|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$196.65
|
|
|
Service Code
|
NDC 65162-681-10
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.53 |
| Max. Negotiated Rate |
$176.98 |
| Rate for Payer: Aetna American Axle |
$127.82
|
| Rate for Payer: Aetna Commercial |
$167.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$127.82
|
| Rate for Payer: Cash Price |
$157.32
|
| Rate for Payer: Cofinity Commercial |
$137.66
|
| Rate for Payer: Cofinity Commercial |
$169.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.32
|
| Rate for Payer: Healthscope Commercial |
$176.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$137.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$147.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$167.15
|
| Rate for Payer: PHP Commercial |
$167.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$137.66
|
| Rate for Payer: Priority Health SBD |
$123.89
|
| Rate for Payer: UMR Bronson Commercial |
$86.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$147.49
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 75826-114-10
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.92 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.92
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UMR Bronson Commercial |
$104.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$282.15
|
|
|
Service Code
|
NDC 51293-810-01
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.15 |
| Max. Negotiated Rate |
$253.94 |
| Rate for Payer: Aetna American Axle |
$183.40
|
| Rate for Payer: Aetna Commercial |
$239.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.40
|
| Rate for Payer: Cash Price |
$225.72
|
| Rate for Payer: Cofinity Commercial |
$197.50
|
| Rate for Payer: Cofinity Commercial |
$242.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.72
|
| Rate for Payer: Healthscope Commercial |
$253.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.83
|
| Rate for Payer: PHP Commercial |
$239.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.50
|
| Rate for Payer: Priority Health SBD |
$177.75
|
| Rate for Payer: UMR Bronson Commercial |
$124.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.61
|
|
|
PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG TABLET
|
Facility
|
IP
|
$4,346.02
|
|
|
Service Code
|
NDC 59212-425-10
|
| Hospital Charge Code |
28134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,912.25 |
| Max. Negotiated Rate |
$3,911.42 |
| Rate for Payer: Aetna American Axle |
$2,824.91
|
| Rate for Payer: Aetna Commercial |
$3,694.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,824.91
|
| Rate for Payer: Cash Price |
$3,476.82
|
| Rate for Payer: Cofinity Commercial |
$3,042.21
|
| Rate for Payer: Cofinity Commercial |
$3,737.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,476.82
|
| Rate for Payer: Healthscope Commercial |
$3,911.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,042.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,259.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,694.12
|
| Rate for Payer: PHP Commercial |
$3,694.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,042.21
|
| Rate for Payer: Priority Health SBD |
$2,737.99
|
| Rate for Payer: UMR Bronson Commercial |
$1,912.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,259.52
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$20.66
|
|
|
Service Code
|
NDC 0121-2826-50
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna American Axle |
$13.43
|
| Rate for Payer: Aetna Commercial |
$17.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.43
|
| Rate for Payer: Cash Price |
$16.53
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$17.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.53
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.56
|
| Rate for Payer: PHP Commercial |
$17.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health SBD |
$13.02
|
| Rate for Payer: UMR Bronson Commercial |
$9.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.50
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$20.66
|
|
|
Service Code
|
NDC 0121-2826-15
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna American Axle |
$13.43
|
| Rate for Payer: Aetna Commercial |
$17.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.43
|
| Rate for Payer: Cash Price |
$16.53
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$17.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.53
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.56
|
| Rate for Payer: PHP Commercial |
$17.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.46
|
| Rate for Payer: Priority Health SBD |
$13.02
|
| Rate for Payer: UMR Bronson Commercial |
$9.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.50
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$216.97
|
|
|
Service Code
|
NDC 0603-1508-58
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.47 |
| Max. Negotiated Rate |
$195.27 |
| Rate for Payer: Aetna American Axle |
$141.03
|
| 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: Encore Health Key Benefits Commercial |
$173.58
|
| Rate for Payer: Healthscope Commercial |
$195.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$151.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$184.42
|
| Rate for Payer: PHP Commercial |
$184.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.88
|
| Rate for Payer: Priority Health SBD |
$136.69
|
| Rate for Payer: UMR Bronson Commercial |
$95.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.73
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
IP
|
$240.96
|
|
|
Service Code
|
NDC 0603-5166-21
|
| Hospital Charge Code |
6217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.02 |
| Max. Negotiated Rate |
$216.86 |
| Rate for Payer: Aetna American Axle |
$156.62
|
| Rate for Payer: Aetna Commercial |
$204.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.62
|
| Rate for Payer: Cash Price |
$192.77
|
| Rate for Payer: Cofinity Commercial |
$168.67
|
| Rate for Payer: Cofinity Commercial |
$207.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.77
|
| Rate for Payer: Healthscope Commercial |
$216.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$204.82
|
| Rate for Payer: PHP Commercial |
$204.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.67
|
| Rate for Payer: Priority Health SBD |
$151.80
|
| Rate for Payer: UMR Bronson Commercial |
$106.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.72
|
|
|
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 |
$120.80 |
| Max. Negotiated Rate |
$247.10 |
| Rate for Payer: Aetna American Axle |
$178.46
|
| Rate for Payer: Aetna Commercial |
$233.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.46
|
| Rate for Payer: Cash Price |
$219.64
|
| Rate for Payer: Cofinity Commercial |
$192.18
|
| Rate for Payer: Cofinity Commercial |
$236.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.64
|
| Rate for Payer: Healthscope Commercial |
$247.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$192.18
|
| 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 SBD |
$172.97
|
| Rate for Payer: UMR Bronson Commercial |
$120.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.91
|
|
|
PHENOBARBITAL 97.2 MG TABLET
|
Facility
|
IP
|
$425.28
|
|
|
Service Code
|
NDC 0603-5168-21
|
| Hospital Charge Code |
6220
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.12 |
| Max. Negotiated Rate |
$382.75 |
| Rate for Payer: Aetna American Axle |
$276.43
|
| Rate for Payer: Aetna Commercial |
$361.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.43
|
| Rate for Payer: Cash Price |
$340.22
|
| Rate for Payer: Cofinity Commercial |
$297.70
|
| Rate for Payer: Cofinity Commercial |
$365.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.22
|
| Rate for Payer: Healthscope Commercial |
$382.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$318.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$361.49
|
| Rate for Payer: PHP Commercial |
$361.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.70
|
| Rate for Payer: Priority Health SBD |
$267.93
|
| Rate for Payer: UMR Bronson Commercial |
$187.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$318.96
|
|
|
PHENOBARBITAL 97.2 MG TABLET
|
Facility
|
IP
|
$425.28
|
|
|
Service Code
|
NDC 51293-628-01
|
| Hospital Charge Code |
6220
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.12 |
| Max. Negotiated Rate |
$382.75 |
| Rate for Payer: Aetna American Axle |
$276.43
|
| Rate for Payer: Aetna Commercial |
$361.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.43
|
| Rate for Payer: Cash Price |
$340.22
|
| Rate for Payer: Cofinity Commercial |
$297.70
|
| Rate for Payer: Cofinity Commercial |
$365.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.22
|
| Rate for Payer: Healthscope Commercial |
$382.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$318.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$361.49
|
| Rate for Payer: PHP Commercial |
$361.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$297.70
|
| Rate for Payer: Priority Health SBD |
$267.93
|
| Rate for Payer: UMR Bronson Commercial |
$187.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$318.96
|
|
|
PHENOBARBITAL 97.2 MG TABLET
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
NDC 16571-668-01
|
| Hospital Charge Code |
6220
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.96 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna American Axle |
$135.85
|
| 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: Encore Health Key Benefits Commercial |
$167.20
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$177.65
|
| Rate for Payer: PHP Commercial |
$177.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.30
|
| Rate for Payer: Priority Health SBD |
$131.67
|
| Rate for Payer: UMR Bronson Commercial |
$91.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.75
|
|
|
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 |
$124.58 |
| Max. Negotiated Rate |
$254.83 |
| Rate for Payer: Aetna American Axle |
$184.04
|
| Rate for Payer: Aetna American Axle |
$196.40
|
| Rate for Payer: Aetna Commercial |
$256.83
|
| Rate for Payer: Aetna Commercial |
$240.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$196.40
|
| Rate for Payer: Cash Price |
$226.51
|
| Rate for Payer: Cash Price |
$241.72
|
| Rate for Payer: Cofinity Commercial |
$243.50
|
| Rate for Payer: Cofinity Commercial |
$198.20
|
| Rate for Payer: Cofinity Commercial |
$211.50
|
| Rate for Payer: Cofinity Commercial |
$259.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$226.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.72
|
| Rate for Payer: Healthscope Commercial |
$271.94
|
| Rate for Payer: Healthscope Commercial |
$254.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$198.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$211.50
|
| 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 SBD |
$178.38
|
| Rate for Payer: Priority Health SBD |
$190.35
|
| Rate for Payer: UMR Bronson Commercial |
$132.95
|
| Rate for Payer: UMR Bronson Commercial |
$124.58
|
| 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
|
$10.36
|
|
|
Service Code
|
NDC 0536-1228-58
|
| Hospital Charge Code |
27889
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.56 |
| Max. Negotiated Rate |
$9.32 |
| Rate for Payer: Aetna American Axle |
$6.73
|
| Rate for Payer: Aetna Commercial |
$8.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.73
|
| Rate for Payer: Cash Price |
$8.29
|
| Rate for Payer: Cofinity Commercial |
$7.25
|
| Rate for Payer: Cofinity Commercial |
$8.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.29
|
| Rate for Payer: Healthscope Commercial |
$9.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.81
|
| Rate for Payer: PHP Commercial |
$8.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.25
|
| Rate for Payer: Priority Health SBD |
$6.53
|
| Rate for Payer: UMR Bronson Commercial |
$4.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.77
|
|
|
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 |
$4.83 |
| Max. Negotiated Rate |
$9.88 |
| Rate for Payer: Aetna American Axle |
$7.14
|
| Rate for Payer: Aetna Commercial |
$9.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.14
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cofinity Commercial |
$7.69
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$7.69
|
| 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 SBD |
$6.92
|
| Rate for Payer: UMR Bronson Commercial |
$4.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.24
|
|
|
PHENOL 1.5 %-GLYCERIN 33 % MUCOSAL SPRAY
|
Facility
|
IP
|
$15.86
|
|
|
Service Code
|
NDC 7811200068
|
| Hospital Charge Code |
164911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$14.27 |
| Rate for Payer: Aetna American Axle |
$10.31
|
| Rate for Payer: Aetna Commercial |
$13.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.31
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cofinity Commercial |
$11.10
|
| Rate for Payer: Cofinity Commercial |
$13.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.69
|
| Rate for Payer: Healthscope Commercial |
$14.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.48
|
| Rate for Payer: PHP Commercial |
$13.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.10
|
| Rate for Payer: Priority Health SBD |
$9.99
|
| Rate for Payer: UMR Bronson Commercial |
$6.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.90
|
|
|
PHENTOLAMINE 0.5 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$309.10
|
|
|
Service Code
|
NDC 9900-0019-43
|
| Hospital Charge Code |
150967
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.00 |
| Max. Negotiated Rate |
$278.19 |
| Rate for Payer: Aetna American Axle |
$200.92
|
| Rate for Payer: Aetna Commercial |
$262.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.92
|
| Rate for Payer: Cash Price |
$247.28
|
| Rate for Payer: Cofinity Commercial |
$216.37
|
| Rate for Payer: Cofinity Commercial |
$265.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.28
|
| Rate for Payer: Healthscope Commercial |
$278.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$262.74
|
| Rate for Payer: PHP Commercial |
$262.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.37
|
| Rate for Payer: Priority Health SBD |
$194.73
|
| Rate for Payer: UMR Bronson Commercial |
$136.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.82
|
|
|
PHENTOLAMINE 1 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$618.20
|
|
|
Service Code
|
NDC 9900-0019-44
|
| Hospital Charge Code |
301530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$272.01 |
| Max. Negotiated Rate |
$556.38 |
| Rate for Payer: Aetna American Axle |
$401.83
|
| 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: Encore Health Key Benefits Commercial |
$494.56
|
| Rate for Payer: Healthscope Commercial |
$556.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$432.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$463.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$525.47
|
| Rate for Payer: PHP Commercial |
$525.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$432.74
|
| Rate for Payer: Priority Health SBD |
$389.47
|
| Rate for Payer: UMR Bronson Commercial |
$272.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$463.65
|
|
|
PHENTOLAMINE 1 MG/ML IN NS SUBCUTANEOUS INJECTION CUSTOM
|
Facility
|
IP
|
$1,671.75
|
|
|
Service Code
|
NDC 9900-0019-45
|
| Hospital Charge Code |
301530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$735.57 |
| Max. Negotiated Rate |
$1,504.58 |
| Rate for Payer: Aetna American Axle |
$1,086.64
|
| 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: Encore Health Key Benefits Commercial |
$1,337.40
|
| Rate for Payer: Healthscope Commercial |
$1,504.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,170.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,253.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,420.99
|
| Rate for Payer: PHP Commercial |
$1,420.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,170.22
|
| Rate for Payer: Priority Health SBD |
$1,053.20
|
| Rate for Payer: UMR Bronson Commercial |
$735.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,253.81
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION
|
Facility
|
IP
|
$1,241.86
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
10947
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$546.42 |
| Max. Negotiated Rate |
$1,117.67 |
| Rate for Payer: Aetna American Axle |
$807.21
|
| Rate for Payer: Aetna American Axle |
$684.57
|
| Rate for Payer: Aetna American Axle |
$900.40
|
| Rate for Payer: Aetna American Axle |
$900.41
|
| Rate for Payer: Aetna Commercial |
$1,177.46
|
| Rate for Payer: Aetna Commercial |
$1,177.45
|
| Rate for Payer: Aetna Commercial |
$1,055.58
|
| Rate for Payer: Aetna Commercial |
$895.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$900.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$900.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$684.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$807.21
|
| Rate for Payer: Cash Price |
$1,108.18
|
| Rate for Payer: Cash Price |
$1,108.20
|
| Rate for Payer: Cash Price |
$842.54
|
| Rate for Payer: Cash Price |
$993.49
|
| Rate for Payer: Cofinity Commercial |
$905.73
|
| Rate for Payer: Cofinity Commercial |
$1,068.00
|
| Rate for Payer: Cofinity Commercial |
$869.30
|
| Rate for Payer: Cofinity Commercial |
$737.23
|
| Rate for Payer: Cofinity Commercial |
$1,191.32
|
| Rate for Payer: Cofinity Commercial |
$969.66
|
| Rate for Payer: Cofinity Commercial |
$1,191.30
|
| Rate for Payer: Cofinity Commercial |
$969.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$993.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$842.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,108.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,108.20
|
| Rate for Payer: Healthscope Commercial |
$947.86
|
| Rate for Payer: Healthscope Commercial |
$1,246.72
|
| Rate for Payer: Healthscope Commercial |
$1,117.67
|
| Rate for Payer: Healthscope Commercial |
$1,246.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$737.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$969.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$869.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$969.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$789.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$931.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,038.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,038.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,177.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$895.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,055.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,177.46
|
| Rate for Payer: PHP Commercial |
$1,055.58
|
| Rate for Payer: PHP Commercial |
$1,177.45
|
| Rate for Payer: PHP Commercial |
$1,177.46
|
| Rate for Payer: PHP Commercial |
$895.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$737.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$969.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$869.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$969.68
|
| Rate for Payer: Priority Health SBD |
$782.37
|
| Rate for Payer: Priority Health SBD |
$872.71
|
| Rate for Payer: Priority Health SBD |
$663.50
|
| Rate for Payer: Priority Health SBD |
$872.69
|
| Rate for Payer: UMR Bronson Commercial |
$609.50
|
| Rate for Payer: UMR Bronson Commercial |
$463.40
|
| Rate for Payer: UMR Bronson Commercial |
$609.51
|
| Rate for Payer: UMR Bronson Commercial |
$546.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,038.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$789.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$931.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,038.94
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT
|
Facility
|
IP
|
$11.29
|
|
|
Service Code
|
NDC 0536-1288-06
|
| Hospital Charge Code |
167632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$10.16 |
| Rate for Payer: Aetna American Axle |
$7.34
|
| Rate for Payer: Aetna Commercial |
$9.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.34
|
| Rate for Payer: Cash Price |
$9.03
|
| Rate for Payer: Cofinity Commercial |
$7.90
|
| Rate for Payer: Cofinity Commercial |
$9.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.03
|
| Rate for Payer: Healthscope Commercial |
$10.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.60
|
| Rate for Payer: PHP Commercial |
$9.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.90
|
| Rate for Payer: Priority Health SBD |
$7.11
|
| Rate for Payer: UMR Bronson Commercial |
$4.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.47
|
|
|
PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT
|
Facility
|
IP
|
$10.01
|
|
|
Service Code
|
NDC 45802-188-16
|
| Hospital Charge Code |
167632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$9.01 |
| Rate for Payer: Aetna American Axle |
$6.51
|
| Rate for Payer: Aetna Commercial |
$8.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.51
|
| Rate for Payer: Cash Price |
$8.01
|
| Rate for Payer: Cofinity Commercial |
$7.01
|
| Rate for Payer: Cofinity Commercial |
$8.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.01
|
| Rate for Payer: Healthscope Commercial |
$9.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.51
|
| Rate for Payer: PHP Commercial |
$8.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.01
|
| Rate for Payer: Priority Health SBD |
$6.31
|
| Rate for Payer: UMR Bronson Commercial |
$4.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.51
|
|
|
PHENYLEPHRINE 0.25 % NASAL SPRAY
|
Facility
|
IP
|
$17.96
|
|
|
Service Code
|
NDC 69536-025-15
|
| Hospital Charge Code |
6243
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna American Axle |
$11.67
|
| Rate for Payer: Aetna Commercial |
$15.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.67
|
| Rate for Payer: Cash Price |
$14.37
|
| Rate for Payer: Cofinity Commercial |
$12.57
|
| Rate for Payer: Cofinity Commercial |
$15.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.37
|
| Rate for Payer: Healthscope Commercial |
$16.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.57
|
| 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 SBD |
$11.31
|
| Rate for Payer: UMR Bronson Commercial |
$7.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.47
|
|
|
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 |
$8.23 |
| Max. Negotiated Rate |
$16.83 |
| Rate for Payer: Aetna American Axle |
$12.16
|
| Rate for Payer: Aetna Commercial |
$15.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.16
|
| Rate for Payer: Cash Price |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$13.09
|
| Rate for Payer: Cofinity Commercial |
$16.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.96
|
| Rate for Payer: Healthscope Commercial |
$16.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.09
|
| 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 SBD |
$11.78
|
| Rate for Payer: UMR Bronson Commercial |
$8.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.02
|
|
|
PHENYLEPHRINE 0.5 % NASAL SPRAY
|
Facility
|
IP
|
$17.96
|
|
|
Service Code
|
NDC 5032300603
|
| Hospital Charge Code |
6244
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.90 |
| Max. Negotiated Rate |
$16.16 |
| Rate for Payer: Aetna American Axle |
$11.67
|
| Rate for Payer: Aetna Commercial |
$15.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.67
|
| Rate for Payer: Cash Price |
$14.37
|
| Rate for Payer: Cofinity Commercial |
$15.45
|
| Rate for Payer: Cofinity Commercial |
$12.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.37
|
| Rate for Payer: Healthscope Commercial |
$16.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.57
|
| 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 SBD |
$11.31
|
| Rate for Payer: UMR Bronson Commercial |
$7.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.47
|
|
