|
THROMBIN 5000UNITS/EPINEPHRINE TOPICAL 30ML/NS 1L
|
Facility
|
IP
|
$218.05
|
|
|
Service Code
|
NDC 09900000200
|
| Hospital Charge Code |
500527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.37 |
| Max. Negotiated Rate |
$196.24 |
| Rate for Payer: Aetna Commercial |
$185.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.73
|
| Rate for Payer: Cash Price |
$174.44
|
| Rate for Payer: Cofinity Commercial |
$152.64
|
| Rate for Payer: Cofinity Commercial |
$187.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.44
|
| Rate for Payer: Healthscope Commercial |
$196.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.34
|
| Rate for Payer: PHP Commercial |
$185.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.73
|
| Rate for Payer: Priority Health SBD |
$137.37
|
|
|
THROMBIN 5000UNITS/EPINEPHRINE TOPICAL 30ML/NS 1L
|
Facility
|
OP
|
$218.05
|
|
|
Service Code
|
NDC 09900000200
|
| Hospital Charge Code |
500527
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.22 |
| Max. Negotiated Rate |
$196.24 |
| Rate for Payer: Aetna Commercial |
$185.34
|
| Rate for Payer: Aetna Medicare |
$109.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$141.73
|
| Rate for Payer: BCBS Complete |
$87.22
|
| Rate for Payer: Cash Price |
$174.44
|
| Rate for Payer: Cofinity Commercial |
$152.64
|
| Rate for Payer: Cofinity Commercial |
$187.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.44
|
| Rate for Payer: Healthscope Commercial |
$196.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.34
|
| Rate for Payer: PHP Commercial |
$185.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.73
|
| Rate for Payer: Priority Health SBD |
$137.37
|
|
|
THROMBIN (BOVINE) 20,000 UNIT TOPICAL SPRAY
|
Facility
|
IP
|
$854.74
|
|
|
Service Code
|
NDC 60793021722
|
| Hospital Charge Code |
108841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$538.49 |
| Max. Negotiated Rate |
$769.27 |
| Rate for Payer: Aetna Commercial |
$726.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$555.58
|
| Rate for Payer: Cash Price |
$683.79
|
| Rate for Payer: Cofinity Commercial |
$598.32
|
| Rate for Payer: Cofinity Commercial |
$735.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$598.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$683.79
|
| Rate for Payer: Healthscope Commercial |
$769.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$726.53
|
| Rate for Payer: PHP Commercial |
$726.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$555.58
|
| Rate for Payer: Priority Health SBD |
$538.49
|
|
|
THROMBIN (BOVINE) 20,000 UNIT TOPICAL SPRAY
|
Facility
|
OP
|
$854.74
|
|
|
Service Code
|
NDC 60793021722
|
| Hospital Charge Code |
108841
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$341.90 |
| Max. Negotiated Rate |
$769.27 |
| Rate for Payer: Aetna Commercial |
$726.53
|
| Rate for Payer: Aetna Medicare |
$427.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$555.58
|
| Rate for Payer: BCBS Complete |
$341.90
|
| Rate for Payer: Cash Price |
$683.79
|
| Rate for Payer: Cofinity Commercial |
$598.32
|
| Rate for Payer: Cofinity Commercial |
$735.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$598.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$683.79
|
| Rate for Payer: Healthscope Commercial |
$769.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$726.53
|
| Rate for Payer: PHP Commercial |
$726.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$555.58
|
| Rate for Payer: Priority Health SBD |
$538.49
|
|
|
THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION
|
Facility
|
OP
|
$189.37
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
117741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.75 |
| Max. Negotiated Rate |
$170.43 |
| Rate for Payer: Aetna Commercial |
$160.96
|
| Rate for Payer: Aetna Medicare |
$94.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.09
|
| Rate for Payer: BCBS Complete |
$75.75
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cofinity Commercial |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.50
|
| Rate for Payer: Healthscope Commercial |
$170.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.96
|
| Rate for Payer: PHP Commercial |
$160.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.09
|
| Rate for Payer: Priority Health SBD |
$119.30
|
|
|
THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION
|
Facility
|
IP
|
$189.37
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
117741
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.30 |
| Max. Negotiated Rate |
$170.43 |
| Rate for Payer: Aetna Commercial |
$160.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.09
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cofinity Commercial |
$132.56
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.50
|
| Rate for Payer: Healthscope Commercial |
$170.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.96
|
| Rate for Payer: PHP Commercial |
$160.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.09
|
| Rate for Payer: Priority Health SBD |
$119.30
|
|
|
THROMBOLYSIS, CEREBRAL, BY INTRAVENOUS INFUSION
|
Facility
|
OP
|
$1,021.42
|
|
|
Service Code
|
CPT 37195
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$149.80 |
| Max. Negotiated Rate |
$1,021.42 |
| Rate for Payer: Aetna Medicare |
$337.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$406.22
|
| Rate for Payer: Amish Plain Church Group Commercial |
$406.22
|
| Rate for Payer: BCBS Complete |
$182.90
|
| Rate for Payer: BCBS MAPPO |
$324.98
|
| Rate for Payer: BCBS Trust/PPO |
$149.80
|
| Rate for Payer: BCN Commercial |
$149.80
|
| Rate for Payer: BCN Medicare Advantage |
$324.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$324.98
|
| Rate for Payer: Mclaren Medicaid |
$174.19
|
| Rate for Payer: Mclaren Medicare |
$324.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$341.23
|
| Rate for Payer: Meridian Medicaid |
$182.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$373.73
|
| Rate for Payer: Nomi Health Commercial |
$682.46
|
| Rate for Payer: PACE Medicare |
$308.73
|
| Rate for Payer: PACE SWMI |
$324.98
|
| Rate for Payer: PHP Medicare Advantage |
$324.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$174.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,021.42
|
| Rate for Payer: Priority Health Medicare |
$324.98
|
| Rate for Payer: Priority Health Narrow Network |
$817.14
|
| Rate for Payer: Railroad Medicare Medicare |
$324.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$914.79
|
| Rate for Payer: UHC Core |
$878.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$324.98
|
| Rate for Payer: UHC Exchange |
$940.00
|
| Rate for Payer: UHC Medicare Advantage |
$324.98
|
| Rate for Payer: UHCCP Medicaid |
$182.96
|
| Rate for Payer: VA VA |
$324.98
|
|
|
THYROIDECTOMY, TOTAL OR COMPLETE
|
Facility
|
OP
|
$17,966.53
|
|
|
Service Code
|
CPT 60240
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$982.30 |
| Max. Negotiated Rate |
$17,966.53 |
| Rate for Payer: Aetna Medicare |
$5,945.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,145.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,145.49
|
| Rate for Payer: BCBS Complete |
$3,217.18
|
| Rate for Payer: BCBS MAPPO |
$5,716.39
|
| Rate for Payer: BCBS Trust/PPO |
$4,222.05
|
| Rate for Payer: BCN Commercial |
$4,222.05
|
| Rate for Payer: BCN Medicare Advantage |
$5,716.39
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,716.39
|
| Rate for Payer: Mclaren Medicaid |
$3,063.99
|
| Rate for Payer: Mclaren Medicare |
$5,716.39
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,002.21
|
| Rate for Payer: Meridian Medicaid |
$3,217.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,573.85
|
| Rate for Payer: Nomi Health Commercial |
$12,004.42
|
| Rate for Payer: PACE Medicare |
$5,430.57
|
| Rate for Payer: PACE SWMI |
$5,716.39
|
| Rate for Payer: PHP Medicare Advantage |
$5,716.39
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,063.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17,966.53
|
| Rate for Payer: Priority Health Medicare |
$5,716.39
|
| Rate for Payer: Priority Health Narrow Network |
$14,373.22
|
| Rate for Payer: Railroad Medicare Medicare |
$5,716.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$982.30
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,716.39
|
| Rate for Payer: UHC Exchange |
$8,174.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,716.39
|
| Rate for Payer: UHCCP Medicaid |
$3,218.33
|
| Rate for Payer: VA VA |
$5,716.39
|
|
|
THYROID (PORK) 30 MG TABLET
|
Facility
|
IP
|
$472.80
|
|
|
Service Code
|
NDC 00456045801
|
| Hospital Charge Code |
119104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$297.86 |
| Max. Negotiated Rate |
$425.52 |
| Rate for Payer: Aetna Commercial |
$401.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.32
|
| Rate for Payer: Cash Price |
$378.24
|
| Rate for Payer: Cofinity Commercial |
$330.96
|
| Rate for Payer: Cofinity Commercial |
$406.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$330.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$378.24
|
| Rate for Payer: Healthscope Commercial |
$425.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.88
|
| Rate for Payer: PHP Commercial |
$401.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$307.32
|
| Rate for Payer: Priority Health SBD |
$297.86
|
|
|
THYROID (PORK) 30 MG TABLET
|
Facility
|
OP
|
$472.80
|
|
|
Service Code
|
NDC 00456045801
|
| Hospital Charge Code |
119104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.12 |
| Max. Negotiated Rate |
$425.52 |
| Rate for Payer: Aetna Commercial |
$401.88
|
| Rate for Payer: Aetna Medicare |
$236.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.32
|
| Rate for Payer: BCBS Complete |
$189.12
|
| Rate for Payer: Cash Price |
$378.24
|
| Rate for Payer: Cofinity Commercial |
$330.96
|
| Rate for Payer: Cofinity Commercial |
$406.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$330.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$378.24
|
| Rate for Payer: Healthscope Commercial |
$425.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$401.88
|
| Rate for Payer: PHP Commercial |
$401.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$307.32
|
| Rate for Payer: Priority Health SBD |
$297.86
|
|
|
THYROID (PORK) 30 MG TABLET
|
Facility
|
IP
|
$330.24
|
|
|
Service Code
|
NDC 42192032901
|
| Hospital Charge Code |
119104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.05 |
| Max. Negotiated Rate |
$297.22 |
| Rate for Payer: Aetna Commercial |
$280.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.66
|
| Rate for Payer: Cash Price |
$264.19
|
| Rate for Payer: Cofinity Commercial |
$231.17
|
| Rate for Payer: Cofinity Commercial |
$284.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.19
|
| Rate for Payer: Healthscope Commercial |
$297.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.70
|
| Rate for Payer: PHP Commercial |
$280.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.66
|
| Rate for Payer: Priority Health SBD |
$208.05
|
|
|
THYROID (PORK) 30 MG TABLET
|
Facility
|
OP
|
$330.24
|
|
|
Service Code
|
NDC 42192032901
|
| Hospital Charge Code |
119104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.10 |
| Max. Negotiated Rate |
$297.22 |
| Rate for Payer: Aetna Commercial |
$280.70
|
| Rate for Payer: Aetna Medicare |
$165.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.66
|
| Rate for Payer: BCBS Complete |
$132.10
|
| Rate for Payer: Cash Price |
$264.19
|
| Rate for Payer: Cofinity Commercial |
$231.17
|
| Rate for Payer: Cofinity Commercial |
$284.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.19
|
| Rate for Payer: Healthscope Commercial |
$297.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.70
|
| Rate for Payer: PHP Commercial |
$280.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.66
|
| Rate for Payer: Priority Health SBD |
$208.05
|
|
|
THYROID (PORK) 60 MG TABLET
|
Facility
|
IP
|
$525.60
|
|
|
Service Code
|
NDC 00456045901
|
| Hospital Charge Code |
119105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.13 |
| Max. Negotiated Rate |
$473.04 |
| Rate for Payer: Aetna Commercial |
$446.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$341.64
|
| Rate for Payer: Cash Price |
$420.48
|
| Rate for Payer: Cofinity Commercial |
$367.92
|
| Rate for Payer: Cofinity Commercial |
$452.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$367.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$420.48
|
| Rate for Payer: Healthscope Commercial |
$473.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$446.76
|
| Rate for Payer: PHP Commercial |
$446.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$341.64
|
| Rate for Payer: Priority Health SBD |
$331.13
|
|
|
THYROID (PORK) 60 MG TABLET
|
Facility
|
OP
|
$525.60
|
|
|
Service Code
|
NDC 00456045901
|
| Hospital Charge Code |
119105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.24 |
| Max. Negotiated Rate |
$473.04 |
| Rate for Payer: Aetna Commercial |
$446.76
|
| Rate for Payer: Aetna Medicare |
$262.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$341.64
|
| Rate for Payer: BCBS Complete |
$210.24
|
| Rate for Payer: Cash Price |
$420.48
|
| Rate for Payer: Cofinity Commercial |
$367.92
|
| Rate for Payer: Cofinity Commercial |
$452.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$367.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$420.48
|
| Rate for Payer: Healthscope Commercial |
$473.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$446.76
|
| Rate for Payer: PHP Commercial |
$446.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$341.64
|
| Rate for Payer: Priority Health SBD |
$331.13
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$6,327.17
|
|
|
Service Code
|
HCPCS J3240
|
| Hospital Charge Code |
196901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,108.40 |
| Max. Negotiated Rate |
$6,203.73 |
| Rate for Payer: Aetna Commercial |
$5,378.09
|
| Rate for Payer: Aetna Medicare |
$2,150.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,112.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,584.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,584.89
|
| Rate for Payer: BCBS Complete |
$1,163.82
|
| Rate for Payer: BCBS MAPPO |
$2,067.91
|
| Rate for Payer: BCBS Trust/PPO |
$5,856.80
|
| Rate for Payer: BCN Commercial |
$5,856.80
|
| Rate for Payer: BCN Medicare Advantage |
$2,067.91
|
| Rate for Payer: Cash Price |
$5,061.74
|
| Rate for Payer: Cash Price |
$5,061.74
|
| Rate for Payer: Cofinity Commercial |
$5,441.37
|
| Rate for Payer: Cofinity Commercial |
$4,429.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,429.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,061.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,067.91
|
| Rate for Payer: Healthscope Commercial |
$5,694.45
|
| Rate for Payer: Mclaren Medicaid |
$1,108.40
|
| Rate for Payer: Mclaren Medicare |
$2,067.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,171.31
|
| Rate for Payer: Meridian Medicaid |
$1,163.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,378.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,378.09
|
| Rate for Payer: Nomi Health Commercial |
$6,203.73
|
| Rate for Payer: PACE Medicare |
$1,964.51
|
| Rate for Payer: PACE SWMI |
$2,067.91
|
| Rate for Payer: PHP Commercial |
$5,378.09
|
| Rate for Payer: PHP Medicare Advantage |
$2,067.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,108.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,112.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5,967.11
|
| Rate for Payer: Priority Health Medicare |
$2,067.91
|
| Rate for Payer: Priority Health Narrow Network |
$4,773.69
|
| Rate for Payer: Priority Health SBD |
$3,986.12
|
| Rate for Payer: Railroad Medicare Medicare |
$2,067.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,820.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,067.91
|
| Rate for Payer: UHC Medicare Advantage |
$2,067.91
|
| Rate for Payer: UHCCP Medicaid |
$1,164.23
|
| Rate for Payer: VA VA |
$2,067.91
|
|
|
TICAGRELOR 60 MG TABLET
|
Facility
|
IP
|
$1,668.33
|
|
|
Service Code
|
NDC 00186077660
|
| Hospital Charge Code |
175597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,051.05 |
| Max. Negotiated Rate |
$1,501.50 |
| Rate for Payer: Aetna Commercial |
$1,418.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,084.41
|
| Rate for Payer: Cash Price |
$1,334.66
|
| Rate for Payer: Cofinity Commercial |
$1,167.83
|
| Rate for Payer: Cofinity Commercial |
$1,434.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,167.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.66
|
| Rate for Payer: Healthscope Commercial |
$1,501.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,418.08
|
| Rate for Payer: PHP Commercial |
$1,418.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,084.41
|
| Rate for Payer: Priority Health SBD |
$1,051.05
|
|
|
TICAGRELOR 60 MG TABLET
|
Facility
|
OP
|
$1,668.33
|
|
|
Service Code
|
NDC 00186077660
|
| Hospital Charge Code |
175597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$667.33 |
| Max. Negotiated Rate |
$1,501.50 |
| Rate for Payer: Aetna Commercial |
$1,418.08
|
| Rate for Payer: Aetna Medicare |
$834.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,084.41
|
| Rate for Payer: BCBS Complete |
$667.33
|
| Rate for Payer: Cash Price |
$1,334.66
|
| Rate for Payer: Cofinity Commercial |
$1,167.83
|
| Rate for Payer: Cofinity Commercial |
$1,434.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,167.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.66
|
| Rate for Payer: Healthscope Commercial |
$1,501.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,418.08
|
| Rate for Payer: PHP Commercial |
$1,418.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,084.41
|
| Rate for Payer: Priority Health SBD |
$1,051.05
|
|
|
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
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
OP
|
$2,780.18
|
|
|
Service Code
|
NDC 00186077739
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,112.07 |
| Max. Negotiated Rate |
$2,502.16 |
| Rate for Payer: Aetna Commercial |
$2,363.15
|
| Rate for Payer: Aetna Medicare |
$1,390.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,807.12
|
| Rate for Payer: BCBS Complete |
$1,112.07
|
| 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
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
OP
|
$1,668.33
|
|
|
Service Code
|
NDC 00186077760
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$667.33 |
| Max. Negotiated Rate |
$1,501.50 |
| Rate for Payer: Aetna Commercial |
$1,418.08
|
| Rate for Payer: Aetna Medicare |
$834.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,084.41
|
| Rate for Payer: BCBS Complete |
$667.33
|
| Rate for Payer: Cash Price |
$1,334.66
|
| Rate for Payer: Cofinity Commercial |
$1,167.83
|
| Rate for Payer: Cofinity Commercial |
$1,434.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,167.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.66
|
| Rate for Payer: Healthscope Commercial |
$1,501.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,418.08
|
| Rate for Payer: PHP Commercial |
$1,418.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,084.41
|
| Rate for Payer: Priority Health SBD |
$1,051.05
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
IP
|
$1,668.33
|
|
|
Service Code
|
NDC 00186077760
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,051.05 |
| Max. Negotiated Rate |
$1,501.50 |
| Rate for Payer: Aetna Commercial |
$1,418.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,084.41
|
| Rate for Payer: Cash Price |
$1,334.66
|
| Rate for Payer: Cofinity Commercial |
$1,434.76
|
| Rate for Payer: Cofinity Commercial |
$1,167.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,167.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.66
|
| Rate for Payer: Healthscope Commercial |
$1,501.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,418.08
|
| Rate for Payer: PHP Commercial |
$1,418.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,084.41
|
| Rate for Payer: Priority Health SBD |
$1,051.05
|
|
|
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 |
$1.47 |
| Max. Negotiated Rate |
$39.45 |
| Rate for Payer: Aetna Commercial |
$37.26
|
| Rate for Payer: Aetna Medicare |
$21.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.49
|
| Rate for Payer: BCBS Complete |
$17.53
|
| Rate for Payer: BCBS Trust/PPO |
$1.47
|
| Rate for Payer: BCN Commercial |
$1.47
|
| Rate for Payer: Cash Price |
$35.06
|
| 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
|
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 SOLUTION
|
Facility
|
OP
|
$57.50
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
41652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$51.75 |
| Rate for Payer: Aetna Commercial |
$48.88
|
| Rate for Payer: Aetna Commercial |
$89.67
|
| Rate for Payer: Aetna Commercial |
$37.26
|
| Rate for Payer: Aetna Commercial |
$196.44
|
| Rate for Payer: Aetna Medicare |
$21.92
|
| Rate for Payer: Aetna Medicare |
$52.74
|
| Rate for Payer: Aetna Medicare |
$28.75
|
| Rate for Payer: Aetna Medicare |
$115.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.38
|
| 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: BCBS Complete |
$17.53
|
| Rate for Payer: BCBS Complete |
$23.00
|
| Rate for Payer: BCBS Complete |
$92.44
|
| Rate for Payer: BCBS Complete |
$42.20
|
| Rate for Payer: BCBS Trust/PPO |
$1.47
|
| Rate for Payer: BCBS Trust/PPO |
$1.47
|
| Rate for Payer: BCBS Trust/PPO |
$1.47
|
| Rate for Payer: BCBS Trust/PPO |
$1.47
|
| Rate for Payer: BCN Commercial |
$1.47
|
| Rate for Payer: BCN Commercial |
$1.47
|
| Rate for Payer: BCN Commercial |
$1.47
|
| Rate for Payer: BCN Commercial |
$1.47
|
| 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 |
$184.89
|
| Rate for Payer: Cash Price |
$35.06
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cash Price |
$84.39
|
| Rate for Payer: Cofinity Commercial |
$161.78
|
| Rate for Payer: Cofinity Commercial |
$73.84
|
| Rate for Payer: Cofinity Commercial |
$90.72
|
| Rate for Payer: Cofinity Commercial |
$198.75
|
| Rate for Payer: Cofinity Commercial |
$30.68
|
| Rate for Payer: Cofinity Commercial |
$37.69
|
| Rate for Payer: Cofinity Commercial |
$40.25
|
| Rate for Payer: Cofinity Commercial |
$49.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.68
|
| 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 |
$46.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.89
|
| Rate for Payer: Healthscope Commercial |
$208.00
|
| Rate for Payer: Healthscope Commercial |
$51.75
|
| Rate for Payer: Healthscope Commercial |
$39.45
|
| Rate for Payer: Healthscope Commercial |
$94.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.88
|
| Rate for Payer: PHP Commercial |
$48.88
|
| Rate for Payer: PHP Commercial |
$196.44
|
| Rate for Payer: PHP Commercial |
$37.26
|
| Rate for Payer: PHP Commercial |
$89.67
|
| 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 Cigna Priority Health |
$28.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.22
|
| Rate for Payer: Priority Health SBD |
$36.22
|
| Rate for Payer: Priority Health SBD |
$145.60
|
| Rate for Payer: Priority Health SBD |
$66.46
|
| Rate for Payer: Priority Health SBD |
$27.61
|
|
|
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 |
$196.44
|
| Rate for Payer: Aetna Commercial |
$48.88
|
| Rate for Payer: Aetna Commercial |
$89.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.57
|
| Rate for Payer: Cash Price |
$35.06
|
| Rate for Payer: Cash Price |
$184.89
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cash Price |
$84.39
|
| Rate for Payer: Cofinity Commercial |
$40.25
|
| 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 Commercial |
$198.75
|
| Rate for Payer: Cofinity Commercial |
$30.68
|
| Rate for Payer: Cofinity Commercial |
$37.69
|
| Rate for Payer: Cofinity Commercial |
$49.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$40.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.84
|
| 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: Encore Health Key Benefits Commercial |
$84.39
|
| Rate for Payer: Healthscope Commercial |
$208.00
|
| Rate for Payer: Healthscope Commercial |
$94.94
|
| Rate for Payer: Healthscope Commercial |
$39.45
|
| Rate for Payer: Healthscope Commercial |
$51.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$37.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.88
|
| Rate for Payer: PHP Commercial |
$48.88
|
| Rate for Payer: PHP Commercial |
$89.67
|
| Rate for Payer: PHP Commercial |
$37.26
|
| Rate for Payer: PHP Commercial |
$196.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.57
|
| Rate for Payer: Priority Health SBD |
$66.46
|
| Rate for Payer: Priority Health SBD |
$145.60
|
| Rate for Payer: Priority Health SBD |
$36.22
|
| Rate for Payer: Priority Health SBD |
$27.61
|
|
