|
TOBRAMYCIN 0.3 % EYE OINTMENT
|
Facility
IP
|
$696.47
|
|
|
Service Code
|
NDC 0065-0644-35
|
| Hospital Charge Code |
19769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$438.78 |
| Max. Negotiated Rate |
$626.82 |
| Rate for Payer: Aetna Commercial |
$592.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$452.71
|
| Rate for Payer: Cash Price |
$557.18
|
| Rate for Payer: Cofinity Commercial |
$487.53
|
| Rate for Payer: Cofinity Commercial |
$598.96
|
| Rate for Payer: Healthscope Commercial |
$626.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$592.00
|
| Rate for Payer: PHP Commercial |
$592.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$487.53
|
| 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 New Business (MI Preferred) |
$120.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.18
|
| Rate for Payer: Cash Price |
$148.31
|
| Rate for Payer: Cash Price |
$147.91
|
| 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: Healthscope Commercial |
$166.40
|
| Rate for Payer: Healthscope Commercial |
$166.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$157.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$157.58
|
| Rate for Payer: PHP Commercial |
$157.16
|
| Rate for Payer: PHP Commercial |
$157.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.42
|
| 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: Healthscope Commercial |
$45.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.06
|
| Rate for Payer: PHP Commercial |
$43.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.46
|
| Rate for Payer: Priority Health SBD |
$31.92
|
|
|
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 |
$15.93
|
| Rate for Payer: Aetna Commercial |
$76.48
|
| Rate for Payer: Aetna Commercial |
$43.35
|
| 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) |
$33.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.49
|
| Rate for Payer: Cash Price |
$71.98
|
| Rate for Payer: Cash Price |
$8.96
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Commercial |
$77.38
|
| Rate for Payer: Cofinity Commercial |
$43.86
|
| Rate for Payer: Cofinity Commercial |
$7.84
|
| Rate for Payer: Cofinity Commercial |
$62.99
|
| Rate for Payer: Cofinity Commercial |
$35.70
|
| Rate for Payer: Cofinity Commercial |
$9.63
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Healthscope Commercial |
$80.98
|
| Rate for Payer: Healthscope Commercial |
$16.87
|
| Rate for Payer: Healthscope Commercial |
$10.08
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$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 |
$76.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.84
|
| Rate for Payer: Priority Health SBD |
$32.13
|
| Rate for Payer: Priority Health SBD |
$7.06
|
| Rate for Payer: Priority Health SBD |
$11.81
|
| Rate for Payer: Priority Health SBD |
$56.69
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT
|
Facility
IP
|
$857.19
|
|
|
Service Code
|
NDC 0078-0876-01
|
| Hospital Charge Code |
11566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$540.03 |
| Max. Negotiated Rate |
$771.47 |
| Rate for Payer: Aetna Commercial |
$728.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$557.17
|
| Rate for Payer: Cash Price |
$685.75
|
| Rate for Payer: Cofinity Commercial |
$600.03
|
| Rate for Payer: Cofinity Commercial |
$737.18
|
| Rate for Payer: Healthscope Commercial |
$771.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$728.61
|
| Rate for Payer: PHP Commercial |
$728.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$600.03
|
| Rate for Payer: Priority Health SBD |
$540.03
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT
|
Facility
IP
|
$736.40
|
|
|
Service Code
|
NDC 0065-0648-35
|
| Hospital Charge Code |
11566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$463.93 |
| Max. Negotiated Rate |
$662.76 |
| Rate for Payer: Aetna Commercial |
$625.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$478.66
|
| Rate for Payer: Cash Price |
$589.12
|
| Rate for Payer: Cofinity Commercial |
$633.30
|
| Rate for Payer: Cofinity Commercial |
$515.48
|
| Rate for Payer: Healthscope Commercial |
$662.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$625.94
|
| Rate for Payer: PHP Commercial |
$625.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$515.48
|
| Rate for Payer: Priority Health SBD |
$463.93
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$3,597.06
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,266.15 |
| Max. Negotiated Rate |
$3,237.35 |
| Rate for Payer: Aetna Commercial |
$3,057.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,338.09
|
| Rate for Payer: Cash Price |
$2,877.65
|
| Rate for Payer: Cofinity Commercial |
$2,517.94
|
| Rate for Payer: Cofinity Commercial |
$3,093.47
|
| Rate for Payer: Healthscope Commercial |
$3,237.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,057.50
|
| Rate for Payer: PHP Commercial |
$3,057.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,517.94
|
| Rate for Payer: Priority Health SBD |
$2,266.15
|
|
|
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$5,845.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119446
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,682.49 |
| Max. Negotiated Rate |
$5,260.70 |
| Rate for Payer: Aetna Commercial |
$4,968.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,799.39
|
| Rate for Payer: Cash Price |
$4,676.18
|
| Rate for Payer: Cofinity Commercial |
$4,091.65
|
| Rate for Payer: Cofinity Commercial |
$5,026.89
|
| Rate for Payer: Healthscope Commercial |
$5,260.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,968.44
|
| Rate for Payer: PHP Commercial |
$4,968.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,091.65
|
| Rate for Payer: Priority Health SBD |
$3,682.49
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$1,532.36
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
99452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$965.39 |
| Max. Negotiated Rate |
$1,379.12 |
| Rate for Payer: Aetna Commercial |
$1,302.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$996.03
|
| Rate for Payer: Cash Price |
$1,225.89
|
| Rate for Payer: Cofinity Commercial |
$1,317.83
|
| Rate for Payer: Cofinity Commercial |
$1,072.65
|
| Rate for Payer: Healthscope Commercial |
$1,379.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,302.51
|
| Rate for Payer: PHP Commercial |
$1,302.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,072.65
|
| Rate for Payer: Priority Health SBD |
$965.39
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
IP
|
$2,064.60
|
|
|
Service Code
|
NDC 49884-768-54
|
| 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: Healthscope Commercial |
$1,858.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,754.91
|
| Rate for Payer: PHP Commercial |
$1,754.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,445.22
|
| Rate for Payer: Priority Health SBD |
$1,300.70
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
IP
|
$19,151.06
|
|
|
Service Code
|
NDC 59148-020-50
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12,065.17 |
| Max. Negotiated Rate |
$17,235.95 |
| Rate for Payer: Aetna Commercial |
$16,278.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,448.19
|
| Rate for Payer: Cash Price |
$15,320.85
|
| Rate for Payer: Cofinity Commercial |
$13,405.74
|
| Rate for Payer: Cofinity Commercial |
$16,469.91
|
| Rate for Payer: Healthscope Commercial |
$17,235.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16,278.40
|
| Rate for Payer: PHP Commercial |
$16,278.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13,405.74
|
| Rate for Payer: Priority Health SBD |
$12,065.17
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
IP
|
$206.46
|
|
|
Service Code
|
NDC 49884-768-52
|
| 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: Healthscope Commercial |
$185.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.49
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.52
|
| Rate for Payer: Priority Health SBD |
$130.07
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$302.56 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,979.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,580.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,580.99
|
| Rate for Payer: BCBS Complete |
$1,645.54
|
| Rate for Payer: BCBS MAPPO |
$2,864.79
|
| Rate for Payer: BCBS Trust/PPO |
$1,054.41
|
| Rate for Payer: BCN Medicare Advantage |
$2,864.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,864.79
|
| Rate for Payer: Mclaren Medicaid |
$1,567.04
|
| Rate for Payer: Mclaren Medicare |
$2,864.79
|
| Rate for Payer: Meridian Medicaid |
$1,645.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,008.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,294.51
|
| Rate for Payer: PACE Medicare |
$2,721.55
|
| Rate for Payer: PACE SWMI |
$2,864.79
|
| Rate for Payer: PHP Medicare Advantage |
$2,864.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,567.04
|
| Rate for Payer: Priority Health Medicare |
$2,864.79
|
| Rate for Payer: Railroad Medicare Medicare |
$2,864.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$332.82
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,864.79
|
| Rate for Payer: UHC Exchange |
$302.56
|
| Rate for Payer: UHC Medicare Advantage |
$2,950.73
|
| Rate for Payer: VA VA |
$2,864.79
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
OP
|
$15,835.74
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$289.79 |
| Max. Negotiated Rate |
$15,835.74 |
| Rate for Payer: Aetna Medicare |
$5,419.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,513.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,513.48
|
| Rate for Payer: BCBS Complete |
$2,993.07
|
| Rate for Payer: BCBS MAPPO |
$5,210.78
|
| Rate for Payer: BCBS Trust/PPO |
$1,563.91
|
| Rate for Payer: BCN Medicare Advantage |
$5,210.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,210.78
|
| Rate for Payer: Mclaren Medicaid |
$2,850.30
|
| Rate for Payer: Mclaren Medicare |
$5,210.78
|
| Rate for Payer: Meridian Medicaid |
$2,993.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,471.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,992.40
|
| Rate for Payer: PACE Medicare |
$4,950.24
|
| Rate for Payer: PACE SWMI |
$5,210.78
|
| Rate for Payer: PHP Medicare Advantage |
$5,210.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,850.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,835.74
|
| Rate for Payer: Priority Health Medicare |
$5,210.78
|
| Rate for Payer: Priority Health Narrow Network |
$12,668.59
|
| Rate for Payer: Railroad Medicare Medicare |
$5,210.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$318.77
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,210.78
|
| Rate for Payer: UHC Exchange |
$289.79
|
| Rate for Payer: UHC Medicare Advantage |
$5,367.10
|
| Rate for Payer: VA VA |
$5,210.78
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
OP
|
$4,155.00
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$254.75 |
| Max. Negotiated Rate |
$4,155.00 |
| Rate for Payer: Aetna Medicare |
$2,979.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,580.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,580.99
|
| Rate for Payer: BCBS Complete |
$1,645.54
|
| Rate for Payer: BCBS MAPPO |
$2,864.79
|
| Rate for Payer: BCBS Trust/PPO |
$1,533.41
|
| Rate for Payer: BCN Medicare Advantage |
$2,864.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,864.79
|
| Rate for Payer: Mclaren Medicaid |
$1,567.04
|
| Rate for Payer: Mclaren Medicare |
$2,864.79
|
| Rate for Payer: Meridian Medicaid |
$1,645.54
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,008.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,294.51
|
| Rate for Payer: PACE Medicare |
$2,721.55
|
| Rate for Payer: PACE SWMI |
$2,864.79
|
| Rate for Payer: PHP Medicare Advantage |
$2,864.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,567.04
|
| Rate for Payer: Priority Health Medicare |
$2,864.79
|
| Rate for Payer: Railroad Medicare Medicare |
$2,864.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$280.22
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,864.79
|
| Rate for Payer: UHC Exchange |
$254.75
|
| Rate for Payer: UHC Medicare Advantage |
$2,950.73
|
| Rate for Payer: VA VA |
$2,864.79
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12
|
Facility
OP
|
$15,835.74
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$267.52 |
| Max. Negotiated Rate |
$15,835.74 |
| Rate for Payer: Aetna Medicare |
$5,419.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,513.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,513.48
|
| Rate for Payer: BCBS Complete |
$2,993.07
|
| Rate for Payer: BCBS MAPPO |
$5,210.78
|
| Rate for Payer: BCBS Trust/PPO |
$1,627.21
|
| Rate for Payer: BCN Medicare Advantage |
$5,210.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,210.78
|
| Rate for Payer: Mclaren Medicaid |
$2,850.30
|
| Rate for Payer: Mclaren Medicare |
$5,210.78
|
| Rate for Payer: Meridian Medicaid |
$2,993.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,471.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,992.40
|
| Rate for Payer: PACE Medicare |
$4,950.24
|
| Rate for Payer: PACE SWMI |
$5,210.78
|
| Rate for Payer: PHP Medicare Advantage |
$5,210.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,850.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,835.74
|
| Rate for Payer: Priority Health Medicare |
$5,210.78
|
| Rate for Payer: Priority Health Narrow Network |
$12,668.59
|
| Rate for Payer: Railroad Medicare Medicare |
$5,210.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$294.27
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,210.78
|
| Rate for Payer: UHC Exchange |
$267.52
|
| Rate for Payer: UHC Medicare Advantage |
$5,367.10
|
| Rate for Payer: VA VA |
$5,210.78
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
IP
|
$383.80
|
|
|
Service Code
|
NDC 68084-344-11
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.79 |
| Max. Negotiated Rate |
$345.42 |
| Rate for Payer: Aetna Commercial |
$326.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$249.47
|
| Rate for Payer: Cash Price |
$307.04
|
| Rate for Payer: Cofinity Commercial |
$268.66
|
| Rate for Payer: Cofinity Commercial |
$330.07
|
| Rate for Payer: Healthscope Commercial |
$345.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$326.23
|
| Rate for Payer: PHP Commercial |
$326.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$268.66
|
| Rate for Payer: Priority Health SBD |
$241.79
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
IP
|
$383.80
|
|
|
Service Code
|
NDC 68084-344-01
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.79 |
| Max. Negotiated Rate |
$345.42 |
| Rate for Payer: Aetna Commercial |
$326.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$249.47
|
| Rate for Payer: Cash Price |
$307.04
|
| Rate for Payer: Cofinity Commercial |
$268.66
|
| Rate for Payer: Cofinity Commercial |
$330.07
|
| Rate for Payer: Healthscope Commercial |
$345.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$326.23
|
| Rate for Payer: PHP Commercial |
$326.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$268.66
|
| Rate for Payer: Priority Health SBD |
$241.79
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
IP
|
$215.65
|
|
|
Service Code
|
NDC 68084-342-01
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.86 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.17
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$150.96
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.30
|
| Rate for Payer: PHP Commercial |
$183.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.96
|
| Rate for Payer: Priority Health SBD |
$135.86
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
IP
|
$1,353.09
|
|
|
Service Code
|
NDC 50458-639-65
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$852.45 |
| Max. Negotiated Rate |
$1,217.78 |
| Rate for Payer: Aetna Commercial |
$1,150.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$879.51
|
| Rate for Payer: Cash Price |
$1,082.47
|
| Rate for Payer: Cofinity Commercial |
$1,163.66
|
| Rate for Payer: Cofinity Commercial |
$947.16
|
| Rate for Payer: Healthscope Commercial |
$1,217.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,150.13
|
| Rate for Payer: PHP Commercial |
$1,150.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$947.16
|
| Rate for Payer: Priority Health SBD |
$852.45
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
IP
|
$470.00
|
|
|
Service Code
|
NDC 0904-6928-61
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$296.10 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Aetna Commercial |
$399.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.50
|
| Rate for Payer: Cash Price |
$376.00
|
| Rate for Payer: Cofinity Commercial |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$404.20
|
| Rate for Payer: Healthscope Commercial |
$423.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$399.50
|
| Rate for Payer: PHP Commercial |
$399.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$329.00
|
| Rate for Payer: Priority Health SBD |
$296.10
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
IP
|
$215.65
|
|
|
Service Code
|
NDC 68084-342-11
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.86 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.17
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$150.96
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.30
|
| Rate for Payer: PHP Commercial |
$183.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.96
|
| Rate for Payer: Priority Health SBD |
$135.86
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
IP
|
$50.76
|
|
|
Service Code
|
NDC 68382-138-14
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$45.68 |
| Rate for Payer: Aetna Commercial |
$43.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.99
|
| Rate for Payer: Cash Price |
$40.61
|
| Rate for Payer: Cofinity Commercial |
$35.53
|
| Rate for Payer: Cofinity Commercial |
$43.65
|
| Rate for Payer: Healthscope Commercial |
$45.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.15
|
| Rate for Payer: PHP Commercial |
$43.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.53
|
| Rate for Payer: Priority Health SBD |
$31.98
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION
|
Facility
IP
|
$369.96
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
152057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$233.07 |
| Max. Negotiated Rate |
$332.96 |
| Rate for Payer: Aetna Commercial |
$314.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.47
|
| Rate for Payer: Cash Price |
$295.97
|
| Rate for Payer: Cofinity Commercial |
$258.97
|
| Rate for Payer: Cofinity Commercial |
$318.17
|
| Rate for Payer: Healthscope Commercial |
$332.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$314.47
|
| Rate for Payer: PHP Commercial |
$314.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.97
|
| Rate for Payer: Priority Health SBD |
$233.07
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION
|
Facility
OP
|
$105.88
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
152057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$95.29 |
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna Commercial |
$384.25
|
| Rate for Payer: Aetna Commercial |
$314.47
|
| Rate for Payer: Aetna Commercial |
$127.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.47
|
| Rate for Payer: BCBS Complete |
$59.80
|
| Rate for Payer: BCBS Complete |
$42.35
|
| Rate for Payer: BCBS Complete |
$147.98
|
| Rate for Payer: BCBS Complete |
$180.82
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: Cash Price |
$119.59
|
| Rate for Payer: Cash Price |
$84.70
|
| Rate for Payer: Cash Price |
$119.59
|
| Rate for Payer: Cash Price |
$361.65
|
| Rate for Payer: Cash Price |
$361.65
|
| Rate for Payer: Cash Price |
$295.97
|
| Rate for Payer: Cash Price |
$84.70
|
| Rate for Payer: Cash Price |
$295.97
|
| Rate for Payer: Cofinity Commercial |
$388.77
|
| Rate for Payer: Cofinity Commercial |
$316.44
|
| Rate for Payer: Cofinity Commercial |
$91.06
|
| Rate for Payer: Cofinity Commercial |
$104.64
|
| Rate for Payer: Cofinity Commercial |
$128.56
|
| Rate for Payer: Cofinity Commercial |
$74.12
|
| Rate for Payer: Cofinity Commercial |
$258.97
|
| Rate for Payer: Cofinity Commercial |
$318.17
|
| Rate for Payer: Healthscope Commercial |
$95.29
|
| Rate for Payer: Healthscope Commercial |
$332.96
|
| Rate for Payer: Healthscope Commercial |
$406.85
|
| Rate for Payer: Healthscope Commercial |
$134.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$314.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$384.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.00
|
| Rate for Payer: PHP Commercial |
$384.25
|
| Rate for Payer: PHP Commercial |
$90.00
|
| Rate for Payer: PHP Commercial |
$314.47
|
| Rate for Payer: PHP Commercial |
$127.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$316.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.12
|
| Rate for Payer: Priority Health SBD |
$94.18
|
| Rate for Payer: Priority Health SBD |
$233.07
|
| Rate for Payer: Priority Health SBD |
$66.70
|
| Rate for Payer: Priority Health SBD |
$284.80
|
|
