|
TICAGRELOR 90 MG TABLET
|
Facility
IP
|
$1,544.90
|
|
|
Service Code
|
NDC 0186-0777-60
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$973.29 |
| Max. Negotiated Rate |
$1,390.41 |
| Rate for Payer: Aetna Commercial |
$1,313.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,004.18
|
| Rate for Payer: Cash Price |
$1,235.92
|
| Rate for Payer: Cofinity Commercial |
$1,081.43
|
| Rate for Payer: Cofinity Commercial |
$1,328.61
|
| Rate for Payer: Healthscope Commercial |
$1,390.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,313.16
|
| Rate for Payer: PHP Commercial |
$1,313.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,081.43
|
| Rate for Payer: Priority Health SBD |
$973.29
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$117.91
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
41652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.28 |
| Max. Negotiated Rate |
$106.12 |
| Rate for Payer: Aetna Commercial |
$100.22
|
| Rate for Payer: Aetna Commercial |
$93.42
|
| Rate for Payer: Aetna Commercial |
$196.44
|
| Rate for Payer: Aetna Commercial |
$69.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.44
|
| Rate for Payer: Cash Price |
$94.33
|
| Rate for Payer: Cash Price |
$184.89
|
| Rate for Payer: Cash Price |
$65.70
|
| Rate for Payer: Cash Price |
$87.93
|
| Rate for Payer: Cofinity Commercial |
$70.63
|
| Rate for Payer: Cofinity Commercial |
$76.94
|
| Rate for Payer: Cofinity Commercial |
$94.52
|
| Rate for Payer: Cofinity Commercial |
$101.40
|
| Rate for Payer: Cofinity Commercial |
$82.54
|
| Rate for Payer: Cofinity Commercial |
$161.78
|
| Rate for Payer: Cofinity Commercial |
$198.75
|
| Rate for Payer: Cofinity Commercial |
$57.49
|
| Rate for Payer: Healthscope Commercial |
$208.00
|
| Rate for Payer: Healthscope Commercial |
$106.12
|
| Rate for Payer: Healthscope Commercial |
$73.92
|
| Rate for Payer: Healthscope Commercial |
$98.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$100.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$196.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.81
|
| Rate for Payer: PHP Commercial |
$196.44
|
| Rate for Payer: PHP Commercial |
$100.22
|
| Rate for Payer: PHP Commercial |
$69.81
|
| Rate for Payer: PHP Commercial |
$93.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$82.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.49
|
| Rate for Payer: Priority Health SBD |
$74.28
|
| Rate for Payer: Priority Health SBD |
$145.60
|
| Rate for Payer: Priority Health SBD |
$51.74
|
| Rate for Payer: Priority Health SBD |
$69.24
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
IP
|
$19.13
|
|
|
Service Code
|
NDC 61314-226-10
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.43
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cofinity Commercial |
$13.39
|
| Rate for Payer: Cofinity Commercial |
$16.45
|
| Rate for Payer: Healthscope Commercial |
$17.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.26
|
| Rate for Payer: PHP Commercial |
$16.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.39
|
| Rate for Payer: Priority Health SBD |
$12.05
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
IP
|
$9.90
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$8.91 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.44
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cofinity Commercial |
$6.93
|
| Rate for Payer: Cofinity Commercial |
$8.51
|
| Rate for Payer: Healthscope Commercial |
$8.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.42
|
| Rate for Payer: PHP Commercial |
$8.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.93
|
| Rate for Payer: Priority Health SBD |
$6.24
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
IP
|
$28.25
|
|
|
Service Code
|
NDC 17478-288-10
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.80 |
| Max. Negotiated Rate |
$25.42 |
| Rate for Payer: Aetna Commercial |
$24.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.36
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$19.78
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Healthscope Commercial |
$25.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.01
|
| Rate for Payer: PHP Commercial |
$24.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.78
|
| Rate for Payer: Priority Health SBD |
$17.80
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
IP
|
$31.57
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.89 |
| Max. Negotiated Rate |
$28.41 |
| Rate for Payer: Aetna Commercial |
$26.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.52
|
| Rate for Payer: Cash Price |
$25.26
|
| Rate for Payer: Cofinity Commercial |
$22.10
|
| Rate for Payer: Cofinity Commercial |
$27.15
|
| Rate for Payer: Healthscope Commercial |
$28.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.83
|
| Rate for Payer: PHP Commercial |
$26.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.10
|
| Rate for Payer: Priority Health SBD |
$19.89
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
IP
|
$688.84
|
|
|
Service Code
|
NDC 24208-813-05
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$433.97 |
| Max. Negotiated Rate |
$619.96 |
| Rate for Payer: Aetna Commercial |
$585.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$447.75
|
| Rate for Payer: Cash Price |
$551.07
|
| Rate for Payer: Cofinity Commercial |
$482.19
|
| Rate for Payer: Cofinity Commercial |
$592.40
|
| Rate for Payer: Healthscope Commercial |
$619.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$585.51
|
| Rate for Payer: PHP Commercial |
$585.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$482.19
|
| Rate for Payer: Priority Health SBD |
$433.97
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
IP
|
$19.71
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.42 |
| Max. Negotiated Rate |
$17.74 |
| Rate for Payer: Aetna Commercial |
$16.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.81
|
| Rate for Payer: Cash Price |
$15.77
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Commercial |
$16.95
|
| Rate for Payer: Healthscope Commercial |
$17.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.75
|
| Rate for Payer: PHP Commercial |
$16.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.80
|
| Rate for Payer: Priority Health SBD |
$12.42
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
IP
|
$22.91
|
|
|
Service Code
|
NDC 60758-801-05
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.43 |
| Max. Negotiated Rate |
$20.62 |
| Rate for Payer: Aetna Commercial |
$19.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.89
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Cofinity Commercial |
$16.04
|
| Rate for Payer: Cofinity Commercial |
$19.70
|
| Rate for Payer: Healthscope Commercial |
$20.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.47
|
| Rate for Payer: PHP Commercial |
$19.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.04
|
| Rate for Payer: Priority Health SBD |
$14.43
|
|
|
TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
|
Facility
OP
|
$46,455.16
|
|
|
Service Code
|
CPT 19357
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,143.10 |
| Max. Negotiated Rate |
$46,455.16 |
| Rate for Payer: Aetna Medicare |
$16,307.04
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19,599.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19,599.81
|
| Rate for Payer: BCBS Complete |
$9,006.51
|
| Rate for Payer: BCBS MAPPO |
$15,679.85
|
| Rate for Payer: BCBS Trust/PPO |
$5,279.68
|
| Rate for Payer: BCN Medicare Advantage |
$15,679.85
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15,679.85
|
| Rate for Payer: Mclaren Medicaid |
$8,576.88
|
| Rate for Payer: Mclaren Medicare |
$15,679.85
|
| Rate for Payer: Meridian Medicaid |
$9,006.51
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$16,463.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18,031.83
|
| Rate for Payer: PACE Medicare |
$14,895.86
|
| Rate for Payer: PACE SWMI |
$15,679.85
|
| Rate for Payer: PHP Medicare Advantage |
$15,679.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,576.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$46,455.16
|
| Rate for Payer: Priority Health Medicare |
$15,679.85
|
| Rate for Payer: Priority Health Narrow Network |
$37,164.13
|
| Rate for Payer: Railroad Medicare Medicare |
$15,679.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,257.41
|
| Rate for Payer: UHC Core |
$7,632.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$15,679.85
|
| Rate for Payer: UHC Exchange |
$1,143.10
|
| Rate for Payer: UHC Medicare Advantage |
$16,150.25
|
| Rate for Payer: VA VA |
$15,679.85
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
IP
|
$137.48
|
|
|
Service Code
|
NDC 57664-502-89
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.61 |
| Max. Negotiated Rate |
$123.73 |
| Rate for Payer: Aetna Commercial |
$116.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.36
|
| Rate for Payer: Cash Price |
$109.98
|
| Rate for Payer: Cofinity Commercial |
$118.23
|
| Rate for Payer: Cofinity Commercial |
$96.24
|
| Rate for Payer: Healthscope Commercial |
$123.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$116.86
|
| Rate for Payer: PHP Commercial |
$116.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.24
|
| Rate for Payer: Priority Health SBD |
$86.61
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
IP
|
$2.89
|
|
|
Service Code
|
NDC 50268-759-11
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.88
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cofinity Commercial |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$2.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.46
|
| Rate for Payer: PHP Commercial |
$2.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.02
|
| Rate for Payer: Priority Health SBD |
$1.82
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084-775-95
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$2.70 |
| Rate for Payer: Aetna Commercial |
$2.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.95
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cofinity Commercial |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$2.58
|
| Rate for Payer: Healthscope Commercial |
$2.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.55
|
| Rate for Payer: PHP Commercial |
$2.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.10
|
| Rate for Payer: Priority Health SBD |
$1.89
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
IP
|
$89.86
|
|
|
Service Code
|
NDC 68084-775-25
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.61 |
| Max. Negotiated Rate |
$80.87 |
| Rate for Payer: Aetna Commercial |
$76.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.41
|
| Rate for Payer: Cash Price |
$71.89
|
| Rate for Payer: Cofinity Commercial |
$62.90
|
| Rate for Payer: Cofinity Commercial |
$77.28
|
| Rate for Payer: Healthscope Commercial |
$80.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$76.38
|
| Rate for Payer: PHP Commercial |
$76.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.90
|
| Rate for Payer: Priority Health SBD |
$56.61
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
IP
|
$144.24
|
|
|
Service Code
|
NDC 50268-759-15
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.87 |
| Max. Negotiated Rate |
$129.82 |
| Rate for Payer: Aetna Commercial |
$122.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.76
|
| Rate for Payer: Cash Price |
$115.39
|
| Rate for Payer: Cofinity Commercial |
$100.97
|
| Rate for Payer: Cofinity Commercial |
$124.05
|
| Rate for Payer: Healthscope Commercial |
$129.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$122.60
|
| Rate for Payer: PHP Commercial |
$122.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.97
|
| Rate for Payer: Priority Health SBD |
$90.87
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
IP
|
$389.50
|
|
|
Service Code
|
NDC 0904-6418-61
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.38 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna Commercial |
$331.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.18
|
| Rate for Payer: Cash Price |
$311.60
|
| Rate for Payer: Cofinity Commercial |
$272.65
|
| Rate for Payer: Cofinity Commercial |
$334.97
|
| Rate for Payer: Healthscope Commercial |
$350.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$331.08
|
| Rate for Payer: PHP Commercial |
$331.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$272.65
|
| Rate for Payer: Priority Health SBD |
$245.38
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
IP
|
$297.40
|
|
|
Service Code
|
NDC 0078-0953-40
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.36 |
| Max. Negotiated Rate |
$267.66 |
| Rate for Payer: Aetna Commercial |
$252.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$193.31
|
| Rate for Payer: Cash Price |
$237.92
|
| Rate for Payer: Cofinity Commercial |
$208.18
|
| Rate for Payer: Cofinity Commercial |
$255.76
|
| Rate for Payer: Healthscope Commercial |
$267.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$252.79
|
| Rate for Payer: PHP Commercial |
$252.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$208.18
|
| Rate for Payer: Priority Health SBD |
$187.36
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
IP
|
$164.61
|
|
|
Service Code
|
NDC 24208-295-25
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.70 |
| Max. Negotiated Rate |
$148.15 |
| Rate for Payer: Aetna Commercial |
$139.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.00
|
| Rate for Payer: Cash Price |
$131.69
|
| Rate for Payer: Cofinity Commercial |
$115.23
|
| Rate for Payer: Cofinity Commercial |
$141.56
|
| Rate for Payer: Healthscope Commercial |
$148.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.92
|
| Rate for Payer: PHP Commercial |
$139.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.23
|
| Rate for Payer: Priority Health SBD |
$103.70
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
IP
|
$270.80
|
|
|
Service Code
|
NDC 0065-0647-25
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.60 |
| Max. Negotiated Rate |
$243.72 |
| Rate for Payer: Aetna Commercial |
$230.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.02
|
| Rate for Payer: Cash Price |
$216.64
|
| Rate for Payer: Cofinity Commercial |
$189.56
|
| Rate for Payer: Cofinity Commercial |
$232.89
|
| Rate for Payer: Healthscope Commercial |
$243.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$230.18
|
| Rate for Payer: PHP Commercial |
$230.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.56
|
| Rate for Payer: Priority Health SBD |
$170.60
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
IP
|
$331.63
|
|
|
Service Code
|
NDC 0065-0643-05
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.93 |
| Max. Negotiated Rate |
$298.47 |
| Rate for Payer: Aetna Commercial |
$281.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.56
|
| Rate for Payer: Cash Price |
$265.30
|
| Rate for Payer: Cofinity Commercial |
$232.14
|
| Rate for Payer: Cofinity Commercial |
$285.20
|
| Rate for Payer: Healthscope Commercial |
$298.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$281.89
|
| Rate for Payer: PHP Commercial |
$281.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.14
|
| Rate for Payer: Priority Health SBD |
$208.93
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
IP
|
$24.19
|
|
|
Service Code
|
NDC 62332-518-05
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.24 |
| Max. Negotiated Rate |
$21.77 |
| Rate for Payer: Aetna Commercial |
$20.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.72
|
| Rate for Payer: Cash Price |
$19.35
|
| Rate for Payer: Cofinity Commercial |
$16.93
|
| Rate for Payer: Cofinity Commercial |
$20.80
|
| Rate for Payer: Healthscope Commercial |
$21.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.56
|
| Rate for Payer: PHP Commercial |
$20.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.93
|
| Rate for Payer: Priority Health SBD |
$15.24
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
IP
|
$20.07
|
|
|
Service Code
|
NDC 70069-131-01
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$18.06 |
| Rate for Payer: Aetna Commercial |
$17.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.05
|
| Rate for Payer: Cash Price |
$16.06
|
| Rate for Payer: Cofinity Commercial |
$14.05
|
| Rate for Payer: Cofinity Commercial |
$17.26
|
| Rate for Payer: Healthscope Commercial |
$18.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.06
|
| Rate for Payer: PHP Commercial |
$17.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.05
|
| Rate for Payer: Priority Health SBD |
$12.64
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
IP
|
$37.84
|
|
|
Service Code
|
NDC 17478-290-10
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.84 |
| Max. Negotiated Rate |
$34.06 |
| Rate for Payer: Aetna Commercial |
$32.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.60
|
| Rate for Payer: Cash Price |
$30.27
|
| Rate for Payer: Cofinity Commercial |
$26.49
|
| Rate for Payer: Cofinity Commercial |
$32.54
|
| Rate for Payer: Healthscope Commercial |
$34.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.16
|
| Rate for Payer: PHP Commercial |
$32.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.49
|
| Rate for Payer: Priority Health SBD |
$23.84
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
IP
|
$51.56
|
|
|
Service Code
|
NDC 61314-643-05
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.48 |
| Max. Negotiated Rate |
$46.40 |
| Rate for Payer: Aetna Commercial |
$43.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.51
|
| Rate for Payer: Cash Price |
$41.25
|
| Rate for Payer: Cofinity Commercial |
$36.09
|
| Rate for Payer: Cofinity Commercial |
$44.34
|
| Rate for Payer: Healthscope Commercial |
$46.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.83
|
| Rate for Payer: PHP Commercial |
$43.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.09
|
| Rate for Payer: Priority Health SBD |
$32.48
|
|
|
TOBRAMYCIN 0.3 % EYE OINTMENT
|
Facility
IP
|
$805.15
|
|
|
Service Code
|
NDC 0078-0813-01
|
| Hospital Charge Code |
19769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$507.24 |
| Max. Negotiated Rate |
$724.64 |
| Rate for Payer: Aetna Commercial |
$684.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$523.35
|
| Rate for Payer: Cash Price |
$644.12
|
| Rate for Payer: Cofinity Commercial |
$692.43
|
| Rate for Payer: Cofinity Commercial |
$563.60
|
| Rate for Payer: Healthscope Commercial |
$724.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$684.38
|
| Rate for Payer: PHP Commercial |
$684.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$563.60
|
| Rate for Payer: Priority Health SBD |
$507.24
|
|
