|
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 |
$1.76 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Aetna Commercial |
$2.46
|
| Rate for Payer: BCBS Trust/PPO |
$2.23
|
| Rate for Payer: BCN Commercial |
$2.23
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cofinity Commercial |
$2.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.31
|
| Rate for Payer: Healthscope Commercial |
$2.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.17
|
| 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 HMO/PPO/Tiered Network |
$2.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.54
|
| Rate for Payer: UHC Core |
$2.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.17
|
|
|
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 |
$83.85 |
| Max. Negotiated Rate |
$123.73 |
| Rate for Payer: Aetna Commercial |
$116.86
|
| Rate for Payer: BCBS Trust/PPO |
$106.24
|
| Rate for Payer: BCN Commercial |
$106.24
|
| Rate for Payer: Cash Price |
$109.98
|
| Rate for Payer: Cofinity Commercial |
$118.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.98
|
| Rate for Payer: Healthscope Commercial |
$123.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.11
|
| 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 HMO/PPO/Tiered Network |
$119.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$83.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$120.98
|
| Rate for Payer: UHC Core |
$114.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.11
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
IP
|
$2.61
|
|
|
Service Code
|
NDC 51079-998-01
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: BCBS Trust/PPO |
$2.02
|
| Rate for Payer: BCN Commercial |
$2.02
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.22
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.30
|
| Rate for Payer: UHC Core |
$2.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
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 |
$237.56 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna Commercial |
$331.08
|
| Rate for Payer: BCBS Trust/PPO |
$301.01
|
| Rate for Payer: BCN Commercial |
$301.01
|
| Rate for Payer: Cash Price |
$311.60
|
| Rate for Payer: Cofinity Commercial |
$334.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.60
|
| Rate for Payer: Healthscope Commercial |
$350.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.12
|
| 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 HMO/PPO/Tiered Network |
$338.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$237.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$342.76
|
| Rate for Payer: UHC Core |
$325.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.12
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
IP
|
$260.64
|
|
|
Service Code
|
NDC 51079-998-20
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.96 |
| Max. Negotiated Rate |
$234.58 |
| Rate for Payer: Aetna Commercial |
$221.54
|
| Rate for Payer: BCBS Trust/PPO |
$201.42
|
| Rate for Payer: BCN Commercial |
$201.42
|
| Rate for Payer: Cash Price |
$208.51
|
| Rate for Payer: Cofinity Commercial |
$224.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.51
|
| Rate for Payer: Healthscope Commercial |
$234.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.54
|
| Rate for Payer: PHP Commercial |
$221.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$226.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$158.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$229.36
|
| Rate for Payer: UHC Core |
$217.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.48
|
|
|
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 |
$100.40 |
| Max. Negotiated Rate |
$148.15 |
| Rate for Payer: Aetna Commercial |
$139.92
|
| Rate for Payer: BCBS Trust/PPO |
$127.21
|
| Rate for Payer: BCN Commercial |
$127.21
|
| Rate for Payer: Cash Price |
$131.69
|
| Rate for Payer: Cofinity Commercial |
$141.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.69
|
| Rate for Payer: Healthscope Commercial |
$148.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.46
|
| 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 HMO/PPO/Tiered Network |
$143.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$100.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$144.86
|
| Rate for Payer: UHC Core |
$137.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.46
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
IP
|
$76.79
|
|
|
Service Code
|
NDC 0574-4031-25
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.83 |
| Max. Negotiated Rate |
$69.11 |
| Rate for Payer: Aetna Commercial |
$65.27
|
| Rate for Payer: BCBS Trust/PPO |
$59.34
|
| Rate for Payer: BCN Commercial |
$59.34
|
| Rate for Payer: Cash Price |
$61.43
|
| Rate for Payer: Cofinity Commercial |
$66.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.43
|
| Rate for Payer: Healthscope Commercial |
$69.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.27
|
| Rate for Payer: PHP Commercial |
$65.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$66.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.58
|
| Rate for Payer: UHC Core |
$64.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.59
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
IP
|
$123.45
|
|
|
Service Code
|
NDC 61314-647-25
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.29 |
| Max. Negotiated Rate |
$111.10 |
| Rate for Payer: Aetna Commercial |
$104.93
|
| Rate for Payer: BCBS Trust/PPO |
$95.40
|
| Rate for Payer: BCN Commercial |
$95.40
|
| Rate for Payer: Cash Price |
$98.76
|
| Rate for Payer: Cofinity Commercial |
$106.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.76
|
| Rate for Payer: Healthscope Commercial |
$111.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$104.93
|
| Rate for Payer: PHP Commercial |
$104.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$107.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$75.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.64
|
| Rate for Payer: UHC Core |
$103.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.59
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
IP
|
$123.45
|
|
|
Service Code
|
NDC 69238-1373-2
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.29 |
| Max. Negotiated Rate |
$111.10 |
| Rate for Payer: Aetna Commercial |
$104.93
|
| Rate for Payer: BCBS Trust/PPO |
$95.40
|
| Rate for Payer: BCN Commercial |
$95.40
|
| Rate for Payer: Cash Price |
$98.76
|
| Rate for Payer: Cofinity Commercial |
$106.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.76
|
| Rate for Payer: Healthscope Commercial |
$111.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$104.93
|
| Rate for Payer: PHP Commercial |
$104.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$107.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$75.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.64
|
| Rate for Payer: UHC Core |
$103.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.59
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
IP
|
$39.06
|
|
|
Service Code
|
NDC 24208-290-05
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.82 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna Commercial |
$33.20
|
| Rate for Payer: BCBS Trust/PPO |
$30.19
|
| Rate for Payer: BCN Commercial |
$30.19
|
| Rate for Payer: Cash Price |
$31.25
|
| Rate for Payer: Cofinity Commercial |
$33.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.25
|
| Rate for Payer: Healthscope Commercial |
$35.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.20
|
| Rate for Payer: PHP Commercial |
$33.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.37
|
| Rate for Payer: UHC Core |
$32.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.30
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION
|
Facility
IP
|
$10.97
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.69 |
| Max. Negotiated Rate |
$9.87 |
| Rate for Payer: Aetna Commercial |
$9.32
|
| Rate for Payer: Aetna Commercial |
$15.93
|
| Rate for Payer: BCBS Trust/PPO |
$14.48
|
| Rate for Payer: BCBS Trust/PPO |
$8.48
|
| Rate for Payer: BCN Commercial |
$8.48
|
| Rate for Payer: BCN Commercial |
$14.48
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cash Price |
$8.78
|
| Rate for Payer: Cofinity Commercial |
$9.43
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.99
|
| Rate for Payer: Healthscope Commercial |
$16.87
|
| Rate for Payer: Healthscope Commercial |
$9.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.93
|
| Rate for Payer: PHP Commercial |
$9.32
|
| Rate for Payer: PHP Commercial |
$15.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.65
|
| Rate for Payer: UHC Core |
$15.65
|
| Rate for Payer: UHC Core |
$9.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.06
|
|
|
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 |
$2,193.85 |
| Max. Negotiated Rate |
$3,237.35 |
| Rate for Payer: Aetna Commercial |
$3,057.50
|
| Rate for Payer: BCBS Trust/PPO |
$2,779.81
|
| Rate for Payer: BCN Commercial |
$2,779.81
|
| Rate for Payer: Cash Price |
$2,877.65
|
| Rate for Payer: Cofinity Commercial |
$3,093.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,877.65
|
| Rate for Payer: Healthscope Commercial |
$3,237.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,697.80
|
| 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 HMO/PPO/Tiered Network |
$3,129.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2,193.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,165.41
|
| Rate for Payer: UHC Core |
$3,003.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,697.80
|
|
|
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 |
$3,565.00 |
| Max. Negotiated Rate |
$5,260.70 |
| Rate for Payer: Aetna Commercial |
$4,968.44
|
| Rate for Payer: BCBS Trust/PPO |
$4,517.19
|
| Rate for Payer: BCN Commercial |
$4,517.19
|
| Rate for Payer: Cash Price |
$4,676.18
|
| Rate for Payer: Cofinity Commercial |
$5,026.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,676.18
|
| Rate for Payer: Healthscope Commercial |
$5,260.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,383.92
|
| 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 HMO/PPO/Tiered Network |
$5,085.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3,565.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,143.79
|
| Rate for Payer: UHC Core |
$4,880.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,383.92
|
|
|
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 |
$934.59 |
| Max. Negotiated Rate |
$1,379.12 |
| Rate for Payer: Aetna Commercial |
$1,302.51
|
| Rate for Payer: BCBS Trust/PPO |
$1,184.21
|
| Rate for Payer: BCN Commercial |
$1,184.21
|
| Rate for Payer: Cash Price |
$1,225.89
|
| Rate for Payer: Cofinity Commercial |
$1,317.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,225.89
|
| Rate for Payer: Healthscope Commercial |
$1,379.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,149.27
|
| 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 HMO/PPO/Tiered Network |
$1,333.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$934.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,348.48
|
| Rate for Payer: UHC Core |
$1,279.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,149.27
|
|
|
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 |
$11,680.23 |
| Max. Negotiated Rate |
$17,235.95 |
| Rate for Payer: Aetna Commercial |
$16,278.40
|
| Rate for Payer: BCBS Trust/PPO |
$14,799.94
|
| Rate for Payer: BCN Commercial |
$14,799.94
|
| Rate for Payer: Cash Price |
$15,320.85
|
| Rate for Payer: Cofinity Commercial |
$16,469.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,320.85
|
| Rate for Payer: Healthscope Commercial |
$17,235.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,363.30
|
| 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 HMO/PPO/Tiered Network |
$16,661.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11,680.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,852.93
|
| Rate for Payer: UHC Core |
$15,991.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,363.30
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
IP
|
$1,967.52
|
|
|
Service Code
|
NDC 67877-635-33
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,199.99 |
| Max. Negotiated Rate |
$1,770.77 |
| Rate for Payer: Aetna Commercial |
$1,672.39
|
| Rate for Payer: BCBS Trust/PPO |
$1,520.50
|
| Rate for Payer: BCN Commercial |
$1,520.50
|
| Rate for Payer: Cash Price |
$1,574.02
|
| Rate for Payer: Cofinity Commercial |
$1,692.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,574.02
|
| Rate for Payer: Healthscope Commercial |
$1,770.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,475.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,672.39
|
| Rate for Payer: PHP Commercial |
$1,672.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,377.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,711.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,199.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,731.42
|
| Rate for Payer: UHC Core |
$1,642.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,475.64
|
|
|
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 |
$234.08 |
| Max. Negotiated Rate |
$345.42 |
| Rate for Payer: Aetna Commercial |
$326.23
|
| Rate for Payer: BCBS Trust/PPO |
$296.60
|
| Rate for Payer: BCN Commercial |
$296.60
|
| Rate for Payer: Cash Price |
$307.04
|
| Rate for Payer: Cofinity Commercial |
$330.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.04
|
| Rate for Payer: Healthscope Commercial |
$345.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.85
|
| 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 HMO/PPO/Tiered Network |
$333.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$234.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$337.74
|
| Rate for Payer: UHC Core |
$320.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.85
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
IP
|
$73.32
|
|
|
Service Code
|
NDC 68382-140-14
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.72 |
| Max. Negotiated Rate |
$65.99 |
| Rate for Payer: Aetna Commercial |
$62.32
|
| Rate for Payer: BCBS Trust/PPO |
$56.66
|
| Rate for Payer: BCN Commercial |
$56.66
|
| Rate for Payer: Cash Price |
$58.66
|
| Rate for Payer: Cofinity Commercial |
$63.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.66
|
| Rate for Payer: Healthscope Commercial |
$65.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.32
|
| Rate for Payer: PHP Commercial |
$62.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$63.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.52
|
| Rate for Payer: UHC Core |
$61.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.99
|
|
|
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 |
$234.08 |
| Max. Negotiated Rate |
$345.42 |
| Rate for Payer: Aetna Commercial |
$326.23
|
| Rate for Payer: BCBS Trust/PPO |
$296.60
|
| Rate for Payer: BCN Commercial |
$296.60
|
| Rate for Payer: Cash Price |
$307.04
|
| Rate for Payer: Cofinity Commercial |
$330.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.04
|
| Rate for Payer: Healthscope Commercial |
$345.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.85
|
| 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 HMO/PPO/Tiered Network |
$333.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$234.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$337.74
|
| Rate for Payer: UHC Core |
$320.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.85
|
|
|
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 |
$131.52 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: BCBS Trust/PPO |
$166.65
|
| Rate for Payer: BCN Commercial |
$166.65
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.52
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$161.74
|
| 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 HMO/PPO/Tiered Network |
$187.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$131.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$189.77
|
| Rate for Payer: UHC Core |
$180.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$161.74
|
|
|
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 |
$286.65 |
| Max. Negotiated Rate |
$423.00 |
| Rate for Payer: Aetna Commercial |
$399.50
|
| Rate for Payer: BCBS Trust/PPO |
$363.22
|
| Rate for Payer: BCN Commercial |
$363.22
|
| Rate for Payer: Cash Price |
$376.00
|
| Rate for Payer: Cofinity Commercial |
$404.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.00
|
| Rate for Payer: Healthscope Commercial |
$423.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.50
|
| 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 HMO/PPO/Tiered Network |
$408.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$286.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$413.60
|
| Rate for Payer: UHC Core |
$392.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.50
|
|
|
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 |
$131.52 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: BCBS Trust/PPO |
$166.65
|
| Rate for Payer: BCN Commercial |
$166.65
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.52
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$161.74
|
| 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 HMO/PPO/Tiered Network |
$187.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$131.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$189.77
|
| Rate for Payer: UHC Core |
$180.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$161.74
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
IP
|
$2.80
|
|
|
Service Code
|
NDC 50268-756-11
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna Commercial |
$2.38
|
| Rate for Payer: BCBS Trust/PPO |
$2.16
|
| Rate for Payer: BCN Commercial |
$2.16
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$2.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.24
|
| Rate for Payer: Healthscope Commercial |
$2.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.38
|
| Rate for Payer: PHP Commercial |
$2.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.96
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.46
|
| Rate for Payer: UHC Core |
$2.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.10
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
IP
|
$280.32
|
|
|
Service Code
|
NDC 50111-917-01
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.97 |
| Max. Negotiated Rate |
$252.29 |
| Rate for Payer: Aetna Commercial |
$238.27
|
| Rate for Payer: BCBS Trust/PPO |
$216.63
|
| Rate for Payer: BCN Commercial |
$216.63
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$241.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$252.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$238.27
|
| Rate for Payer: PHP Commercial |
$238.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$243.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$170.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$246.68
|
| Rate for Payer: UHC Core |
$234.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.24
|
|
|
TORSEMIDE 20 MG TABLET
|
Facility
IP
|
$216.20
|
|
|
Service Code
|
NDC 31722-531-01
|
| Hospital Charge Code |
18293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.86 |
| Max. Negotiated Rate |
$194.58 |
| Rate for Payer: Aetna Commercial |
$183.77
|
| Rate for Payer: BCBS Trust/PPO |
$167.08
|
| Rate for Payer: BCN Commercial |
$167.08
|
| Rate for Payer: Cash Price |
$172.96
|
| Rate for Payer: Cofinity Commercial |
$185.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.96
|
| Rate for Payer: Healthscope Commercial |
$194.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.77
|
| Rate for Payer: PHP Commercial |
$183.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$188.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$131.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$190.26
|
| Rate for Payer: UHC Core |
$180.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.15
|
|
