|
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 |
$10.58
|
| 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 Commercial |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.82
|
| 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: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.76
|
| Rate for Payer: Priority Health SBD |
$13.34
|
| 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 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 Commercial |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.82
|
| 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: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.76
|
| 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
|
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 |
$147.60
|
| 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 Commercial |
$206.63
|
| Rate for Payer: Cofinity Commercial |
$253.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$206.63
|
| 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: PHP Commercial |
$250.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.87
|
| Rate for Payer: Priority Health SBD |
$185.97
|
| 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
|
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 Commercial |
$413.26
|
| Rate for Payer: Cofinity Commercial |
$507.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$413.26
|
| 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: PHP Commercial |
$501.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$383.74
|
| 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 Commercial |
$206.63
|
| Rate for Payer: Cofinity Commercial |
$253.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$206.63
|
| 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: PHP Commercial |
$250.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.87
|
| 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
|
$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 |
$295.18
|
| 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 Commercial |
$413.26
|
| Rate for Payer: Cofinity Commercial |
$507.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$413.26
|
| 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: PHP Commercial |
$501.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$383.74
|
| Rate for Payer: Priority Health SBD |
$371.93
|
| Rate for Payer: UMR Bronson Commercial |
$218.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$442.78
|
|
|
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 Commercial |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$320.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$260.68
|
| 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: PHP Commercial |
$316.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.06
|
| 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
|
IP
|
$147.75
|
|
|
Service Code
|
NDC 00904719907
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.01 |
| Max. Negotiated Rate |
$132.98 |
| Rate for Payer: Aetna American Axle |
$96.04
|
| Rate for Payer: Aetna Commercial |
$125.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.04
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cofinity Commercial |
$103.42
|
| Rate for Payer: Cofinity Commercial |
$127.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.20
|
| Rate for Payer: Healthscope Commercial |
$132.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.59
|
| Rate for Payer: PHP Commercial |
$125.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.04
|
| Rate for Payer: Priority Health SBD |
$93.08
|
| Rate for Payer: UMR Bronson Commercial |
$65.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.81
|
|
|
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 Commercial |
$538.72
|
| Rate for Payer: Cofinity Commercial |
$661.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$538.72
|
| 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: PHP Commercial |
$654.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$500.24
|
| 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
|
$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 Commercial |
$538.72
|
| Rate for Payer: Cofinity Commercial |
$661.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$538.72
|
| 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: PHP Commercial |
$654.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$500.24
|
| Rate for Payer: Priority Health SBD |
$484.85
|
| 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
|
OP
|
$147.75
|
|
|
Service Code
|
NDC 00904719907
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.67 |
| Max. Negotiated Rate |
$132.98 |
| Rate for Payer: Aetna American Axle |
$96.04
|
| Rate for Payer: Aetna Commercial |
$125.59
|
| Rate for Payer: Aetna Medicare |
$73.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.04
|
| Rate for Payer: BCBS Complete |
$59.10
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cofinity Commercial |
$103.42
|
| Rate for Payer: Cofinity Commercial |
$127.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.20
|
| Rate for Payer: Healthscope Commercial |
$132.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.59
|
| Rate for Payer: PHP Commercial |
$125.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.04
|
| Rate for Payer: Priority Health SBD |
$93.08
|
| Rate for Payer: UMR Bronson Commercial |
$54.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.81
|
|
|
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 Commercial |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$320.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$260.68
|
| 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: PHP Commercial |
$316.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.06
|
| Rate for Payer: Priority Health SBD |
$234.61
|
| Rate for Payer: UMR Bronson Commercial |
$137.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.30
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$17.81
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$16.03 |
| Rate for Payer: Aetna American Axle |
$11.58
|
| Rate for Payer: Aetna American Axle |
$15.94
|
| Rate for Payer: Aetna American Axle |
$14.00
|
| Rate for Payer: Aetna American Axle |
$9.73
|
| Rate for Payer: Aetna American Axle |
$18.76
|
| Rate for Payer: Aetna Commercial |
$15.14
|
| Rate for Payer: Aetna Commercial |
$12.72
|
| Rate for Payer: Aetna Commercial |
$24.53
|
| Rate for Payer: Aetna Commercial |
$18.31
|
| Rate for Payer: Aetna Commercial |
$20.85
|
| Rate for Payer: Aetna Medicare |
$10.77
|
| Rate for Payer: Aetna Medicare |
$12.26
|
| Rate for Payer: Aetna Medicare |
$8.90
|
| Rate for Payer: Aetna Medicare |
$7.48
|
| Rate for Payer: Aetna Medicare |
$14.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.00
|
| Rate for Payer: BCBS Complete |
$7.12
|
| Rate for Payer: BCBS Complete |
$5.99
|
| Rate for Payer: BCBS Complete |
$9.81
|
| Rate for Payer: BCBS Complete |
$11.54
|
| Rate for Payer: BCBS Complete |
$8.62
|
| Rate for Payer: BCBS Trust/PPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$1.19
|
| Rate for Payer: BCN Commercial |
$1.19
|
| Rate for Payer: BCN Commercial |
$1.19
|
| Rate for Payer: BCN Commercial |
$1.19
|
| Rate for Payer: BCN Commercial |
$1.19
|
| Rate for Payer: BCN Commercial |
$1.19
|
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: Cash Price |
$17.23
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cash Price |
$17.23
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$19.62
|
| Rate for Payer: Cash Price |
$19.62
|
| Rate for Payer: Cofinity Commercial |
$12.47
|
| Rate for Payer: Cofinity Commercial |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$10.48
|
| Rate for Payer: Cofinity Commercial |
$18.52
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Cofinity Commercial |
$20.20
|
| Rate for Payer: Cofinity Commercial |
$21.10
|
| Rate for Payer: Cofinity Commercial |
$17.17
|
| Rate for Payer: Cofinity Commercial |
$15.32
|
| Rate for Payer: Cofinity Commercial |
$12.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.48
|
| 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 |
$14.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.62
|
| Rate for Payer: Healthscope Commercial |
$22.08
|
| Rate for Payer: Healthscope Commercial |
$13.47
|
| Rate for Payer: Healthscope Commercial |
$16.03
|
| Rate for Payer: Healthscope Commercial |
$19.39
|
| Rate for Payer: Healthscope Commercial |
$25.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.72
|
| Rate for Payer: PHP Commercial |
$24.53
|
| Rate for Payer: PHP Commercial |
$20.85
|
| Rate for Payer: PHP Commercial |
$15.14
|
| Rate for Payer: PHP Commercial |
$12.72
|
| Rate for Payer: PHP Commercial |
$18.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.58
|
| Rate for Payer: Priority Health SBD |
$11.22
|
| Rate for Payer: Priority Health SBD |
$18.18
|
| Rate for Payer: Priority Health SBD |
$15.45
|
| Rate for Payer: Priority Health SBD |
$9.43
|
| Rate for Payer: Priority Health SBD |
$13.57
|
| Rate for Payer: UMR Bronson Commercial |
$5.54
|
| Rate for Payer: UMR Bronson Commercial |
$7.97
|
| Rate for Payer: UMR Bronson Commercial |
$6.59
|
| Rate for Payer: UMR Bronson Commercial |
$9.08
|
| Rate for Payer: UMR Bronson Commercial |
$10.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.23
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.53
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna American Axle |
$15.94
|
| Rate for Payer: Aetna American Axle |
$9.73
|
| Rate for Payer: Aetna American Axle |
$11.58
|
| Rate for Payer: Aetna American Axle |
$18.76
|
| Rate for Payer: Aetna American Axle |
$14.00
|
| Rate for Payer: Aetna Commercial |
$20.85
|
| Rate for Payer: Aetna Commercial |
$15.14
|
| Rate for Payer: Aetna Commercial |
$12.72
|
| Rate for Payer: Aetna Commercial |
$24.53
|
| Rate for Payer: Aetna Commercial |
$18.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.58
|
| Rate for Payer: Cash Price |
$19.62
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$14.25
|
| Rate for Payer: Cash Price |
$17.23
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cofinity Commercial |
$20.20
|
| Rate for Payer: Cofinity Commercial |
$10.48
|
| Rate for Payer: Cofinity Commercial |
$21.10
|
| Rate for Payer: Cofinity Commercial |
$17.17
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Cofinity Commercial |
$12.47
|
| Rate for Payer: Cofinity Commercial |
$15.32
|
| Rate for Payer: Cofinity Commercial |
$18.52
|
| Rate for Payer: Cofinity Commercial |
$12.87
|
| Rate for Payer: Cofinity Commercial |
$24.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.25
|
| 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 |
$16.03
|
| Rate for Payer: Healthscope Commercial |
$22.08
|
| Rate for Payer: Healthscope Commercial |
$19.39
|
| Rate for Payer: Healthscope Commercial |
$25.97
|
| Rate for Payer: Healthscope Commercial |
$13.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.17
|
| 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 |
$12.47
|
| 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 |
$13.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.72
|
| Rate for Payer: PHP Commercial |
$12.72
|
| Rate for Payer: PHP Commercial |
$24.53
|
| Rate for Payer: PHP Commercial |
$18.31
|
| Rate for Payer: PHP Commercial |
$20.85
|
| Rate for Payer: PHP Commercial |
$15.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.73
|
| Rate for Payer: Priority Health SBD |
$18.18
|
| Rate for Payer: Priority Health SBD |
$13.57
|
| Rate for Payer: Priority Health SBD |
$11.22
|
| Rate for Payer: Priority Health SBD |
$9.43
|
| Rate for Payer: Priority Health SBD |
$15.45
|
| Rate for Payer: UMR Bronson Commercial |
$6.59
|
| Rate for Payer: UMR Bronson Commercial |
$7.84
|
| Rate for Payer: UMR Bronson Commercial |
$10.79
|
| Rate for Payer: UMR Bronson Commercial |
$12.70
|
| Rate for Payer: UMR Bronson Commercial |
$9.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.40
|
|
|
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 |
$191.42
|
| 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 Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| 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: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| 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
|
$253.44
|
|
|
Service Code
|
NDC 51079090520
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.77 |
| Max. Negotiated Rate |
$228.10 |
| Rate for Payer: Aetna American Axle |
$164.74
|
| Rate for Payer: Aetna Commercial |
$215.42
|
| Rate for Payer: Aetna Medicare |
$126.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.74
|
| Rate for Payer: BCBS Complete |
$101.38
|
| Rate for Payer: Cash Price |
$202.75
|
| Rate for Payer: Cofinity Commercial |
$177.41
|
| Rate for Payer: Cofinity Commercial |
$217.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.75
|
| Rate for Payer: Healthscope Commercial |
$228.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.42
|
| Rate for Payer: PHP Commercial |
$215.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.74
|
| Rate for Payer: Priority Health SBD |
$159.67
|
| Rate for Payer: UMR Bronson Commercial |
$93.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.08
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$751.20
|
|
|
Service Code
|
NDC 00071036924
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$330.53 |
| Max. Negotiated Rate |
$676.08 |
| Rate for Payer: Aetna American Axle |
$488.28
|
| Rate for Payer: Aetna Commercial |
$638.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$488.28
|
| Rate for Payer: Cash Price |
$600.96
|
| Rate for Payer: Cofinity Commercial |
$525.84
|
| Rate for Payer: Cofinity Commercial |
$646.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$525.84
|
| 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: Multiplan/Beech St/PHCS Commercial |
$638.52
|
| Rate for Payer: PHP Commercial |
$638.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$488.28
|
| Rate for Payer: Priority Health SBD |
$473.26
|
| Rate for Payer: UMR Bronson Commercial |
$330.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$563.40
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$452.20
|
|
|
Service Code
|
NDC 68084037601
|
| 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 Commercial |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$316.54
|
| 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: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.93
|
| Rate for Payer: Priority Health SBD |
$284.89
|
| 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
|
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 Commercial |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$316.54
|
| 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: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.93
|
| 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 Commercial |
$208.81
|
| Rate for Payer: Cofinity Commercial |
$256.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$208.81
|
| 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: PHP Commercial |
$253.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.90
|
| 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
|
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 Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| 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: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| 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
|
|
|
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 Commercial |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$316.54
|
| 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: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.93
|
| Rate for Payer: Priority Health SBD |
$284.89
|
| 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
|
IP
|
$253.44
|
|
|
Service Code
|
NDC 51079090520
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.51 |
| Max. Negotiated Rate |
$228.10 |
| Rate for Payer: Aetna American Axle |
$164.74
|
| Rate for Payer: Aetna Commercial |
$215.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.74
|
| Rate for Payer: Cash Price |
$202.75
|
| Rate for Payer: Cofinity Commercial |
$177.41
|
| Rate for Payer: Cofinity Commercial |
$217.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$177.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$202.75
|
| Rate for Payer: Healthscope Commercial |
$228.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.42
|
| Rate for Payer: PHP Commercial |
$215.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.74
|
| Rate for Payer: Priority Health SBD |
$159.67
|
| Rate for Payer: UMR Bronson Commercial |
$111.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.08
|
|
|
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 Commercial |
$525.84
|
| Rate for Payer: Cofinity Commercial |
$646.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$525.84
|
| 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: Multiplan/Beech St/PHCS Commercial |
$638.52
|
| Rate for Payer: PHP Commercial |
$638.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$488.28
|
| Rate for Payer: Priority Health SBD |
$473.26
|
| 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
|
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 Commercial |
$316.54
|
| Rate for Payer: Cofinity Commercial |
$388.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$316.54
|
| 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: PHP Commercial |
$384.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.93
|
| 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
|
|
