|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$590.37
|
|
|
Service Code
|
NDC 60432013108
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$218.44 |
| Max. Negotiated Rate |
$531.33 |
| Rate for Payer: Aetna American Axle |
$383.74
|
| Rate for Payer: Aetna Commercial |
$501.81
|
| Rate for Payer: Aetna Medicare |
$295.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$383.74
|
| Rate for Payer: BCBS Complete |
$236.15
|
| Rate for Payer: Cash Price |
$472.30
|
| Rate for Payer: Cofinity 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: MI Amish Medical Board Commercial |
$472.30
|
| 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: UHC All Payor (Choice/PPO) |
$383.74
|
| Rate for Payer: UHC Core |
$307.58
|
| Rate for Payer: UHC Exchange |
$232.02
|
| Rate for Payer: UMR Bronson Commercial |
$218.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$442.78
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$523.54
|
|
|
Service Code
|
NDC 59762053102
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.71 |
| Max. Negotiated Rate |
$471.19 |
| Rate for Payer: Aetna American Axle |
$340.30
|
| Rate for Payer: Aetna Commercial |
$445.01
|
| Rate for Payer: Aetna Medicare |
$261.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.30
|
| Rate for Payer: BCBS Complete |
$209.42
|
| Rate for Payer: Cash Price |
$418.83
|
| Rate for Payer: Cofinity Advantage |
$366.48
|
| Rate for Payer: Cofinity Commercial |
$450.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$418.83
|
| Rate for Payer: Healthscope Commercial |
$471.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$418.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.65
|
| Rate for Payer: PHP Commercial |
$445.01
|
| Rate for Payer: Priority Health SBD |
$329.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.30
|
| Rate for Payer: UHC Core |
$272.76
|
| Rate for Payer: UHC Exchange |
$205.75
|
| Rate for Payer: UMR Bronson Commercial |
$193.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.65
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$523.54
|
|
|
Service Code
|
NDC 59762053102
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.36 |
| Max. Negotiated Rate |
$471.19 |
| Rate for Payer: Aetna American Axle |
$340.30
|
| Rate for Payer: Aetna Commercial |
$445.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.30
|
| Rate for Payer: Cash Price |
$418.83
|
| Rate for Payer: Cofinity Advantage |
$366.48
|
| Rate for Payer: Cofinity Commercial |
$450.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$418.83
|
| Rate for Payer: Healthscope Commercial |
$471.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.65
|
| Rate for Payer: PHP Commercial |
$445.01
|
| Rate for Payer: Priority Health SBD |
$329.83
|
| Rate for Payer: UMR Bronson Commercial |
$230.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.65
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$891.88
|
|
|
Service Code
|
NDC 58151011535
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$802.69 |
| Rate for Payer: Aetna American Axle |
$579.72
|
| Rate for Payer: Aetna Commercial |
$758.10
|
| Rate for Payer: Aetna Medicare |
$445.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$579.72
|
| Rate for Payer: BCBS Complete |
$356.75
|
| Rate for Payer: Cash Price |
$713.50
|
| Rate for Payer: Cofinity Advantage |
$624.32
|
| Rate for Payer: Cofinity Commercial |
$767.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$713.50
|
| Rate for Payer: Healthscope Commercial |
$802.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$624.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$668.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$713.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$758.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$668.91
|
| Rate for Payer: PHP Commercial |
$758.10
|
| Rate for Payer: Priority Health SBD |
$561.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$579.72
|
| Rate for Payer: UHC Core |
$464.67
|
| Rate for Payer: UHC Exchange |
$350.51
|
| Rate for Payer: UMR Bronson Commercial |
$330.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$668.91
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$891.88
|
|
|
Service Code
|
NDC 58151011535
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$392.43 |
| Max. Negotiated Rate |
$802.69 |
| Rate for Payer: Aetna American Axle |
$579.72
|
| Rate for Payer: Aetna Commercial |
$758.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$579.72
|
| Rate for Payer: Cash Price |
$713.50
|
| Rate for Payer: Cofinity Advantage |
$624.32
|
| Rate for Payer: Cofinity Commercial |
$767.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$713.50
|
| Rate for Payer: Healthscope Commercial |
$802.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$624.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$668.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$758.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$668.91
|
| Rate for Payer: PHP Commercial |
$758.10
|
| Rate for Payer: Priority Health SBD |
$561.88
|
| Rate for Payer: UMR Bronson Commercial |
$392.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$668.91
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$216.60
|
|
|
Service Code
|
NDC 64980057301
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.30 |
| Max. Negotiated Rate |
$194.94 |
| Rate for Payer: Aetna American Axle |
$140.79
|
| Rate for Payer: Aetna Commercial |
$184.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.79
|
| Rate for Payer: Cash Price |
$173.28
|
| Rate for Payer: Cofinity Advantage |
$151.62
|
| Rate for Payer: Cofinity Commercial |
$186.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.28
|
| Rate for Payer: Healthscope Commercial |
$194.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$151.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.45
|
| Rate for Payer: PHP Commercial |
$184.11
|
| Rate for Payer: Priority Health SBD |
$136.46
|
| Rate for Payer: UMR Bronson Commercial |
$95.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.45
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$769.60
|
|
|
Service Code
|
NDC 00071000740
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$338.62 |
| Max. Negotiated Rate |
$692.64 |
| Rate for Payer: Aetna American Axle |
$500.24
|
| Rate for Payer: Aetna Commercial |
$654.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$500.24
|
| Rate for Payer: Cash Price |
$615.68
|
| Rate for Payer: Cofinity Advantage |
$538.72
|
| Rate for Payer: Cofinity Commercial |
$661.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$615.68
|
| Rate for Payer: Healthscope Commercial |
$692.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$538.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$577.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$654.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$577.20
|
| Rate for Payer: PHP Commercial |
$654.16
|
| Rate for Payer: Priority Health SBD |
$484.85
|
| Rate for Payer: UMR Bronson Commercial |
$338.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$577.20
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
OP
|
$372.40
|
|
|
Service Code
|
NDC 51672414601
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.79 |
| Max. Negotiated Rate |
$335.16 |
| Rate for Payer: Aetna American Axle |
$242.06
|
| Rate for Payer: Aetna Commercial |
$316.54
|
| Rate for Payer: Aetna Medicare |
$186.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.06
|
| Rate for Payer: BCBS Complete |
$148.96
|
| Rate for Payer: Cash Price |
$297.92
|
| Rate for Payer: Cofinity Advantage |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$320.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.92
|
| Rate for Payer: Healthscope Commercial |
$335.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$297.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$316.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$279.30
|
| Rate for Payer: PHP Commercial |
$316.54
|
| Rate for Payer: Priority Health SBD |
$234.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$242.06
|
| Rate for Payer: UHC Core |
$194.02
|
| Rate for Payer: UHC Exchange |
$146.35
|
| Rate for Payer: UMR Bronson Commercial |
$137.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.30
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
OP
|
$151.06
|
|
|
Service Code
|
NDC 00904719907
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.89 |
| Max. Negotiated Rate |
$135.95 |
| Rate for Payer: Aetna American Axle |
$98.19
|
| Rate for Payer: Aetna Commercial |
$128.40
|
| Rate for Payer: Aetna Medicare |
$75.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.19
|
| Rate for Payer: BCBS Complete |
$60.42
|
| Rate for Payer: Cash Price |
$120.85
|
| Rate for Payer: Cofinity Advantage |
$105.74
|
| Rate for Payer: Cofinity Commercial |
$129.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.85
|
| Rate for Payer: Healthscope Commercial |
$135.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$105.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$113.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$128.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$113.30
|
| Rate for Payer: PHP Commercial |
$128.40
|
| Rate for Payer: Priority Health SBD |
$95.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.19
|
| Rate for Payer: UHC Core |
$78.70
|
| Rate for Payer: UHC Exchange |
$59.37
|
| Rate for Payer: UMR Bronson Commercial |
$55.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$113.30
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$372.40
|
|
|
Service Code
|
NDC 51672414601
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.86 |
| Max. Negotiated Rate |
$335.16 |
| Rate for Payer: Aetna American Axle |
$242.06
|
| Rate for Payer: Aetna Commercial |
$316.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.06
|
| Rate for Payer: Cash Price |
$297.92
|
| Rate for Payer: Cofinity Advantage |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$320.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.92
|
| Rate for Payer: Healthscope Commercial |
$335.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$316.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$279.30
|
| Rate for Payer: PHP Commercial |
$316.54
|
| Rate for Payer: Priority Health SBD |
$234.61
|
| Rate for Payer: UMR Bronson Commercial |
$163.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.30
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
OP
|
$769.60
|
|
|
Service Code
|
NDC 00071000740
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.75 |
| Max. Negotiated Rate |
$692.64 |
| Rate for Payer: Aetna American Axle |
$500.24
|
| Rate for Payer: Aetna Commercial |
$654.16
|
| Rate for Payer: Aetna Medicare |
$384.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$500.24
|
| Rate for Payer: BCBS Complete |
$307.84
|
| Rate for Payer: Cash Price |
$615.68
|
| Rate for Payer: Cofinity Advantage |
$538.72
|
| Rate for Payer: Cofinity Commercial |
$661.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$615.68
|
| Rate for Payer: Healthscope Commercial |
$692.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$538.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$577.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$615.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$654.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$577.20
|
| Rate for Payer: PHP Commercial |
$654.16
|
| Rate for Payer: Priority Health SBD |
$484.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$500.24
|
| Rate for Payer: UHC Core |
$400.96
|
| Rate for Payer: UHC Exchange |
$302.45
|
| Rate for Payer: UMR Bronson Commercial |
$284.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$577.20
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$151.06
|
|
|
Service Code
|
NDC 00904719907
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.47 |
| Max. Negotiated Rate |
$135.95 |
| Rate for Payer: Aetna American Axle |
$98.19
|
| Rate for Payer: Aetna Commercial |
$128.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.19
|
| Rate for Payer: Cash Price |
$120.85
|
| Rate for Payer: Cofinity Advantage |
$105.74
|
| Rate for Payer: Cofinity Commercial |
$129.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.85
|
| Rate for Payer: Healthscope Commercial |
$135.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$105.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$113.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$128.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$113.30
|
| Rate for Payer: PHP Commercial |
$128.40
|
| Rate for Payer: Priority Health SBD |
$95.17
|
| Rate for Payer: UMR Bronson Commercial |
$66.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$113.30
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
OP
|
$216.60
|
|
|
Service Code
|
NDC 64980057301
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.14 |
| Max. Negotiated Rate |
$194.94 |
| Rate for Payer: Aetna American Axle |
$140.79
|
| Rate for Payer: Aetna Commercial |
$184.11
|
| Rate for Payer: Aetna Medicare |
$108.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.79
|
| Rate for Payer: BCBS Complete |
$86.64
|
| Rate for Payer: Cash Price |
$173.28
|
| Rate for Payer: Cofinity Advantage |
$151.62
|
| Rate for Payer: Cofinity Commercial |
$186.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.28
|
| Rate for Payer: Healthscope Commercial |
$194.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$151.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$173.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$184.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$162.45
|
| Rate for Payer: PHP Commercial |
$184.11
|
| Rate for Payer: Priority Health SBD |
$136.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$140.79
|
| Rate for Payer: UHC Core |
$112.85
|
| Rate for Payer: UHC Exchange |
$85.12
|
| Rate for Payer: UMR Bronson Commercial |
$80.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.45
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.84
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.93 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna American Axle |
$16.15
|
| Rate for Payer: Aetna American Axle |
$14.00
|
| Rate for Payer: Aetna American Axle |
$18.76
|
| Rate for Payer: Aetna American Axle |
$9.73
|
| Rate for Payer: Aetna Commercial |
$24.53
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Commercial |
$12.72
|
| Rate for Payer: Aetna Commercial |
$18.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.73
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$17.23
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cofinity Advantage |
$15.08
|
| Rate for Payer: Cofinity Advantage |
$10.48
|
| Rate for Payer: Cofinity Advantage |
$17.39
|
| Rate for Payer: Cofinity Advantage |
$20.20
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$12.87
|
| Rate for Payer: Cofinity Commercial |
$18.52
|
| Rate for Payer: Cofinity Commercial |
$24.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.23
|
| Rate for Payer: Healthscope Commercial |
$19.39
|
| Rate for Payer: Healthscope Commercial |
$25.97
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Commercial |
$13.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.23
|
| Rate for Payer: PHP Commercial |
$12.72
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$18.31
|
| Rate for Payer: PHP Commercial |
$24.53
|
| Rate for Payer: Priority Health SBD |
$18.18
|
| Rate for Payer: Priority Health SBD |
$9.43
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$13.57
|
| Rate for Payer: UMR Bronson Commercial |
$9.48
|
| Rate for Payer: UMR Bronson Commercial |
$10.93
|
| Rate for Payer: UMR Bronson Commercial |
$6.59
|
| Rate for Payer: UMR Bronson Commercial |
$12.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.64
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$28.86
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna American Axle |
$18.76
|
| Rate for Payer: Aetna American Axle |
$9.73
|
| Rate for Payer: Aetna American Axle |
$14.00
|
| Rate for Payer: Aetna American Axle |
$16.15
|
| Rate for Payer: Aetna Commercial |
$24.53
|
| Rate for Payer: Aetna Commercial |
$21.11
|
| Rate for Payer: Aetna Commercial |
$12.72
|
| Rate for Payer: Aetna Commercial |
$18.31
|
| Rate for Payer: Aetna Medicare |
$12.42
|
| Rate for Payer: Aetna Medicare |
$10.77
|
| Rate for Payer: Aetna Medicare |
$14.43
|
| Rate for Payer: Aetna Medicare |
$7.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.15
|
| Rate for Payer: BCBS Complete |
$5.99
|
| Rate for Payer: BCBS Complete |
$8.62
|
| Rate for Payer: BCBS Complete |
$9.94
|
| Rate for Payer: BCBS Complete |
$11.54
|
| Rate for Payer: BCBS Trust/PPO |
$1.91
|
| Rate for Payer: BCBS Trust/PPO |
$1.91
|
| Rate for Payer: BCBS Trust/PPO |
$1.91
|
| Rate for Payer: BCBS Trust/PPO |
$1.91
|
| Rate for Payer: BCN Commercial |
$1.91
|
| Rate for Payer: BCN Commercial |
$1.91
|
| Rate for Payer: BCN Commercial |
$1.91
|
| Rate for Payer: BCN Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$19.87
|
| Rate for Payer: Cash Price |
$17.23
|
| Rate for Payer: Cash Price |
$17.23
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cofinity Advantage |
$20.20
|
| Rate for Payer: Cofinity Advantage |
$17.39
|
| Rate for Payer: Cofinity Advantage |
$15.08
|
| Rate for Payer: Cofinity Advantage |
$10.48
|
| Rate for Payer: Cofinity Commercial |
$18.52
|
| Rate for Payer: Cofinity Commercial |
$21.36
|
| Rate for Payer: Cofinity Commercial |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$12.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.98
|
| Rate for Payer: Healthscope Commercial |
$22.36
|
| Rate for Payer: Healthscope Commercial |
$13.47
|
| Rate for Payer: Healthscope Commercial |
$19.39
|
| Rate for Payer: Healthscope Commercial |
$25.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$21.64
|
| Rate for Payer: PHP Commercial |
$12.72
|
| Rate for Payer: PHP Commercial |
$21.11
|
| Rate for Payer: PHP Commercial |
$24.53
|
| Rate for Payer: PHP Commercial |
$18.31
|
| Rate for Payer: Priority Health SBD |
$15.65
|
| Rate for Payer: Priority Health SBD |
$9.43
|
| Rate for Payer: Priority Health SBD |
$13.57
|
| Rate for Payer: Priority Health SBD |
$18.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.99
|
| Rate for Payer: UHC Core |
$0.99
|
| Rate for Payer: UHC Core |
$0.99
|
| Rate for Payer: UHC Core |
$0.99
|
| Rate for Payer: UHC Core |
$0.99
|
| Rate for Payer: UHC Exchange |
$0.99
|
| Rate for Payer: UHC Exchange |
$0.99
|
| Rate for Payer: UHC Exchange |
$0.99
|
| Rate for Payer: UHC Exchange |
$0.99
|
| Rate for Payer: UMR Bronson Commercial |
$10.68
|
| Rate for Payer: UMR Bronson Commercial |
$5.54
|
| Rate for Payer: UMR Bronson Commercial |
$7.97
|
| Rate for Payer: UMR Bronson Commercial |
$9.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.64
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$685.92
|
|
|
Service Code
|
NDC 60687084101
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$301.80 |
| Max. Negotiated Rate |
$617.33 |
| Rate for Payer: Aetna American Axle |
$445.85
|
| Rate for Payer: Aetna Commercial |
$583.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$445.85
|
| Rate for Payer: Cash Price |
$548.74
|
| Rate for Payer: Cofinity Advantage |
$480.14
|
| Rate for Payer: Cofinity Commercial |
$589.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$548.74
|
| Rate for Payer: Healthscope Commercial |
$617.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$480.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$514.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$583.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$514.44
|
| Rate for Payer: PHP Commercial |
$583.03
|
| Rate for Payer: Priority Health SBD |
$432.13
|
| Rate for Payer: UMR Bronson Commercial |
$301.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$514.44
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$452.20
|
|
|
Service Code
|
NDC 68084037611
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.31 |
| Max. Negotiated Rate |
$406.98 |
| Rate for Payer: Aetna American Axle |
$293.93
|
| Rate for Payer: Aetna Commercial |
$384.37
|
| Rate for Payer: Aetna Medicare |
$226.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.93
|
| Rate for Payer: BCBS Complete |
$180.88
|
| Rate for Payer: Cash Price |
$361.76
|
| Rate for Payer: Cofinity Advantage |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$361.76
|
| Rate for Payer: Healthscope Commercial |
$406.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$316.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$339.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$361.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$384.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$339.15
|
| Rate for Payer: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health SBD |
$284.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$293.93
|
| Rate for Payer: UHC Core |
$235.60
|
| Rate for Payer: UHC Exchange |
$177.71
|
| Rate for Payer: UMR Bronson Commercial |
$167.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$339.15
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$685.92
|
|
|
Service Code
|
NDC 60687084101
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.79 |
| Max. Negotiated Rate |
$617.33 |
| Rate for Payer: Aetna American Axle |
$445.85
|
| Rate for Payer: Aetna Commercial |
$583.03
|
| Rate for Payer: Aetna Medicare |
$342.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$445.85
|
| Rate for Payer: BCBS Complete |
$274.37
|
| Rate for Payer: Cash Price |
$548.74
|
| Rate for Payer: Cofinity Advantage |
$480.14
|
| Rate for Payer: Cofinity Commercial |
$589.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$548.74
|
| Rate for Payer: Healthscope Commercial |
$617.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$480.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$514.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$548.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$583.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$514.44
|
| Rate for Payer: PHP Commercial |
$583.03
|
| Rate for Payer: Priority Health SBD |
$432.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$445.85
|
| Rate for Payer: UHC Core |
$357.36
|
| Rate for Payer: UHC Exchange |
$269.57
|
| Rate for Payer: UMR Bronson Commercial |
$253.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$514.44
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$452.20
|
|
|
Service Code
|
NDC 68084037611
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.97 |
| Max. Negotiated Rate |
$406.98 |
| Rate for Payer: Aetna American Axle |
$293.93
|
| Rate for Payer: Aetna Commercial |
$384.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.93
|
| Rate for Payer: Cash Price |
$361.76
|
| Rate for Payer: Cofinity Advantage |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$361.76
|
| Rate for Payer: Healthscope Commercial |
$406.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$316.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$339.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$384.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$339.15
|
| Rate for Payer: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health SBD |
$284.89
|
| Rate for Payer: UMR Bronson Commercial |
$198.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$339.15
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$298.30
|
|
|
Service Code
|
NDC 65862069201
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.25 |
| Max. Negotiated Rate |
$268.47 |
| Rate for Payer: Aetna American Axle |
$193.90
|
| Rate for Payer: Aetna Commercial |
$253.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$193.90
|
| Rate for Payer: Cash Price |
$238.64
|
| Rate for Payer: Cofinity Advantage |
$208.81
|
| Rate for Payer: Cofinity Commercial |
$256.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$238.64
|
| Rate for Payer: Healthscope Commercial |
$268.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$208.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$223.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$253.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$223.72
|
| Rate for Payer: PHP Commercial |
$253.56
|
| Rate for Payer: Priority Health SBD |
$187.93
|
| Rate for Payer: UMR Bronson Commercial |
$131.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$223.72
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$382.85
|
|
|
Service Code
|
NDC 00904618761
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.65 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna American Axle |
$248.85
|
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna Medicare |
$191.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: BCBS Complete |
$153.14
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Advantage |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$306.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$287.14
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.85
|
| Rate for Payer: UHC Core |
$199.46
|
| Rate for Payer: UHC Exchange |
$150.46
|
| Rate for Payer: UMR Bronson Commercial |
$141.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.14
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$751.20
|
|
|
Service Code
|
NDC 00071036924
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$277.94 |
| Max. Negotiated Rate |
$676.08 |
| Rate for Payer: Aetna American Axle |
$488.28
|
| Rate for Payer: Aetna Commercial |
$638.52
|
| Rate for Payer: Aetna Medicare |
$375.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$488.28
|
| Rate for Payer: BCBS Complete |
$300.48
|
| Rate for Payer: Cash Price |
$600.96
|
| Rate for Payer: Cofinity Advantage |
$525.84
|
| Rate for Payer: Cofinity Commercial |
$646.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$600.96
|
| Rate for Payer: Healthscope Commercial |
$676.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$525.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$563.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$600.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$638.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$563.40
|
| Rate for Payer: PHP Commercial |
$638.52
|
| Rate for Payer: Priority Health SBD |
$473.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$488.28
|
| Rate for Payer: UHC Core |
$391.38
|
| Rate for Payer: UHC Exchange |
$295.22
|
| Rate for Payer: UMR Bronson Commercial |
$277.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$563.40
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$298.30
|
|
|
Service Code
|
NDC 65862069201
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.37 |
| Max. Negotiated Rate |
$268.47 |
| Rate for Payer: Aetna American Axle |
$193.90
|
| Rate for Payer: Aetna Commercial |
$253.56
|
| Rate for Payer: Aetna Medicare |
$149.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$193.90
|
| Rate for Payer: BCBS Complete |
$119.32
|
| Rate for Payer: Cash Price |
$238.64
|
| Rate for Payer: Cofinity Advantage |
$208.81
|
| Rate for Payer: Cofinity Commercial |
$256.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$238.64
|
| Rate for Payer: Healthscope Commercial |
$268.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$208.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$223.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$238.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$253.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$223.72
|
| Rate for Payer: PHP Commercial |
$253.56
|
| Rate for Payer: Priority Health SBD |
$187.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$193.90
|
| Rate for Payer: UHC Core |
$155.41
|
| Rate for Payer: UHC Exchange |
$117.23
|
| Rate for Payer: UMR Bronson Commercial |
$110.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$223.72
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$452.20
|
|
|
Service Code
|
NDC 68084037601
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.97 |
| Max. Negotiated Rate |
$406.98 |
| Rate for Payer: Aetna American Axle |
$293.93
|
| Rate for Payer: Aetna Commercial |
$384.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.93
|
| Rate for Payer: Cash Price |
$361.76
|
| Rate for Payer: Cofinity Advantage |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$361.76
|
| Rate for Payer: Healthscope Commercial |
$406.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$316.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$339.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$384.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$339.15
|
| Rate for Payer: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health SBD |
$284.89
|
| Rate for Payer: UMR Bronson Commercial |
$198.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$339.15
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$382.85
|
|
|
Service Code
|
NDC 00904618761
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.45 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna American Axle |
$248.85
|
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Advantage |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$287.14
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| Rate for Payer: UMR Bronson Commercial |
$168.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.14
|
|
