|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
OP
|
$294.63
|
|
|
Service Code
|
NDC 42702010215
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.85 |
| Max. Negotiated Rate |
$294.63 |
| Rate for Payer: Aetna Commercial |
$265.17
|
| Rate for Payer: Aetna Medicare |
$147.31
|
| Rate for Payer: ASR ASR |
$285.79
|
| Rate for Payer: ASR Commercial |
$285.79
|
| Rate for Payer: BCBS Complete |
$117.85
|
| Rate for Payer: BCBS Trust/PPO |
$241.27
|
| Rate for Payer: BCN Commercial |
$228.43
|
| Rate for Payer: Cash Price |
$235.70
|
| Rate for Payer: Cofinity Commercial |
$276.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.70
|
| Rate for Payer: Healthscope Commercial |
$294.63
|
| Rate for Payer: Healthscope Whirlpool |
$285.79
|
| Rate for Payer: Mclaren Commercial |
$265.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.44
|
| Rate for Payer: Nomi Health Commercial |
$241.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$258.15
|
| Rate for Payer: Priority Health Narrow Network |
$206.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$259.27
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
IP
|
$294.63
|
|
|
Service Code
|
NDC 42702010215
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.51 |
| Max. Negotiated Rate |
$294.63 |
| Rate for Payer: Aetna Commercial |
$265.17
|
| Rate for Payer: ASR ASR |
$285.79
|
| Rate for Payer: ASR Commercial |
$285.79
|
| Rate for Payer: BCBS Trust/PPO |
$240.09
|
| Rate for Payer: BCN Commercial |
$228.43
|
| Rate for Payer: Cash Price |
$235.70
|
| Rate for Payer: Cofinity Commercial |
$276.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.70
|
| Rate for Payer: Healthscope Commercial |
$294.63
|
| Rate for Payer: Healthscope Whirlpool |
$285.79
|
| Rate for Payer: Mclaren Commercial |
$265.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$250.44
|
| Rate for Payer: Nomi Health Commercial |
$241.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$259.27
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS
|
Facility
|
OP
|
$276.68
|
|
|
Service Code
|
NDC 17478020115
|
| Hospital Charge Code |
6246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.67 |
| Max. Negotiated Rate |
$276.68 |
| Rate for Payer: Aetna Commercial |
$249.01
|
| Rate for Payer: Aetna Medicare |
$138.34
|
| Rate for Payer: ASR ASR |
$268.38
|
| Rate for Payer: ASR Commercial |
$268.38
|
| Rate for Payer: BCBS Complete |
$110.67
|
| Rate for Payer: BCBS Trust/PPO |
$226.57
|
| Rate for Payer: BCN Commercial |
$214.51
|
| Rate for Payer: Cash Price |
$221.34
|
| Rate for Payer: Cofinity Commercial |
$260.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.34
|
| Rate for Payer: Healthscope Commercial |
$276.68
|
| Rate for Payer: Healthscope Whirlpool |
$268.38
|
| Rate for Payer: Mclaren Commercial |
$249.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$235.18
|
| Rate for Payer: Nomi Health Commercial |
$226.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$242.43
|
| Rate for Payer: Priority Health Narrow Network |
$193.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$243.48
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
OP
|
$162.58
|
|
|
Service Code
|
NDC 60687015625
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.03 |
| Max. Negotiated Rate |
$162.58 |
| Rate for Payer: Aetna Commercial |
$146.32
|
| Rate for Payer: Aetna Medicare |
$81.29
|
| Rate for Payer: ASR ASR |
$157.70
|
| Rate for Payer: ASR Commercial |
$157.70
|
| Rate for Payer: BCBS Complete |
$65.03
|
| Rate for Payer: BCBS Trust/PPO |
$133.14
|
| Rate for Payer: BCN Commercial |
$126.05
|
| Rate for Payer: Cash Price |
$130.06
|
| Rate for Payer: Cofinity Commercial |
$152.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.06
|
| Rate for Payer: Healthscope Commercial |
$162.58
|
| Rate for Payer: Healthscope Whirlpool |
$157.70
|
| Rate for Payer: Mclaren Commercial |
$146.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.19
|
| Rate for Payer: Nomi Health Commercial |
$133.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$142.45
|
| Rate for Payer: Priority Health Narrow Network |
$113.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$143.07
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
OP
|
$5.42
|
|
|
Service Code
|
NDC 60687015695
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$5.42 |
| Rate for Payer: Aetna Commercial |
$4.88
|
| Rate for Payer: Aetna Medicare |
$2.71
|
| Rate for Payer: ASR ASR |
$5.26
|
| Rate for Payer: ASR Commercial |
$5.26
|
| Rate for Payer: BCBS Complete |
$2.17
|
| Rate for Payer: BCBS Trust/PPO |
$4.44
|
| 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: Priority Health HMO/PPO/Tiered Network |
$4.75
|
| Rate for Payer: Priority Health Narrow Network |
$3.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.77
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET
|
Facility
|
IP
|
$162.58
|
|
|
Service Code
|
NDC 60687015625
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.68 |
| Max. Negotiated Rate |
$162.58 |
| Rate for Payer: Aetna Commercial |
$146.32
|
| Rate for Payer: ASR ASR |
$157.70
|
| Rate for Payer: ASR Commercial |
$157.70
|
| Rate for Payer: BCBS Trust/PPO |
$132.49
|
| Rate for Payer: BCN Commercial |
$126.05
|
| Rate for Payer: Cash Price |
$130.06
|
| Rate for Payer: Cofinity Commercial |
$152.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.06
|
| Rate for Payer: Healthscope Commercial |
$162.58
|
| Rate for Payer: Healthscope Whirlpool |
$157.70
|
| Rate for Payer: Mclaren Commercial |
$146.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.19
|
| Rate for Payer: Nomi Health Commercial |
$133.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$143.07
|
|
|
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 50 MG CHEWABLE TABLET
|
Facility
|
OP
|
$769.60
|
|
|
Service Code
|
NDC 00071000740
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$307.84 |
| Max. Negotiated Rate |
$769.60 |
| Rate for Payer: Aetna Commercial |
$692.64
|
| Rate for Payer: Aetna Medicare |
$384.80
|
| Rate for Payer: ASR ASR |
$746.51
|
| Rate for Payer: ASR Commercial |
$746.51
|
| Rate for Payer: BCBS Complete |
$307.84
|
| Rate for Payer: BCBS Trust/PPO |
$630.23
|
| Rate for Payer: BCN Commercial |
$596.67
|
| 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 |
$769.60
|
| Rate for Payer: Healthscope Whirlpool |
$746.51
|
| 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: Priority Health Cigna Priority Health |
$500.24
|
| Rate for Payer: 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
|
$769.60
|
|
|
Service Code
|
NDC 00071000740
|
| Hospital Charge Code |
11018
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$500.24 |
| Max. Negotiated Rate |
$769.60 |
| Rate for Payer: Aetna Commercial |
$692.64
|
| Rate for Payer: ASR ASR |
$746.51
|
| Rate for Payer: ASR Commercial |
$746.51
|
| Rate for Payer: BCBS Trust/PPO |
$627.15
|
| Rate for Payer: BCN Commercial |
$596.67
|
| 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 |
$769.60
|
| Rate for Payer: Healthscope Whirlpool |
$746.51
|
| 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: Priority Health Cigna Priority Health |
$500.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$677.25
|
|
|
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 |
$6.25 |
| Max. Negotiated Rate |
$15.63 |
| Rate for Payer: Aetna Commercial |
$14.07
|
| Rate for Payer: Aetna Commercial |
$16.03
|
| Rate for Payer: Aetna Commercial |
$19.84
|
| Rate for Payer: Aetna Medicare |
$8.90
|
| Rate for Payer: Aetna Medicare |
$11.02
|
| Rate for Payer: Aetna Medicare |
$7.82
|
| 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 |
$21.38
|
| Rate for Payer: ASR Commercial |
$17.28
|
| Rate for Payer: ASR Commercial |
$15.16
|
| 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 |
$12.80
|
| Rate for Payer: BCBS Trust/PPO |
$14.58
|
| Rate for Payer: BCBS Trust/PPO |
$18.05
|
| Rate for Payer: BCN Commercial |
$17.09
|
| Rate for Payer: BCN Commercial |
$12.12
|
| 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 |
$14.07
|
| Rate for Payer: Mclaren Commercial |
$16.03
|
| Rate for Payer: Mclaren Commercial |
$19.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.73
|
| Rate for Payer: Nomi Health Commercial |
$12.82
|
| Rate for Payer: Nomi Health Commercial |
$14.60
|
| Rate for Payer: Nomi Health Commercial |
$18.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.31
|
| Rate for Payer: Priority Health Narrow Network |
$15.45
|
| Rate for Payer: Priority Health Narrow Network |
$10.96
|
| Rate for Payer: Priority Health Narrow Network |
$12.48
|
| 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
|
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
|
|
|
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 |
$191.43
|
| 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
|
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
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$107.60
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
11023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.04 |
| Max. Negotiated Rate |
$107.60 |
| Rate for Payer: Aetna Commercial |
$96.84
|
| Rate for Payer: Aetna Commercial |
$73.75
|
| Rate for Payer: Aetna Medicare |
$53.80
|
| Rate for Payer: Aetna Medicare |
$40.97
|
| Rate for Payer: ASR ASR |
$104.37
|
| Rate for Payer: ASR ASR |
$79.48
|
| Rate for Payer: ASR Commercial |
$79.48
|
| Rate for Payer: ASR Commercial |
$104.37
|
| Rate for Payer: BCBS Complete |
$43.04
|
| Rate for Payer: BCBS Complete |
$32.78
|
| Rate for Payer: BCBS Trust/PPO |
$88.11
|
| Rate for Payer: BCBS Trust/PPO |
$67.10
|
| Rate for Payer: BCN Commercial |
$63.53
|
| Rate for Payer: BCN Commercial |
$83.42
|
| Rate for Payer: Cash Price |
$86.08
|
| 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 |
$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 |
$69.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.46
|
| 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: Priority Health HMO/PPO/Tiered Network |
$94.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$71.80
|
| Rate for Payer: Priority Health Narrow Network |
$57.44
|
| Rate for Payer: Priority Health Narrow Network |
$75.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$94.69
|
|
|
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 |
$104.37
|
| Rate for Payer: ASR ASR |
$79.48
|
| 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 |
$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 |
$69.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.26
|
| 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
|
OP
|
$24.09
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
108266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.64 |
| 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: 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 |
$21.11
|
| Rate for Payer: Priority Health Narrow Network |
$16.89
|
| 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 |
$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) 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
|
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
|
$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
|
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
|
$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
|
|
|
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 |
$320.85
|
| 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
|
|
