|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE
|
Facility
|
OP
|
$1.50
|
|
|
Service Code
|
NDC 09900001005
|
| Hospital Charge Code |
119800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna American Axle |
$0.98
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.98
|
| Rate for Payer: BCBS Complete |
$0.60
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cofinity Advantage |
$1.05
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.20
|
| Rate for Payer: Healthscope Commercial |
$1.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.12
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health SBD |
$0.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.98
|
| Rate for Payer: UHC Core |
$0.78
|
| Rate for Payer: UHC Exchange |
$0.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
NDC 69374095710
|
| Hospital Charge Code |
119800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna American Axle |
$2.76
|
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.76
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cofinity Advantage |
$2.98
|
| Rate for Payer: Cofinity Commercial |
$3.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.40
|
| Rate for Payer: Healthscope Commercial |
$3.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.19
|
| Rate for Payer: PHP Commercial |
$3.61
|
| Rate for Payer: Priority Health SBD |
$2.68
|
| Rate for Payer: UMR Bronson Commercial |
$1.87
|
| 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
|
OP
|
$23.86
|
|
|
Service Code
|
NDC 70092004646
|
| Hospital Charge Code |
119800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.83 |
| Max. Negotiated Rate |
$21.47 |
| Rate for Payer: Aetna American Axle |
$15.51
|
| Rate for Payer: Aetna Commercial |
$20.28
|
| Rate for Payer: Aetna Medicare |
$11.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.51
|
| Rate for Payer: BCBS Complete |
$9.54
|
| Rate for Payer: Cash Price |
$19.09
|
| Rate for Payer: Cofinity Advantage |
$16.70
|
| Rate for Payer: Cofinity Commercial |
$20.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.09
|
| Rate for Payer: Healthscope Commercial |
$21.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.89
|
| Rate for Payer: PHP Commercial |
$20.28
|
| Rate for Payer: Priority Health SBD |
$15.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.51
|
| Rate for Payer: UHC Core |
$12.43
|
| Rate for Payer: UHC Exchange |
$9.38
|
| Rate for Payer: UMR Bronson Commercial |
$8.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.89
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE
|
Facility
|
IP
|
$1.50
|
|
|
Service Code
|
NDC 09900001005
|
| Hospital Charge Code |
119800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.35 |
| Rate for Payer: Aetna American Axle |
$0.98
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.98
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cofinity Advantage |
$1.05
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.20
|
| Rate for Payer: Healthscope Commercial |
$1.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.12
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health SBD |
$0.95
|
| Rate for Payer: UMR Bronson Commercial |
$0.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
OP
|
$23.50
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
155583
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$21.15 |
| Rate for Payer: Aetna American Axle |
$15.28
|
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: Aetna Medicare |
$11.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.28
|
| Rate for Payer: BCBS Complete |
$9.40
|
| Rate for Payer: Cash Price |
$18.80
|
| Rate for Payer: Cofinity Advantage |
$16.45
|
| Rate for Payer: Cofinity Commercial |
$20.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.80
|
| Rate for Payer: Healthscope Commercial |
$21.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.62
|
| Rate for Payer: PHP Commercial |
$19.98
|
| Rate for Payer: Priority Health SBD |
$14.80
|
| Rate for Payer: UMR Bronson Commercial |
$8.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.62
|
|
|
PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV
|
Facility
|
IP
|
$23.50
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
155583
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.34 |
| Max. Negotiated Rate |
$21.15 |
| Rate for Payer: Aetna American Axle |
$15.28
|
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.28
|
| Rate for Payer: Cash Price |
$18.80
|
| Rate for Payer: Cofinity Advantage |
$16.45
|
| Rate for Payer: Cofinity Commercial |
$20.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.80
|
| Rate for Payer: Healthscope Commercial |
$21.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.62
|
| Rate for Payer: PHP Commercial |
$19.98
|
| Rate for Payer: Priority Health SBD |
$14.80
|
| Rate for Payer: UMR Bronson Commercial |
$10.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.62
|
|
|
PHENYLEPHRINE 20MG/250ML NS (IV PREMIX)
|
Facility
|
OP
|
$9.50
|
|
|
Service Code
|
NDC 09900000162
|
| Hospital Charge Code |
500533
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Aetna American Axle |
$6.17
|
| Rate for Payer: Aetna Commercial |
$8.07
|
| Rate for Payer: Aetna Medicare |
$4.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.17
|
| Rate for Payer: BCBS Complete |
$3.80
|
| Rate for Payer: Cash Price |
$7.60
|
| Rate for Payer: Cofinity Advantage |
$6.65
|
| Rate for Payer: Cofinity Commercial |
$8.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.60
|
| Rate for Payer: Healthscope Commercial |
$8.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.12
|
| Rate for Payer: PHP Commercial |
$8.07
|
| Rate for Payer: Priority Health SBD |
$5.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.17
|
| Rate for Payer: UHC Core |
$4.95
|
| Rate for Payer: UHC Exchange |
$3.73
|
| Rate for Payer: UMR Bronson Commercial |
$3.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.12
|
|
|
PHENYLEPHRINE 20MG/250ML NS (IV PREMIX)
|
Facility
|
IP
|
$9.50
|
|
|
Service Code
|
NDC 09900000162
|
| Hospital Charge Code |
500533
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.18 |
| Max. Negotiated Rate |
$8.55 |
| Rate for Payer: Aetna American Axle |
$6.17
|
| Rate for Payer: Aetna Commercial |
$8.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.17
|
| Rate for Payer: Cash Price |
$7.60
|
| Rate for Payer: Cofinity Advantage |
$6.65
|
| Rate for Payer: Cofinity Commercial |
$8.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.60
|
| Rate for Payer: Healthscope Commercial |
$8.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.12
|
| Rate for Payer: PHP Commercial |
$8.07
|
| Rate for Payer: Priority Health SBD |
$5.99
|
| Rate for Payer: UMR Bronson Commercial |
$4.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.12
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
OP
|
$45.54
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.85 |
| Max. Negotiated Rate |
$40.99 |
| Rate for Payer: Aetna American Axle |
$29.60
|
| Rate for Payer: Aetna Commercial |
$38.71
|
| Rate for Payer: Aetna Medicare |
$22.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.60
|
| Rate for Payer: BCBS Complete |
$18.22
|
| Rate for Payer: Cash Price |
$36.43
|
| Rate for Payer: Cofinity Advantage |
$31.88
|
| Rate for Payer: Cofinity Commercial |
$39.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.43
|
| Rate for Payer: Healthscope Commercial |
$40.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$36.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.16
|
| Rate for Payer: PHP Commercial |
$38.71
|
| Rate for Payer: Priority Health SBD |
$28.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.60
|
| Rate for Payer: UHC Core |
$23.73
|
| Rate for Payer: UHC Exchange |
$17.90
|
| Rate for Payer: UMR Bronson Commercial |
$16.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.16
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
OP
|
$41.41
|
|
|
Service Code
|
NDC 75907012907
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.32 |
| Max. Negotiated Rate |
$37.27 |
| Rate for Payer: Aetna American Axle |
$26.92
|
| Rate for Payer: Aetna Commercial |
$35.20
|
| Rate for Payer: Aetna Medicare |
$20.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.92
|
| Rate for Payer: BCBS Complete |
$16.56
|
| Rate for Payer: Cash Price |
$33.13
|
| Rate for Payer: Cofinity Advantage |
$28.99
|
| Rate for Payer: Cofinity Commercial |
$35.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.13
|
| Rate for Payer: Healthscope Commercial |
$37.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$28.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$33.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.06
|
| Rate for Payer: PHP Commercial |
$35.20
|
| Rate for Payer: Priority Health SBD |
$26.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.92
|
| Rate for Payer: UHC Core |
$21.57
|
| Rate for Payer: UHC Exchange |
$16.27
|
| Rate for Payer: UMR Bronson Commercial |
$15.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.06
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
IP
|
$45.54
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.04 |
| Max. Negotiated Rate |
$40.99 |
| Rate for Payer: Aetna American Axle |
$29.60
|
| Rate for Payer: Aetna Commercial |
$38.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.60
|
| Rate for Payer: Cash Price |
$36.43
|
| Rate for Payer: Cofinity Advantage |
$31.88
|
| Rate for Payer: Cofinity Commercial |
$39.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.43
|
| Rate for Payer: Healthscope Commercial |
$40.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.16
|
| Rate for Payer: PHP Commercial |
$38.71
|
| Rate for Payer: Priority Health SBD |
$28.69
|
| Rate for Payer: UMR Bronson Commercial |
$20.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.16
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
OP
|
$168.06
|
|
|
Service Code
|
NDC 70756064935
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.18 |
| Max. Negotiated Rate |
$151.25 |
| Rate for Payer: Aetna American Axle |
$109.24
|
| Rate for Payer: Aetna Commercial |
$142.85
|
| Rate for Payer: Aetna Medicare |
$84.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.24
|
| Rate for Payer: BCBS Complete |
$67.22
|
| Rate for Payer: Cash Price |
$134.45
|
| Rate for Payer: Cofinity Advantage |
$117.64
|
| Rate for Payer: Cofinity Commercial |
$144.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.45
|
| Rate for Payer: Healthscope Commercial |
$151.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$117.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.05
|
| Rate for Payer: PHP Commercial |
$142.85
|
| Rate for Payer: Priority Health SBD |
$105.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$109.24
|
| Rate for Payer: UHC Core |
$87.56
|
| Rate for Payer: UHC Exchange |
$66.05
|
| Rate for Payer: UMR Bronson Commercial |
$62.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.05
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
IP
|
$41.41
|
|
|
Service Code
|
NDC 75907012907
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.22 |
| Max. Negotiated Rate |
$37.27 |
| Rate for Payer: Aetna American Axle |
$26.92
|
| Rate for Payer: Aetna Commercial |
$35.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.92
|
| Rate for Payer: Cash Price |
$33.13
|
| Rate for Payer: Cofinity Advantage |
$28.99
|
| Rate for Payer: Cofinity Commercial |
$35.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.13
|
| Rate for Payer: Healthscope Commercial |
$37.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$28.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.06
|
| Rate for Payer: PHP Commercial |
$35.20
|
| Rate for Payer: Priority Health SBD |
$26.09
|
| Rate for Payer: UMR Bronson Commercial |
$18.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.06
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
IP
|
$168.06
|
|
|
Service Code
|
NDC 70756064935
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.95 |
| Max. Negotiated Rate |
$151.25 |
| Rate for Payer: Aetna American Axle |
$109.24
|
| Rate for Payer: Aetna Commercial |
$142.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.24
|
| Rate for Payer: Cash Price |
$134.45
|
| Rate for Payer: Cofinity Advantage |
$117.64
|
| Rate for Payer: Cofinity Commercial |
$144.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.45
|
| Rate for Payer: Healthscope Commercial |
$151.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$117.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$126.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$126.05
|
| Rate for Payer: PHP Commercial |
$142.85
|
| Rate for Payer: Priority Health SBD |
$105.88
|
| Rate for Payer: UMR Bronson Commercial |
$73.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$126.05
|
|
|
PHENYLEPHRINE IV INFUSION (INTRA-OP)
|
Facility
|
OP
|
$16.25
|
|
|
Service Code
|
NDC 09900000362
|
| Hospital Charge Code |
155179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.01 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Aetna American Axle |
$10.56
|
| Rate for Payer: Aetna Commercial |
$13.81
|
| Rate for Payer: Aetna Medicare |
$8.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.56
|
| Rate for Payer: BCBS Complete |
$6.50
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cofinity Advantage |
$11.38
|
| Rate for Payer: Cofinity Commercial |
$13.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.00
|
| Rate for Payer: Healthscope Commercial |
$14.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.19
|
| Rate for Payer: PHP Commercial |
$13.81
|
| Rate for Payer: Priority Health SBD |
$10.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.56
|
| Rate for Payer: UHC Core |
$8.47
|
| Rate for Payer: UHC Exchange |
$6.39
|
| Rate for Payer: UMR Bronson Commercial |
$6.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.19
|
|
|
PHENYLEPHRINE IV INFUSION (INTRA-OP)
|
Facility
|
IP
|
$16.25
|
|
|
Service Code
|
NDC 09900000362
|
| Hospital Charge Code |
155179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$14.62 |
| Rate for Payer: Aetna American Axle |
$10.56
|
| Rate for Payer: Aetna Commercial |
$13.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.56
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cofinity Advantage |
$11.38
|
| Rate for Payer: Cofinity Commercial |
$13.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.00
|
| Rate for Payer: Healthscope Commercial |
$14.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.19
|
| Rate for Payer: PHP Commercial |
$13.81
|
| Rate for Payer: Priority Health SBD |
$10.24
|
| Rate for Payer: UMR Bronson Commercial |
$7.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.19
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION
|
Facility
|
OP
|
$21.17
|
|
|
Service Code
|
NDC 66689003650
|
| Hospital Charge Code |
118124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$19.05 |
| Rate for Payer: Aetna American Axle |
$13.76
|
| Rate for Payer: Aetna Commercial |
$17.99
|
| Rate for Payer: Aetna Medicare |
$10.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.76
|
| Rate for Payer: BCBS Complete |
$8.47
|
| Rate for Payer: Cash Price |
$16.94
|
| Rate for Payer: Cofinity Advantage |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.94
|
| Rate for Payer: Healthscope Commercial |
$19.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.88
|
| Rate for Payer: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health SBD |
$13.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.76
|
| Rate for Payer: UHC Core |
$11.03
|
| Rate for Payer: UHC Exchange |
$8.32
|
| Rate for Payer: UMR Bronson Commercial |
$7.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.88
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION
|
Facility
|
OP
|
$21.17
|
|
|
Service Code
|
NDC 66689003601
|
| Hospital Charge Code |
118124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$19.05 |
| Rate for Payer: Aetna American Axle |
$13.76
|
| Rate for Payer: Aetna Commercial |
$17.99
|
| Rate for Payer: Aetna Medicare |
$10.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.76
|
| Rate for Payer: BCBS Complete |
$8.47
|
| Rate for Payer: Cash Price |
$16.94
|
| Rate for Payer: Cofinity Advantage |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.94
|
| Rate for Payer: Healthscope Commercial |
$19.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.88
|
| Rate for Payer: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health SBD |
$13.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.76
|
| Rate for Payer: UHC Core |
$11.03
|
| Rate for Payer: UHC Exchange |
$8.32
|
| Rate for Payer: UMR Bronson Commercial |
$7.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.88
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION
|
Facility
|
IP
|
$21.17
|
|
|
Service Code
|
NDC 66689003601
|
| Hospital Charge Code |
118124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$19.05 |
| Rate for Payer: Aetna American Axle |
$13.76
|
| Rate for Payer: Aetna Commercial |
$17.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.76
|
| Rate for Payer: Cash Price |
$16.94
|
| Rate for Payer: Cofinity Advantage |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.94
|
| Rate for Payer: Healthscope Commercial |
$19.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.88
|
| Rate for Payer: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health SBD |
$13.34
|
| Rate for Payer: UMR Bronson Commercial |
$9.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.88
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION
|
Facility
|
IP
|
$21.17
|
|
|
Service Code
|
NDC 66689003650
|
| Hospital Charge Code |
118124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$19.05 |
| Rate for Payer: Aetna American Axle |
$13.76
|
| Rate for Payer: Aetna Commercial |
$17.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.76
|
| Rate for Payer: Cash Price |
$16.94
|
| Rate for Payer: Cofinity Advantage |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.94
|
| Rate for Payer: Healthscope Commercial |
$19.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.88
|
| Rate for Payer: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health SBD |
$13.34
|
| Rate for Payer: UMR Bronson Commercial |
$9.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.88
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$295.19
|
|
|
Service Code
|
NDC 51672406902
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.88 |
| Max. Negotiated Rate |
$265.67 |
| Rate for Payer: Aetna American Axle |
$191.87
|
| Rate for Payer: Aetna Commercial |
$250.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.87
|
| Rate for Payer: Cash Price |
$236.15
|
| Rate for Payer: Cofinity Advantage |
$206.63
|
| Rate for Payer: Cofinity Commercial |
$253.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.15
|
| Rate for Payer: Healthscope Commercial |
$265.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$221.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$221.39
|
| Rate for Payer: PHP Commercial |
$250.91
|
| Rate for Payer: Priority Health SBD |
$185.97
|
| Rate for Payer: UMR Bronson Commercial |
$129.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$221.39
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$590.37
|
|
|
Service Code
|
NDC 60432013108
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$259.76 |
| Max. Negotiated Rate |
$531.33 |
| Rate for Payer: Aetna American Axle |
$383.74
|
| Rate for Payer: Aetna Commercial |
$501.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$383.74
|
| Rate for Payer: Cash Price |
$472.30
|
| Rate for Payer: Cofinity Advantage |
$413.26
|
| Rate for Payer: Cofinity Commercial |
$507.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$472.30
|
| Rate for Payer: Healthscope Commercial |
$531.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$413.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$442.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$501.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$442.78
|
| Rate for Payer: PHP Commercial |
$501.81
|
| Rate for Payer: Priority Health SBD |
$371.93
|
| Rate for Payer: UMR Bronson Commercial |
$259.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$442.78
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$295.19
|
|
|
Service Code
|
NDC 51672406901
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.88 |
| Max. Negotiated Rate |
$265.67 |
| Rate for Payer: Aetna American Axle |
$191.87
|
| Rate for Payer: Aetna Commercial |
$250.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.87
|
| Rate for Payer: Cash Price |
$236.15
|
| Rate for Payer: Cofinity Advantage |
$206.63
|
| Rate for Payer: Cofinity Commercial |
$253.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.15
|
| Rate for Payer: Healthscope Commercial |
$265.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$221.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$221.39
|
| Rate for Payer: PHP Commercial |
$250.91
|
| Rate for Payer: Priority Health SBD |
$185.97
|
| Rate for Payer: UMR Bronson Commercial |
$129.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$221.39
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$295.19
|
|
|
Service Code
|
NDC 51672406901
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.22 |
| Max. Negotiated Rate |
$265.67 |
| Rate for Payer: Aetna American Axle |
$191.87
|
| Rate for Payer: Aetna Commercial |
$250.91
|
| Rate for Payer: Aetna Medicare |
$147.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.87
|
| Rate for Payer: BCBS Complete |
$118.08
|
| Rate for Payer: Cash Price |
$236.15
|
| Rate for Payer: Cofinity Advantage |
$206.63
|
| Rate for Payer: Cofinity Commercial |
$253.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.15
|
| Rate for Payer: Healthscope Commercial |
$265.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$221.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$236.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$221.39
|
| Rate for Payer: PHP Commercial |
$250.91
|
| Rate for Payer: Priority Health SBD |
$185.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$191.87
|
| Rate for Payer: UHC Core |
$153.79
|
| Rate for Payer: UHC Exchange |
$116.01
|
| Rate for Payer: UMR Bronson Commercial |
$109.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$221.39
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$295.19
|
|
|
Service Code
|
NDC 51672406902
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.22 |
| Max. Negotiated Rate |
$265.67 |
| Rate for Payer: Aetna American Axle |
$191.87
|
| Rate for Payer: Aetna Commercial |
$250.91
|
| Rate for Payer: Aetna Medicare |
$147.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.87
|
| Rate for Payer: BCBS Complete |
$118.08
|
| Rate for Payer: Cash Price |
$236.15
|
| Rate for Payer: Cofinity Advantage |
$206.63
|
| Rate for Payer: Cofinity Commercial |
$253.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.15
|
| Rate for Payer: Healthscope Commercial |
$265.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$221.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$236.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$221.39
|
| Rate for Payer: PHP Commercial |
$250.91
|
| Rate for Payer: Priority Health SBD |
$185.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$191.87
|
| Rate for Payer: UHC Core |
$153.79
|
| Rate for Payer: UHC Exchange |
$116.01
|
| Rate for Payer: UMR Bronson Commercial |
$109.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$221.39
|
|
