|
TOBRAMYCIN 0.3 % EYE OINTMENT
|
Facility
|
OP
|
$829.33
|
|
|
Service Code
|
NDC 00078081301
|
| Hospital Charge Code |
19769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.73 |
| Max. Negotiated Rate |
$746.40 |
| Rate for Payer: Aetna Commercial |
$704.93
|
| Rate for Payer: Aetna Medicare |
$414.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$539.06
|
| Rate for Payer: BCBS Complete |
$331.73
|
| Rate for Payer: Cash Price |
$663.46
|
| Rate for Payer: Cofinity Commercial |
$580.53
|
| Rate for Payer: Cofinity Commercial |
$713.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$580.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$663.46
|
| Rate for Payer: Healthscope Commercial |
$746.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$704.93
|
| Rate for Payer: PHP Commercial |
$704.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$539.06
|
| Rate for Payer: Priority Health SBD |
$522.48
|
|
|
TOBRAMYCIN 0.3 % EYE OINTMENT
|
Facility
|
OP
|
$696.47
|
|
|
Service Code
|
NDC 00065064435
|
| Hospital Charge Code |
19769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.59 |
| Max. Negotiated Rate |
$626.82 |
| Rate for Payer: Aetna Commercial |
$592.00
|
| Rate for Payer: Aetna Medicare |
$348.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$452.71
|
| Rate for Payer: BCBS Complete |
$278.59
|
| Rate for Payer: Cash Price |
$557.18
|
| Rate for Payer: Cofinity Commercial |
$487.53
|
| Rate for Payer: Cofinity Commercial |
$598.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$487.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.18
|
| Rate for Payer: Healthscope Commercial |
$626.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.00
|
| Rate for Payer: PHP Commercial |
$592.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$452.71
|
| Rate for Payer: Priority Health SBD |
$438.78
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$185.39
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$116.80 |
| Max. Negotiated Rate |
$166.85 |
| Rate for Payer: Aetna Commercial |
$157.58
|
| Rate for Payer: Aetna Commercial |
$157.16
|
| Rate for Payer: Aetna Commercial |
$180.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.50
|
| Rate for Payer: Cash Price |
$148.31
|
| Rate for Payer: Cash Price |
$147.91
|
| Rate for Payer: Cash Price |
$169.92
|
| Rate for Payer: Cofinity Commercial |
$148.68
|
| Rate for Payer: Cofinity Commercial |
$182.66
|
| Rate for Payer: Cofinity Commercial |
$159.44
|
| Rate for Payer: Cofinity Commercial |
$159.01
|
| Rate for Payer: Cofinity Commercial |
$129.42
|
| Rate for Payer: Cofinity Commercial |
$129.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.92
|
| Rate for Payer: Healthscope Commercial |
$166.40
|
| Rate for Payer: Healthscope Commercial |
$166.85
|
| Rate for Payer: Healthscope Commercial |
$191.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.54
|
| Rate for Payer: PHP Commercial |
$157.16
|
| Rate for Payer: PHP Commercial |
$157.58
|
| Rate for Payer: PHP Commercial |
$180.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.06
|
| Rate for Payer: Priority Health SBD |
$133.81
|
| Rate for Payer: Priority Health SBD |
$116.48
|
| Rate for Payer: Priority Health SBD |
$116.80
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION
|
Facility
|
OP
|
$184.89
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.96 |
| Max. Negotiated Rate |
$166.40 |
| Rate for Payer: Aetna Commercial |
$157.16
|
| Rate for Payer: Aetna Commercial |
$180.54
|
| Rate for Payer: Aetna Commercial |
$157.58
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: Aetna Medicare |
$92.44
|
| Rate for Payer: Aetna Medicare |
$92.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.50
|
| Rate for Payer: BCBS Complete |
$74.16
|
| Rate for Payer: BCBS Complete |
$73.96
|
| Rate for Payer: BCBS Complete |
$84.96
|
| Rate for Payer: Cash Price |
$169.92
|
| Rate for Payer: Cash Price |
$147.91
|
| Rate for Payer: Cash Price |
$148.31
|
| Rate for Payer: Cofinity Commercial |
$182.66
|
| Rate for Payer: Cofinity Commercial |
$159.01
|
| Rate for Payer: Cofinity Commercial |
$129.42
|
| Rate for Payer: Cofinity Commercial |
$159.44
|
| Rate for Payer: Cofinity Commercial |
$129.77
|
| Rate for Payer: Cofinity Commercial |
$148.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.91
|
| Rate for Payer: Healthscope Commercial |
$166.85
|
| Rate for Payer: Healthscope Commercial |
$166.40
|
| Rate for Payer: Healthscope Commercial |
$191.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.16
|
| Rate for Payer: PHP Commercial |
$157.58
|
| Rate for Payer: PHP Commercial |
$157.16
|
| Rate for Payer: PHP Commercial |
$180.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.50
|
| Rate for Payer: Priority Health SBD |
$133.81
|
| Rate for Payer: Priority Health SBD |
$116.80
|
| Rate for Payer: Priority Health SBD |
$116.48
|
|
|
TOBRAMYCIN 300 MG/5 ML NEBULIZATION CUSTOM
|
Facility
|
IP
|
$50.66
|
|
|
Service Code
|
HCPCS J7682
|
| Hospital Charge Code |
168920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.93
|
| Rate for Payer: Cash Price |
$40.53
|
| Rate for Payer: Cofinity Commercial |
$35.46
|
| Rate for Payer: Cofinity Commercial |
$43.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.53
|
| Rate for Payer: Healthscope Commercial |
$45.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.06
|
| Rate for Payer: PHP Commercial |
$43.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.93
|
| Rate for Payer: Priority Health SBD |
$31.92
|
|
|
TOBRAMYCIN 300 MG/5 ML NEBULIZATION CUSTOM
|
Facility
|
OP
|
$50.66
|
|
|
Service Code
|
HCPCS J7682
|
| Hospital Charge Code |
168920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.26 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: Aetna Medicare |
$25.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.93
|
| Rate for Payer: BCBS Complete |
$20.26
|
| Rate for Payer: Cash Price |
$40.53
|
| Rate for Payer: Cofinity Commercial |
$35.46
|
| Rate for Payer: Cofinity Commercial |
$43.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.53
|
| Rate for Payer: Healthscope Commercial |
$45.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.06
|
| Rate for Payer: PHP Commercial |
$43.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.93
|
| Rate for Payer: Priority Health SBD |
$31.92
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$80.77
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.31 |
| Max. Negotiated Rate |
$72.69 |
| Rate for Payer: Aetna Commercial |
$68.65
|
| Rate for Payer: Aetna Commercial |
$43.35
|
| Rate for Payer: Aetna Commercial |
$76.48
|
| Rate for Payer: Aetna Commercial |
$9.52
|
| Rate for Payer: Aetna Commercial |
$15.93
|
| Rate for Payer: Aetna Medicare |
$25.50
|
| Rate for Payer: Aetna Medicare |
$44.99
|
| Rate for Payer: Aetna Medicare |
$40.38
|
| Rate for Payer: Aetna Medicare |
$9.37
|
| Rate for Payer: Aetna Medicare |
$5.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.28
|
| Rate for Payer: BCBS Complete |
$7.50
|
| Rate for Payer: BCBS Complete |
$32.31
|
| Rate for Payer: BCBS Complete |
$20.40
|
| Rate for Payer: BCBS Complete |
$4.48
|
| Rate for Payer: BCBS Complete |
$35.99
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$71.98
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cash Price |
$64.62
|
| Rate for Payer: Cofinity Commercial |
$69.46
|
| Rate for Payer: Cofinity Commercial |
$7.84
|
| Rate for Payer: Cofinity Commercial |
$9.63
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Commercial |
$35.70
|
| Rate for Payer: Cofinity Commercial |
$43.86
|
| Rate for Payer: Cofinity Commercial |
$56.54
|
| Rate for Payer: Cofinity Commercial |
$62.99
|
| Rate for Payer: Cofinity Commercial |
$77.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.99
|
| Rate for Payer: Healthscope Commercial |
$16.87
|
| Rate for Payer: Healthscope Commercial |
$10.08
|
| Rate for Payer: Healthscope Commercial |
$72.69
|
| Rate for Payer: Healthscope Commercial |
$80.98
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.48
|
| Rate for Payer: PHP Commercial |
$68.65
|
| Rate for Payer: PHP Commercial |
$43.35
|
| Rate for Payer: PHP Commercial |
$15.93
|
| Rate for Payer: PHP Commercial |
$9.52
|
| Rate for Payer: PHP Commercial |
$76.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.15
|
| Rate for Payer: Priority Health SBD |
$56.69
|
| Rate for Payer: Priority Health SBD |
$7.06
|
| Rate for Payer: Priority Health SBD |
$11.81
|
| Rate for Payer: Priority Health SBD |
$50.89
|
| Rate for Payer: Priority Health SBD |
$32.13
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$11.20
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Aetna Commercial |
$9.52
|
| Rate for Payer: Aetna Commercial |
$76.48
|
| Rate for Payer: Aetna Commercial |
$68.65
|
| Rate for Payer: Aetna Commercial |
$15.93
|
| Rate for Payer: Aetna Commercial |
$43.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.15
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$71.98
|
| Rate for Payer: Cash Price |
$64.62
|
| Rate for Payer: Cofinity Commercial |
$9.63
|
| Rate for Payer: Cofinity Commercial |
$69.46
|
| Rate for Payer: Cofinity Commercial |
$56.54
|
| Rate for Payer: Cofinity Commercial |
$43.86
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Commercial |
$35.70
|
| Rate for Payer: Cofinity Commercial |
$7.84
|
| Rate for Payer: Cofinity Commercial |
$77.38
|
| Rate for Payer: Cofinity Commercial |
$62.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.98
|
| Rate for Payer: Healthscope Commercial |
$80.98
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Commercial |
$16.87
|
| Rate for Payer: Healthscope Commercial |
$72.69
|
| Rate for Payer: Healthscope Commercial |
$10.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.48
|
| Rate for Payer: PHP Commercial |
$68.65
|
| Rate for Payer: PHP Commercial |
$76.48
|
| Rate for Payer: PHP Commercial |
$15.93
|
| Rate for Payer: PHP Commercial |
$43.35
|
| Rate for Payer: PHP Commercial |
$9.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.28
|
| Rate for Payer: Priority Health SBD |
$11.81
|
| Rate for Payer: Priority Health SBD |
$7.06
|
| Rate for Payer: Priority Health SBD |
$50.89
|
| Rate for Payer: Priority Health SBD |
$32.13
|
| Rate for Payer: Priority Health SBD |
$56.69
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT
|
Facility
|
OP
|
$882.87
|
|
|
Service Code
|
NDC 00078087601
|
| Hospital Charge Code |
11566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$353.15 |
| Max. Negotiated Rate |
$794.58 |
| Rate for Payer: Aetna Commercial |
$750.44
|
| Rate for Payer: Aetna Medicare |
$441.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$573.87
|
| Rate for Payer: BCBS Complete |
$353.15
|
| Rate for Payer: Cash Price |
$706.30
|
| Rate for Payer: Cofinity Commercial |
$618.01
|
| Rate for Payer: Cofinity Commercial |
$759.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$618.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$706.30
|
| Rate for Payer: Healthscope Commercial |
$794.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$750.44
|
| Rate for Payer: PHP Commercial |
$750.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$573.87
|
| Rate for Payer: Priority Health SBD |
$556.21
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT
|
Facility
|
IP
|
$882.87
|
|
|
Service Code
|
NDC 00078087601
|
| Hospital Charge Code |
11566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$556.21 |
| Max. Negotiated Rate |
$794.58 |
| Rate for Payer: Aetna Commercial |
$750.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$573.87
|
| Rate for Payer: Cash Price |
$706.30
|
| Rate for Payer: Cofinity Commercial |
$618.01
|
| Rate for Payer: Cofinity Commercial |
$759.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$618.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$706.30
|
| Rate for Payer: Healthscope Commercial |
$794.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$750.44
|
| Rate for Payer: PHP Commercial |
$750.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$573.87
|
| Rate for Payer: Priority Health SBD |
$556.21
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$4,143.08
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,610.14 |
| Max. Negotiated Rate |
$3,728.77 |
| Rate for Payer: Aetna Commercial |
$3,521.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,693.00
|
| Rate for Payer: Cash Price |
$3,314.46
|
| Rate for Payer: Cofinity Commercial |
$2,900.16
|
| Rate for Payer: Cofinity Commercial |
$3,563.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,900.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,314.46
|
| Rate for Payer: Healthscope Commercial |
$3,728.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,521.62
|
| Rate for Payer: PHP Commercial |
$3,521.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,693.00
|
| Rate for Payer: Priority Health SBD |
$2,610.14
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$4,143.08
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$3,728.77 |
| Rate for Payer: Aetna Commercial |
$3,521.62
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,693.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.14
|
| Rate for Payer: BCBS Complete |
$3.21
|
| Rate for Payer: BCBS MAPPO |
$5.71
|
| Rate for Payer: BCN Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$3,314.46
|
| Rate for Payer: Cash Price |
$3,314.46
|
| Rate for Payer: Cofinity Commercial |
$3,563.05
|
| Rate for Payer: Cofinity Commercial |
$2,900.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,900.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,314.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$3,728.77
|
| Rate for Payer: Mclaren Medicaid |
$3.06
|
| Rate for Payer: Mclaren Medicare |
$5.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.00
|
| Rate for Payer: Meridian Medicaid |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,521.62
|
| Rate for Payer: PACE Medicare |
$5.42
|
| Rate for Payer: PACE SWMI |
$5.71
|
| Rate for Payer: PHP Commercial |
$3,521.62
|
| Rate for Payer: PHP Medicare Advantage |
$5.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,693.00
|
| Rate for Payer: Priority Health Medicare |
$5.71
|
| Rate for Payer: Priority Health SBD |
$2,610.14
|
| Rate for Payer: Railroad Medicare Medicare |
$5.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.71
|
| Rate for Payer: UHC Medicare Advantage |
$5.71
|
| Rate for Payer: UHCCP Medicaid |
$3.21
|
| Rate for Payer: VA VA |
$5.71
|
|
|
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$6,732.50
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119446
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$6,059.25 |
| Rate for Payer: Aetna Commercial |
$5,722.62
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,376.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.14
|
| Rate for Payer: BCBS Complete |
$3.21
|
| Rate for Payer: BCBS MAPPO |
$5.71
|
| Rate for Payer: BCN Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$5,386.00
|
| Rate for Payer: Cash Price |
$5,386.00
|
| Rate for Payer: Cofinity Commercial |
$5,789.95
|
| Rate for Payer: Cofinity Commercial |
$4,712.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,712.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,386.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$6,059.25
|
| Rate for Payer: Mclaren Medicaid |
$3.06
|
| Rate for Payer: Mclaren Medicare |
$5.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.00
|
| Rate for Payer: Meridian Medicaid |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,722.62
|
| Rate for Payer: PACE Medicare |
$5.42
|
| Rate for Payer: PACE SWMI |
$5.71
|
| Rate for Payer: PHP Commercial |
$5,722.62
|
| Rate for Payer: PHP Medicare Advantage |
$5.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,376.12
|
| Rate for Payer: Priority Health Medicare |
$5.71
|
| Rate for Payer: Priority Health SBD |
$4,241.48
|
| Rate for Payer: Railroad Medicare Medicare |
$5.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.71
|
| Rate for Payer: UHC Medicare Advantage |
$5.71
|
| Rate for Payer: UHCCP Medicaid |
$3.21
|
| Rate for Payer: VA VA |
$5.71
|
|
|
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$6,732.50
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119446
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,241.48 |
| Max. Negotiated Rate |
$6,059.25 |
| Rate for Payer: Aetna Commercial |
$5,722.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,376.12
|
| Rate for Payer: Cash Price |
$5,386.00
|
| Rate for Payer: Cofinity Commercial |
$4,712.75
|
| Rate for Payer: Cofinity Commercial |
$5,789.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,712.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,386.00
|
| Rate for Payer: Healthscope Commercial |
$6,059.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,722.62
|
| Rate for Payer: PHP Commercial |
$5,722.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,376.12
|
| Rate for Payer: Priority Health SBD |
$4,241.48
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,657.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
99452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$1,491.50 |
| Rate for Payer: Aetna Commercial |
$1,408.64
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.14
|
| Rate for Payer: BCBS Complete |
$3.21
|
| Rate for Payer: BCBS MAPPO |
$5.71
|
| Rate for Payer: BCN Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$1,325.78
|
| Rate for Payer: Cash Price |
$1,325.78
|
| Rate for Payer: Cofinity Commercial |
$1,425.21
|
| Rate for Payer: Cofinity Commercial |
$1,160.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,160.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,325.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$1,491.50
|
| Rate for Payer: Mclaren Medicaid |
$3.06
|
| Rate for Payer: Mclaren Medicare |
$5.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.00
|
| Rate for Payer: Meridian Medicaid |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.64
|
| Rate for Payer: PACE Medicare |
$5.42
|
| Rate for Payer: PACE SWMI |
$5.71
|
| Rate for Payer: PHP Commercial |
$1,408.64
|
| Rate for Payer: PHP Medicare Advantage |
$5.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.19
|
| Rate for Payer: Priority Health Medicare |
$5.71
|
| Rate for Payer: Priority Health SBD |
$1,044.05
|
| Rate for Payer: Railroad Medicare Medicare |
$5.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.71
|
| Rate for Payer: UHC Medicare Advantage |
$5.71
|
| Rate for Payer: UHCCP Medicaid |
$3.21
|
| Rate for Payer: VA VA |
$5.71
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,657.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
99452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,044.05 |
| Max. Negotiated Rate |
$1,491.50 |
| Rate for Payer: Aetna Commercial |
$1,408.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.19
|
| Rate for Payer: Cash Price |
$1,325.78
|
| Rate for Payer: Cofinity Commercial |
$1,160.05
|
| Rate for Payer: Cofinity Commercial |
$1,425.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,160.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,325.78
|
| Rate for Payer: Healthscope Commercial |
$1,491.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.64
|
| Rate for Payer: PHP Commercial |
$1,408.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.19
|
| Rate for Payer: Priority Health SBD |
$1,044.05
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$2,064.60
|
|
|
Service Code
|
NDC 49884076854
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,300.70 |
| Max. Negotiated Rate |
$1,858.14 |
| Rate for Payer: Aetna Commercial |
$1,754.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,341.99
|
| Rate for Payer: Cash Price |
$1,651.68
|
| Rate for Payer: Cofinity Commercial |
$1,445.22
|
| Rate for Payer: Cofinity Commercial |
$1,775.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,445.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,651.68
|
| Rate for Payer: Healthscope Commercial |
$1,858.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,754.91
|
| Rate for Payer: PHP Commercial |
$1,754.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,341.99
|
| Rate for Payer: Priority Health SBD |
$1,300.70
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$19,247.29
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12,125.79 |
| Max. Negotiated Rate |
$17,322.56 |
| Rate for Payer: Aetna Commercial |
$16,360.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,510.74
|
| Rate for Payer: Cash Price |
$15,397.83
|
| Rate for Payer: Cofinity Commercial |
$13,473.10
|
| Rate for Payer: Cofinity Commercial |
$16,552.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,473.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,397.83
|
| Rate for Payer: Healthscope Commercial |
$17,322.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,360.20
|
| Rate for Payer: PHP Commercial |
$16,360.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,510.74
|
| Rate for Payer: Priority Health SBD |
$12,125.79
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 49884076852
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.07 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.20
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$144.52
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health SBD |
$130.07
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 49884076852
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.58 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna Medicare |
$103.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.20
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$144.52
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health SBD |
$130.07
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$2,012.99
|
|
|
Service Code
|
NDC 67877063533
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,268.18 |
| Max. Negotiated Rate |
$1,811.69 |
| Rate for Payer: Aetna Commercial |
$1,711.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,308.44
|
| Rate for Payer: Cash Price |
$1,610.39
|
| Rate for Payer: Cofinity Commercial |
$1,409.09
|
| Rate for Payer: Cofinity Commercial |
$1,731.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,409.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,610.39
|
| Rate for Payer: Healthscope Commercial |
$1,811.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,711.04
|
| Rate for Payer: PHP Commercial |
$1,711.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,308.44
|
| Rate for Payer: Priority Health SBD |
$1,268.18
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
OP
|
$19,247.29
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,698.92 |
| Max. Negotiated Rate |
$17,322.56 |
| Rate for Payer: Aetna Commercial |
$16,360.20
|
| Rate for Payer: Aetna Medicare |
$9,623.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,510.74
|
| Rate for Payer: BCBS Complete |
$7,698.92
|
| Rate for Payer: Cash Price |
$15,397.83
|
| Rate for Payer: Cofinity Commercial |
$13,473.10
|
| Rate for Payer: Cofinity Commercial |
$16,552.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,473.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,397.83
|
| Rate for Payer: Healthscope Commercial |
$17,322.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,360.20
|
| Rate for Payer: PHP Commercial |
$16,360.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,510.74
|
| Rate for Payer: Priority Health SBD |
$12,125.79
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
OP
|
$2,012.99
|
|
|
Service Code
|
NDC 67877063533
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$805.20 |
| Max. Negotiated Rate |
$1,811.69 |
| Rate for Payer: Aetna Commercial |
$1,711.04
|
| Rate for Payer: Aetna Medicare |
$1,006.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,308.44
|
| Rate for Payer: BCBS Complete |
$805.20
|
| Rate for Payer: Cash Price |
$1,610.39
|
| Rate for Payer: Cofinity Commercial |
$1,409.09
|
| Rate for Payer: Cofinity Commercial |
$1,731.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,409.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,610.39
|
| Rate for Payer: Healthscope Commercial |
$1,811.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,711.04
|
| Rate for Payer: PHP Commercial |
$1,711.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,308.44
|
| Rate for Payer: Priority Health SBD |
$1,268.18
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
OP
|
$2,064.60
|
|
|
Service Code
|
NDC 49884076854
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$825.84 |
| Max. Negotiated Rate |
$1,858.14 |
| Rate for Payer: Aetna Commercial |
$1,754.91
|
| Rate for Payer: Aetna Medicare |
$1,032.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,341.99
|
| Rate for Payer: BCBS Complete |
$825.84
|
| Rate for Payer: Cash Price |
$1,651.68
|
| Rate for Payer: Cofinity Commercial |
$1,445.22
|
| Rate for Payer: Cofinity Commercial |
$1,775.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,445.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,651.68
|
| Rate for Payer: Healthscope Commercial |
$1,858.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,754.91
|
| Rate for Payer: PHP Commercial |
$1,754.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,341.99
|
| Rate for Payer: Priority Health SBD |
$1,300.70
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
|
OP
|
$8,903.25
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,695.31 |
| Max. Negotiated Rate |
$8,903.25 |
| Rate for Payer: Aetna Medicare |
$3,289.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,953.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,953.62
|
| Rate for Payer: BCBS Complete |
$1,780.08
|
| Rate for Payer: BCBS MAPPO |
$3,162.90
|
| Rate for Payer: BCN Medicare Advantage |
$3,162.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,162.90
|
| Rate for Payer: Mclaren Medicaid |
$1,695.31
|
| Rate for Payer: Mclaren Medicare |
$3,162.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,321.05
|
| Rate for Payer: Meridian Medicaid |
$1,780.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,637.34
|
| Rate for Payer: PACE Medicare |
$3,004.76
|
| Rate for Payer: PACE SWMI |
$3,162.90
|
| Rate for Payer: PHP Medicare Advantage |
$3,162.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.31
|
| Rate for Payer: Priority Health Medicare |
$3,162.90
|
| Rate for Payer: Railroad Medicare Medicare |
$3,162.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,903.25
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,162.90
|
| Rate for Payer: UHC Medicare Advantage |
$3,162.90
|
| Rate for Payer: UHCCP Medicaid |
$1,780.71
|
| Rate for Payer: VA VA |
$3,162.90
|
|
