBD |
$114.84
|
| Rate for Payer: Priority Health SBD |
$81.91
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$25.49
|
|
|
Service Code
|
NDC 78112001103
|
| 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: Cofinity Medicare Advantage |
$17.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.39
|
| Rate for Payer: Healthscope Commercial |
$22.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.67
|
| Rate for Payer: PHP Commercial |
$21.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.57
|
| Rate for Payer: Priority Health SBD |
$16.06
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$10.62
|
|
|
Service Code
|
NDC 70000045801
|
| 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: Cofinity Medicare Advantage |
$7.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.50
|
| Rate for Payer: Healthscope Commercial |
$9.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.03
|
| Rate for Payer: PHP Commercial |
$9.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.90
|
| Rate for Payer: Priority Health SBD |
$6.69
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$9.56
|
|
|
Service Code
|
NDC 96295013644
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$8.60 |
| Rate for Payer: Aetna Commercial |
$8.13
|
| Rate for Payer: Aetna Medicare |
$4.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.21
|
| Rate for Payer: BCBS Complete |
$3.82
|
| Rate for Payer: Cash Price |
$7.65
|
| Rate for Payer: Cofinity Commercial |
$6.69
|
| Rate for Payer: Cofinity Commercial |
$8.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.65
|
| Rate for Payer: Healthscope Commercial |
$8.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.13
|
| Rate for Payer: PHP Commercial |
$8.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.21
|
| Rate for Payer: Priority Health SBD |
$6.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$9.56
|
|
|
Service Code
|
NDC 96295013644
|
| 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: Cofinity Medicare Advantage |
$6.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.65
|
| Rate for Payer: Healthscope Commercial |
$8.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.13
|
| Rate for Payer: PHP Commercial |
$8.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.21
|
| Rate for Payer: Priority Health SBD |
$6.02
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$10.62
|
|
|
Service Code
|
NDC 70000045801
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: Aetna Commercial |
$9.03
|
| Rate for Payer: Aetna Medicare |
$5.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.90
|
| Rate for Payer: BCBS Complete |
$4.25
|
| Rate for Payer: Cash Price |
$8.50
|
| Rate for Payer: Cofinity Commercial |
$7.43
|
| Rate for Payer: Cofinity Commercial |
$9.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.50
|
| Rate for Payer: Healthscope Commercial |
$9.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.03
|
| Rate for Payer: PHP Commercial |
$9.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.90
|
| Rate for Payer: Priority Health SBD |
$6.69
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
OP
|
$25.49
|
|
|
Service Code
|
NDC 78112001103
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$22.94 |
| Rate for Payer: Aetna Commercial |
$21.67
|
| Rate for Payer: Aetna Medicare |
$12.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.57
|
| Rate for Payer: BCBS Complete |
$10.20
|
| Rate for Payer: Cash Price |
$20.39
|
| Rate for Payer: Cofinity Commercial |
$17.84
|
| Rate for Payer: Cofinity Commercial |
$21.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.39
|
| Rate for Payer: Healthscope Commercial |
$22.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.67
|
| Rate for Payer: PHP Commercial |
$21.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.57
|
| Rate for Payer: Priority Health SBD |
$16.06
|
|
|
PHENTOLAMINE 0.5 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$309.10
|
|
|
Service Code
|
NDC 09900001943
|
| 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) |
$200.91
|
| Rate for Payer: Cash Price |
$247.28
|
| Rate for Payer: Cofinity Commercial |
$216.37
|
| Rate for Payer: Cofinity Commercial |
$265.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.28
|
| Rate for Payer: Healthscope Commercial |
$278.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$262.74
|
| Rate for Payer: PHP Commercial |
$262.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.91
|
| Rate for Payer: Priority Health SBD |
$194.73
|
|
|
PHENTOLAMINE 0.5 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
OP
|
$309.10
|
|
|
Service Code
|
NDC 09900001943
|
| Hospital Charge Code |
150967
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$123.64 |
| Max. Negotiated Rate |
$278.19 |
| Rate for Payer: Aetna Commercial |
$262.74
|
| Rate for Payer: Aetna Medicare |
$154.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.91
|
| Rate for Payer: BCBS Complete |
$123.64
|
| Rate for Payer: Cash Price |
$247.28
|
| Rate for Payer: Cofinity Commercial |
$216.37
|
| Rate for Payer: Cofinity Commercial |
$265.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.28
|
| Rate for Payer: Healthscope Commercial |
$278.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$262.74
|
| Rate for Payer: PHP Commercial |
$262.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.91
|
| Rate for Payer: Priority Health SBD |
$194.73
|
|
|
PHENTOLAMINE 1 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
OP
|
$1,671.75
|
|
|
Service Code
|
NDC 09900001945
|
| Hospital Charge Code |
301530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$668.70 |
| Max. Negotiated Rate |
$1,504.58 |
| Rate for Payer: Aetna Commercial |
$1,420.99
|
| Rate for Payer: Aetna Medicare |
$835.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,086.64
|
| Rate for Payer: BCBS Complete |
$668.70
|
| 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: Cofinity Medicare Advantage |
$1,170.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,337.40
|
| Rate for Payer: Healthscope Commercial |
$1,504.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,420.99
|
| Rate for Payer: PHP Commercial |
$1,420.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,086.64
|
| Rate for Payer: Priority Health SBD |
$1,053.20
|
|
|
PHENTOLAMINE 1 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
OP
|
$618.20
|
|
|
Service Code
|
NDC 09900001944
|
| Hospital Charge Code |
301530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$247.28 |
| Max. Negotiated Rate |
$556.38 |
| Rate for Payer: Aetna Commercial |
$525.47
|
| Rate for Payer: Aetna Medicare |
$309.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$401.83
|
| Rate for Payer: BCBS Complete |
$247.28
|
| Rate for Payer: Cash Price |
$494.56
|
| Rate for Payer: Cofinity Commercial |
$432.74
|
| Rate for Payer: Cofinity Commercial |
$531.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$432.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$494.56
|
| Rate for Payer: Healthscope Commercial |
$556.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$525.47
|
| Rate for Payer: PHP Commercial |
$525.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$401.83
|
| Rate for Payer: Priority Health SBD |
$389.47
|
|
|
PHENTOLAMINE 1 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$618.20
|
|
|
Service Code
|
NDC 09900001944
|
| 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: Cofinity Medicare Advantage |
$432.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$494.56
|
| Rate for Payer: Healthscope Commercial |
$556.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$525.47
|
| Rate for Payer: PHP Commercial |
$525.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$401.83
|
| Rate for Payer: Priority Health SBD |
$389.47
|
|
|
PHENTOLAMINE 1 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$1,671.75
|
|
|
Service Code
|
NDC 09900001945
|
| 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: Cofinity Medicare Advantage |
$1,170.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,337.40
|
| Rate for Payer: Healthscope Commercial |
$1,504.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,420.99
|
| Rate for Payer: PHP Commercial |
$1,420.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,086.64
|
| Rate for Payer: Priority Health SBD |
$1,053.20
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION
|
Facility
|
OP
|
$1,385.25
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
10947
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$231.56 |
| Max. Negotiated Rate |
$1,246.72 |
| Rate for Payer: Aetna Commercial |
$1,177.46
|
| Rate for Payer: Aetna Medicare |
$449.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$900.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$540.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$540.02
|
| Rate for Payer: BCBS Complete |
$243.14
|
| Rate for Payer: BCBS MAPPO |
$432.02
|
| Rate for Payer: BCN Medicare Advantage |
$432.02
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cofinity Commercial |
$969.67
|
| Rate for Payer: Cofinity Commercial |
$1,191.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$969.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,108.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$432.02
|
| Rate for Payer: Healthscope Commercial |
$1,246.72
|
| Rate for Payer: Mclaren Medicaid |
$231.56
|
| Rate for Payer: Mclaren Medicare |
$432.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$453.62
|
| Rate for Payer: Meridian Medicaid |
$243.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$496.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,177.46
|
| Rate for Payer: PACE Medicare |
$410.42
|
| Rate for Payer: PACE SWMI |
$432.02
|
| Rate for Payer: PHP Commercial |
$1,177.46
|
| Rate for Payer: PHP Medicare Advantage |
$432.02
|
| Rate for Payer: Priority Health Choice Medicaid |
$231.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$900.41
|
| Rate for Payer: Priority Health Medicare |
$432.02
|
| Rate for Payer: Priority Health SBD |
$872.71
|
| Rate for Payer: Railroad Medicare Medicare |
$432.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,216.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$432.02
|
| Rate for Payer: UHC Medicare Advantage |
$432.02
|
| Rate for Payer: UHCCP Medicaid |
$243.23
|
| Rate for Payer: VA VA |
$432.02
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION
|
Facility
|
IP
|
$1,385.25
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
10947
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$872.71 |
| Max. Negotiated Rate |
$1,246.72 |
| Rate for Payer: Aetna Commercial |
$1,177.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$900.41
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cofinity Commercial |
$1,191.32
|
| Rate for Payer: Cofinity Commercial |
$969.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$969.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,108.20
|
| Rate for Payer: Healthscope Commercial |
$1,246.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,177.46
|
| Rate for Payer: PHP Commercial |
$1,177.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$900.41
|
| Rate for Payer: Priority Health SBD |
$872.71
|
|
