|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$5.42
|
|
|
Service Code
|
NDC 60687015695
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna Commercial |
$4.88
|
| Rate for Payer: ASR ASR |
$5.26
|
| Rate for Payer: ASR Commercial |
$5.26
|
| Rate for Payer: BCBS Trust/PPO |
$4.42
|
| Rate for Payer: BCN Commercial |
$4.20
|
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Cofinity Commercial |
$5.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.34
|
| Rate for Payer: Healthscope Commercial |
$5.42
|
| Rate for Payer: Healthscope Whirlpool |
$5.26
|
| Rate for Payer: Mclaren Commercial |
$4.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.61
|
| Rate for Payer: Nomi Health Commercial |
$4.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.77
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$17.81
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.58 |
| Max. Negotiated Rate |
$17.81 |
| Rate for Payer: Aetna Commercial |
$16.03
|
| Rate for Payer: Aetna Commercial |
$14.07
|
| Rate for Payer: Aetna Commercial |
$19.84
|
| Rate for Payer: ASR ASR |
$15.16
|
| Rate for Payer: ASR ASR |
$17.28
|
| Rate for Payer: ASR ASR |
$21.38
|
| Rate for Payer: ASR Commercial |
$17.28
|
| Rate for Payer: ASR Commercial |
$15.16
|
| Rate for Payer: ASR Commercial |
$21.38
|
| Rate for Payer: BCBS Trust/PPO |
$17.96
|
| Rate for Payer: BCBS Trust/PPO |
$12.74
|
| Rate for Payer: BCBS Trust/PPO |
$14.51
|
| Rate for Payer: BCN Commercial |
$12.12
|
| Rate for Payer: BCN Commercial |
$17.09
|
| Rate for Payer: BCN Commercial |
$13.81
|
| Rate for Payer: Cash Price |
$14.24
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$17.63
|
| Rate for Payer: Cofinity Commercial |
$20.72
|
| Rate for Payer: Cofinity Commercial |
$14.69
|
| Rate for Payer: Cofinity Commercial |
$16.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.63
|
| Rate for Payer: Healthscope Commercial |
$15.63
|
| Rate for Payer: Healthscope Commercial |
$17.81
|
| Rate for Payer: Healthscope Commercial |
$22.04
|
| Rate for Payer: Healthscope Whirlpool |
$17.28
|
| Rate for Payer: Healthscope Whirlpool |
$15.16
|
| Rate for Payer: Healthscope Whirlpool |
$21.38
|
| Rate for Payer: Mclaren Commercial |
$16.03
|
| Rate for Payer: Mclaren Commercial |
$14.07
|
| Rate for Payer: Mclaren Commercial |
$19.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.29
|
| Rate for Payer: Nomi Health Commercial |
$14.60
|
| Rate for Payer: Nomi Health Commercial |
$12.82
|
| Rate for Payer: Nomi Health Commercial |
$18.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.75
|
|
|
PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.63
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.43 |
| Max. Negotiated Rate |
$15.63 |
| Rate for Payer: Aetna Commercial |
$14.07
|
| Rate for Payer: Aetna Commercial |
$19.84
|
| Rate for Payer: Aetna Commercial |
$16.03
|
| Rate for Payer: Aetna Medicare |
$11.02
|
| Rate for Payer: Aetna Medicare |
$7.82
|
| Rate for Payer: Aetna Medicare |
$8.90
|
| Rate for Payer: ASR ASR |
$17.28
|
| Rate for Payer: ASR ASR |
$15.16
|
| Rate for Payer: ASR ASR |
$21.38
|
| Rate for Payer: ASR Commercial |
$17.28
|
| Rate for Payer: ASR Commercial |
$15.16
|
| Rate for Payer: ASR Commercial |
$21.38
|
| Rate for Payer: BCBS Complete |
$6.25
|
| Rate for Payer: BCBS Complete |
$7.12
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: BCBS Trust/PPO |
$18.05
|
| Rate for Payer: BCBS Trust/PPO |
$12.80
|
| Rate for Payer: BCBS Trust/PPO |
$14.58
|
| Rate for Payer: BCN Commercial |
$13.81
|
| Rate for Payer: BCN Commercial |
$17.09
|
| Rate for Payer: BCN Commercial |
$12.12
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cash Price |
$14.24
|
| Rate for Payer: Cash Price |
$14.24
|
| Rate for Payer: Cash Price |
$17.63
|
| Rate for Payer: Cash Price |
$17.63
|
| Rate for Payer: Cofinity Commercial |
$20.72
|
| Rate for Payer: Cofinity Commercial |
$14.69
|
| Rate for Payer: Cofinity Commercial |
$16.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.25
|
| Rate for Payer: Healthscope Commercial |
$22.04
|
| Rate for Payer: Healthscope Commercial |
$17.81
|
| Rate for Payer: Healthscope Commercial |
$15.63
|
| Rate for Payer: Healthscope Whirlpool |
$21.38
|
| Rate for Payer: Healthscope Whirlpool |
$17.28
|
| Rate for Payer: Healthscope Whirlpool |
$15.16
|
| Rate for Payer: Mclaren Commercial |
$16.03
|
| Rate for Payer: Mclaren Commercial |
$19.84
|
| Rate for Payer: Mclaren Commercial |
$14.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.29
|
| Rate for Payer: Nomi Health Commercial |
$12.82
|
| Rate for Payer: Nomi Health Commercial |
$18.07
|
| Rate for Payer: Nomi Health Commercial |
$14.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.54
|
| Rate for Payer: Priority Health Narrow Network |
$0.43
|
| Rate for Payer: Priority Health Narrow Network |
$0.43
|
| Rate for Payer: Priority Health Narrow Network |
$0.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.40
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
IP
|
$828.96
|
|
|
Service Code
|
NDC 00071036940
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$538.82 |
| Max. Negotiated Rate |
$828.96 |
| Rate for Payer: Aetna Commercial |
$746.06
|
| Rate for Payer: ASR ASR |
$804.09
|
| Rate for Payer: ASR Commercial |
$804.09
|
| Rate for Payer: BCBS Trust/PPO |
$675.52
|
| Rate for Payer: BCN Commercial |
$642.69
|
| 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 |
$828.96
|
| Rate for Payer: Healthscope Whirlpool |
$804.09
|
| 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: Priority Health Cigna Priority Health |
$538.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$729.48
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE
|
Facility
|
OP
|
$828.96
|
|
|
Service Code
|
NDC 00071036940
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.58 |
| Max. Negotiated Rate |
$828.96 |
| Rate for Payer: Aetna Commercial |
$746.06
|
| Rate for Payer: Aetna Medicare |
$414.48
|
| Rate for Payer: ASR ASR |
$804.09
|
| Rate for Payer: ASR Commercial |
$804.09
|
| Rate for Payer: BCBS Complete |
$331.58
|
| Rate for Payer: BCBS Trust/PPO |
$678.84
|
| Rate for Payer: BCN Commercial |
$642.69
|
| 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 |
$828.96
|
| Rate for Payer: Healthscope Whirlpool |
$804.09
|
| 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: Priority Health Cigna Priority Health |
$538.82
|
| Rate for Payer: 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
|
|
|
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 |
$153.14 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna Commercial |
$344.56
|
| Rate for Payer: Aetna Medicare |
$191.42
|
| Rate for Payer: ASR ASR |
$371.36
|
| Rate for Payer: ASR Commercial |
$371.36
|
| Rate for Payer: BCBS Complete |
$153.14
|
| Rate for Payer: BCBS Trust/PPO |
$313.52
|
| Rate for Payer: BCN Commercial |
$296.82
|
| 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 |
$382.85
|
| Rate for Payer: Healthscope Whirlpool |
$371.36
|
| 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: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: 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
|
IP
|
$382.85
|
|
|
Service Code
|
NDC 00904618761
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$248.85 |
| Max. Negotiated Rate |
$382.85 |
| Rate for Payer: Aetna Commercial |
$344.56
|
| Rate for Payer: ASR ASR |
$371.36
|
| Rate for Payer: ASR Commercial |
$371.36
|
| Rate for Payer: BCBS Trust/PPO |
$311.98
|
| Rate for Payer: BCN Commercial |
$296.82
|
| 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 |
$382.85
|
| Rate for Payer: Healthscope Whirlpool |
$371.36
|
| 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: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$336.91
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$81.94
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.26 |
| Max. Negotiated Rate |
$81.94 |
| Rate for Payer: Aetna Commercial |
$73.75
|
| Rate for Payer: Aetna Commercial |
$96.84
|
| Rate for Payer: ASR ASR |
$79.48
|
| Rate for Payer: ASR ASR |
$104.37
|
| Rate for Payer: ASR Commercial |
$104.37
|
| Rate for Payer: ASR Commercial |
$79.48
|
| Rate for Payer: BCBS Trust/PPO |
$87.68
|
| Rate for Payer: BCBS Trust/PPO |
$66.77
|
| Rate for Payer: BCN Commercial |
$63.53
|
| Rate for Payer: BCN Commercial |
$83.42
|
| Rate for Payer: Cash Price |
$65.55
|
| Rate for Payer: Cash Price |
$86.08
|
| Rate for Payer: Cofinity Commercial |
$101.14
|
| Rate for Payer: Cofinity Commercial |
$77.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.55
|
| Rate for Payer: Healthscope Commercial |
$107.60
|
| Rate for Payer: Healthscope Commercial |
$81.94
|
| Rate for Payer: Healthscope Whirlpool |
$104.37
|
| Rate for Payer: Healthscope Whirlpool |
$79.48
|
| Rate for Payer: Mclaren Commercial |
$96.84
|
| Rate for Payer: Mclaren Commercial |
$73.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.65
|
| Rate for Payer: Nomi Health Commercial |
$88.23
|
| Rate for Payer: Nomi Health Commercial |
$67.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$94.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.11
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$81.94
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$81.94 |
| Rate for Payer: Aetna Commercial |
$73.75
|
| Rate for Payer: Aetna Commercial |
$96.84
|
| Rate for Payer: Aetna Medicare |
$53.80
|
| Rate for Payer: Aetna Medicare |
$40.97
|
| Rate for Payer: ASR ASR |
$79.48
|
| Rate for Payer: ASR ASR |
$104.37
|
| Rate for Payer: ASR Commercial |
$104.37
|
| Rate for Payer: ASR Commercial |
$79.48
|
| Rate for Payer: BCBS Complete |
$32.78
|
| Rate for Payer: BCBS Complete |
$43.04
|
| Rate for Payer: BCBS Trust/PPO |
$67.10
|
| Rate for Payer: BCBS Trust/PPO |
$88.11
|
| Rate for Payer: BCN Commercial |
$83.42
|
| Rate for Payer: BCN Commercial |
$63.53
|
| Rate for Payer: Cash Price |
$86.08
|
| Rate for Payer: Cash Price |
$86.08
|
| Rate for Payer: Cash Price |
$65.55
|
| Rate for Payer: Cash Price |
$65.55
|
| Rate for Payer: Cofinity Commercial |
$101.14
|
| Rate for Payer: Cofinity Commercial |
$77.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.08
|
| Rate for Payer: Healthscope Commercial |
$81.94
|
| Rate for Payer: Healthscope Commercial |
$107.60
|
| Rate for Payer: Healthscope Whirlpool |
$79.48
|
| Rate for Payer: Healthscope Whirlpool |
$104.37
|
| Rate for Payer: Mclaren Commercial |
$96.84
|
| Rate for Payer: Mclaren Commercial |
$73.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.46
|
| Rate for Payer: Nomi Health Commercial |
$67.19
|
| Rate for Payer: Nomi Health Commercial |
$88.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.54
|
| Rate for Payer: Priority Health Narrow Network |
$2.03
|
| Rate for Payer: Priority Health Narrow Network |
$2.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$94.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.11
|
|
|
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 |
$15.66 |
| Max. Negotiated Rate |
$24.09 |
| Rate for Payer: Aetna Commercial |
$21.68
|
| Rate for Payer: ASR ASR |
$23.37
|
| Rate for Payer: ASR Commercial |
$23.37
|
| Rate for Payer: BCBS Trust/PPO |
$19.63
|
| Rate for Payer: BCN Commercial |
$18.68
|
| 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 |
$24.09
|
| Rate for Payer: Healthscope Whirlpool |
$23.37
|
| Rate for Payer: Mclaren Commercial |
$21.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.48
|
| Rate for Payer: Nomi Health Commercial |
$19.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.20
|
|
|
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 |
$2.03 |
| Max. Negotiated Rate |
$24.09 |
| Rate for Payer: Aetna Commercial |
$21.68
|
| Rate for Payer: Aetna Medicare |
$12.04
|
| Rate for Payer: ASR ASR |
$23.37
|
| Rate for Payer: ASR Commercial |
$23.37
|
| Rate for Payer: BCBS Complete |
$9.64
|
| Rate for Payer: BCBS Trust/PPO |
$19.73
|
| Rate for Payer: BCN Commercial |
$18.68
|
| 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 |
$24.09
|
| Rate for Payer: Healthscope Whirlpool |
$23.37
|
| Rate for Payer: Mclaren Commercial |
$21.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.48
|
| Rate for Payer: Nomi Health Commercial |
$19.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.54
|
| Rate for Payer: Priority Health Narrow Network |
$2.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.20
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
IP
|
$4,114.66
|
|
|
Service Code
|
NDC 69238105103
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,674.53 |
| Max. Negotiated Rate |
$4,114.66 |
| Rate for Payer: Aetna Commercial |
$3,703.19
|
| Rate for Payer: ASR ASR |
$3,991.22
|
| Rate for Payer: ASR Commercial |
$3,991.22
|
| Rate for Payer: BCBS Trust/PPO |
$3,353.04
|
| Rate for Payer: BCN Commercial |
$3,190.10
|
| Rate for Payer: Cash Price |
$3,291.73
|
| Rate for Payer: Cofinity Commercial |
$3,867.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,291.73
|
| Rate for Payer: Healthscope Commercial |
$4,114.66
|
| Rate for Payer: Healthscope Whirlpool |
$3,991.22
|
| Rate for Payer: Mclaren Commercial |
$3,703.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,497.46
|
| Rate for Payer: Nomi Health Commercial |
$3,374.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,674.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,620.90
|
|
|
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 |
$1,887.81 |
| Max. Negotiated Rate |
$2,904.32 |
| Rate for Payer: Aetna Commercial |
$2,613.89
|
| Rate for Payer: ASR ASR |
$2,817.19
|
| Rate for Payer: ASR Commercial |
$2,817.19
|
| Rate for Payer: BCBS Trust/PPO |
$2,366.73
|
| Rate for Payer: BCN Commercial |
$2,251.72
|
| Rate for Payer: Cash Price |
$2,323.45
|
| Rate for Payer: Cofinity Commercial |
$2,730.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,323.46
|
| Rate for Payer: Healthscope Commercial |
$2,904.32
|
| Rate for Payer: Healthscope Whirlpool |
$2,817.19
|
| Rate for Payer: Mclaren Commercial |
$2,613.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,468.67
|
| Rate for Payer: Nomi Health Commercial |
$2,381.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,887.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,555.80
|
|
|
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 |
$1,161.73 |
| Max. Negotiated Rate |
$2,904.32 |
| Rate for Payer: Aetna Commercial |
$2,613.89
|
| Rate for Payer: Aetna Medicare |
$1,452.16
|
| Rate for Payer: ASR ASR |
$2,817.19
|
| Rate for Payer: ASR Commercial |
$2,817.19
|
| Rate for Payer: BCBS Complete |
$1,161.73
|
| Rate for Payer: BCBS Trust/PPO |
$2,378.35
|
| Rate for Payer: BCN Commercial |
$2,251.72
|
| Rate for Payer: Cash Price |
$2,323.45
|
| Rate for Payer: Cofinity Commercial |
$2,730.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,323.46
|
| Rate for Payer: Healthscope Commercial |
$2,904.32
|
| Rate for Payer: Healthscope Whirlpool |
$2,817.19
|
| Rate for Payer: Mclaren Commercial |
$2,613.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,468.67
|
| Rate for Payer: Nomi Health Commercial |
$2,381.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,887.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,544.77
|
| Rate for Payer: Priority Health Narrow Network |
$2,035.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,555.80
|
|
|
PHYTONADIONE (VITAMIN K1) 5 MG TABLET
|
Facility
|
OP
|
$4,114.66
|
|
|
Service Code
|
NDC 69238105103
|
| Hospital Charge Code |
11024
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,645.86 |
| Max. Negotiated Rate |
$4,114.66 |
| Rate for Payer: Aetna Commercial |
$3,703.19
|
| Rate for Payer: Aetna Medicare |
$2,057.33
|
| Rate for Payer: ASR ASR |
$3,991.22
|
| Rate for Payer: ASR Commercial |
$3,991.22
|
| Rate for Payer: BCBS Complete |
$1,645.86
|
| Rate for Payer: BCBS Trust/PPO |
$3,369.50
|
| Rate for Payer: BCN Commercial |
$3,190.10
|
| Rate for Payer: Cash Price |
$3,291.73
|
| Rate for Payer: Cofinity Commercial |
$3,867.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,291.73
|
| Rate for Payer: Healthscope Commercial |
$4,114.66
|
| Rate for Payer: Healthscope Whirlpool |
$3,991.22
|
| Rate for Payer: Mclaren Commercial |
$3,703.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,497.46
|
| Rate for Payer: Nomi Health Commercial |
$3,374.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,674.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3,605.27
|
| Rate for Payer: Priority Health Narrow Network |
$2,884.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3,620.90
|
|
|
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 |
$256.68 |
| Max. Negotiated Rate |
$641.69 |
| Rate for Payer: Aetna Commercial |
$577.52
|
| Rate for Payer: Aetna Medicare |
$320.84
|
| Rate for Payer: ASR ASR |
$622.44
|
| Rate for Payer: ASR Commercial |
$622.44
|
| Rate for Payer: BCBS Complete |
$256.68
|
| Rate for Payer: BCBS Trust/PPO |
$525.48
|
| Rate for Payer: BCN Commercial |
$497.50
|
| 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 |
$641.69
|
| Rate for Payer: Healthscope Whirlpool |
$622.44
|
| 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: Priority Health Cigna Priority Health |
$417.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$562.25
|
| Rate for Payer: Priority Health Narrow Network |
$449.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$564.69
|
|
|
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 |
$417.10 |
| Max. Negotiated Rate |
$641.69 |
| Rate for Payer: Aetna Commercial |
$577.52
|
| Rate for Payer: ASR ASR |
$622.44
|
| Rate for Payer: ASR Commercial |
$622.44
|
| Rate for Payer: BCBS Trust/PPO |
$522.91
|
| Rate for Payer: BCN Commercial |
$497.50
|
| 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 |
$641.69
|
| Rate for Payer: Healthscope Whirlpool |
$622.44
|
| 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: Priority Health Cigna Priority Health |
$417.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$564.69
|
|
|
PILOCARPINE 2 % EYE DROPS
|
Facility
|
IP
|
$136.18
|
|
|
Service Code
|
NDC 61314020415
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.52 |
| Max. Negotiated Rate |
$136.18 |
| Rate for Payer: Aetna Commercial |
$122.56
|
| Rate for Payer: ASR ASR |
$132.09
|
| Rate for Payer: ASR Commercial |
$132.09
|
| Rate for Payer: BCBS Trust/PPO |
$110.97
|
| Rate for Payer: BCN Commercial |
$105.58
|
| Rate for Payer: Cash Price |
$108.95
|
| Rate for Payer: Cofinity Commercial |
$128.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.94
|
| Rate for Payer: Healthscope Commercial |
$136.18
|
| Rate for Payer: Healthscope Whirlpool |
$132.09
|
| Rate for Payer: Mclaren Commercial |
$122.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.75
|
| Rate for Payer: Nomi Health Commercial |
$111.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$119.84
|
|
|
PILOCARPINE 2 % EYE DROPS
|
Facility
|
OP
|
$136.18
|
|
|
Service Code
|
NDC 61314020415
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.47 |
| Max. Negotiated Rate |
$136.18 |
| Rate for Payer: Aetna Commercial |
$122.56
|
| Rate for Payer: Aetna Medicare |
$68.09
|
| Rate for Payer: ASR ASR |
$132.09
|
| Rate for Payer: ASR Commercial |
$132.09
|
| Rate for Payer: BCBS Complete |
$54.47
|
| Rate for Payer: BCBS Trust/PPO |
$111.52
|
| Rate for Payer: BCN Commercial |
$105.58
|
| Rate for Payer: Cash Price |
$108.95
|
| Rate for Payer: Cofinity Commercial |
$128.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.94
|
| Rate for Payer: Healthscope Commercial |
$136.18
|
| Rate for Payer: Healthscope Whirlpool |
$132.09
|
| Rate for Payer: Mclaren Commercial |
$122.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.75
|
| Rate for Payer: Nomi Health Commercial |
$111.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$119.32
|
| Rate for Payer: Priority Health Narrow Network |
$95.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$119.84
|
|
|
PILOCARPINE 2 % EYE DROPS
|
Facility
|
OP
|
$136.71
|
|
|
Service Code
|
NDC 70069019101
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.68 |
| Max. Negotiated Rate |
$136.71 |
| Rate for Payer: Aetna Commercial |
$123.04
|
| Rate for Payer: Aetna Medicare |
$68.36
|
| Rate for Payer: ASR ASR |
$132.61
|
| Rate for Payer: ASR Commercial |
$132.61
|
| Rate for Payer: BCBS Complete |
$54.68
|
| Rate for Payer: BCBS Trust/PPO |
$111.95
|
| Rate for Payer: BCN Commercial |
$105.99
|
| Rate for Payer: Cash Price |
$109.37
|
| Rate for Payer: Cofinity Commercial |
$128.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.37
|
| Rate for Payer: Healthscope Commercial |
$136.71
|
| Rate for Payer: Healthscope Whirlpool |
$132.61
|
| Rate for Payer: Mclaren Commercial |
$123.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.20
|
| Rate for Payer: Nomi Health Commercial |
$112.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$119.79
|
| Rate for Payer: Priority Health Narrow Network |
$95.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$120.30
|
|
|
PILOCARPINE 2 % EYE DROPS
|
Facility
|
IP
|
$136.71
|
|
|
Service Code
|
NDC 70069019101
|
| Hospital Charge Code |
6280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.86 |
| Max. Negotiated Rate |
$136.71 |
| Rate for Payer: Aetna Commercial |
$123.04
|
| Rate for Payer: ASR ASR |
$132.61
|
| Rate for Payer: ASR Commercial |
$132.61
|
| Rate for Payer: BCBS Trust/PPO |
$111.40
|
| Rate for Payer: BCN Commercial |
$105.99
|
| Rate for Payer: Cash Price |
$109.37
|
| Rate for Payer: Cofinity Commercial |
$128.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.37
|
| Rate for Payer: Healthscope Commercial |
$136.71
|
| Rate for Payer: Healthscope Whirlpool |
$132.61
|
| Rate for Payer: Mclaren Commercial |
$123.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.20
|
| Rate for Payer: Nomi Health Commercial |
$112.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$120.30
|
|
|
PILOCARPINE 5 MG TABLET
|
Facility
|
OP
|
$361.00
|
|
|
Service Code
|
NDC 00574079201
|
| Hospital Charge Code |
12803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.40 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Aetna Commercial |
$324.90
|
| Rate for Payer: Aetna Medicare |
$180.50
|
| Rate for Payer: ASR ASR |
$350.17
|
| Rate for Payer: ASR Commercial |
$350.17
|
| Rate for Payer: BCBS Complete |
$144.40
|
| Rate for Payer: BCBS Trust/PPO |
$295.62
|
| Rate for Payer: BCN Commercial |
$279.88
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cofinity Commercial |
$339.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$288.80
|
| Rate for Payer: Healthscope Commercial |
$361.00
|
| Rate for Payer: Healthscope Whirlpool |
$350.17
|
| Rate for Payer: Mclaren Commercial |
$324.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.85
|
| Rate for Payer: Nomi Health Commercial |
$296.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$316.31
|
| Rate for Payer: Priority Health Narrow Network |
$253.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$317.68
|
|
|
PILOCARPINE 5 MG TABLET
|
Facility
|
IP
|
$361.00
|
|
|
Service Code
|
NDC 00574079201
|
| Hospital Charge Code |
12803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$361.00 |
| Rate for Payer: Aetna Commercial |
$324.90
|
| Rate for Payer: ASR ASR |
$350.17
|
| Rate for Payer: ASR Commercial |
$350.17
|
| Rate for Payer: BCBS Trust/PPO |
$294.18
|
| Rate for Payer: BCN Commercial |
$279.88
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cofinity Commercial |
$339.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$288.80
|
| Rate for Payer: Healthscope Commercial |
$361.00
|
| Rate for Payer: Healthscope Whirlpool |
$350.17
|
| Rate for Payer: Mclaren Commercial |
$324.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.85
|
| Rate for Payer: Nomi Health Commercial |
$296.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$317.68
|
|
|
PIOGLITAZONE 15 MG TABLET
|
Facility
|
OP
|
$1,337.11
|
|
|
Service Code
|
NDC 64764015104
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$534.84 |
| Max. Negotiated Rate |
$1,337.11 |
| Rate for Payer: Aetna Commercial |
$1,203.40
|
| Rate for Payer: Aetna Medicare |
$668.56
|
| Rate for Payer: ASR ASR |
$1,297.00
|
| Rate for Payer: ASR Commercial |
$1,297.00
|
| Rate for Payer: BCBS Complete |
$534.84
|
| Rate for Payer: BCBS Trust/PPO |
$1,094.96
|
| Rate for Payer: BCN Commercial |
$1,036.66
|
| Rate for Payer: Cash Price |
$1,069.68
|
| Rate for Payer: Cofinity Commercial |
$1,256.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,069.69
|
| Rate for Payer: Healthscope Commercial |
$1,337.11
|
| Rate for Payer: Healthscope Whirlpool |
$1,297.00
|
| Rate for Payer: Mclaren Commercial |
$1,203.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,136.54
|
| Rate for Payer: Nomi Health Commercial |
$1,096.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$869.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,171.58
|
| Rate for Payer: Priority Health Narrow Network |
$937.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,176.66
|
|
|
PIOGLITAZONE 15 MG TABLET
|
Facility
|
IP
|
$1,337.11
|
|
|
Service Code
|
NDC 64764015104
|
| Hospital Charge Code |
25528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$869.12 |
| Max. Negotiated Rate |
$1,337.11 |
| Rate for Payer: Aetna Commercial |
$1,203.40
|
| Rate for Payer: ASR ASR |
$1,297.00
|
| Rate for Payer: ASR Commercial |
$1,297.00
|
| Rate for Payer: BCBS Trust/PPO |
$1,089.61
|
| Rate for Payer: BCN Commercial |
$1,036.66
|
| Rate for Payer: Cash Price |
$1,069.68
|
| Rate for Payer: Cofinity Commercial |
$1,256.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,069.69
|
| Rate for Payer: Healthscope Commercial |
$1,337.11
|
| Rate for Payer: Healthscope Whirlpool |
$1,297.00
|
| Rate for Payer: Mclaren Commercial |
$1,203.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,136.54
|
| Rate for Payer: Nomi Health Commercial |
$1,096.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$869.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,176.66
|
|
