|
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 40 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.40 |
| Max. Negotiated Rate |
$45.90 |
| 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 |
$68.65
|
| Rate for Payer: Aetna Commercial |
$15.93
|
| Rate for Payer: Aetna Medicare |
$40.38
|
| Rate for Payer: Aetna Medicare |
$25.50
|
| Rate for Payer: Aetna Medicare |
$5.60
|
| Rate for Payer: Aetna Medicare |
$9.37
|
| Rate for Payer: Aetna Medicare |
$44.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.15
|
| Rate for Payer: BCBS Complete |
$4.48
|
| Rate for Payer: BCBS Complete |
$35.99
|
| Rate for Payer: BCBS Complete |
$20.40
|
| Rate for Payer: BCBS Complete |
$32.31
|
| Rate for Payer: BCBS Complete |
$7.50
|
| Rate for Payer: BCBS Trust/PPO |
$6.40
|
| Rate for Payer: BCBS Trust/PPO |
$6.40
|
| Rate for Payer: BCBS Trust/PPO |
$6.40
|
| Rate for Payer: BCBS Trust/PPO |
$6.40
|
| Rate for Payer: BCBS Trust/PPO |
$6.40
|
| Rate for Payer: BCN Commercial |
$6.40
|
| Rate for Payer: BCN Commercial |
$6.40
|
| Rate for Payer: BCN Commercial |
$6.40
|
| Rate for Payer: BCN Commercial |
$6.40
|
| Rate for Payer: BCN Commercial |
$6.40
|
| Rate for Payer: Cash Price |
$64.62
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$71.98
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cash Price |
$71.98
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$64.62
|
| Rate for Payer: Cofinity Commercial |
$77.38
|
| Rate for Payer: Cofinity Commercial |
$62.99
|
| 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 |
$69.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$7.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.62
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Commercial |
$80.98
|
| 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 |
$43.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.65
|
| Rate for Payer: PHP Commercial |
$76.48
|
| Rate for Payer: PHP Commercial |
$9.52
|
| Rate for Payer: PHP Commercial |
$43.35
|
| Rate for Payer: PHP Commercial |
$15.93
|
| Rate for Payer: PHP Commercial |
$68.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.50
|
| 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 |
$32.13
|
| Rate for Payer: Priority Health SBD |
$7.06
|
| Rate for Payer: Priority Health SBD |
$56.69
|
| Rate for Payer: Priority Health SBD |
$50.89
|
|
|
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
|
OP
|
$4,143.08
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$3,728.77 |
| Rate for Payer: Aetna Commercial |
$3,521.62
|
| Rate for Payer: Aetna Medicare |
$6.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,693.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.46
|
| Rate for Payer: BCBS Complete |
$3.36
|
| Rate for Payer: BCBS MAPPO |
$5.97
|
| Rate for Payer: BCBS Trust/PPO |
$18.05
|
| Rate for Payer: BCN Commercial |
$18.05
|
| Rate for Payer: BCN Medicare Advantage |
$5.97
|
| 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 |
$5.97
|
| Rate for Payer: Healthscope Commercial |
$3,728.77
|
| Rate for Payer: Mclaren Medicaid |
$3.20
|
| Rate for Payer: Mclaren Medicare |
$5.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.27
|
| Rate for Payer: Meridian Medicaid |
$3.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,521.62
|
| Rate for Payer: Nomi Health Commercial |
$17.91
|
| Rate for Payer: PACE Medicare |
$5.67
|
| Rate for Payer: PACE SWMI |
$5.97
|
| Rate for Payer: PHP Commercial |
$3,521.62
|
| Rate for Payer: PHP Medicare Advantage |
$5.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,693.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.17
|
| Rate for Payer: Priority Health Medicare |
$5.97
|
| Rate for Payer: Priority Health Narrow Network |
$13.74
|
| Rate for Payer: Priority Health SBD |
$2,610.14
|
| Rate for Payer: Railroad Medicare Medicare |
$5.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.97
|
| Rate for Payer: UHC Medicare Advantage |
$5.97
|
| Rate for Payer: UHCCP Medicaid |
$3.36
|
| Rate for Payer: VA VA |
$5.97
|
|
|
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 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 |
$3.20 |
| Max. Negotiated Rate |
$6,059.25 |
| Rate for Payer: Aetna Commercial |
$5,722.62
|
| Rate for Payer: Aetna Medicare |
$6.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,376.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.46
|
| Rate for Payer: BCBS Complete |
$3.36
|
| Rate for Payer: BCBS MAPPO |
$5.97
|
| Rate for Payer: BCBS Trust/PPO |
$18.05
|
| Rate for Payer: BCN Commercial |
$18.05
|
| Rate for Payer: BCN Medicare Advantage |
$5.97
|
| 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 |
$5.97
|
| Rate for Payer: Healthscope Commercial |
$6,059.25
|
| Rate for Payer: Mclaren Medicaid |
$3.20
|
| Rate for Payer: Mclaren Medicare |
$5.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.27
|
| Rate for Payer: Meridian Medicaid |
$3.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,722.62
|
| Rate for Payer: Nomi Health Commercial |
$17.91
|
| Rate for Payer: PACE Medicare |
$5.67
|
| Rate for Payer: PACE SWMI |
$5.97
|
| Rate for Payer: PHP Commercial |
$5,722.62
|
| Rate for Payer: PHP Medicare Advantage |
$5.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,376.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.17
|
| Rate for Payer: Priority Health Medicare |
$5.97
|
| Rate for Payer: Priority Health Narrow Network |
$13.74
|
| Rate for Payer: Priority Health SBD |
$4,241.48
|
| Rate for Payer: Railroad Medicare Medicare |
$5.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.97
|
| Rate for Payer: UHC Medicare Advantage |
$5.97
|
| Rate for Payer: UHCCP Medicaid |
$3.36
|
| Rate for Payer: VA VA |
$5.97
|
|
|
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 |
$3.20 |
| Max. Negotiated Rate |
$1,491.50 |
| Rate for Payer: Aetna Commercial |
$1,408.64
|
| Rate for Payer: Aetna Medicare |
$6.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.46
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.46
|
| Rate for Payer: BCBS Complete |
$3.36
|
| Rate for Payer: BCBS MAPPO |
$5.97
|
| Rate for Payer: BCBS Trust/PPO |
$18.05
|
| Rate for Payer: BCN Commercial |
$18.05
|
| Rate for Payer: BCN Medicare Advantage |
$5.97
|
| 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 |
$5.97
|
| Rate for Payer: Healthscope Commercial |
$1,491.50
|
| Rate for Payer: Mclaren Medicaid |
$3.20
|
| Rate for Payer: Mclaren Medicare |
$5.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.27
|
| Rate for Payer: Meridian Medicaid |
$3.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.64
|
| Rate for Payer: Nomi Health Commercial |
$17.91
|
| Rate for Payer: PACE Medicare |
$5.67
|
| Rate for Payer: PACE SWMI |
$5.97
|
| Rate for Payer: PHP Commercial |
$1,408.64
|
| Rate for Payer: PHP Medicare Advantage |
$5.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.17
|
| Rate for Payer: Priority Health Medicare |
$5.97
|
| Rate for Payer: Priority Health Narrow Network |
$13.74
|
| Rate for Payer: Priority Health SBD |
$1,044.05
|
| Rate for Payer: Railroad Medicare Medicare |
$5.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.80
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.97
|
| Rate for Payer: UHC Medicare Advantage |
$5.97
|
| Rate for Payer: UHCCP Medicaid |
$3.36
|
| Rate for Payer: VA VA |
$5.97
|
|
|
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
|
$2,012.99
|
|
|
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
|
$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
|
$2,064.60
|
|
|
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
|
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 |
$9,623.64
|
| 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
|
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 |
$177.56
|
| Rate for Payer: Cofinity Commercial |
$144.52
|
| 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
|
$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
|
|
|
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
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
|
OP
|
$9,986.81
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$323.11 |
| Max. Negotiated Rate |
$9,986.81 |
| Rate for Payer: Aetna Medicare |
$3,304.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,971.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,971.88
|
| Rate for Payer: BCBS Complete |
$1,788.30
|
| Rate for Payer: BCBS MAPPO |
$3,177.50
|
| Rate for Payer: BCBS Trust/PPO |
$1,085.79
|
| Rate for Payer: BCN Commercial |
$1,085.79
|
| Rate for Payer: BCN Medicare Advantage |
$3,177.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,177.50
|
| Rate for Payer: Mclaren Medicaid |
$1,703.14
|
| Rate for Payer: Mclaren Medicare |
$3,177.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,336.38
|
| Rate for Payer: Meridian Medicaid |
$1,788.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,654.12
|
| Rate for Payer: Nomi Health Commercial |
$6,672.75
|
| Rate for Payer: PACE Medicare |
$3,018.62
|
| Rate for Payer: PACE SWMI |
$3,177.50
|
| Rate for Payer: PHP Medicare Advantage |
$3,177.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,986.81
|
| Rate for Payer: Priority Health Medicare |
$3,177.50
|
| Rate for Payer: Priority Health Narrow Network |
$7,989.45
|
| Rate for Payer: Railroad Medicare Medicare |
$3,177.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$323.11
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,177.50
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,177.50
|
| Rate for Payer: UHCCP Medicaid |
$1,788.93
|
| Rate for Payer: VA VA |
$3,177.50
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$309.68 |
| Max. Negotiated Rate |
$18,216.88 |
| Rate for Payer: Aetna Medicare |
$6,027.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,245.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,245.06
|
| Rate for Payer: BCBS Complete |
$3,262.02
|
| Rate for Payer: BCBS MAPPO |
$5,796.05
|
| Rate for Payer: BCBS Trust/PPO |
$1,610.44
|
| Rate for Payer: BCN Commercial |
$1,610.44
|
| Rate for Payer: BCN Medicare Advantage |
$5,796.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,796.05
|
| Rate for Payer: Mclaren Medicaid |
$3,106.68
|
| Rate for Payer: Mclaren Medicare |
$5,796.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,085.85
|
| Rate for Payer: Meridian Medicaid |
$3,262.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,665.46
|
| Rate for Payer: Nomi Health Commercial |
$12,171.70
|
| Rate for Payer: PACE Medicare |
$5,506.25
|
| Rate for Payer: PACE SWMI |
$5,796.05
|
| Rate for Payer: PHP Medicare Advantage |
$5,796.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,106.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,216.88
|
| Rate for Payer: Priority Health Medicare |
$5,796.05
|
| Rate for Payer: Priority Health Narrow Network |
$14,573.50
|
| Rate for Payer: Railroad Medicare Medicare |
$5,796.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$309.68
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,796.05
|
| Rate for Payer: UHCCP Medicaid |
$3,263.18
|
| Rate for Payer: VA VA |
$5,796.05
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
|
OP
|
$9,986.81
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$271.06 |
| Max. Negotiated Rate |
$9,986.81 |
| Rate for Payer: Aetna Medicare |
$3,304.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,971.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,971.88
|
| Rate for Payer: BCBS Complete |
$1,788.30
|
| Rate for Payer: BCBS MAPPO |
$3,177.50
|
| Rate for Payer: BCBS Trust/PPO |
$1,579.03
|
| Rate for Payer: BCN Commercial |
$1,579.03
|
| Rate for Payer: BCN Medicare Advantage |
$3,177.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,177.50
|
| Rate for Payer: Mclaren Medicaid |
$1,703.14
|
| Rate for Payer: Mclaren Medicare |
$3,177.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,336.38
|
| Rate for Payer: Meridian Medicaid |
$1,788.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,654.12
|
| Rate for Payer: Nomi Health Commercial |
$6,672.75
|
| Rate for Payer: PACE Medicare |
$3,018.62
|
| Rate for Payer: PACE SWMI |
$3,177.50
|
| Rate for Payer: PHP Medicare Advantage |
$3,177.50
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,703.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,986.81
|
| Rate for Payer: Priority Health Medicare |
$3,177.50
|
| Rate for Payer: Priority Health Narrow Network |
$7,989.45
|
| Rate for Payer: Railroad Medicare Medicare |
$3,177.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$271.06
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,177.50
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$3,177.50
|
| Rate for Payer: UHCCP Medicaid |
$1,788.93
|
| Rate for Payer: VA VA |
$3,177.50
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$284.05 |
| Max. Negotiated Rate |
$18,216.88 |
| Rate for Payer: Aetna Medicare |
$6,027.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,245.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,245.06
|
| Rate for Payer: BCBS Complete |
$3,262.02
|
| Rate for Payer: BCBS MAPPO |
$5,796.05
|
| Rate for Payer: BCBS Trust/PPO |
$1,675.63
|
| Rate for Payer: BCN Commercial |
$1,675.63
|
| Rate for Payer: BCN Medicare Advantage |
$5,796.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,796.05
|
| Rate for Payer: Mclaren Medicaid |
$3,106.68
|
| Rate for Payer: Mclaren Medicare |
$5,796.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,085.85
|
| Rate for Payer: Meridian Medicaid |
$3,262.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,665.46
|
| Rate for Payer: Nomi Health Commercial |
$12,171.70
|
| Rate for Payer: PACE Medicare |
$5,506.25
|
| Rate for Payer: PACE SWMI |
$5,796.05
|
| Rate for Payer: PHP Medicare Advantage |
$5,796.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,106.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,216.88
|
| Rate for Payer: Priority Health Medicare |
$5,796.05
|
| Rate for Payer: Priority Health Narrow Network |
$14,573.50
|
| Rate for Payer: Railroad Medicare Medicare |
$5,796.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$284.05
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,796.05
|
| Rate for Payer: UHCCP Medicaid |
$3,263.18
|
| Rate for Payer: VA VA |
$5,796.05
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$382.85
|
|
|
Service Code
|
NDC 68084034401
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.20 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
OP
|
$382.85
|
|
|
Service Code
|
NDC 68084034401
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.14 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna Medicare |
$191.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: BCBS Complete |
$153.14
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
|
