|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
OP
|
$769.60
|
|
|
Service Code
|
NDC 71000740
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.75 |
| Max. Negotiated Rate |
$769.60 |
| Rate for Payer: Aetna Commercial |
$692.64
|
| Rate for Payer: Aetna Medicare |
$284.75
|
| Rate for Payer: ASR ASR |
$746.51
|
| Rate for Payer: BCBS Complete |
$307.84
|
| Rate for Payer: BCBS Trust/PPO |
$634.54
|
| Rate for Payer: BCN Commercial |
$634.54
|
| Rate for Payer: Cash Price |
$615.68
|
| Rate for Payer: Cofinity Commercial |
$723.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$615.68
|
| Rate for Payer: Healthscope Commercial |
$746.51
|
| Rate for Payer: Healthscope Whirlpool |
$769.60
|
| Rate for Payer: Mclaren Commercial |
$692.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$615.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$654.16
|
| Rate for Payer: Nomi Health Commercial |
$631.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$577.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$674.32
|
| Rate for Payer: Priority Health Narrow Network |
$539.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$677.25
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$166.18
|
|
|
Service Code
|
NDC 60687015625
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.63 |
| Max. Negotiated Rate |
$166.18 |
| Rate for Payer: Aetna Commercial |
$149.56
|
| Rate for Payer: ASR ASR |
$161.19
|
| Rate for Payer: BCBS Trust/PPO |
$136.46
|
| Rate for Payer: BCN Commercial |
$136.46
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cofinity Commercial |
$156.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.94
|
| Rate for Payer: Healthscope Commercial |
$161.19
|
| Rate for Payer: Healthscope Whirlpool |
$166.18
|
| Rate for Payer: Mclaren Commercial |
$149.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.25
|
| Rate for Payer: Nomi Health Commercial |
$136.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$124.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$146.23
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$769.60
|
|
|
Service Code
|
NDC 71000740
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$577.20 |
| Max. Negotiated Rate |
$769.60 |
| Rate for Payer: Aetna Commercial |
$692.64
|
| Rate for Payer: ASR ASR |
$746.51
|
| Rate for Payer: BCBS Trust/PPO |
$632.00
|
| Rate for Payer: BCN Commercial |
$632.00
|
| Rate for Payer: Cash Price |
$615.68
|
| Rate for Payer: Cofinity Commercial |
$723.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$615.68
|
| Rate for Payer: Healthscope Commercial |
$746.51
|
| Rate for Payer: Healthscope Whirlpool |
$769.60
|
| Rate for Payer: Mclaren Commercial |
$692.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$654.16
|
| Rate for Payer: Nomi Health Commercial |
$631.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$577.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$677.25
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$15.37
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$15.37 |
| Rate for Payer: Aetna Commercial |
$13.83
|
| Rate for Payer: Aetna Commercial |
$19.84
|
| Rate for Payer: ASR ASR |
$21.38
|
| Rate for Payer: ASR ASR |
$14.91
|
| Rate for Payer: BCBS Trust/PPO |
$18.10
|
| Rate for Payer: BCBS Trust/PPO |
$12.62
|
| Rate for Payer: BCN Commercial |
$18.10
|
| Rate for Payer: BCN Commercial |
$12.62
|
| Rate for Payer: Cash Price |
$17.63
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cofinity Commercial |
$14.45
|
| Rate for Payer: Cofinity Commercial |
$20.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Healthscope Commercial |
$14.91
|
| Rate for Payer: Healthscope Commercial |
$21.38
|
| Rate for Payer: Healthscope Whirlpool |
$22.04
|
| Rate for Payer: Healthscope Whirlpool |
$15.37
|
| Rate for Payer: Mclaren Commercial |
$19.84
|
| Rate for Payer: Mclaren Commercial |
$13.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: Nomi Health Commercial |
$18.07
|
| Rate for Payer: Nomi Health Commercial |
$12.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.40
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$22.04
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$22.04 |
| Rate for Payer: Aetna Commercial |
$19.84
|
| Rate for Payer: Aetna Commercial |
$13.83
|
| Rate for Payer: Aetna Medicare |
$5.69
|
| Rate for Payer: Aetna Medicare |
$8.15
|
| Rate for Payer: ASR ASR |
$21.38
|
| Rate for Payer: ASR ASR |
$14.91
|
| Rate for Payer: BCBS Complete |
$6.15
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: BCBS Trust/PPO |
$18.17
|
| Rate for Payer: BCBS Trust/PPO |
$12.67
|
| Rate for Payer: BCN Commercial |
$12.67
|
| Rate for Payer: BCN Commercial |
$18.17
|
| Rate for Payer: Cash Price |
$17.63
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cash Price |
$17.63
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cofinity Commercial |
$14.45
|
| Rate for Payer: Cofinity Commercial |
$20.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Healthscope Commercial |
$21.38
|
| Rate for Payer: Healthscope Commercial |
$14.91
|
| Rate for Payer: Healthscope Whirlpool |
$22.04
|
| Rate for Payer: Healthscope Whirlpool |
$15.37
|
| Rate for Payer: Mclaren Commercial |
$19.84
|
| Rate for Payer: Mclaren Commercial |
$13.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.73
|
| Rate for Payer: Nomi Health Commercial |
$12.60
|
| Rate for Payer: Nomi Health Commercial |
$18.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.53
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.62
|
| Rate for Payer: Priority Health Narrow Network |
$0.50
|
| Rate for Payer: Priority Health Narrow Network |
$0.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.40
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$8.96
|
|
|
Service Code
|
NDC 58151011032
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna Commercial |
$8.07
|
| Rate for Payer: Aetna Medicare |
$3.32
|
| Rate for Payer: ASR ASR |
$8.69
|
| Rate for Payer: BCBS Complete |
$3.58
|
| Rate for Payer: BCBS Trust/PPO |
$7.39
|
| Rate for Payer: BCN Commercial |
$7.39
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cofinity Commercial |
$8.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.17
|
| Rate for Payer: Healthscope Commercial |
$8.69
|
| Rate for Payer: Healthscope Whirlpool |
$8.96
|
| Rate for Payer: Mclaren Commercial |
$8.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.62
|
| Rate for Payer: Nomi Health Commercial |
$7.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$7.85
|
| Rate for Payer: Priority Health Narrow Network |
$6.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.89
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$8.96
|
|
|
Service Code
|
NDC 58151011032
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.72 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna Commercial |
$8.07
|
| Rate for Payer: ASR ASR |
$8.69
|
| Rate for Payer: BCBS Trust/PPO |
$7.36
|
| Rate for Payer: BCN Commercial |
$7.36
|
| Rate for Payer: Cash Price |
$7.17
|
| Rate for Payer: Cofinity Commercial |
$8.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.17
|
| Rate for Payer: Healthscope Commercial |
$8.69
|
| Rate for Payer: Healthscope Whirlpool |
$8.96
|
| Rate for Payer: Mclaren Commercial |
$8.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.62
|
| Rate for Payer: Nomi Health Commercial |
$7.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.89
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$896.16
|
|
|
Service Code
|
NDC 58151011088
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$672.12 |
| Max. Negotiated Rate |
$896.16 |
| Rate for Payer: Aetna Commercial |
$806.54
|
| Rate for Payer: ASR ASR |
$869.28
|
| Rate for Payer: BCBS Trust/PPO |
$735.93
|
| Rate for Payer: BCN Commercial |
$735.93
|
| Rate for Payer: Cash Price |
$716.93
|
| Rate for Payer: Cofinity Commercial |
$842.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$716.93
|
| Rate for Payer: Healthscope Commercial |
$869.28
|
| Rate for Payer: Healthscope Whirlpool |
$896.16
|
| Rate for Payer: Mclaren Commercial |
$806.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$761.74
|
| Rate for Payer: Nomi Health Commercial |
$734.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$672.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$788.62
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$828.96
|
|
|
Service Code
|
NDC 71036940
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$621.72 |
| Max. Negotiated Rate |
$828.96 |
| Rate for Payer: Aetna Commercial |
$746.06
|
| Rate for Payer: ASR ASR |
$804.09
|
| Rate for Payer: BCBS Trust/PPO |
$680.74
|
| Rate for Payer: BCN Commercial |
$680.74
|
| Rate for Payer: Cash Price |
$663.17
|
| Rate for Payer: Cofinity Commercial |
$779.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$663.17
|
| Rate for Payer: Healthscope Commercial |
$804.09
|
| Rate for Payer: Healthscope Whirlpool |
$828.96
|
| Rate for Payer: Mclaren Commercial |
$746.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$704.62
|
| Rate for Payer: Nomi Health Commercial |
$679.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$621.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$729.48
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$382.85
|
|
|
Service Code
|
NDC 904618761
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.14 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna Commercial |
$344.56
|
| Rate for Payer: ASR ASR |
$371.36
|
| Rate for Payer: BCBS Trust/PPO |
$314.40
|
| Rate for Payer: BCN Commercial |
$314.40
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$359.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$371.36
|
| Rate for Payer: Healthscope Whirlpool |
$382.85
|
| Rate for Payer: Mclaren Commercial |
$344.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: Nomi Health Commercial |
$313.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$287.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$336.91
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$896.16
|
|
|
Service Code
|
NDC 58151011088
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.58 |
| Max. Negotiated Rate |
$896.16 |
| Rate for Payer: Aetna Commercial |
$806.54
|
| Rate for Payer: Aetna Medicare |
$331.58
|
| Rate for Payer: ASR ASR |
$869.28
|
| Rate for Payer: BCBS Complete |
$358.46
|
| Rate for Payer: BCBS Trust/PPO |
$738.88
|
| Rate for Payer: BCN Commercial |
$738.88
|
| Rate for Payer: Cash Price |
$716.93
|
| Rate for Payer: Cofinity Commercial |
$842.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$716.93
|
| Rate for Payer: Healthscope Commercial |
$869.28
|
| Rate for Payer: Healthscope Whirlpool |
$896.16
|
| Rate for Payer: Mclaren Commercial |
$806.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$716.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$761.74
|
| Rate for Payer: Nomi Health Commercial |
$734.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$672.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$785.22
|
| Rate for Payer: Priority Health Narrow Network |
$628.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$788.62
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$382.85
|
|
|
Service Code
|
NDC 904618761
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.65 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna Commercial |
$344.56
|
| Rate for Payer: Aetna Medicare |
$141.65
|
| Rate for Payer: ASR ASR |
$371.36
|
| Rate for Payer: BCBS Complete |
$153.14
|
| Rate for Payer: BCBS Trust/PPO |
$315.66
|
| Rate for Payer: BCN Commercial |
$315.66
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$359.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$371.36
|
| Rate for Payer: Healthscope Whirlpool |
$382.85
|
| Rate for Payer: Mclaren Commercial |
$344.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$306.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: Nomi Health Commercial |
$313.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$287.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$335.45
|
| Rate for Payer: Priority Health Narrow Network |
$268.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$336.91
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$828.96
|
|
|
Service Code
|
NDC 71036940
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.72 |
| Max. Negotiated Rate |
$828.96 |
| Rate for Payer: Aetna Commercial |
$746.06
|
| Rate for Payer: Aetna Medicare |
$306.72
|
| Rate for Payer: ASR ASR |
$804.09
|
| Rate for Payer: BCBS Complete |
$331.58
|
| Rate for Payer: BCBS Trust/PPO |
$683.48
|
| Rate for Payer: BCN Commercial |
$683.48
|
| Rate for Payer: Cash Price |
$663.17
|
| Rate for Payer: Cofinity Commercial |
$779.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$663.17
|
| Rate for Payer: Healthscope Commercial |
$804.09
|
| Rate for Payer: Healthscope Whirlpool |
$828.96
|
| Rate for Payer: Mclaren Commercial |
$746.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$663.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$704.62
|
| Rate for Payer: Nomi Health Commercial |
$679.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$621.72
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$726.33
|
| Rate for Payer: Priority Health Narrow Network |
$581.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$729.48
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$86.08
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.56 |
| Max. Negotiated Rate |
$86.08 |
| Rate for Payer: Aetna Commercial |
$77.47
|
| Rate for Payer: Aetna Commercial |
$73.75
|
| Rate for Payer: ASR ASR |
$79.48
|
| Rate for Payer: ASR ASR |
$83.50
|
| Rate for Payer: BCBS Trust/PPO |
$67.29
|
| Rate for Payer: BCBS Trust/PPO |
$70.69
|
| Rate for Payer: BCN Commercial |
$67.29
|
| Rate for Payer: BCN Commercial |
$70.69
|
| Rate for Payer: Cash Price |
$65.55
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cofinity Commercial |
$80.92
|
| Rate for Payer: Cofinity Commercial |
$77.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.55
|
| Rate for Payer: Healthscope Commercial |
$83.50
|
| Rate for Payer: Healthscope Commercial |
$79.48
|
| Rate for Payer: Healthscope Whirlpool |
$81.94
|
| Rate for Payer: Healthscope Whirlpool |
$86.08
|
| Rate for Payer: Mclaren Commercial |
$73.75
|
| Rate for Payer: Mclaren Commercial |
$77.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.17
|
| Rate for Payer: Nomi Health Commercial |
$67.19
|
| Rate for Payer: Nomi Health Commercial |
$70.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.11
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$86.08
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$86.08 |
| Rate for Payer: Aetna Commercial |
$77.47
|
| Rate for Payer: Aetna Commercial |
$73.75
|
| Rate for Payer: Aetna Medicare |
$30.32
|
| Rate for Payer: Aetna Medicare |
$31.85
|
| Rate for Payer: ASR ASR |
$83.50
|
| Rate for Payer: ASR ASR |
$79.48
|
| Rate for Payer: BCBS Complete |
$32.78
|
| Rate for Payer: BCBS Complete |
$34.43
|
| Rate for Payer: BCBS Trust/PPO |
$67.56
|
| Rate for Payer: BCBS Trust/PPO |
$70.97
|
| Rate for Payer: BCN Commercial |
$67.56
|
| Rate for Payer: BCN Commercial |
$70.97
|
| Rate for Payer: Cash Price |
$65.55
|
| Rate for Payer: Cash Price |
$65.55
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cash Price |
$68.86
|
| Rate for Payer: Cofinity Commercial |
$77.03
|
| Rate for Payer: Cofinity Commercial |
$80.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.55
|
| Rate for Payer: Healthscope Commercial |
$79.48
|
| Rate for Payer: Healthscope Commercial |
$83.50
|
| Rate for Payer: Healthscope Whirlpool |
$86.08
|
| Rate for Payer: Healthscope Whirlpool |
$81.94
|
| Rate for Payer: Mclaren Commercial |
$77.47
|
| Rate for Payer: Mclaren Commercial |
$73.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.17
|
| Rate for Payer: Nomi Health Commercial |
$67.19
|
| Rate for Payer: Nomi Health Commercial |
$70.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.91
|
| Rate for Payer: Priority Health Narrow Network |
$2.33
|
| Rate for Payer: Priority Health Narrow Network |
$2.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.11
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION
|
Facility
|
OP
|
$24.09
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
108266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$24.09 |
| Rate for Payer: Aetna Commercial |
$21.68
|
| Rate for Payer: Aetna Medicare |
$8.91
|
| Rate for Payer: ASR ASR |
$23.36
|
| Rate for Payer: BCBS Complete |
$9.63
|
| Rate for Payer: BCBS Trust/PPO |
$19.86
|
| Rate for Payer: BCN Commercial |
$19.86
|
| Rate for Payer: Cash Price |
$19.27
|
| Rate for Payer: Cash Price |
$19.27
|
| Rate for Payer: Cofinity Commercial |
$22.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.27
|
| Rate for Payer: Healthscope Commercial |
$23.36
|
| Rate for Payer: Healthscope Whirlpool |
$24.09
|
| Rate for Payer: Mclaren Commercial |
$21.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.47
|
| Rate for Payer: Nomi Health Commercial |
$19.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.91
|
| Rate for Payer: Priority Health Narrow Network |
$2.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.20
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION
|
Facility
|
IP
|
$24.09
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
108266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.07 |
| Max. Negotiated Rate |
$24.09 |
| Rate for Payer: Aetna Commercial |
$21.68
|
| Rate for Payer: ASR ASR |
$23.36
|
| Rate for Payer: BCBS Trust/PPO |
$19.78
|
| Rate for Payer: BCN Commercial |
$19.78
|
| Rate for Payer: Cash Price |
$19.27
|
| Rate for Payer: Cofinity Commercial |
$22.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.27
|
| Rate for Payer: Healthscope Commercial |
$23.36
|
| Rate for Payer: Healthscope Whirlpool |
$24.09
|
| Rate for Payer: Mclaren Commercial |
$21.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.47
|
| Rate for Payer: Nomi Health Commercial |
$19.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.20
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
OP
|
$3,747.69
|
|
|
Service Code
|
NDC 69238105103
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,386.65 |
| Max. Negotiated Rate |
$3,747.69 |
| Rate for Payer: Aetna Commercial |
$3,372.92
|
| Rate for Payer: Aetna Medicare |
$1,386.65
|
| Rate for Payer: ASR ASR |
$3,635.26
|
| Rate for Payer: BCBS Complete |
$1,499.08
|
| Rate for Payer: BCBS Trust/PPO |
$3,089.97
|
| Rate for Payer: BCN Commercial |
$3,089.97
|
| Rate for Payer: Cash Price |
$2,998.15
|
| Rate for Payer: Cofinity Commercial |
$3,522.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,998.15
|
| Rate for Payer: Healthscope Commercial |
$3,635.26
|
| Rate for Payer: Healthscope Whirlpool |
$3,747.69
|
| Rate for Payer: Mclaren Commercial |
$3,372.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,998.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,185.54
|
| Rate for Payer: Nomi Health Commercial |
$3,073.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,810.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3,283.73
|
| Rate for Payer: Priority Health Narrow Network |
$2,627.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,297.97
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
IP
|
$641.69
|
|
|
Service Code
|
NDC 69097099902
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$481.27 |
| Max. Negotiated Rate |
$641.69 |
| Rate for Payer: Aetna Commercial |
$577.52
|
| Rate for Payer: ASR ASR |
$622.44
|
| Rate for Payer: BCBS Trust/PPO |
$526.96
|
| Rate for Payer: BCN Commercial |
$526.96
|
| Rate for Payer: Cash Price |
$513.35
|
| Rate for Payer: Cofinity Commercial |
$603.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$513.35
|
| Rate for Payer: Healthscope Commercial |
$622.44
|
| Rate for Payer: Healthscope Whirlpool |
$641.69
|
| Rate for Payer: Mclaren Commercial |
$577.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$545.44
|
| Rate for Payer: Nomi Health Commercial |
$526.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$481.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$564.69
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
OP
|
$641.69
|
|
|
Service Code
|
NDC 69097099902
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$237.43 |
| Max. Negotiated Rate |
$641.69 |
| Rate for Payer: Aetna Commercial |
$577.52
|
| Rate for Payer: Aetna Medicare |
$237.43
|
| Rate for Payer: ASR ASR |
$622.44
|
| Rate for Payer: BCBS Complete |
$256.68
|
| Rate for Payer: BCBS Trust/PPO |
$529.07
|
| Rate for Payer: BCN Commercial |
$529.07
|
| Rate for Payer: Cash Price |
$513.35
|
| Rate for Payer: Cofinity Commercial |
$603.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$513.35
|
| Rate for Payer: Healthscope Commercial |
$622.44
|
| Rate for Payer: Healthscope Whirlpool |
$641.69
|
| Rate for Payer: Mclaren Commercial |
$577.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$513.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$545.44
|
| Rate for Payer: Nomi Health Commercial |
$526.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$481.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$562.25
|
| Rate for Payer: Priority Health Narrow Network |
$449.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$564.69
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
OP
|
$2,904.32
|
|
|
Service Code
|
NDC 70710101403
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,074.60 |
| Max. Negotiated Rate |
$2,904.32 |
| Rate for Payer: Aetna Commercial |
$2,613.88
|
| Rate for Payer: Aetna Medicare |
$1,074.60
|
| Rate for Payer: ASR ASR |
$2,817.19
|
| Rate for Payer: BCBS Complete |
$1,161.73
|
| Rate for Payer: BCBS Trust/PPO |
$2,394.61
|
| Rate for Payer: BCN Commercial |
$2,394.61
|
| Rate for Payer: Cash Price |
$2,323.45
|
| Rate for Payer: Cofinity Commercial |
$2,730.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,323.45
|
| Rate for Payer: Healthscope Commercial |
$2,817.19
|
| Rate for Payer: Healthscope Whirlpool |
$2,904.32
|
| Rate for Payer: Mclaren Commercial |
$2,613.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,323.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,468.67
|
| Rate for Payer: Nomi Health Commercial |
$2,381.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,178.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2,544.76
|
| Rate for Payer: Priority Health Narrow Network |
$2,035.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,555.80
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
IP
|
$2,904.32
|
|
|
Service Code
|
NDC 70710101403
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,178.24 |
| Max. Negotiated Rate |
$2,904.32 |
| Rate for Payer: Aetna Commercial |
$2,613.88
|
| Rate for Payer: ASR ASR |
$2,817.19
|
| Rate for Payer: BCBS Trust/PPO |
$2,385.02
|
| Rate for Payer: BCN Commercial |
$2,385.02
|
| Rate for Payer: Cash Price |
$2,323.45
|
| Rate for Payer: Cofinity Commercial |
$2,730.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,323.45
|
| Rate for Payer: Healthscope Commercial |
$2,817.19
|
| Rate for Payer: Healthscope Whirlpool |
$2,904.32
|
| Rate for Payer: Mclaren Commercial |
$2,613.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,468.67
|
| Rate for Payer: Nomi Health Commercial |
$2,381.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,178.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,555.80
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
IP
|
$3,747.69
|
|
|
Service Code
|
NDC 69238105103
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,810.77 |
| Max. Negotiated Rate |
$3,747.69 |
| Rate for Payer: Aetna Commercial |
$3,372.92
|
| Rate for Payer: ASR ASR |
$3,635.26
|
| Rate for Payer: BCBS Trust/PPO |
$3,077.61
|
| Rate for Payer: BCN Commercial |
$3,077.61
|
| Rate for Payer: Cash Price |
$2,998.15
|
| Rate for Payer: Cofinity Commercial |
$3,522.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,998.15
|
| Rate for Payer: Healthscope Commercial |
$3,635.26
|
| Rate for Payer: Healthscope Whirlpool |
$3,747.69
|
| Rate for Payer: Mclaren Commercial |
$3,372.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,185.54
|
| Rate for Payer: Nomi Health Commercial |
$3,073.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,810.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,297.97
|
|
|
PILOCARPINE 2 % EYE DROPS
|
Facility
|
OP
|
$107.42
|
|
|
Service Code
|
NDC 70069019101
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.74 |
| Max. Negotiated Rate |
$107.42 |
| Rate for Payer: Aetna Commercial |
$96.67
|
| Rate for Payer: Aetna Medicare |
$39.74
|
| Rate for Payer: ASR ASR |
$104.19
|
| Rate for Payer: BCBS Complete |
$42.97
|
| Rate for Payer: BCBS Trust/PPO |
$88.56
|
| Rate for Payer: BCN Commercial |
$88.56
|
| Rate for Payer: Cash Price |
$85.93
|
| Rate for Payer: Cofinity Commercial |
$100.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.93
|
| Rate for Payer: Healthscope Commercial |
$104.19
|
| Rate for Payer: Healthscope Whirlpool |
$107.42
|
| Rate for Payer: Mclaren Commercial |
$96.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$85.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.30
|
| Rate for Payer: Nomi Health Commercial |
$88.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$94.12
|
| Rate for Payer: Priority Health Narrow Network |
$75.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$94.53
|
|
|
PILOCARPINE 2 % EYE DROPS
|
Facility
|
IP
|
$130.67
|
|
|
Service Code
|
NDC 61314020415
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$130.67 |
| Rate for Payer: Aetna Commercial |
$117.61
|
| Rate for Payer: ASR ASR |
$126.75
|
| Rate for Payer: BCBS Trust/PPO |
$107.31
|
| Rate for Payer: BCN Commercial |
$107.31
|
| Rate for Payer: Cash Price |
$104.54
|
| Rate for Payer: Cofinity Commercial |
$122.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.54
|
| Rate for Payer: Healthscope Commercial |
$126.75
|
| Rate for Payer: Healthscope Whirlpool |
$130.67
|
| Rate for Payer: Mclaren Commercial |
$117.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$111.07
|
| Rate for Payer: Nomi Health Commercial |
$107.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$98.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$114.99
|
|
