Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$21.17

Service Code	NDC 66689003601
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$13.34
Max. Negotiated Rate	$19.05
Rate for Payer: Aetna Commercial	$17.99
Rate for Payer: Aetna New Business (MI Preferred)	$13.76
Rate for Payer: Cash Price	$16.94
Rate for Payer: Cofinity Advantage	$14.82
Rate for Payer: Cofinity Commercial	$18.21
Rate for Payer: Encore Health Key Benefits Commercial	$16.94
Rate for Payer: Healthscope Commercial	$19.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.99
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.88
Rate for Payer: PHP Commercial	$17.99
Rate for Payer: Priority Health SBD	$13.34

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$22.38

Service Code	NDC 60687027566
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$20.14
Rate for Payer: Aetna Commercial	$19.02
Rate for Payer: Aetna Medicare	$11.19
Rate for Payer: Aetna New Business (MI Preferred)	$14.55
Rate for Payer: BCBS Complete	$8.95
Rate for Payer: Cash Price	$17.90
Rate for Payer: Cofinity Advantage	$15.67
Rate for Payer: Cofinity Commercial	$19.25
Rate for Payer: Encore Health Key Benefits Commercial	$17.90
Rate for Payer: Healthscope Commercial	$20.14
Rate for Payer: MI Amish Medical Board Commercial	$17.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.79
Rate for Payer: PHP Commercial	$19.02
Rate for Payer: Priority Health SBD	$14.10
Rate for Payer: UHC All Payor (Choice/PPO)	$14.55
Rate for Payer: UHC Core	$11.66
Rate for Payer: UHC Exchange	$8.80

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$22.38

Service Code	NDC 60687027562
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$14.10
Max. Negotiated Rate	$20.14
Rate for Payer: Aetna Commercial	$19.02
Rate for Payer: Aetna New Business (MI Preferred)	$14.55
Rate for Payer: Cash Price	$17.90
Rate for Payer: Cofinity Advantage	$15.67
Rate for Payer: Cofinity Commercial	$19.25
Rate for Payer: Encore Health Key Benefits Commercial	$17.90
Rate for Payer: Healthscope Commercial	$20.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.79
Rate for Payer: PHP Commercial	$19.02
Rate for Payer: Priority Health SBD	$14.10

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$21.17

Service Code	NDC 66689003650
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$13.34
Max. Negotiated Rate	$19.05
Rate for Payer: Aetna Commercial	$17.99
Rate for Payer: Aetna New Business (MI Preferred)	$13.76
Rate for Payer: Cash Price	$16.94
Rate for Payer: Cofinity Advantage	$14.82
Rate for Payer: Cofinity Commercial	$18.21
Rate for Payer: Encore Health Key Benefits Commercial	$16.94
Rate for Payer: Healthscope Commercial	$19.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.99
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.88
Rate for Payer: PHP Commercial	$17.99
Rate for Payer: Priority Health SBD	$13.34

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$21.17

Service Code	NDC 66689003601
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$19.05
Rate for Payer: Aetna Commercial	$17.99
Rate for Payer: Aetna Medicare	$10.59
Rate for Payer: Aetna New Business (MI Preferred)	$13.76
Rate for Payer: BCBS Complete	$8.47
Rate for Payer: Cash Price	$16.94
Rate for Payer: Cofinity Advantage	$14.82
Rate for Payer: Cofinity Commercial	$18.21
Rate for Payer: Encore Health Key Benefits Commercial	$16.94
Rate for Payer: Healthscope Commercial	$19.05
Rate for Payer: MI Amish Medical Board Commercial	$16.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.99
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.88
Rate for Payer: PHP Commercial	$17.99
Rate for Payer: Priority Health SBD	$13.34
Rate for Payer: UHC All Payor (Choice/PPO)	$13.76
Rate for Payer: UHC Core	$11.03
Rate for Payer: UHC Exchange	$8.32

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$22.38

Service Code	NDC 60687027563
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$20.14
Rate for Payer: Aetna Commercial	$19.02
Rate for Payer: Aetna Medicare	$11.19
Rate for Payer: Aetna New Business (MI Preferred)	$14.55
Rate for Payer: BCBS Complete	$8.95
Rate for Payer: Cash Price	$17.90
Rate for Payer: Cofinity Advantage	$15.67
Rate for Payer: Cofinity Commercial	$19.25
Rate for Payer: Encore Health Key Benefits Commercial	$17.90
Rate for Payer: Healthscope Commercial	$20.14
Rate for Payer: MI Amish Medical Board Commercial	$17.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.79
Rate for Payer: PHP Commercial	$19.02
Rate for Payer: Priority Health SBD	$14.10
Rate for Payer: UHC All Payor (Choice/PPO)	$14.55
Rate for Payer: UHC Core	$11.66
Rate for Payer: UHC Exchange	$8.80

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$3.47

Service Code	NDC 09900000406
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$3.12
Rate for Payer: Aetna Commercial	$2.95
Rate for Payer: Aetna Medicare	$1.74
Rate for Payer: Aetna New Business (MI Preferred)	$2.26
Rate for Payer: BCBS Complete	$1.39
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cofinity Advantage	$2.43
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Encore Health Key Benefits Commercial	$2.78
Rate for Payer: Healthscope Commercial	$3.12
Rate for Payer: MI Amish Medical Board Commercial	$2.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.60
Rate for Payer: PHP Commercial	$2.95
Rate for Payer: Priority Health SBD	$2.19
Rate for Payer: UHC All Payor (Choice/PPO)	$2.26
Rate for Payer: UHC Core	$1.81
Rate for Payer: UHC Exchange	$1.36

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$3.47

Service Code	NDC 09900000406
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$3.12
Rate for Payer: Aetna Commercial	$2.95
Rate for Payer: Aetna New Business (MI Preferred)	$2.26
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cofinity Advantage	$2.43
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Encore Health Key Benefits Commercial	$2.78
Rate for Payer: Healthscope Commercial	$3.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.60
Rate for Payer: PHP Commercial	$2.95
Rate for Payer: Priority Health SBD	$2.19

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$22.38

Service Code	NDC 60687027566
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$14.10
Max. Negotiated Rate	$20.14
Rate for Payer: Aetna Commercial	$19.02
Rate for Payer: Aetna New Business (MI Preferred)	$14.55
Rate for Payer: Cash Price	$17.90
Rate for Payer: Cofinity Advantage	$15.67
Rate for Payer: Cofinity Commercial	$19.25
Rate for Payer: Encore Health Key Benefits Commercial	$17.90
Rate for Payer: Healthscope Commercial	$20.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.02
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.79
Rate for Payer: PHP Commercial	$19.02
Rate for Payer: Priority Health SBD	$14.10

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION

Facility

$590.37

Service Code	NDC 60432013108
Hospital Charge Code	6255
Hospital Revenue Code	637
Min. Negotiated Rate	$371.93
Max. Negotiated Rate	$531.33
Rate for Payer: Aetna Commercial	$501.81
Rate for Payer: Aetna New Business (MI Preferred)	$383.74
Rate for Payer: Cash Price	$472.30
Rate for Payer: Cofinity Advantage	$413.26
Rate for Payer: Cofinity Commercial	$507.72
Rate for Payer: Encore Health Key Benefits Commercial	$472.30
Rate for Payer: Healthscope Commercial	$531.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$501.81
Rate for Payer: Opus (Opus Packaging Group) HMA	$442.78
Rate for Payer: PHP Commercial	$501.81
Rate for Payer: Priority Health SBD	$371.93

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION

Facility

$295.19

Service Code	NDC 51672406901
Hospital Charge Code	6255
Hospital Revenue Code	637
Min. Negotiated Rate	$185.97
Max. Negotiated Rate	$265.67
Rate for Payer: Aetna Commercial	$250.91
Rate for Payer: Aetna New Business (MI Preferred)	$191.87
Rate for Payer: Cash Price	$236.15
Rate for Payer: Cofinity Advantage	$206.63
Rate for Payer: Cofinity Commercial	$253.86
Rate for Payer: Encore Health Key Benefits Commercial	$236.15
Rate for Payer: Healthscope Commercial	$265.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$250.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$221.39
Rate for Payer: PHP Commercial	$250.91
Rate for Payer: Priority Health SBD	$185.97

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION

Facility

$295.19

Service Code	NDC 51672406901
Hospital Charge Code	6255
Hospital Revenue Code	637
Min. Negotiated Rate	$116.01
Max. Negotiated Rate	$265.67
Rate for Payer: Aetna Commercial	$250.91
Rate for Payer: Aetna Medicare	$147.59
Rate for Payer: Aetna New Business (MI Preferred)	$191.87
Rate for Payer: BCBS Complete	$118.08
Rate for Payer: Cash Price	$236.15
Rate for Payer: Cofinity Advantage	$206.63
Rate for Payer: Cofinity Commercial	$253.86
Rate for Payer: Encore Health Key Benefits Commercial	$236.15
Rate for Payer: Healthscope Commercial	$265.67
Rate for Payer: MI Amish Medical Board Commercial	$236.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$250.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$221.39
Rate for Payer: PHP Commercial	$250.91
Rate for Payer: Priority Health SBD	$185.97
Rate for Payer: UHC All Payor (Choice/PPO)	$191.87
Rate for Payer: UHC Core	$153.79
Rate for Payer: UHC Exchange	$116.01

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION

Facility

$891.88

Service Code	NDC 58151011535
Hospital Charge Code	6255
Hospital Revenue Code	637
Min. Negotiated Rate	$350.51
Max. Negotiated Rate	$802.69
Rate for Payer: Aetna Commercial	$758.10
Rate for Payer: Aetna Medicare	$445.94
Rate for Payer: Aetna New Business (MI Preferred)	$579.72
Rate for Payer: BCBS Complete	$356.75
Rate for Payer: Cash Price	$713.50
Rate for Payer: Cofinity Advantage	$624.32
Rate for Payer: Cofinity Commercial	$767.02
Rate for Payer: Encore Health Key Benefits Commercial	$713.50
Rate for Payer: Healthscope Commercial	$802.69
Rate for Payer: MI Amish Medical Board Commercial	$713.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$758.10
Rate for Payer: Opus (Opus Packaging Group) HMA	$668.91
Rate for Payer: PHP Commercial	$758.10
Rate for Payer: Priority Health SBD	$561.88
Rate for Payer: UHC All Payor (Choice/PPO)	$579.72
Rate for Payer: UHC Core	$464.67
Rate for Payer: UHC Exchange	$350.51

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION

Facility

$891.88

Service Code	NDC 58151011535
Hospital Charge Code	6255
Hospital Revenue Code	637
Min. Negotiated Rate	$561.88
Max. Negotiated Rate	$802.69
Rate for Payer: Aetna Commercial	$758.10
Rate for Payer: Aetna New Business (MI Preferred)	$579.72
Rate for Payer: Cash Price	$713.50
Rate for Payer: Cofinity Advantage	$624.32
Rate for Payer: Cofinity Commercial	$767.02
Rate for Payer: Encore Health Key Benefits Commercial	$713.50
Rate for Payer: Healthscope Commercial	$802.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$758.10
Rate for Payer: Opus (Opus Packaging Group) HMA	$668.91
Rate for Payer: PHP Commercial	$758.10
Rate for Payer: Priority Health SBD	$561.88

PHENYTOIN 125 MG/5 ML ORAL SUSPENSION

Facility

$590.37

Service Code	NDC 60432013108
Hospital Charge Code	6255
Hospital Revenue Code	637
Min. Negotiated Rate	$232.02
Max. Negotiated Rate	$531.33
Rate for Payer: Aetna Commercial	$501.81
Rate for Payer: Aetna Medicare	$295.19
Rate for Payer: Aetna New Business (MI Preferred)	$383.74
Rate for Payer: BCBS Complete	$236.15
Rate for Payer: Cash Price	$472.30
Rate for Payer: Cofinity Advantage	$413.26
Rate for Payer: Cofinity Commercial	$507.72
Rate for Payer: Encore Health Key Benefits Commercial	$472.30
Rate for Payer: Healthscope Commercial	$531.33
Rate for Payer: MI Amish Medical Board Commercial	$472.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$501.81
Rate for Payer: Opus (Opus Packaging Group) HMA	$442.78
Rate for Payer: PHP Commercial	$501.81
Rate for Payer: Priority Health SBD	$371.93
Rate for Payer: UHC All Payor (Choice/PPO)	$383.74
Rate for Payer: UHC Core	$307.58
Rate for Payer: UHC Exchange	$232.02

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$140.64

Service Code	NDC 51079012906
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$88.60
Max. Negotiated Rate	$126.58
Rate for Payer: Aetna Commercial	$119.54
Rate for Payer: Aetna New Business (MI Preferred)	$91.42
Rate for Payer: Cash Price	$112.51
Rate for Payer: Cofinity Advantage	$98.45
Rate for Payer: Cofinity Commercial	$120.95
Rate for Payer: Encore Health Key Benefits Commercial	$112.51
Rate for Payer: Healthscope Commercial	$126.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.54
Rate for Payer: Opus (Opus Packaging Group) HMA	$105.48
Rate for Payer: PHP Commercial	$119.54
Rate for Payer: Priority Health SBD	$88.60

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$140.64

Service Code	NDC 51079012906
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$55.27
Max. Negotiated Rate	$126.58
Rate for Payer: Aetna Commercial	$119.54
Rate for Payer: Aetna Medicare	$70.32
Rate for Payer: Aetna New Business (MI Preferred)	$91.42
Rate for Payer: BCBS Complete	$56.26
Rate for Payer: Cash Price	$112.51
Rate for Payer: Cofinity Advantage	$98.45
Rate for Payer: Cofinity Commercial	$120.95
Rate for Payer: Encore Health Key Benefits Commercial	$112.51
Rate for Payer: Healthscope Commercial	$126.58
Rate for Payer: MI Amish Medical Board Commercial	$112.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.54
Rate for Payer: Opus (Opus Packaging Group) HMA	$105.48
Rate for Payer: PHP Commercial	$119.54
Rate for Payer: Priority Health SBD	$88.60
Rate for Payer: UHC All Payor (Choice/PPO)	$91.42
Rate for Payer: UHC Core	$73.27
Rate for Payer: UHC Exchange	$55.27

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$2.82

Service Code	NDC 51079012901
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna Commercial	$2.40
Rate for Payer: Aetna New Business (MI Preferred)	$1.83
Rate for Payer: Cash Price	$2.26
Rate for Payer: Cofinity Advantage	$1.97
Rate for Payer: Cofinity Commercial	$2.43
Rate for Payer: Encore Health Key Benefits Commercial	$2.26
Rate for Payer: Healthscope Commercial	$2.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.12
Rate for Payer: PHP Commercial	$2.40
Rate for Payer: Priority Health SBD	$1.78

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$372.40

Service Code	NDC 51672414601
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$146.35
Max. Negotiated Rate	$335.16
Rate for Payer: Aetna Commercial	$316.54
Rate for Payer: Aetna Medicare	$186.20
Rate for Payer: Aetna New Business (MI Preferred)	$242.06
Rate for Payer: BCBS Complete	$148.96
Rate for Payer: Cash Price	$297.92
Rate for Payer: Cofinity Advantage	$260.68
Rate for Payer: Cofinity Commercial	$320.26
Rate for Payer: Encore Health Key Benefits Commercial	$297.92
Rate for Payer: Healthscope Commercial	$335.16
Rate for Payer: MI Amish Medical Board Commercial	$297.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$316.54
Rate for Payer: Opus (Opus Packaging Group) HMA	$279.30
Rate for Payer: PHP Commercial	$316.54
Rate for Payer: Priority Health SBD	$234.61
Rate for Payer: UHC All Payor (Choice/PPO)	$242.06
Rate for Payer: UHC Core	$194.02
Rate for Payer: UHC Exchange	$146.35

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$738.72

Service Code	NDC 00071000724
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$465.39
Max. Negotiated Rate	$664.85
Rate for Payer: Aetna Commercial	$627.91
Rate for Payer: Aetna New Business (MI Preferred)	$480.17
Rate for Payer: Cash Price	$590.98
Rate for Payer: Cofinity Advantage	$517.10
Rate for Payer: Cofinity Commercial	$635.30
Rate for Payer: Encore Health Key Benefits Commercial	$590.98
Rate for Payer: Healthscope Commercial	$664.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$627.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$554.04
Rate for Payer: PHP Commercial	$627.91
Rate for Payer: Priority Health SBD	$465.39

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$738.72

Service Code	NDC 00071000724
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$290.32
Max. Negotiated Rate	$664.85
Rate for Payer: Aetna Commercial	$627.91
Rate for Payer: Aetna Medicare	$369.36
Rate for Payer: Aetna New Business (MI Preferred)	$480.17
Rate for Payer: BCBS Complete	$295.49
Rate for Payer: Cash Price	$590.98
Rate for Payer: Cofinity Advantage	$517.10
Rate for Payer: Cofinity Commercial	$635.30
Rate for Payer: Encore Health Key Benefits Commercial	$590.98
Rate for Payer: Healthscope Commercial	$664.85
Rate for Payer: MI Amish Medical Board Commercial	$590.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$627.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$554.04
Rate for Payer: PHP Commercial	$627.91
Rate for Payer: Priority Health SBD	$465.39
Rate for Payer: UHC All Payor (Choice/PPO)	$480.17
Rate for Payer: UHC Core	$384.87
Rate for Payer: UHC Exchange	$290.32

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$372.40

Service Code	NDC 51672414601
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$234.61
Max. Negotiated Rate	$335.16
Rate for Payer: Aetna Commercial	$316.54
Rate for Payer: Aetna New Business (MI Preferred)	$242.06
Rate for Payer: Cash Price	$297.92
Rate for Payer: Cofinity Advantage	$260.68
Rate for Payer: Cofinity Commercial	$320.26
Rate for Payer: Encore Health Key Benefits Commercial	$297.92
Rate for Payer: Healthscope Commercial	$335.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$316.54
Rate for Payer: Opus (Opus Packaging Group) HMA	$279.30
Rate for Payer: PHP Commercial	$316.54
Rate for Payer: Priority Health SBD	$234.61

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$2.82

Service Code	NDC 51079012901
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna Commercial	$2.40
Rate for Payer: Aetna Medicare	$1.41
Rate for Payer: Aetna New Business (MI Preferred)	$1.83
Rate for Payer: BCBS Complete	$1.13
Rate for Payer: Cash Price	$2.26
Rate for Payer: Cofinity Advantage	$1.97
Rate for Payer: Cofinity Commercial	$2.43
Rate for Payer: Encore Health Key Benefits Commercial	$2.26
Rate for Payer: Healthscope Commercial	$2.54
Rate for Payer: MI Amish Medical Board Commercial	$2.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.12
Rate for Payer: PHP Commercial	$2.40
Rate for Payer: Priority Health SBD	$1.78
Rate for Payer: UHC All Payor (Choice/PPO)	$1.83
Rate for Payer: UHC Core	$1.47
Rate for Payer: UHC Exchange	$1.11

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION

Facility

$14.97

Service Code	HCPCS J1165
Hospital Charge Code	6256
Hospital Revenue Code	636
Min. Negotiated Rate	$9.43
Max. Negotiated Rate	$13.47
Rate for Payer: Aetna Commercial	$12.72
Rate for Payer: Aetna Commercial	$18.31
Rate for Payer: Aetna Commercial	$24.53
Rate for Payer: Aetna New Business (MI Preferred)	$14.00
Rate for Payer: Aetna New Business (MI Preferred)	$9.73
Rate for Payer: Aetna New Business (MI Preferred)	$18.76
Rate for Payer: Cash Price	$23.09
Rate for Payer: Cash Price	$11.98
Rate for Payer: Cash Price	$17.23
Rate for Payer: Cofinity Advantage	$15.08
Rate for Payer: Cofinity Advantage	$10.48
Rate for Payer: Cofinity Advantage	$20.20
Rate for Payer: Cofinity Commercial	$18.52
Rate for Payer: Cofinity Commercial	$24.82
Rate for Payer: Cofinity Commercial	$12.87
Rate for Payer: Encore Health Key Benefits Commercial	$23.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.23
Rate for Payer: Encore Health Key Benefits Commercial	$11.98
Rate for Payer: Healthscope Commercial	$19.39
Rate for Payer: Healthscope Commercial	$13.47
Rate for Payer: Healthscope Commercial	$25.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$24.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$21.64
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.23
Rate for Payer: PHP Commercial	$12.72
Rate for Payer: PHP Commercial	$18.31
Rate for Payer: PHP Commercial	$24.53
Rate for Payer: Priority Health SBD	$13.57
Rate for Payer: Priority Health SBD	$9.43
Rate for Payer: Priority Health SBD	$18.18

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION

Facility

$14.97

Service Code	HCPCS J1165
Hospital Charge Code	6256
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$13.47
Rate for Payer: Aetna Commercial	$12.72
Rate for Payer: Aetna Commercial	$18.31
Rate for Payer: Aetna Commercial	$24.53
Rate for Payer: Aetna Medicare	$7.49
Rate for Payer: Aetna Medicare	$10.77
Rate for Payer: Aetna Medicare	$14.43
Rate for Payer: Aetna New Business (MI Preferred)	$9.73
Rate for Payer: Aetna New Business (MI Preferred)	$14.00
Rate for Payer: Aetna New Business (MI Preferred)	$18.76
Rate for Payer: BCBS Complete	$11.54
Rate for Payer: BCBS Complete	$5.99
Rate for Payer: BCBS Complete	$8.62
Rate for Payer: BCBS Trust/PPO	$1.48
Rate for Payer: BCBS Trust/PPO	$1.48
Rate for Payer: BCBS Trust/PPO	$1.48
Rate for Payer: BCN Commercial	$1.48
Rate for Payer: BCN Commercial	$1.48
Rate for Payer: BCN Commercial	$1.48
Rate for Payer: Cash Price	$23.09
Rate for Payer: Cash Price	$11.98
Rate for Payer: Cash Price	$11.98
Rate for Payer: Cash Price	$17.23
Rate for Payer: Cash Price	$23.09
Rate for Payer: Cash Price	$17.23
Rate for Payer: Cofinity Advantage	$15.08
Rate for Payer: Cofinity Advantage	$10.48
Rate for Payer: Cofinity Advantage	$20.20
Rate for Payer: Cofinity Commercial	$12.87
Rate for Payer: Cofinity Commercial	$18.52
Rate for Payer: Cofinity Commercial	$24.82
Rate for Payer: Encore Health Key Benefits Commercial	$17.23
Rate for Payer: Encore Health Key Benefits Commercial	$23.09
Rate for Payer: Encore Health Key Benefits Commercial	$11.98
Rate for Payer: Healthscope Commercial	$25.97
Rate for Payer: Healthscope Commercial	$19.39
Rate for Payer: Healthscope Commercial	$13.47
Rate for Payer: MI Amish Medical Board Commercial	$11.98
Rate for Payer: MI Amish Medical Board Commercial	$23.09
Rate for Payer: MI Amish Medical Board Commercial	$17.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$24.53
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.23
Rate for Payer: Opus (Opus Packaging Group) HMA	$21.64
Rate for Payer: PHP Commercial	$12.72
Rate for Payer: PHP Commercial	$18.31
Rate for Payer: PHP Commercial	$24.53
Rate for Payer: Priority Health SBD	$9.43
Rate for Payer: Priority Health SBD	$18.18
Rate for Payer: Priority Health SBD	$13.57
Rate for Payer: UHC All Payor (Choice/PPO)	$0.99
Rate for Payer: UHC All Payor (Choice/PPO)	$0.99
Rate for Payer: UHC All Payor (Choice/PPO)	$0.99
Rate for Payer: UHC Core	$0.99
Rate for Payer: UHC Core	$0.99
Rate for Payer: UHC Core	$0.99
Rate for Payer: UHC Exchange	$0.99
Rate for Payer: UHC Exchange	$0.99
Rate for Payer: UHC Exchange	$0.99

Know your out-of-pocket cost for care.

All Charges