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 Commercial	$14.82
Rate for Payer: Cofinity Commercial	$18.21
Rate for Payer: Cofinity Medicare Advantage	$14.82
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: PHP Commercial	$17.99
Rate for Payer: Priority Health Cigna Priority Health	$13.76
Rate for Payer: Priority Health SBD	$13.34

PHENYTOIN 100 MG/4 ML ORAL SUSPENSION

Facility

$19.30

Service Code	NDC 60687027562
Hospital Charge Code	118124
Hospital Revenue Code	637
Min. Negotiated Rate	$7.72
Max. Negotiated Rate	$17.37
Rate for Payer: Aetna Commercial	$16.40
Rate for Payer: Aetna Medicare	$9.65
Rate for Payer: Aetna New Business (MI Preferred)	$12.54
Rate for Payer: BCBS Complete	$7.72
Rate for Payer: Cash Price	$15.44
Rate for Payer: Cofinity Commercial	$13.51
Rate for Payer: Cofinity Commercial	$16.60
Rate for Payer: Cofinity Medicare Advantage	$13.51
Rate for Payer: Encore Health Key Benefits Commercial	$15.44
Rate for Payer: Healthscope Commercial	$17.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.40
Rate for Payer: PHP Commercial	$16.40
Rate for Payer: Priority Health Cigna Priority Health	$12.54
Rate for Payer: Priority Health SBD	$12.16

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	$8.47
Max. Negotiated Rate	$19.05
Rate for Payer: Aetna Commercial	$17.99
Rate for Payer: Aetna Medicare	$10.58
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 Commercial	$14.82
Rate for Payer: Cofinity Commercial	$18.21
Rate for Payer: Cofinity Medicare Advantage	$14.82
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: PHP Commercial	$17.99
Rate for Payer: Priority Health Cigna Priority Health	$13.76
Rate for Payer: Priority Health SBD	$13.34

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	$118.08
Max. Negotiated Rate	$265.67
Rate for Payer: Aetna Commercial	$250.91
Rate for Payer: Aetna Medicare	$147.60
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 Commercial	$206.63
Rate for Payer: Cofinity Commercial	$253.86
Rate for Payer: Cofinity Medicare Advantage	$206.63
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: PHP Commercial	$250.91
Rate for Payer: Priority Health Cigna Priority Health	$191.87
Rate for Payer: Priority Health SBD	$185.97

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	$236.15
Max. Negotiated Rate	$531.33
Rate for Payer: Aetna Commercial	$501.81
Rate for Payer: Aetna Medicare	$295.18
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 Commercial	$413.26
Rate for Payer: Cofinity Commercial	$507.72
Rate for Payer: Cofinity Medicare Advantage	$413.26
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: PHP Commercial	$501.81
Rate for Payer: Priority Health Cigna Priority Health	$383.74
Rate for Payer: Priority Health SBD	$371.93

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 Commercial	$413.26
Rate for Payer: Cofinity Commercial	$507.72
Rate for Payer: Cofinity Medicare Advantage	$413.26
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: PHP Commercial	$501.81
Rate for Payer: Priority Health Cigna Priority Health	$383.74
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 Commercial	$206.63
Rate for Payer: Cofinity Commercial	$253.86
Rate for Payer: Cofinity Medicare Advantage	$206.63
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: PHP Commercial	$250.91
Rate for Payer: Priority Health Cigna Priority Health	$191.87
Rate for Payer: Priority Health SBD	$185.97

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$2.82

Service Code	NDC 51079012901
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$1.13
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 Commercial	$1.97
Rate for Payer: Cofinity Commercial	$2.43
Rate for Payer: Cofinity Medicare Advantage	$1.97
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: PHP Commercial	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.83
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	$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 Commercial	$260.68
Rate for Payer: Cofinity Commercial	$320.26
Rate for Payer: Cofinity Medicare Advantage	$260.68
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: PHP Commercial	$316.54
Rate for Payer: Priority Health Cigna Priority Health	$242.06
Rate for Payer: Priority Health SBD	$234.61

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$703.68

Service Code	NDC 00071000724
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$281.47
Max. Negotiated Rate	$633.31
Rate for Payer: Aetna Commercial	$598.13
Rate for Payer: Aetna Medicare	$351.84
Rate for Payer: Aetna New Business (MI Preferred)	$457.39
Rate for Payer: BCBS Complete	$281.47
Rate for Payer: Cash Price	$562.94
Rate for Payer: Cofinity Commercial	$492.58
Rate for Payer: Cofinity Commercial	$605.16
Rate for Payer: Cofinity Medicare Advantage	$492.58
Rate for Payer: Encore Health Key Benefits Commercial	$562.94
Rate for Payer: Healthscope Commercial	$633.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$598.13
Rate for Payer: PHP Commercial	$598.13
Rate for Payer: Priority Health Cigna Priority Health	$457.39
Rate for Payer: Priority Health SBD	$443.32

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 Commercial	$1.97
Rate for Payer: Cofinity Commercial	$2.43
Rate for Payer: Cofinity Medicare Advantage	$1.97
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: PHP Commercial	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.83
Rate for Payer: Priority Health SBD	$1.78

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 Commercial	$120.95
Rate for Payer: Cofinity Commercial	$98.45
Rate for Payer: Cofinity Medicare Advantage	$98.45
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: PHP Commercial	$119.54
Rate for Payer: Priority Health Cigna Priority Health	$91.42
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	$56.26
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 Commercial	$120.95
Rate for Payer: Cofinity Commercial	$98.45
Rate for Payer: Cofinity Medicare Advantage	$98.45
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: PHP Commercial	$119.54
Rate for Payer: Priority Health Cigna Priority Health	$91.42
Rate for Payer: Priority Health SBD	$88.60

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$374.30

Service Code	NDC 00378385001
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$149.72
Max. Negotiated Rate	$336.87
Rate for Payer: Aetna Commercial	$318.16
Rate for Payer: Aetna Medicare	$187.15
Rate for Payer: Aetna New Business (MI Preferred)	$243.30
Rate for Payer: BCBS Complete	$149.72
Rate for Payer: Cash Price	$299.44
Rate for Payer: Cofinity Commercial	$262.01
Rate for Payer: Cofinity Commercial	$321.90
Rate for Payer: Cofinity Medicare Advantage	$262.01
Rate for Payer: Encore Health Key Benefits Commercial	$299.44
Rate for Payer: Healthscope Commercial	$336.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$318.16
Rate for Payer: PHP Commercial	$318.16
Rate for Payer: Priority Health Cigna Priority Health	$243.30
Rate for Payer: Priority Health SBD	$235.81

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$703.68

Service Code	NDC 00071000724
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$443.32
Max. Negotiated Rate	$633.31
Rate for Payer: Aetna Commercial	$598.13
Rate for Payer: Aetna New Business (MI Preferred)	$457.39
Rate for Payer: Cash Price	$562.94
Rate for Payer: Cofinity Commercial	$492.58
Rate for Payer: Cofinity Commercial	$605.16
Rate for Payer: Cofinity Medicare Advantage	$492.58
Rate for Payer: Encore Health Key Benefits Commercial	$562.94
Rate for Payer: Healthscope Commercial	$633.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$598.13
Rate for Payer: PHP Commercial	$598.13
Rate for Payer: Priority Health Cigna Priority Health	$457.39
Rate for Payer: Priority Health SBD	$443.32

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$374.30

Service Code	NDC 00378385001
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$235.81
Max. Negotiated Rate	$336.87
Rate for Payer: Aetna Commercial	$318.16
Rate for Payer: Aetna New Business (MI Preferred)	$243.30
Rate for Payer: Cash Price	$299.44
Rate for Payer: Cofinity Commercial	$262.01
Rate for Payer: Cofinity Commercial	$321.90
Rate for Payer: Cofinity Medicare Advantage	$262.01
Rate for Payer: Encore Health Key Benefits Commercial	$299.44
Rate for Payer: Healthscope Commercial	$336.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$318.16
Rate for Payer: PHP Commercial	$318.16
Rate for Payer: Priority Health Cigna Priority Health	$243.30
Rate for Payer: Priority Health SBD	$235.81

PHENYTOIN 50 MG CHEWABLE TABLET

Facility

$372.40

Service Code	NDC 51672414601
Hospital Charge Code	11018
Hospital Revenue Code	637
Min. Negotiated Rate	$148.96
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 Commercial	$260.68
Rate for Payer: Cofinity Commercial	$320.26
Rate for Payer: Cofinity Medicare Advantage	$260.68
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: PHP Commercial	$316.54
Rate for Payer: Priority Health Cigna Priority Health	$242.06
Rate for Payer: Priority Health SBD	$234.61

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION

Facility

$17.81

Service Code	HCPCS J1165
Hospital Charge Code	6256
Hospital Revenue Code	636
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$16.03
Rate for Payer: Aetna Commercial	$15.14
Rate for Payer: Aetna Commercial	$18.31
Rate for Payer: Aetna Medicare	$10.77
Rate for Payer: Aetna Medicare	$8.90
Rate for Payer: Aetna New Business (MI Preferred)	$11.58
Rate for Payer: Aetna New Business (MI Preferred)	$14.00
Rate for Payer: BCBS Complete	$8.62
Rate for Payer: BCBS Complete	$7.12
Rate for Payer: BCBS Trust/PPO	$1.25
Rate for Payer: BCBS Trust/PPO	$1.25
Rate for Payer: BCN Commercial	$1.25
Rate for Payer: BCN Commercial	$1.25
Rate for Payer: Cash Price	$17.23
Rate for Payer: Cash Price	$14.25
Rate for Payer: Cash Price	$14.25
Rate for Payer: Cash Price	$17.23
Rate for Payer: Cofinity Commercial	$15.32
Rate for Payer: Cofinity Commercial	$12.47
Rate for Payer: Cofinity Commercial	$15.08
Rate for Payer: Cofinity Commercial	$18.52
Rate for Payer: Cofinity Medicare Advantage	$12.47
Rate for Payer: Cofinity Medicare Advantage	$15.08
Rate for Payer: Encore Health Key Benefits Commercial	$14.25
Rate for Payer: Encore Health Key Benefits Commercial	$17.23
Rate for Payer: Healthscope Commercial	$19.39
Rate for Payer: Healthscope Commercial	$16.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.14
Rate for Payer: PHP Commercial	$18.31
Rate for Payer: PHP Commercial	$15.14
Rate for Payer: Priority Health Cigna Priority Health	$14.00
Rate for Payer: Priority Health Cigna Priority Health	$11.58
Rate for Payer: Priority Health SBD	$13.57
Rate for Payer: Priority Health SBD	$11.22

PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION

Facility

$17.81

Service Code	HCPCS J1165
Hospital Charge Code	6256
Hospital Revenue Code	636
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$16.03
Rate for Payer: Aetna Commercial	$15.14
Rate for Payer: Aetna Commercial	$18.31
Rate for Payer: Aetna New Business (MI Preferred)	$11.58
Rate for Payer: Aetna New Business (MI Preferred)	$14.00
Rate for Payer: Cash Price	$14.25
Rate for Payer: Cash Price	$17.23
Rate for Payer: Cofinity Commercial	$12.47
Rate for Payer: Cofinity Commercial	$15.08
Rate for Payer: Cofinity Commercial	$18.52
Rate for Payer: Cofinity Commercial	$15.32
Rate for Payer: Cofinity Medicare Advantage	$15.08
Rate for Payer: Cofinity Medicare Advantage	$12.47
Rate for Payer: Encore Health Key Benefits Commercial	$14.25
Rate for Payer: Encore Health Key Benefits Commercial	$17.23
Rate for Payer: Healthscope Commercial	$16.03
Rate for Payer: Healthscope Commercial	$19.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.31
Rate for Payer: PHP Commercial	$15.14
Rate for Payer: PHP Commercial	$18.31
Rate for Payer: Priority Health Cigna Priority Health	$14.00
Rate for Payer: Priority Health Cigna Priority Health	$11.58
Rate for Payer: Priority Health SBD	$13.57
Rate for Payer: Priority Health SBD	$11.22

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE

Facility

$382.85

Service Code	NDC 00904618761
Hospital Charge Code	6257
Hospital Revenue Code	637
Min. Negotiated Rate	$241.20
Max. Negotiated Rate	$344.56
Rate for Payer: Aetna Commercial	$325.42
Rate for Payer: Aetna New Business (MI Preferred)	$248.85
Rate for Payer: Cash Price	$306.28
Rate for Payer: Cofinity Commercial	$268.00
Rate for Payer: Cofinity Commercial	$329.25
Rate for Payer: Cofinity Medicare Advantage	$268.00
Rate for Payer: Encore Health Key Benefits Commercial	$306.28
Rate for Payer: Healthscope Commercial	$344.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$325.42
Rate for Payer: PHP Commercial	$325.42
Rate for Payer: Priority Health Cigna Priority Health	$248.85
Rate for Payer: Priority Health SBD	$241.20

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE

Facility

$828.96

Service Code	NDC 00071036940
Hospital Charge Code	6257
Hospital Revenue Code	637
Min. Negotiated Rate	$331.58
Max. Negotiated Rate	$746.06
Rate for Payer: Aetna Commercial	$704.62
Rate for Payer: Aetna Medicare	$414.48
Rate for Payer: Aetna New Business (MI Preferred)	$538.82
Rate for Payer: BCBS Complete	$331.58
Rate for Payer: Cash Price	$663.17
Rate for Payer: Cofinity Commercial	$580.27
Rate for Payer: Cofinity Commercial	$712.91
Rate for Payer: Cofinity Medicare Advantage	$580.27
Rate for Payer: Encore Health Key Benefits Commercial	$663.17
Rate for Payer: Healthscope Commercial	$746.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$704.62
Rate for Payer: PHP Commercial	$704.62
Rate for Payer: Priority Health Cigna Priority Health	$538.82
Rate for Payer: Priority Health SBD	$522.24

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE

Facility

$828.96

Service Code	NDC 00071036940
Hospital Charge Code	6257
Hospital Revenue Code	637
Min. Negotiated Rate	$522.24
Max. Negotiated Rate	$746.06
Rate for Payer: Aetna Commercial	$704.62
Rate for Payer: Aetna New Business (MI Preferred)	$538.82
Rate for Payer: Cash Price	$663.17
Rate for Payer: Cofinity Commercial	$580.27
Rate for Payer: Cofinity Commercial	$712.91
Rate for Payer: Cofinity Medicare Advantage	$580.27
Rate for Payer: Encore Health Key Benefits Commercial	$663.17
Rate for Payer: Healthscope Commercial	$746.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$704.62
Rate for Payer: PHP Commercial	$704.62
Rate for Payer: Priority Health Cigna Priority Health	$538.82
Rate for Payer: Priority Health SBD	$522.24

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE

Facility

$253.44

Service Code	NDC 51079090520
Hospital Charge Code	6257
Hospital Revenue Code	637
Min. Negotiated Rate	$159.67
Max. Negotiated Rate	$228.10
Rate for Payer: Aetna Commercial	$215.42
Rate for Payer: Aetna New Business (MI Preferred)	$164.74
Rate for Payer: Cash Price	$202.75
Rate for Payer: Cofinity Commercial	$177.41
Rate for Payer: Cofinity Commercial	$217.96
Rate for Payer: Cofinity Medicare Advantage	$177.41
Rate for Payer: Encore Health Key Benefits Commercial	$202.75
Rate for Payer: Healthscope Commercial	$228.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.42
Rate for Payer: PHP Commercial	$215.42
Rate for Payer: Priority Health Cigna Priority Health	$164.74
Rate for Payer: Priority Health SBD	$159.67

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE

Facility

$382.85

Service Code	NDC 00904618761
Hospital Charge Code	6257
Hospital Revenue Code	637
Min. Negotiated Rate	$153.14
Max. Negotiated Rate	$344.56
Rate for Payer: Aetna Commercial	$325.42
Rate for Payer: Aetna Medicare	$191.42
Rate for Payer: Aetna New Business (MI Preferred)	$248.85
Rate for Payer: BCBS Complete	$153.14
Rate for Payer: Cash Price	$306.28
Rate for Payer: Cofinity Commercial	$268.00
Rate for Payer: Cofinity Commercial	$329.25
Rate for Payer: Cofinity Medicare Advantage	$268.00
Rate for Payer: Encore Health Key Benefits Commercial	$306.28
Rate for Payer: Healthscope Commercial	$344.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$325.42
Rate for Payer: PHP Commercial	$325.42
Rate for Payer: Priority Health Cigna Priority Health	$248.85
Rate for Payer: Priority Health SBD	$241.20

PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE

Facility

$253.44

Service Code	NDC 51079090520
Hospital Charge Code	6257
Hospital Revenue Code	637
Min. Negotiated Rate	$101.38
Max. Negotiated Rate	$228.10
Rate for Payer: Aetna Commercial	$215.42
Rate for Payer: Aetna Medicare	$126.72
Rate for Payer: Aetna New Business (MI Preferred)	$164.74
Rate for Payer: BCBS Complete	$101.38
Rate for Payer: Cash Price	$202.75
Rate for Payer: Cofinity Commercial	$177.41
Rate for Payer: Cofinity Commercial	$217.96
Rate for Payer: Cofinity Medicare Advantage	$177.41
Rate for Payer: Encore Health Key Benefits Commercial	$202.75
Rate for Payer: Healthscope Commercial	$228.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.42
Rate for Payer: PHP Commercial	$215.42
Rate for Payer: Priority Health Cigna Priority Health	$164.74
Rate for Payer: Priority Health SBD	$159.67

Know your out-of-pocket cost for care.

All Charges