Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility

$31.57

Service Code	NDC 64980051405
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$19.89
Max. Negotiated Rate	$28.41
Rate for Payer: Aetna Commercial	$26.83
Rate for Payer: Aetna New Business (MI Preferred)	$20.52
Rate for Payer: Cash Price	$25.26
Rate for Payer: Cofinity Advantage	$22.10
Rate for Payer: Cofinity Commercial	$27.15
Rate for Payer: Encore Health Key Benefits Commercial	$25.26
Rate for Payer: Healthscope Commercial	$28.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26.83
Rate for Payer: Opus (Opus Packaging Group) HMA	$23.68
Rate for Payer: PHP Commercial	$26.83
Rate for Payer: Priority Health SBD	$19.89

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility

$20.61

Service Code	NDC 61314022705
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$18.55
Rate for Payer: Aetna Commercial	$17.52
Rate for Payer: Aetna Medicare	$10.30
Rate for Payer: Aetna New Business (MI Preferred)	$13.40
Rate for Payer: BCBS Complete	$8.24
Rate for Payer: Cash Price	$16.49
Rate for Payer: Cofinity Advantage	$14.43
Rate for Payer: Cofinity Commercial	$17.72
Rate for Payer: Encore Health Key Benefits Commercial	$16.49
Rate for Payer: Healthscope Commercial	$18.55
Rate for Payer: MI Amish Medical Board Commercial	$16.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.46
Rate for Payer: PHP Commercial	$17.52
Rate for Payer: Priority Health SBD	$12.98
Rate for Payer: UHC All Payor (Choice/PPO)	$13.40
Rate for Payer: UHC Core	$10.74
Rate for Payer: UHC Exchange	$8.10

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility

$31.57

Service Code	NDC 64980051405
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$28.41
Rate for Payer: Aetna Commercial	$26.83
Rate for Payer: Aetna Medicare	$15.79
Rate for Payer: Aetna New Business (MI Preferred)	$20.52
Rate for Payer: BCBS Complete	$12.63
Rate for Payer: Cash Price	$25.26
Rate for Payer: Cofinity Advantage	$22.10
Rate for Payer: Cofinity Commercial	$27.15
Rate for Payer: Encore Health Key Benefits Commercial	$25.26
Rate for Payer: Healthscope Commercial	$28.41
Rate for Payer: MI Amish Medical Board Commercial	$25.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26.83
Rate for Payer: Opus (Opus Packaging Group) HMA	$23.68
Rate for Payer: PHP Commercial	$26.83
Rate for Payer: Priority Health SBD	$19.89
Rate for Payer: UHC All Payor (Choice/PPO)	$20.52
Rate for Payer: UHC Core	$16.45
Rate for Payer: UHC Exchange	$12.41

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility

$22.91

Service Code	NDC 60758080105
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$14.43
Max. Negotiated Rate	$20.62
Rate for Payer: Aetna Commercial	$19.47
Rate for Payer: Aetna New Business (MI Preferred)	$14.89
Rate for Payer: Cash Price	$18.33
Rate for Payer: Cofinity Advantage	$16.04
Rate for Payer: Cofinity Commercial	$19.70
Rate for Payer: Encore Health Key Benefits Commercial	$18.33
Rate for Payer: Healthscope Commercial	$20.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.47
Rate for Payer: Opus (Opus Packaging Group) HMA	$17.18
Rate for Payer: PHP Commercial	$19.47
Rate for Payer: Priority Health SBD	$14.43

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility

$20.61

Service Code	NDC 61314022705
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$12.98
Max. Negotiated Rate	$18.55
Rate for Payer: Aetna Commercial	$17.52
Rate for Payer: Aetna New Business (MI Preferred)	$13.40
Rate for Payer: Cash Price	$16.49
Rate for Payer: Cofinity Advantage	$14.43
Rate for Payer: Cofinity Commercial	$17.72
Rate for Payer: Encore Health Key Benefits Commercial	$16.49
Rate for Payer: Healthscope Commercial	$18.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.46
Rate for Payer: PHP Commercial	$17.52
Rate for Payer: Priority Health SBD	$12.98

TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)

Facility

$44,406.09

Service Code	CPT 19357
Hospital Revenue Code	360
Min. Negotiated Rate	$6,963.84
Max. Negotiated Rate	$44,406.09
Rate for Payer: Aetna Medicare	$14,280.66
Rate for Payer: Allen County Amish Medical Aid Commercial	$17,164.25
Rate for Payer: Amish Plain Church Group Commercial	$17,164.25
Rate for Payer: BCBS Complete	$7,541.28
Rate for Payer: BCBS MAPPO	$13,731.40
Rate for Payer: BCBS Trust/PPO	$6,963.84
Rate for Payer: BCN Commercial	$6,963.84
Rate for Payer: BCN Medicare Advantage	$13,731.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$13,731.40
Rate for Payer: Mclaren Medicaid	$7,181.52
Rate for Payer: Mclaren Medicare	$13,731.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$14,417.97
Rate for Payer: Meridian Medicaid	$14,417.97
Rate for Payer: MI Amish Medical Board Commercial	$15,791.11
Rate for Payer: Molina Medicare/Medicaid	$15,104.54
Rate for Payer: Nomi Health Commercial	$41,194.20
Rate for Payer: PACE Medicare	$13,044.83
Rate for Payer: PACE SWMI	$13,731.40
Rate for Payer: PHP Medicare Advantage	$13,731.40
Rate for Payer: Priority Health Choice Medicaid	$7,181.52
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$44,406.09
Rate for Payer: Priority Health Medicare	$13,731.40
Rate for Payer: Priority Health Tiered Network	$35,524.87
Rate for Payer: Railroad Medicare Medicare	$13,731.40
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$13,731.40
Rate for Payer: UHC Medicaid	$7,181.52
Rate for Payer: UHCCP Medicaid	$7,181.52
Rate for Payer: VA VA	$13,731.40

TIZANIDINE 2 MG TABLET

Facility

$159.84

Service Code	NDC 50268075915
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$62.82
Max. Negotiated Rate	$143.86
Rate for Payer: Aetna Commercial	$135.86
Rate for Payer: Aetna Medicare	$79.92
Rate for Payer: Aetna New Business (MI Preferred)	$103.90
Rate for Payer: BCBS Complete	$63.94
Rate for Payer: Cash Price	$127.87
Rate for Payer: Cofinity Advantage	$111.89
Rate for Payer: Cofinity Commercial	$137.46
Rate for Payer: Encore Health Key Benefits Commercial	$127.87
Rate for Payer: Healthscope Commercial	$143.86
Rate for Payer: MI Amish Medical Board Commercial	$127.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.86
Rate for Payer: Opus (Opus Packaging Group) HMA	$119.88
Rate for Payer: PHP Commercial	$135.86
Rate for Payer: Priority Health SBD	$100.70
Rate for Payer: UHC All Payor (Choice/PPO)	$103.90
Rate for Payer: UHC Core	$83.28
Rate for Payer: UHC Exchange	$62.82

TIZANIDINE 2 MG TABLET

Facility

$274.95

Service Code	NDC 72578009621
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$173.22
Max. Negotiated Rate	$247.46
Rate for Payer: Aetna Commercial	$233.71
Rate for Payer: Aetna New Business (MI Preferred)	$178.72
Rate for Payer: Cash Price	$219.96
Rate for Payer: Cofinity Advantage	$192.47
Rate for Payer: Cofinity Commercial	$236.46
Rate for Payer: Encore Health Key Benefits Commercial	$219.96
Rate for Payer: Healthscope Commercial	$247.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$233.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$206.21
Rate for Payer: PHP Commercial	$233.71
Rate for Payer: Priority Health SBD	$173.22

TIZANIDINE 2 MG TABLET

Facility

$159.84

Service Code	NDC 50268075915
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$100.70
Max. Negotiated Rate	$143.86
Rate for Payer: Aetna Commercial	$135.86
Rate for Payer: Aetna New Business (MI Preferred)	$103.90
Rate for Payer: Cash Price	$127.87
Rate for Payer: Cofinity Advantage	$111.89
Rate for Payer: Cofinity Commercial	$137.46
Rate for Payer: Encore Health Key Benefits Commercial	$127.87
Rate for Payer: Healthscope Commercial	$143.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.86
Rate for Payer: Opus (Opus Packaging Group) HMA	$119.88
Rate for Payer: PHP Commercial	$135.86
Rate for Payer: Priority Health SBD	$100.70

TIZANIDINE 2 MG TABLET

Facility

$103.25

Service Code	NDC 68084077525
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$65.05
Max. Negotiated Rate	$92.92
Rate for Payer: Aetna Commercial	$87.76
Rate for Payer: Aetna New Business (MI Preferred)	$67.11
Rate for Payer: Cash Price	$82.60
Rate for Payer: Cofinity Advantage	$72.28
Rate for Payer: Cofinity Commercial	$88.80
Rate for Payer: Encore Health Key Benefits Commercial	$82.60
Rate for Payer: Healthscope Commercial	$92.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$87.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$77.44
Rate for Payer: PHP Commercial	$87.76
Rate for Payer: Priority Health SBD	$65.05

TIZANIDINE 2 MG TABLET

Facility

$183.30

Service Code	NDC 57664050289
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$72.04
Max. Negotiated Rate	$164.97
Rate for Payer: Aetna Commercial	$155.81
Rate for Payer: Aetna Medicare	$91.65
Rate for Payer: Aetna New Business (MI Preferred)	$119.14
Rate for Payer: BCBS Complete	$73.32
Rate for Payer: Cash Price	$146.64
Rate for Payer: Cofinity Advantage	$128.31
Rate for Payer: Cofinity Commercial	$157.64
Rate for Payer: Encore Health Key Benefits Commercial	$146.64
Rate for Payer: Healthscope Commercial	$164.97
Rate for Payer: MI Amish Medical Board Commercial	$146.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.81
Rate for Payer: Opus (Opus Packaging Group) HMA	$137.47
Rate for Payer: PHP Commercial	$155.81
Rate for Payer: Priority Health SBD	$115.48
Rate for Payer: UHC All Payor (Choice/PPO)	$119.14
Rate for Payer: UHC Core	$95.50
Rate for Payer: UHC Exchange	$72.04

TIZANIDINE 2 MG TABLET

Facility

$3.20

Service Code	NDC 50268075911
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna Medicare	$1.60
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: BCBS Complete	$1.28
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Advantage	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Encore Health Key Benefits Commercial	$2.56
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: MI Amish Medical Board Commercial	$2.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.40
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health SBD	$2.02
Rate for Payer: UHC All Payor (Choice/PPO)	$2.08
Rate for Payer: UHC Core	$1.67
Rate for Payer: UHC Exchange	$1.26

TIZANIDINE 2 MG TABLET

Facility

$274.95

Service Code	NDC 72578009621
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$108.06
Max. Negotiated Rate	$247.46
Rate for Payer: Aetna Commercial	$233.71
Rate for Payer: Aetna Medicare	$137.47
Rate for Payer: Aetna New Business (MI Preferred)	$178.72
Rate for Payer: BCBS Complete	$109.98
Rate for Payer: Cash Price	$219.96
Rate for Payer: Cofinity Advantage	$192.47
Rate for Payer: Cofinity Commercial	$236.46
Rate for Payer: Encore Health Key Benefits Commercial	$219.96
Rate for Payer: Healthscope Commercial	$247.46
Rate for Payer: MI Amish Medical Board Commercial	$219.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$233.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$206.21
Rate for Payer: PHP Commercial	$233.71
Rate for Payer: Priority Health SBD	$173.22
Rate for Payer: UHC All Payor (Choice/PPO)	$178.72
Rate for Payer: UHC Core	$143.25
Rate for Payer: UHC Exchange	$108.06

TIZANIDINE 2 MG TABLET

Facility

$3.20

Service Code	NDC 50268075911
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Advantage	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Encore Health Key Benefits Commercial	$2.56
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.40
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health SBD	$2.02

TIZANIDINE 2 MG TABLET

Facility

$183.30

Service Code	NDC 57664050289
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$115.48
Max. Negotiated Rate	$164.97
Rate for Payer: Aetna Commercial	$155.81
Rate for Payer: Aetna New Business (MI Preferred)	$119.14
Rate for Payer: Cash Price	$146.64
Rate for Payer: Cofinity Advantage	$128.31
Rate for Payer: Cofinity Commercial	$157.64
Rate for Payer: Encore Health Key Benefits Commercial	$146.64
Rate for Payer: Healthscope Commercial	$164.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.81
Rate for Payer: Opus (Opus Packaging Group) HMA	$137.47
Rate for Payer: PHP Commercial	$155.81
Rate for Payer: Priority Health SBD	$115.48

TIZANIDINE 2 MG TABLET

Facility

$103.25

Service Code	NDC 68084077525
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$40.58
Max. Negotiated Rate	$92.92
Rate for Payer: Aetna Commercial	$87.76
Rate for Payer: Aetna Medicare	$51.62
Rate for Payer: Aetna New Business (MI Preferred)	$67.11
Rate for Payer: BCBS Complete	$41.30
Rate for Payer: Cash Price	$82.60
Rate for Payer: Cofinity Advantage	$72.28
Rate for Payer: Cofinity Commercial	$88.80
Rate for Payer: Encore Health Key Benefits Commercial	$82.60
Rate for Payer: Healthscope Commercial	$92.92
Rate for Payer: MI Amish Medical Board Commercial	$82.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$87.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$77.44
Rate for Payer: PHP Commercial	$87.76
Rate for Payer: Priority Health SBD	$65.05
Rate for Payer: UHC All Payor (Choice/PPO)	$67.11
Rate for Payer: UHC Core	$53.79
Rate for Payer: UHC Exchange	$40.58

TIZANIDINE 2 MG TABLET

Facility

$3.45

Service Code	NDC 68084077595
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna Medicare	$1.73
Rate for Payer: Aetna New Business (MI Preferred)	$2.24
Rate for Payer: BCBS Complete	$1.38
Rate for Payer: Cash Price	$2.76
Rate for Payer: Cofinity Advantage	$2.42
Rate for Payer: Cofinity Commercial	$2.97
Rate for Payer: Encore Health Key Benefits Commercial	$2.76
Rate for Payer: Healthscope Commercial	$3.10
Rate for Payer: MI Amish Medical Board Commercial	$2.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.59
Rate for Payer: PHP Commercial	$2.93
Rate for Payer: Priority Health SBD	$2.17
Rate for Payer: UHC All Payor (Choice/PPO)	$2.24
Rate for Payer: UHC Core	$1.80
Rate for Payer: UHC Exchange	$1.36

TIZANIDINE 2 MG TABLET

Facility

$3.45

Service Code	NDC 68084077595
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna New Business (MI Preferred)	$2.24
Rate for Payer: Cash Price	$2.76
Rate for Payer: Cofinity Advantage	$2.42
Rate for Payer: Cofinity Commercial	$2.97
Rate for Payer: Encore Health Key Benefits Commercial	$2.76
Rate for Payer: Healthscope Commercial	$3.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.59
Rate for Payer: PHP Commercial	$2.93
Rate for Payer: Priority Health SBD	$2.17

TIZANIDINE 4 MG TABLET

Facility

$465.50

Service Code	NDC 00904641861
Hospital Charge Code	14793
Hospital Revenue Code	637
Min. Negotiated Rate	$293.26
Max. Negotiated Rate	$418.95
Rate for Payer: Aetna Commercial	$395.68
Rate for Payer: Aetna New Business (MI Preferred)	$302.57
Rate for Payer: Cash Price	$372.40
Rate for Payer: Cofinity Advantage	$325.85
Rate for Payer: Cofinity Commercial	$400.33
Rate for Payer: Encore Health Key Benefits Commercial	$372.40
Rate for Payer: Healthscope Commercial	$418.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$395.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$349.12
Rate for Payer: PHP Commercial	$395.68
Rate for Payer: Priority Health SBD	$293.26

TIZANIDINE 4 MG TABLET

Facility

$465.50

Service Code	NDC 00904641861
Hospital Charge Code	14793
Hospital Revenue Code	637
Min. Negotiated Rate	$182.94
Max. Negotiated Rate	$418.95
Rate for Payer: Aetna Commercial	$395.68
Rate for Payer: Aetna Medicare	$232.75
Rate for Payer: Aetna New Business (MI Preferred)	$302.57
Rate for Payer: BCBS Complete	$186.20
Rate for Payer: Cash Price	$372.40
Rate for Payer: Cofinity Advantage	$325.85
Rate for Payer: Cofinity Commercial	$400.33
Rate for Payer: Encore Health Key Benefits Commercial	$372.40
Rate for Payer: Healthscope Commercial	$418.95
Rate for Payer: MI Amish Medical Board Commercial	$372.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$395.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$349.12
Rate for Payer: PHP Commercial	$395.68
Rate for Payer: Priority Health SBD	$293.26
Rate for Payer: UHC All Payor (Choice/PPO)	$302.57
Rate for Payer: UHC Core	$242.53
Rate for Payer: UHC Exchange	$182.94

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION

Facility

$123.45

Service Code	NDC 61314064725
Hospital Charge Code	11567
Hospital Revenue Code	637
Min. Negotiated Rate	$48.52
Max. Negotiated Rate	$111.11
Rate for Payer: Aetna Commercial	$104.93
Rate for Payer: Aetna Medicare	$61.73
Rate for Payer: Aetna New Business (MI Preferred)	$80.24
Rate for Payer: BCBS Complete	$49.38
Rate for Payer: Cash Price	$98.76
Rate for Payer: Cofinity Advantage	$86.42
Rate for Payer: Cofinity Commercial	$106.17
Rate for Payer: Encore Health Key Benefits Commercial	$98.76
Rate for Payer: Healthscope Commercial	$111.11
Rate for Payer: MI Amish Medical Board Commercial	$98.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$104.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$92.59
Rate for Payer: PHP Commercial	$104.93
Rate for Payer: Priority Health SBD	$77.77
Rate for Payer: UHC All Payor (Choice/PPO)	$80.24
Rate for Payer: UHC Core	$64.32
Rate for Payer: UHC Exchange	$48.52

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION

Facility

$297.40

Service Code	NDC 00078095340
Hospital Charge Code	11567
Hospital Revenue Code	637
Min. Negotiated Rate	$116.88
Max. Negotiated Rate	$267.66
Rate for Payer: Aetna Commercial	$252.79
Rate for Payer: Aetna Medicare	$148.70
Rate for Payer: Aetna New Business (MI Preferred)	$193.31
Rate for Payer: BCBS Complete	$118.96
Rate for Payer: Cash Price	$237.92
Rate for Payer: Cofinity Advantage	$208.18
Rate for Payer: Cofinity Commercial	$255.76
Rate for Payer: Encore Health Key Benefits Commercial	$237.92
Rate for Payer: Healthscope Commercial	$267.66
Rate for Payer: MI Amish Medical Board Commercial	$237.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$252.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$223.05
Rate for Payer: PHP Commercial	$252.79
Rate for Payer: Priority Health SBD	$187.36
Rate for Payer: UHC All Payor (Choice/PPO)	$193.31
Rate for Payer: UHC Core	$154.95
Rate for Payer: UHC Exchange	$116.88

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION

Facility

$123.45

Service Code	NDC 61314064725
Hospital Charge Code	11567
Hospital Revenue Code	637
Min. Negotiated Rate	$77.77
Max. Negotiated Rate	$111.11
Rate for Payer: Aetna Commercial	$104.93
Rate for Payer: Aetna New Business (MI Preferred)	$80.24
Rate for Payer: Cash Price	$98.76
Rate for Payer: Cofinity Advantage	$86.42
Rate for Payer: Cofinity Commercial	$106.17
Rate for Payer: Encore Health Key Benefits Commercial	$98.76
Rate for Payer: Healthscope Commercial	$111.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$104.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$92.59
Rate for Payer: PHP Commercial	$104.93
Rate for Payer: Priority Health SBD	$77.77

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION

Facility

$297.40

Service Code	NDC 00078095340
Hospital Charge Code	11567
Hospital Revenue Code	637
Min. Negotiated Rate	$187.36
Max. Negotiated Rate	$267.66
Rate for Payer: Aetna Commercial	$252.79
Rate for Payer: Aetna New Business (MI Preferred)	$193.31
Rate for Payer: Cash Price	$237.92
Rate for Payer: Cofinity Advantage	$208.18
Rate for Payer: Cofinity Commercial	$255.76
Rate for Payer: Encore Health Key Benefits Commercial	$237.92
Rate for Payer: Healthscope Commercial	$267.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$252.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$223.05
Rate for Payer: PHP Commercial	$252.79
Rate for Payer: Priority Health SBD	$187.36

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION

Facility

$164.61

Service Code	NDC 24208029525
Hospital Charge Code	11567
Hospital Revenue Code	637
Min. Negotiated Rate	$64.69
Max. Negotiated Rate	$148.15
Rate for Payer: Aetna Commercial	$139.92
Rate for Payer: Aetna Medicare	$82.31
Rate for Payer: Aetna New Business (MI Preferred)	$107.00
Rate for Payer: BCBS Complete	$65.84
Rate for Payer: Cash Price	$131.69
Rate for Payer: Cofinity Advantage	$115.23
Rate for Payer: Cofinity Commercial	$141.56
Rate for Payer: Encore Health Key Benefits Commercial	$131.69
Rate for Payer: Healthscope Commercial	$148.15
Rate for Payer: MI Amish Medical Board Commercial	$131.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$139.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$123.46
Rate for Payer: PHP Commercial	$139.92
Rate for Payer: Priority Health SBD	$103.70
Rate for Payer: UHC All Payor (Choice/PPO)	$107.00
Rate for Payer: UHC Core	$85.76
Rate for Payer: UHC Exchange	$64.69

Know your out-of-pocket cost for care.

All Charges