|
PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$387.75
|
|
|
Service Code
|
NDC 0904-5448-61
|
| Hospital Charge Code |
10911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$236.49 |
| Max. Negotiated Rate |
$348.98 |
| Rate for Payer: Aetna Commercial |
$329.59
|
| Rate for Payer: BCBS Trust/PPO |
$299.65
|
| Rate for Payer: BCN Commercial |
$299.65
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cofinity Commercial |
$333.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.20
|
| Rate for Payer: Healthscope Commercial |
$348.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$329.59
|
| Rate for Payer: PHP Commercial |
$329.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$337.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$236.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$341.22
|
| Rate for Payer: UHC Core |
$323.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.81
|
|
|
PEPTAMEN AF INTERMITTENT FEED
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 9871666360
|
| Hospital Charge Code |
200078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$13.32 |
| Rate for Payer: Aetna Commercial |
$12.58
|
| Rate for Payer: BCBS Trust/PPO |
$11.44
|
| Rate for Payer: BCN Commercial |
$11.44
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$12.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$13.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.58
|
| Rate for Payer: PHP Commercial |
$12.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.02
|
| Rate for Payer: UHC Core |
$12.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.10
|
|
|
PERPHENAZINE 2 MG TABLET
|
Facility
|
IP
|
$360.96
|
|
|
Service Code
|
NDC 0904-6599-61
|
| Hospital Charge Code |
6157
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.15 |
| Max. Negotiated Rate |
$324.86 |
| Rate for Payer: Aetna Commercial |
$306.82
|
| Rate for Payer: BCBS Trust/PPO |
$278.95
|
| Rate for Payer: BCN Commercial |
$278.95
|
| Rate for Payer: Cash Price |
$288.77
|
| Rate for Payer: Cofinity Commercial |
$310.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$288.77
|
| Rate for Payer: Healthscope Commercial |
$324.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$270.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$306.82
|
| Rate for Payer: PHP Commercial |
$306.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$314.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$220.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$317.64
|
| Rate for Payer: UHC Core |
$301.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$270.72
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
IP
|
$318.25
|
|
|
Service Code
|
NDC 42192-802-01
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.10 |
| Max. Negotiated Rate |
$286.42 |
| Rate for Payer: Aetna Commercial |
$270.51
|
| Rate for Payer: BCBS Trust/PPO |
$245.94
|
| Rate for Payer: BCN Commercial |
$245.94
|
| Rate for Payer: Cash Price |
$254.60
|
| Rate for Payer: Cofinity Commercial |
$273.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.60
|
| Rate for Payer: Healthscope Commercial |
$286.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$270.51
|
| Rate for Payer: PHP Commercial |
$270.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$222.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$276.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$194.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$280.06
|
| Rate for Payer: UHC Core |
$265.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.69
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
IP
|
$426.55
|
|
|
Service Code
|
NDC 51293-811-01
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$260.15 |
| Max. Negotiated Rate |
$383.90 |
| Rate for Payer: Aetna Commercial |
$362.57
|
| Rate for Payer: BCBS Trust/PPO |
$329.64
|
| Rate for Payer: BCN Commercial |
$329.64
|
| Rate for Payer: Cash Price |
$341.24
|
| Rate for Payer: Cofinity Commercial |
$366.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$341.24
|
| Rate for Payer: Healthscope Commercial |
$383.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$362.57
|
| Rate for Payer: PHP Commercial |
$362.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$371.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$260.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$375.36
|
| Rate for Payer: UHC Core |
$356.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.91
|
|
|
PHENAZOPYRIDINE 200 MG TABLET
|
Facility
|
IP
|
$345.80
|
|
|
Service Code
|
NDC 65162-682-10
|
| Hospital Charge Code |
6194
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.90 |
| Max. Negotiated Rate |
$311.22 |
| Rate for Payer: Aetna Commercial |
$293.93
|
| Rate for Payer: BCBS Trust/PPO |
$267.23
|
| Rate for Payer: BCN Commercial |
$267.23
|
| Rate for Payer: Cash Price |
$276.64
|
| Rate for Payer: Cofinity Commercial |
$297.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.64
|
| Rate for Payer: Healthscope Commercial |
$311.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.93
|
| Rate for Payer: PHP Commercial |
$293.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.06
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$300.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$210.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$304.30
|
| Rate for Payer: UHC Core |
$288.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.35
|
|
|
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 |
$199.32 |
| Max. Negotiated Rate |
$294.12 |
| Rate for Payer: Aetna Commercial |
$277.78
|
| Rate for Payer: BCBS Trust/PPO |
$252.55
|
| Rate for Payer: BCN Commercial |
$252.55
|
| Rate for Payer: Cash Price |
$261.44
|
| Rate for Payer: Cofinity Commercial |
$281.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.44
|
| Rate for Payer: Healthscope Commercial |
$294.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.10
|
| 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 HMO/PPO/Tiered Network |
$284.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$287.58
|
| Rate for Payer: UHC Core |
$272.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.10
|
|
|
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 |
$167.45 |
| Max. Negotiated Rate |
$247.10 |
| Rate for Payer: Aetna Commercial |
$233.37
|
| Rate for Payer: BCBS Trust/PPO |
$212.17
|
| Rate for Payer: BCN Commercial |
$212.17
|
| Rate for Payer: Cash Price |
$219.64
|
| Rate for Payer: Cofinity Commercial |
$236.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.64
|
| Rate for Payer: Healthscope Commercial |
$247.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.91
|
| 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 HMO/PPO/Tiered Network |
$238.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$241.60
|
| Rate for Payer: UHC Core |
$229.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.91
|
|
|
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$283.14
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
6221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.69 |
| Max. Negotiated Rate |
$254.83 |
| Rate for Payer: Aetna Commercial |
$240.67
|
| Rate for Payer: Aetna Commercial |
$256.83
|
| Rate for Payer: BCBS Trust/PPO |
$233.50
|
| Rate for Payer: BCBS Trust/PPO |
$218.81
|
| Rate for Payer: BCN Commercial |
$218.81
|
| Rate for Payer: BCN Commercial |
$233.50
|
| Rate for Payer: Cash Price |
$241.72
|
| Rate for Payer: Cash Price |
$226.51
|
| Rate for Payer: Cofinity Commercial |
$243.50
|
| Rate for Payer: Cofinity Commercial |
$259.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$226.51
|
| Rate for Payer: Healthscope Commercial |
$271.94
|
| Rate for Payer: Healthscope Commercial |
$254.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$212.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$226.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$240.67
|
| 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 |
$256.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$246.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$262.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$184.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$172.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$249.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.89
|
| Rate for Payer: UHC Core |
$236.42
|
| Rate for Payer: UHC Core |
$252.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$226.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$212.36
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY
|
Facility
|
IP
|
$10.98
|
|
|
Service Code
|
NDC 7811269480
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna Commercial |
$9.33
|
| Rate for Payer: BCBS Trust/PPO |
$8.49
|
| Rate for Payer: BCN Commercial |
$8.49
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cofinity Commercial |
$9.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.78
|
| Rate for Payer: Healthscope Commercial |
$9.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.33
|
| Rate for Payer: PHP Commercial |
$9.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.66
|
| Rate for Payer: UHC Core |
$9.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.24
|
|
|
PHENYLEPHRINE 0.1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.72
|
|
|
Service Code
|
HCPCS J2372
|
| Hospital Charge Code |
192051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$24.05 |
| Rate for Payer: Aetna Commercial |
$22.71
|
| Rate for Payer: Aetna Commercial |
$22.96
|
| Rate for Payer: BCBS Trust/PPO |
$20.65
|
| Rate for Payer: BCBS Trust/PPO |
$20.87
|
| Rate for Payer: BCN Commercial |
$20.87
|
| Rate for Payer: BCN Commercial |
$20.65
|
| Rate for Payer: Cash Price |
$21.61
|
| Rate for Payer: Cash Price |
$21.38
|
| Rate for Payer: Cofinity Commercial |
$23.23
|
| Rate for Payer: Cofinity Commercial |
$22.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.38
|
| Rate for Payer: Healthscope Commercial |
$24.05
|
| Rate for Payer: Healthscope Commercial |
$24.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.71
|
| Rate for Payer: PHP Commercial |
$22.96
|
| Rate for Payer: PHP Commercial |
$22.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.51
|
| Rate for Payer: UHC Core |
$22.31
|
| Rate for Payer: UHC Core |
$22.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.26
|
|
|
PHENYLEPHRINE 0.25 % NASAL SPRAY
|
Facility
|
IP
|
$18.70
|
|
|
Service Code
|
NDC 0225-0800-47
|
| Hospital Charge Code |
6243
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$16.83 |
| Rate for Payer: Aetna Commercial |
$15.90
|
| Rate for Payer: BCBS Trust/PPO |
$14.45
|
| Rate for Payer: BCN Commercial |
$14.45
|
| Rate for Payer: Cash Price |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$16.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.96
|
| Rate for Payer: Healthscope Commercial |
$16.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.02
|
| 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 HMO/PPO/Tiered Network |
$16.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.46
|
| Rate for Payer: UHC Core |
$15.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.02
|
|
|
PHENYLEPHRINE 0.25 %-PRAMOXINE 1 %-GLYCERIN-WH.PETROLATUM RECTAL CREAM
|
Facility
|
IP
|
$9.25
|
|
|
Service Code
|
NDC 49781-090-01
|
| Hospital Charge Code |
77868
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.64 |
| Max. Negotiated Rate |
$8.32 |
| Rate for Payer: Aetna Commercial |
$7.86
|
| Rate for Payer: BCBS Trust/PPO |
$7.15
|
| Rate for Payer: BCN Commercial |
$7.15
|
| Rate for Payer: Cash Price |
$7.40
|
| Rate for Payer: Cofinity Commercial |
$7.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.40
|
| Rate for Payer: Healthscope Commercial |
$8.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.86
|
| Rate for Payer: PHP Commercial |
$7.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.14
|
| Rate for Payer: UHC Core |
$7.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.94
|
|
|
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 |
$10.95 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna Commercial |
$15.27
|
| Rate for Payer: BCBS Trust/PPO |
$13.88
|
| Rate for Payer: BCN Commercial |
$13.88
|
| Rate for Payer: Cash Price |
$14.37
|
| Rate for Payer: Cofinity Commercial |
$15.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.37
|
| Rate for Payer: Healthscope Commercial |
$16.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.47
|
| 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 HMO/PPO/Tiered Network |
$15.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.80
|
| Rate for Payer: UHC Core |
$15.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.47
|
|
|
PHENYLEPHRINE 10 % EYE DROPS
|
Facility
|
IP
|
$119.25
|
|
|
Service Code
|
NDC 17478-206-05
|
| Hospital Charge Code |
19636
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.73 |
| Max. Negotiated Rate |
$107.32 |
| Rate for Payer: Aetna Commercial |
$101.36
|
| Rate for Payer: BCBS Trust/PPO |
$92.16
|
| Rate for Payer: BCN Commercial |
$92.16
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cofinity Commercial |
$102.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.40
|
| Rate for Payer: Healthscope Commercial |
$107.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$101.36
|
| Rate for Payer: PHP Commercial |
$101.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$103.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$72.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.94
|
| Rate for Payer: UHC Core |
$99.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.44
|
|
|
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 |
$21.35 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: BCBS Trust/PPO |
$27.05
|
| Rate for Payer: BCN Commercial |
$27.05
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.00
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.25
|
| 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 HMO/PPO/Tiered Network |
$30.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$30.80
|
| Rate for Payer: UHC Core |
$29.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.25
|
|
|
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$16.65
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
6242
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.15 |
| Max. Negotiated Rate |
$14.98 |
| Rate for Payer: Aetna Commercial |
$14.15
|
| Rate for Payer: Aetna Commercial |
$13.66
|
| Rate for Payer: Aetna Commercial |
$13.76
|
| Rate for Payer: BCBS Trust/PPO |
$12.51
|
| Rate for Payer: BCBS Trust/PPO |
$12.42
|
| Rate for Payer: BCBS Trust/PPO |
$12.87
|
| Rate for Payer: BCN Commercial |
$12.87
|
| Rate for Payer: BCN Commercial |
$12.51
|
| Rate for Payer: BCN Commercial |
$12.42
|
| Rate for Payer: Cash Price |
$13.32
|
| Rate for Payer: Cash Price |
$12.95
|
| Rate for Payer: Cash Price |
$12.86
|
| Rate for Payer: Cofinity Commercial |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$14.32
|
| Rate for Payer: Cofinity Commercial |
$13.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.32
|
| Rate for Payer: Healthscope Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$14.46
|
| Rate for Payer: Healthscope Commercial |
$14.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.15
|
| Rate for Payer: PHP Commercial |
$14.15
|
| Rate for Payer: PHP Commercial |
$13.66
|
| Rate for Payer: PHP Commercial |
$13.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.65
|
| Rate for Payer: UHC Core |
$13.42
|
| Rate for Payer: UHC Core |
$13.52
|
| Rate for Payer: UHC Core |
$13.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.05
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
NDC 69374-957-10
|
| Hospital Charge Code |
119800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.28
|
| Rate for Payer: BCN Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cofinity Commercial |
$3.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.40
|
| Rate for Payer: Healthscope Commercial |
$3.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.61
|
| Rate for Payer: PHP Commercial |
$3.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.74
|
| Rate for Payer: UHC Core |
$3.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.19
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE
|
Facility
|
IP
|
$23.19
|
|
|
Service Code
|
NDC 70092-1046-46
|
| Hospital Charge Code |
119800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$20.87 |
| Rate for Payer: Aetna Commercial |
$19.71
|
| Rate for Payer: BCBS Trust/PPO |
$17.92
|
| Rate for Payer: BCN Commercial |
$17.92
|
| Rate for Payer: Cash Price |
$18.55
|
| Rate for Payer: Cofinity Commercial |
$19.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.55
|
| Rate for Payer: Healthscope Commercial |
$20.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.71
|
| Rate for Payer: PHP Commercial |
$19.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.23
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.41
|
| Rate for Payer: UHC Core |
$19.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.39
|
|
|
PHENYLEPHRINE IV INFUSION (INTRA-OP)
|
Facility
|
IP
|
$16.25
|
|
|
Service Code
|
NDC 9900-0003-62
|
| Hospital Charge Code |
155179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Aetna Commercial |
$13.81
|
| Rate for Payer: BCBS Trust/PPO |
$12.56
|
| Rate for Payer: BCN Commercial |
$12.56
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cofinity Commercial |
$13.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.00
|
| Rate for Payer: Healthscope Commercial |
$14.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.81
|
| Rate for Payer: PHP Commercial |
$13.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.30
|
| Rate for Payer: UHC Core |
$13.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.19
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$256.20
|
|
|
Service Code
|
NDC 51672-4069-1
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.26 |
| Max. Negotiated Rate |
$230.58 |
| Rate for Payer: Aetna Commercial |
$217.77
|
| Rate for Payer: BCBS Trust/PPO |
$197.99
|
| Rate for Payer: BCN Commercial |
$197.99
|
| Rate for Payer: Cash Price |
$204.96
|
| Rate for Payer: Cofinity Commercial |
$220.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.96
|
| Rate for Payer: Healthscope Commercial |
$230.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.77
|
| Rate for Payer: PHP Commercial |
$217.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$222.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$156.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$225.46
|
| Rate for Payer: UHC Core |
$213.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.15
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$590.37
|
|
|
Service Code
|
NDC 60432-131-08
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$360.07 |
| Max. Negotiated Rate |
$531.33 |
| Rate for Payer: Aetna Commercial |
$501.81
|
| Rate for Payer: BCBS Trust/PPO |
$456.24
|
| Rate for Payer: BCN Commercial |
$456.24
|
| Rate for Payer: Cash Price |
$472.30
|
| 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: Lakeland Regional Health Systems Commercial |
$442.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$501.81
|
| Rate for Payer: PHP Commercial |
$501.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$413.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$513.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$360.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$519.53
|
| Rate for Payer: UHC Core |
$492.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$442.78
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 51079-129-01
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.18
|
| Rate for Payer: BCN Commercial |
$2.18
|
| Rate for Payer: Cash Price |
$2.26
|
| 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: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.48
|
| Rate for Payer: UHC Core |
$2.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$140.64
|
|
|
Service Code
|
NDC 51079-129-06
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.78 |
| Max. Negotiated Rate |
$126.58 |
| Rate for Payer: Aetna Commercial |
$119.54
|
| Rate for Payer: BCBS Trust/PPO |
$108.69
|
| Rate for Payer: BCN Commercial |
$108.69
|
| Rate for Payer: Cash Price |
$112.51
|
| 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: Lakeland Regional Health Systems Commercial |
$105.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.54
|
| Rate for Payer: PHP Commercial |
$119.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$122.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$85.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$123.76
|
| Rate for Payer: UHC Core |
$117.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.48
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$146.16
|
|
|
Service Code
|
NDC 0904-7199-07
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.14 |
| Max. Negotiated Rate |
$131.54 |
| Rate for Payer: Aetna Commercial |
$124.24
|
| Rate for Payer: BCBS Trust/PPO |
$112.95
|
| Rate for Payer: BCN Commercial |
$112.95
|
| Rate for Payer: Cash Price |
$116.93
|
| Rate for Payer: Cofinity Commercial |
$125.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.93
|
| Rate for Payer: Healthscope Commercial |
$131.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$124.24
|
| Rate for Payer: PHP Commercial |
$124.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$127.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$89.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.62
|
| Rate for Payer: UHC Core |
$122.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.62
|
|
