|
TICAGRELOR 90 MG TABLET
|
Facility
|
IP
|
$2,780.18
|
|
|
Service Code
|
NDC 00186077739
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,751.51 |
| Max. Negotiated Rate |
$2,502.16 |
| Rate for Payer: Aetna Commercial |
$2,363.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,807.12
|
| Rate for Payer: Cash Price |
$2,224.14
|
| Rate for Payer: Cofinity Commercial |
$1,946.13
|
| Rate for Payer: Cofinity Commercial |
$2,390.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,946.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,224.14
|
| Rate for Payer: Healthscope Commercial |
$2,502.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,363.15
|
| Rate for Payer: PHP Commercial |
$2,363.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,807.12
|
| Rate for Payer: Priority Health SBD |
$1,751.51
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
IP
|
$43.83
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
301711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.61 |
| Max. Negotiated Rate |
$39.45 |
| Rate for Payer: Aetna Commercial |
$37.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.49
|
| Rate for Payer: Cash Price |
$35.06
|
| Rate for Payer: Cofinity Commercial |
$30.68
|
| Rate for Payer: Cofinity Commercial |
$37.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.06
|
| Rate for Payer: Healthscope Commercial |
$39.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.26
|
| Rate for Payer: PHP Commercial |
$37.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.49
|
| Rate for Payer: Priority Health SBD |
$27.61
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
OP
|
$43.83
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
301711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.53 |
| Max. Negotiated Rate |
$39.45 |
| Rate for Payer: Aetna Commercial |
$37.26
|
| Rate for Payer: Aetna Medicare |
$21.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.49
|
| Rate for Payer: BCBS Complete |
$17.53
|
| Rate for Payer: Cash Price |
$35.06
|
| Rate for Payer: Cofinity Commercial |
$30.68
|
| Rate for Payer: Cofinity Commercial |
$37.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.06
|
| Rate for Payer: Healthscope Commercial |
$39.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.26
|
| Rate for Payer: PHP Commercial |
$37.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.49
|
| Rate for Payer: Priority Health SBD |
$27.61
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$43.83
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
41652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.53 |
| Max. Negotiated Rate |
$39.45 |
| Rate for Payer: Aetna Commercial |
$37.26
|
| Rate for Payer: Aetna Commercial |
$196.44
|
| Rate for Payer: Aetna Commercial |
$48.88
|
| Rate for Payer: Aetna Commercial |
$89.67
|
| Rate for Payer: Aetna Medicare |
$28.75
|
| Rate for Payer: Aetna Medicare |
$21.91
|
| Rate for Payer: Aetna Medicare |
$115.56
|
| Rate for Payer: Aetna Medicare |
$52.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.38
|
| Rate for Payer: BCBS Complete |
$42.20
|
| Rate for Payer: BCBS Complete |
$23.00
|
| Rate for Payer: BCBS Complete |
$92.44
|
| Rate for Payer: BCBS Complete |
$17.53
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cash Price |
$184.89
|
| Rate for Payer: Cash Price |
$35.06
|
| Rate for Payer: Cash Price |
$84.39
|
| Rate for Payer: Cofinity Commercial |
$198.75
|
| Rate for Payer: Cofinity Commercial |
$49.45
|
| Rate for Payer: Cofinity Commercial |
$30.68
|
| Rate for Payer: Cofinity Commercial |
$40.25
|
| Rate for Payer: Cofinity Commercial |
$37.69
|
| Rate for Payer: Cofinity Commercial |
$73.84
|
| Rate for Payer: Cofinity Commercial |
$90.72
|
| Rate for Payer: Cofinity Commercial |
$161.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.89
|
| Rate for Payer: Healthscope Commercial |
$94.94
|
| Rate for Payer: Healthscope Commercial |
$51.75
|
| Rate for Payer: Healthscope Commercial |
$208.00
|
| Rate for Payer: Healthscope Commercial |
$39.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.67
|
| Rate for Payer: PHP Commercial |
$196.44
|
| Rate for Payer: PHP Commercial |
$48.88
|
| Rate for Payer: PHP Commercial |
$37.26
|
| Rate for Payer: PHP Commercial |
$89.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.38
|
| Rate for Payer: Priority Health SBD |
$66.46
|
| Rate for Payer: Priority Health SBD |
$27.61
|
| Rate for Payer: Priority Health SBD |
$145.60
|
| Rate for Payer: Priority Health SBD |
$36.23
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$43.83
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
41652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.61 |
| Max. Negotiated Rate |
$39.45 |
| Rate for Payer: Aetna Commercial |
$37.26
|
| Rate for Payer: Aetna Commercial |
$48.88
|
| Rate for Payer: Aetna Commercial |
$89.67
|
| Rate for Payer: Aetna Commercial |
$196.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.38
|
| Rate for Payer: Cash Price |
$184.89
|
| Rate for Payer: Cash Price |
$84.39
|
| Rate for Payer: Cash Price |
$35.06
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cofinity Commercial |
$73.84
|
| Rate for Payer: Cofinity Commercial |
$90.72
|
| Rate for Payer: Cofinity Commercial |
$37.69
|
| Rate for Payer: Cofinity Commercial |
$161.78
|
| Rate for Payer: Cofinity Commercial |
$198.75
|
| Rate for Payer: Cofinity Commercial |
$30.68
|
| Rate for Payer: Cofinity Commercial |
$49.45
|
| Rate for Payer: Cofinity Commercial |
$40.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.00
|
| Rate for Payer: Healthscope Commercial |
$39.45
|
| Rate for Payer: Healthscope Commercial |
$208.00
|
| Rate for Payer: Healthscope Commercial |
$94.94
|
| Rate for Payer: Healthscope Commercial |
$51.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.44
|
| Rate for Payer: PHP Commercial |
$196.44
|
| Rate for Payer: PHP Commercial |
$89.67
|
| Rate for Payer: PHP Commercial |
$48.88
|
| Rate for Payer: PHP Commercial |
$37.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.49
|
| Rate for Payer: Priority Health SBD |
$66.46
|
| Rate for Payer: Priority Health SBD |
$27.61
|
| Rate for Payer: Priority Health SBD |
$145.60
|
| Rate for Payer: Priority Health SBD |
$36.23
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
|
IP
|
$25.56
|
|
|
Service Code
|
NDC 61314022610
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.61
|
| Rate for Payer: Cash Price |
$20.45
|
| Rate for Payer: Cofinity Commercial |
$17.89
|
| Rate for Payer: Cofinity Commercial |
$21.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.45
|
| Rate for Payer: Healthscope Commercial |
$23.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.73
|
| Rate for Payer: PHP Commercial |
$21.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.61
|
| Rate for Payer: Priority Health SBD |
$16.10
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
|
OP
|
$25.56
|
|
|
Service Code
|
NDC 61314022610
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.22 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$21.73
|
| Rate for Payer: Aetna Medicare |
$12.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.61
|
| Rate for Payer: BCBS Complete |
$10.22
|
| Rate for Payer: Cash Price |
$20.45
|
| Rate for Payer: Cofinity Commercial |
$17.89
|
| Rate for Payer: Cofinity Commercial |
$21.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.45
|
| Rate for Payer: Healthscope Commercial |
$23.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.73
|
| Rate for Payer: PHP Commercial |
$21.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.61
|
| Rate for Payer: Priority Health SBD |
$16.10
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
|
IP
|
$14.90
|
|
|
Service Code
|
NDC 61314022605
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$13.41 |
| Rate for Payer: Aetna Commercial |
$12.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.69
|
| Rate for Payer: Cash Price |
$11.92
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$12.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.92
|
| Rate for Payer: Healthscope Commercial |
$13.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.66
|
| Rate for Payer: PHP Commercial |
$12.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.69
|
| Rate for Payer: Priority Health SBD |
$9.39
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
|
OP
|
$14.90
|
|
|
Service Code
|
NDC 61314022605
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.96 |
| Max. Negotiated Rate |
$13.41 |
| Rate for Payer: Aetna Commercial |
$12.66
|
| Rate for Payer: Aetna Medicare |
$7.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.69
|
| Rate for Payer: BCBS Complete |
$5.96
|
| Rate for Payer: Cash Price |
$11.92
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$12.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.92
|
| Rate for Payer: Healthscope Commercial |
$13.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.66
|
| Rate for Payer: PHP Commercial |
$12.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.69
|
| Rate for Payer: Priority Health SBD |
$9.39
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$20.21
|
|
|
Service Code
|
NDC 61314022705
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$18.19 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna Medicare |
$10.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.14
|
| Rate for Payer: BCBS Complete |
$8.08
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: Cofinity Commercial |
$14.15
|
| Rate for Payer: Cofinity Commercial |
$17.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.17
|
| Rate for Payer: Healthscope Commercial |
$18.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.18
|
| Rate for Payer: PHP Commercial |
$17.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.14
|
| Rate for Payer: Priority Health SBD |
$12.73
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$31.57
|
|
|
Service Code
|
NDC 64980051405
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.63 |
| 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 Commercial |
$22.10
|
| Rate for Payer: Cofinity Commercial |
$27.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.10
|
| 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: PHP Commercial |
$26.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.52
|
| Rate for Payer: Priority Health SBD |
$19.89
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$22.91
|
|
|
Service Code
|
NDC 60758080105
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$20.62 |
| Rate for Payer: Aetna Commercial |
$19.47
|
| Rate for Payer: Aetna Medicare |
$11.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.89
|
| Rate for Payer: BCBS Complete |
$9.16
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Cofinity Commercial |
$16.04
|
| Rate for Payer: Cofinity Commercial |
$19.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.04
|
| 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: PHP Commercial |
$19.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.89
|
| Rate for Payer: Priority Health SBD |
$14.43
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$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 Commercial |
$22.10
|
| Rate for Payer: Cofinity Commercial |
$27.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.10
|
| 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: PHP Commercial |
$26.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.52
|
| Rate for Payer: Priority Health SBD |
$19.89
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$28.25
|
|
|
Service Code
|
NDC 17478028810
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.30 |
| Max. Negotiated Rate |
$25.43 |
| Rate for Payer: Aetna Commercial |
$24.01
|
| Rate for Payer: Aetna Medicare |
$14.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.36
|
| Rate for Payer: BCBS Complete |
$11.30
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$19.77
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.60
|
| Rate for Payer: Healthscope Commercial |
$25.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.01
|
| Rate for Payer: PHP Commercial |
$24.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.36
|
| Rate for Payer: Priority Health SBD |
$17.80
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$20.21
|
|
|
Service Code
|
NDC 61314022705
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.73 |
| Max. Negotiated Rate |
$18.19 |
| Rate for Payer: Aetna Commercial |
$17.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.14
|
| Rate for Payer: Cash Price |
$16.17
|
| Rate for Payer: Cofinity Commercial |
$14.15
|
| Rate for Payer: Cofinity Commercial |
$17.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.17
|
| Rate for Payer: Healthscope Commercial |
$18.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.18
|
| Rate for Payer: PHP Commercial |
$17.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.14
|
| Rate for Payer: Priority Health SBD |
$12.73
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$28.25
|
|
|
Service Code
|
NDC 17478028810
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.80 |
| Max. Negotiated Rate |
$25.43 |
| Rate for Payer: Aetna Commercial |
$24.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.36
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$19.77
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.60
|
| Rate for Payer: Healthscope Commercial |
$25.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.01
|
| Rate for Payer: PHP Commercial |
$24.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.36
|
| Rate for Payer: Priority Health SBD |
$17.80
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$688.84
|
|
|
Service Code
|
NDC 24208081305
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$275.54 |
| Max. Negotiated Rate |
$619.96 |
| Rate for Payer: Aetna Commercial |
$585.51
|
| Rate for Payer: Aetna Medicare |
$344.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$447.75
|
| Rate for Payer: BCBS Complete |
$275.54
|
| Rate for Payer: Cash Price |
$551.07
|
| Rate for Payer: Cofinity Commercial |
$482.19
|
| Rate for Payer: Cofinity Commercial |
$592.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$482.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$551.07
|
| Rate for Payer: Healthscope Commercial |
$619.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$585.51
|
| Rate for Payer: PHP Commercial |
$585.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$447.75
|
| Rate for Payer: Priority Health SBD |
$433.97
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$688.84
|
|
|
Service Code
|
NDC 24208081305
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$433.97 |
| Max. Negotiated Rate |
$619.96 |
| Rate for Payer: Aetna Commercial |
$585.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$447.75
|
| Rate for Payer: Cash Price |
$551.07
|
| Rate for Payer: Cofinity Commercial |
$482.19
|
| Rate for Payer: Cofinity Commercial |
$592.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$482.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$551.07
|
| Rate for Payer: Healthscope Commercial |
$619.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$585.51
|
| Rate for Payer: PHP Commercial |
$585.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$447.75
|
| Rate for Payer: Priority Health SBD |
$433.97
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$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 Commercial |
$16.04
|
| Rate for Payer: Cofinity Commercial |
$19.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.04
|
| 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: PHP Commercial |
$19.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.89
|
| Rate for Payer: Priority Health SBD |
$14.43
|
|
|
TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
|
Facility
|
OP
|
$47,763.96
|
|
|
Service Code
|
CPT 19357
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$9,094.99 |
| Max. Negotiated Rate |
$47,763.96 |
| Rate for Payer: Aetna Medicare |
$17,646.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21,210.33
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21,210.33
|
| Rate for Payer: BCBS Complete |
$9,549.74
|
| Rate for Payer: BCBS MAPPO |
$16,968.26
|
| Rate for Payer: BCN Medicare Advantage |
$16,968.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16,968.26
|
| Rate for Payer: Mclaren Medicaid |
$9,094.99
|
| Rate for Payer: Mclaren Medicare |
$16,968.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17,816.67
|
| Rate for Payer: Meridian Medicaid |
$9,549.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19,513.50
|
| Rate for Payer: PACE Medicare |
$16,119.85
|
| Rate for Payer: PACE SWMI |
$16,968.26
|
| Rate for Payer: PHP Medicare Advantage |
$16,968.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,094.99
|
| Rate for Payer: Priority Health Medicare |
$16,968.26
|
| Rate for Payer: Railroad Medicare Medicare |
$16,968.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47,763.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$16,968.26
|
| Rate for Payer: UHC Medicare Advantage |
$16,968.26
|
| Rate for Payer: UHCCP Medicaid |
$9,553.13
|
| Rate for Payer: VA VA |
$16,968.26
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
|
OP
|
$183.30
|
|
|
Service Code
|
NDC 57664050289
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.32 |
| 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 Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.31
|
| 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: PHP Commercial |
$155.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.14
|
| Rate for Payer: Priority Health SBD |
$115.48
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
|
IP
|
$91.44
|
|
|
Service Code
|
NDC 68084077525
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.61 |
| Max. Negotiated Rate |
$82.30 |
| Rate for Payer: Aetna Commercial |
$77.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.44
|
| Rate for Payer: Cash Price |
$73.15
|
| Rate for Payer: Cofinity Commercial |
$64.01
|
| Rate for Payer: Cofinity Commercial |
$78.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$64.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.15
|
| Rate for Payer: Healthscope Commercial |
$82.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.72
|
| Rate for Payer: PHP Commercial |
$77.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.44
|
| Rate for Payer: Priority Health SBD |
$57.61
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
|
IP
|
$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 Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$128.31
|
| 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: PHP Commercial |
$155.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.14
|
| Rate for Payer: Priority Health SBD |
$115.48
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
|
IP
|
$157.68
|
|
|
Service Code
|
NDC 50268075915
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.34 |
| Max. Negotiated Rate |
$141.91 |
| Rate for Payer: Aetna Commercial |
$134.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$102.49
|
| Rate for Payer: Cash Price |
$126.14
|
| Rate for Payer: Cofinity Commercial |
$110.38
|
| Rate for Payer: Cofinity Commercial |
$135.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$110.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$126.14
|
| Rate for Payer: Healthscope Commercial |
$141.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$134.03
|
| Rate for Payer: PHP Commercial |
$134.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.49
|
| Rate for Payer: Priority Health SBD |
$99.34
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
|
OP
|
$91.44
|
|
|
Service Code
|
NDC 68084077525
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.58 |
| Max. Negotiated Rate |
$82.30 |
| Rate for Payer: Aetna Commercial |
$77.72
|
| Rate for Payer: Aetna Medicare |
$45.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.44
|
| Rate for Payer: BCBS Complete |
$36.58
|
| Rate for Payer: Cash Price |
$73.15
|
| Rate for Payer: Cofinity Commercial |
$64.01
|
| Rate for Payer: Cofinity Commercial |
$78.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$64.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.15
|
| Rate for Payer: Healthscope Commercial |
$82.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.72
|
| Rate for Payer: PHP Commercial |
$77.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$59.44
|
| Rate for Payer: Priority Health SBD |
$57.61
|
|
