|
PE/TROP/CYC/KETOR (PF) 10-1-0.5% OPH (EYE DROP #4)
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
NDC 09900000895
|
| Hospital Charge Code |
180468
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna American Axle |
$32.50
|
| Rate for Payer: Aetna Commercial |
$42.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.50
|
| Rate for Payer: Cash Price |
$40.00
|
| Rate for Payer: Cofinity Advantage |
$35.00
|
| Rate for Payer: Cofinity Commercial |
$43.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.00
|
| Rate for Payer: Healthscope Commercial |
$45.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.50
|
| Rate for Payer: PHP Commercial |
$42.50
|
| Rate for Payer: Priority Health SBD |
$31.50
|
| Rate for Payer: UMR Bronson Commercial |
$22.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.50
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
OP
|
$211.85
|
|
|
Service Code
|
NDC 42192080101
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.38 |
| Max. Negotiated Rate |
$190.66 |
| Rate for Payer: Aetna American Axle |
$137.70
|
| Rate for Payer: Aetna Commercial |
$180.07
|
| Rate for Payer: Aetna Medicare |
$105.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.70
|
| Rate for Payer: BCBS Complete |
$84.74
|
| Rate for Payer: Cash Price |
$169.48
|
| Rate for Payer: Cofinity Advantage |
$148.29
|
| Rate for Payer: Cofinity Commercial |
$182.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.48
|
| Rate for Payer: Healthscope Commercial |
$190.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$169.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$158.89
|
| Rate for Payer: PHP Commercial |
$180.07
|
| Rate for Payer: Priority Health SBD |
$133.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$137.70
|
| Rate for Payer: UHC Core |
$110.37
|
| Rate for Payer: UHC Exchange |
$83.26
|
| Rate for Payer: UMR Bronson Commercial |
$78.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.89
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$379.68
|
|
|
Service Code
|
NDC 69367016204
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.06 |
| Max. Negotiated Rate |
$341.71 |
| Rate for Payer: Aetna American Axle |
$246.79
|
| Rate for Payer: Aetna Commercial |
$322.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.79
|
| Rate for Payer: Cash Price |
$303.74
|
| Rate for Payer: Cofinity Advantage |
$265.78
|
| Rate for Payer: Cofinity Commercial |
$326.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.74
|
| Rate for Payer: Healthscope Commercial |
$341.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$284.76
|
| Rate for Payer: PHP Commercial |
$322.73
|
| Rate for Payer: Priority Health SBD |
$239.20
|
| Rate for Payer: UMR Bronson Commercial |
$167.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.76
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$240.35
|
|
|
Service Code
|
NDC 65162068110
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.75 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Advantage |
$168.25
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$180.26
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UMR Bronson Commercial |
$105.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 75826011410
|
| 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 Advantage |
$166.91
|
| 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 |
$166.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| 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
|
OP
|
$379.68
|
|
|
Service Code
|
NDC 69367016204
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.48 |
| Max. Negotiated Rate |
$341.71 |
| Rate for Payer: Aetna American Axle |
$246.79
|
| Rate for Payer: Aetna Commercial |
$322.73
|
| Rate for Payer: Aetna Medicare |
$189.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.79
|
| Rate for Payer: BCBS Complete |
$151.87
|
| Rate for Payer: Cash Price |
$303.74
|
| Rate for Payer: Cofinity Advantage |
$265.78
|
| Rate for Payer: Cofinity Commercial |
$326.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.74
|
| Rate for Payer: Healthscope Commercial |
$341.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$303.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$284.76
|
| Rate for Payer: PHP Commercial |
$322.73
|
| Rate for Payer: Priority Health SBD |
$239.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$246.79
|
| Rate for Payer: UHC Core |
$197.81
|
| Rate for Payer: UHC Exchange |
$149.21
|
| Rate for Payer: UMR Bronson Commercial |
$140.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.76
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
OP
|
$238.45
|
|
|
Service Code
|
NDC 75826011410
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna Medicare |
$119.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: BCBS Complete |
$95.38
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Advantage |
$166.91
|
| 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 |
$166.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.99
|
| Rate for Payer: UHC Core |
$124.23
|
| Rate for Payer: UHC Exchange |
$93.71
|
| Rate for Payer: UMR Bronson Commercial |
$88.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
OP
|
$282.15
|
|
|
Service Code
|
NDC 51293081001
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.40 |
| Max. Negotiated Rate |
$253.94 |
| Rate for Payer: Aetna American Axle |
$183.40
|
| Rate for Payer: Aetna Commercial |
$239.83
|
| Rate for Payer: Aetna Medicare |
$141.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.40
|
| Rate for Payer: BCBS Complete |
$112.86
|
| Rate for Payer: Cash Price |
$225.72
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$225.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$211.61
|
| Rate for Payer: PHP Commercial |
$239.83
|
| Rate for Payer: Priority Health SBD |
$177.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$183.40
|
| Rate for Payer: UHC Core |
$147.00
|
| Rate for Payer: UHC Exchange |
$110.88
|
| Rate for Payer: UMR Bronson Commercial |
$104.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.61
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$282.15
|
|
|
Service Code
|
NDC 51293081001
|
| 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 Advantage |
$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 Commercial |
$239.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$211.61
|
| Rate for Payer: PHP Commercial |
$239.83
|
| 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
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
OP
|
$240.35
|
|
|
Service Code
|
NDC 65162068110
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.93 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: Aetna American Axle |
$156.23
|
| Rate for Payer: Aetna Commercial |
$204.30
|
| Rate for Payer: Aetna Medicare |
$120.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.23
|
| Rate for Payer: BCBS Complete |
$96.14
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Advantage |
$168.25
|
| Rate for Payer: Cofinity Commercial |
$206.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$216.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$192.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$180.26
|
| Rate for Payer: PHP Commercial |
$204.30
|
| Rate for Payer: Priority Health SBD |
$151.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$156.23
|
| Rate for Payer: UHC Core |
$125.22
|
| Rate for Payer: UHC Exchange |
$94.46
|
| Rate for Payer: UMR Bronson Commercial |
$88.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.26
|
|
|
PHENAZOPYRIDINE 100 MG TABLET
|
Facility
|
IP
|
$211.85
|
|
|
Service Code
|
NDC 42192080101
|
| Hospital Charge Code |
6193
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.21 |
| Max. Negotiated Rate |
$190.66 |
| Rate for Payer: Aetna American Axle |
$137.70
|
| Rate for Payer: Aetna Commercial |
$180.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$137.70
|
| Rate for Payer: Cash Price |
$169.48
|
| Rate for Payer: Cofinity Advantage |
$148.29
|
| Rate for Payer: Cofinity Commercial |
$182.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.48
|
| Rate for Payer: Healthscope Commercial |
$190.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$158.89
|
| Rate for Payer: PHP Commercial |
$180.07
|
| Rate for Payer: Priority Health SBD |
$133.47
|
| Rate for Payer: UMR Bronson Commercial |
$93.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.89
|
|
|
PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG TABLET
|
Facility
|
IP
|
$4,787.06
|
|
|
Service Code
|
NDC 59212042510
|
| Hospital Charge Code |
28134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,106.31 |
| Max. Negotiated Rate |
$4,308.35 |
| Rate for Payer: Aetna American Axle |
$3,111.59
|
| Rate for Payer: Aetna Commercial |
$4,069.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,111.59
|
| Rate for Payer: Cash Price |
$3,829.65
|
| Rate for Payer: Cofinity Advantage |
$3,350.94
|
| Rate for Payer: Cofinity Commercial |
$4,116.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,829.65
|
| Rate for Payer: Healthscope Commercial |
$4,308.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,350.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,590.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,069.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,590.30
|
| Rate for Payer: PHP Commercial |
$4,069.00
|
| Rate for Payer: Priority Health SBD |
$3,015.85
|
| Rate for Payer: UMR Bronson Commercial |
$2,106.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,590.30
|
|
|
PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG TABLET
|
Facility
|
OP
|
$4,787.06
|
|
|
Service Code
|
NDC 59212042510
|
| Hospital Charge Code |
28134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,771.21 |
| Max. Negotiated Rate |
$4,308.35 |
| Rate for Payer: Aetna American Axle |
$3,111.59
|
| Rate for Payer: Aetna Commercial |
$4,069.00
|
| Rate for Payer: Aetna Medicare |
$2,393.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,111.59
|
| Rate for Payer: BCBS Complete |
$1,914.82
|
| Rate for Payer: Cash Price |
$3,829.65
|
| Rate for Payer: Cofinity Advantage |
$3,350.94
|
| Rate for Payer: Cofinity Commercial |
$4,116.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,829.65
|
| Rate for Payer: Healthscope Commercial |
$4,308.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,350.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,590.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,829.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,069.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,590.30
|
| Rate for Payer: PHP Commercial |
$4,069.00
|
| Rate for Payer: Priority Health SBD |
$3,015.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,111.59
|
| Rate for Payer: UHC Core |
$2,494.06
|
| Rate for Payer: UHC Exchange |
$1,881.31
|
| Rate for Payer: UMR Bronson Commercial |
$1,771.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,590.30
|
|
|
PHENOBARBITAL 16.2 MG TABLET
|
Facility
|
OP
|
$913.50
|
|
|
Service Code
|
NDC 63739019210
|
| Hospital Charge Code |
6215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$338.00 |
| Max. Negotiated Rate |
$822.15 |
| Rate for Payer: Aetna American Axle |
$593.77
|
| Rate for Payer: Aetna Commercial |
$776.48
|
| Rate for Payer: Aetna Medicare |
$456.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$593.77
|
| Rate for Payer: BCBS Complete |
$365.40
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cofinity Advantage |
$639.45
|
| Rate for Payer: Cofinity Commercial |
$785.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$730.80
|
| Rate for Payer: Healthscope Commercial |
$822.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$639.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$685.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$730.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$776.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$685.12
|
| Rate for Payer: PHP Commercial |
$776.48
|
| Rate for Payer: Priority Health SBD |
$575.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$593.77
|
| Rate for Payer: UHC Core |
$475.93
|
| Rate for Payer: UHC Exchange |
$359.01
|
| Rate for Payer: UMR Bronson Commercial |
$338.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$685.12
|
|
|
PHENOBARBITAL 16.2 MG TABLET
|
Facility
|
IP
|
$913.50
|
|
|
Service Code
|
NDC 63739019210
|
| Hospital Charge Code |
6215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$401.94 |
| Max. Negotiated Rate |
$822.15 |
| Rate for Payer: Aetna American Axle |
$593.77
|
| Rate for Payer: Aetna Commercial |
$776.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$593.77
|
| Rate for Payer: Cash Price |
$730.80
|
| Rate for Payer: Cofinity Advantage |
$639.45
|
| Rate for Payer: Cofinity Commercial |
$785.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$730.80
|
| Rate for Payer: Healthscope Commercial |
$822.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$639.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$685.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$776.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$685.12
|
| Rate for Payer: PHP Commercial |
$776.48
|
| Rate for Payer: Priority Health SBD |
$575.50
|
| Rate for Payer: UMR Bronson Commercial |
$401.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$685.12
|
|
|
PHENOBARBITAL 16.2 MG TABLET
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
NDC 13517062501
|
| Hospital Charge Code |
6215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.14 |
| Max. Negotiated Rate |
$289.80 |
| Rate for Payer: Aetna American Axle |
$209.30
|
| Rate for Payer: Aetna Commercial |
$273.70
|
| Rate for Payer: Aetna Medicare |
$161.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.30
|
| Rate for Payer: BCBS Complete |
$128.80
|
| Rate for Payer: Cash Price |
$257.60
|
| Rate for Payer: Cofinity Advantage |
$225.40
|
| Rate for Payer: Cofinity Commercial |
$276.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.60
|
| Rate for Payer: Healthscope Commercial |
$289.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$257.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.50
|
| Rate for Payer: PHP Commercial |
$273.70
|
| Rate for Payer: Priority Health SBD |
$202.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.30
|
| Rate for Payer: UHC Core |
$167.76
|
| Rate for Payer: UHC Exchange |
$126.55
|
| Rate for Payer: UMR Bronson Commercial |
$119.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.50
|
|
|
PHENOBARBITAL 16.2 MG TABLET
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
NDC 13517062501
|
| Hospital Charge Code |
6215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.68 |
| Max. Negotiated Rate |
$289.80 |
| Rate for Payer: Aetna American Axle |
$209.30
|
| Rate for Payer: Aetna Commercial |
$273.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.30
|
| Rate for Payer: Cash Price |
$257.60
|
| Rate for Payer: Cofinity Advantage |
$225.40
|
| Rate for Payer: Cofinity Commercial |
$276.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.60
|
| Rate for Payer: Healthscope Commercial |
$289.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.50
|
| Rate for Payer: PHP Commercial |
$273.70
|
| Rate for Payer: Priority Health SBD |
$202.86
|
| Rate for Payer: UMR Bronson Commercial |
$141.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.50
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$21.94
|
|
|
Service Code
|
NDC 00121282650
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.65 |
| Max. Negotiated Rate |
$19.75 |
| Rate for Payer: Aetna American Axle |
$14.26
|
| Rate for Payer: Aetna Commercial |
$18.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.26
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cofinity Advantage |
$15.36
|
| Rate for Payer: Cofinity Commercial |
$18.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$19.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.45
|
| Rate for Payer: PHP Commercial |
$18.65
|
| Rate for Payer: Priority Health SBD |
$13.82
|
| Rate for Payer: UMR Bronson Commercial |
$9.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.45
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$216.97
|
|
|
Service Code
|
NDC 00603150858
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$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 Advantage |
$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 Commercial |
$184.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.73
|
| Rate for Payer: PHP Commercial |
$184.42
|
| 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 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
OP
|
$21.94
|
|
|
Service Code
|
NDC 00121282615
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.12 |
| Max. Negotiated Rate |
$19.75 |
| Rate for Payer: Aetna American Axle |
$14.26
|
| Rate for Payer: Aetna Commercial |
$18.65
|
| Rate for Payer: Aetna Medicare |
$10.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.26
|
| Rate for Payer: BCBS Complete |
$8.78
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cofinity Advantage |
$15.36
|
| Rate for Payer: Cofinity Commercial |
$18.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$19.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.45
|
| Rate for Payer: PHP Commercial |
$18.65
|
| Rate for Payer: Priority Health SBD |
$13.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.26
|
| Rate for Payer: UHC Core |
$11.43
|
| Rate for Payer: UHC Exchange |
$8.62
|
| Rate for Payer: UMR Bronson Commercial |
$8.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.45
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
OP
|
$21.94
|
|
|
Service Code
|
NDC 00121282650
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.12 |
| Max. Negotiated Rate |
$19.75 |
| Rate for Payer: Aetna American Axle |
$14.26
|
| Rate for Payer: Aetna Commercial |
$18.65
|
| Rate for Payer: Aetna Medicare |
$10.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.26
|
| Rate for Payer: BCBS Complete |
$8.78
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cofinity Advantage |
$15.36
|
| Rate for Payer: Cofinity Commercial |
$18.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$19.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.45
|
| Rate for Payer: PHP Commercial |
$18.65
|
| Rate for Payer: Priority Health SBD |
$13.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.26
|
| Rate for Payer: UHC Core |
$11.43
|
| Rate for Payer: UHC Exchange |
$8.62
|
| Rate for Payer: UMR Bronson Commercial |
$8.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.45
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
IP
|
$21.94
|
|
|
Service Code
|
NDC 00121282615
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.65 |
| Max. Negotiated Rate |
$19.75 |
| Rate for Payer: Aetna American Axle |
$14.26
|
| Rate for Payer: Aetna Commercial |
$18.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.26
|
| Rate for Payer: Cash Price |
$17.55
|
| Rate for Payer: Cofinity Advantage |
$15.36
|
| Rate for Payer: Cofinity Commercial |
$18.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$19.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.45
|
| Rate for Payer: PHP Commercial |
$18.65
|
| Rate for Payer: Priority Health SBD |
$13.82
|
| Rate for Payer: UMR Bronson Commercial |
$9.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.45
|
|
|
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR
|
Facility
|
OP
|
$216.97
|
|
|
Service Code
|
NDC 00603150858
|
| Hospital Charge Code |
6212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.28 |
| Max. Negotiated Rate |
$195.27 |
| Rate for Payer: Aetna American Axle |
$141.03
|
| Rate for Payer: Aetna Commercial |
$184.42
|
| Rate for Payer: Aetna Medicare |
$108.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.03
|
| Rate for Payer: BCBS Complete |
$86.79
|
| Rate for Payer: Cash Price |
$173.58
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$173.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.73
|
| Rate for Payer: PHP Commercial |
$184.42
|
| Rate for Payer: Priority Health SBD |
$136.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$141.03
|
| Rate for Payer: UHC Core |
$113.04
|
| Rate for Payer: UHC Exchange |
$85.27
|
| Rate for Payer: UMR Bronson Commercial |
$80.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.73
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
OP
|
$374.30
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
6217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.49 |
| Max. Negotiated Rate |
$336.87 |
| Rate for Payer: Aetna American Axle |
$243.29
|
| Rate for Payer: Aetna Commercial |
$318.15
|
| Rate for Payer: Aetna Medicare |
$187.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$243.29
|
| Rate for Payer: BCBS Complete |
$149.72
|
| Rate for Payer: Cash Price |
$299.44
|
| Rate for Payer: Cofinity Advantage |
$262.01
|
| Rate for Payer: Cofinity Commercial |
$321.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$299.44
|
| Rate for Payer: Healthscope Commercial |
$336.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$262.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$299.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$318.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$280.73
|
| Rate for Payer: PHP Commercial |
$318.15
|
| Rate for Payer: Priority Health SBD |
$235.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$243.29
|
| Rate for Payer: UHC Core |
$195.01
|
| Rate for Payer: UHC Exchange |
$147.10
|
| Rate for Payer: UMR Bronson Commercial |
$138.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.73
|
|
|
PHENOBARBITAL 32.4 MG TABLET
|
Facility
|
OP
|
$240.96
|
|
|
Service Code
|
NDC 00603516621
|
| Hospital Charge Code |
6217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.16 |
| Max. Negotiated Rate |
$216.86 |
| Rate for Payer: Aetna American Axle |
$156.62
|
| Rate for Payer: Aetna Commercial |
$204.82
|
| Rate for Payer: Aetna Medicare |
$120.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.62
|
| Rate for Payer: BCBS Complete |
$96.38
|
| Rate for Payer: Cash Price |
$192.77
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$192.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$180.72
|
| Rate for Payer: PHP Commercial |
$204.82
|
| Rate for Payer: Priority Health SBD |
$151.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$156.62
|
| Rate for Payer: UHC Core |
$125.54
|
| Rate for Payer: UHC Exchange |
$94.70
|
| Rate for Payer: UMR Bronson Commercial |
$89.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.72
|
|
