|
TICAGRELOR 90 MG TABLET
|
Facility
|
OP
|
$2,780.18
|
|
|
Service Code
|
NDC 00186077739
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,112.07 |
| Max. Negotiated Rate |
$2,780.18 |
| Rate for Payer: Aetna Commercial |
$2,502.16
|
| Rate for Payer: Aetna Medicare |
$1,390.09
|
| Rate for Payer: ASR ASR |
$2,696.77
|
| Rate for Payer: ASR Commercial |
$2,696.77
|
| Rate for Payer: BCBS Complete |
$1,112.07
|
| Rate for Payer: BCBS Trust/PPO |
$2,276.69
|
| Rate for Payer: BCN Commercial |
$2,155.47
|
| Rate for Payer: Cash Price |
$2,224.14
|
| Rate for Payer: Cofinity Commercial |
$2,613.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,224.14
|
| Rate for Payer: Healthscope Commercial |
$2,780.18
|
| Rate for Payer: Healthscope Whirlpool |
$2,696.77
|
| Rate for Payer: Mclaren Commercial |
$2,502.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,363.15
|
| Rate for Payer: Nomi Health Commercial |
$2,279.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,807.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,435.99
|
| Rate for Payer: Priority Health Narrow Network |
$1,948.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,446.56
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
IP
|
$2,780.18
|
|
|
Service Code
|
NDC 00186077739
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,807.12 |
| Max. Negotiated Rate |
$2,780.18 |
| Rate for Payer: Aetna Commercial |
$2,502.16
|
| Rate for Payer: ASR ASR |
$2,696.77
|
| Rate for Payer: ASR Commercial |
$2,696.77
|
| Rate for Payer: BCBS Trust/PPO |
$2,265.57
|
| Rate for Payer: BCN Commercial |
$2,155.47
|
| Rate for Payer: Cash Price |
$2,224.14
|
| Rate for Payer: Cofinity Commercial |
$2,613.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,224.14
|
| Rate for Payer: Healthscope Commercial |
$2,780.18
|
| Rate for Payer: Healthscope Whirlpool |
$2,696.77
|
| Rate for Payer: Mclaren Commercial |
$2,502.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,363.15
|
| Rate for Payer: Nomi Health Commercial |
$2,279.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,807.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2,446.56
|
|
|
TIMOLOL 5 MG TABLET
|
Facility
|
OP
|
$372.00
|
|
|
Service Code
|
NDC 00378005501
|
| Hospital Charge Code |
7969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.80 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$334.80
|
| Rate for Payer: Aetna Medicare |
$186.00
|
| Rate for Payer: ASR ASR |
$360.84
|
| Rate for Payer: ASR Commercial |
$360.84
|
| Rate for Payer: BCBS Complete |
$148.80
|
| Rate for Payer: BCBS Trust/PPO |
$304.63
|
| Rate for Payer: BCN Commercial |
$288.41
|
| Rate for Payer: Cash Price |
$297.60
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.60
|
| Rate for Payer: Healthscope Commercial |
$372.00
|
| Rate for Payer: Healthscope Whirlpool |
$360.84
|
| Rate for Payer: Mclaren Commercial |
$334.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$316.20
|
| Rate for Payer: Nomi Health Commercial |
$305.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$325.95
|
| Rate for Payer: Priority Health Narrow Network |
$260.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$327.36
|
|
|
TIMOLOL 5 MG TABLET
|
Facility
|
IP
|
$372.00
|
|
|
Service Code
|
NDC 00378005501
|
| Hospital Charge Code |
7969
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.80 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$334.80
|
| Rate for Payer: ASR ASR |
$360.84
|
| Rate for Payer: ASR Commercial |
$360.84
|
| Rate for Payer: BCBS Trust/PPO |
$303.14
|
| Rate for Payer: BCN Commercial |
$288.41
|
| Rate for Payer: Cash Price |
$297.60
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.60
|
| Rate for Payer: Healthscope Commercial |
$372.00
|
| Rate for Payer: Healthscope Whirlpool |
$360.84
|
| Rate for Payer: Mclaren Commercial |
$334.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$316.20
|
| Rate for Payer: Nomi Health Commercial |
$305.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$327.36
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$20.20
|
|
|
Service Code
|
NDC 61314022705
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.13 |
| Max. Negotiated Rate |
$20.20 |
| Rate for Payer: Aetna Commercial |
$18.18
|
| Rate for Payer: ASR ASR |
$19.59
|
| Rate for Payer: ASR Commercial |
$19.59
|
| Rate for Payer: BCBS Trust/PPO |
$16.46
|
| Rate for Payer: BCN Commercial |
$15.66
|
| Rate for Payer: Cash Price |
$16.16
|
| Rate for Payer: Cofinity Commercial |
$18.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.16
|
| Rate for Payer: Healthscope Commercial |
$20.20
|
| Rate for Payer: Healthscope Whirlpool |
$19.59
|
| Rate for Payer: Mclaren Commercial |
$18.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.17
|
| Rate for Payer: Nomi Health Commercial |
$16.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.78
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$22.91
|
|
|
Service Code
|
NDC 60758080105
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$22.91 |
| Rate for Payer: Aetna Commercial |
$20.62
|
| Rate for Payer: Aetna Medicare |
$11.46
|
| Rate for Payer: ASR ASR |
$22.22
|
| Rate for Payer: ASR Commercial |
$22.22
|
| Rate for Payer: BCBS Complete |
$9.16
|
| Rate for Payer: BCBS Trust/PPO |
$18.76
|
| Rate for Payer: BCN Commercial |
$17.76
|
| Rate for Payer: Cash Price |
$18.32
|
| Rate for Payer: Cofinity Commercial |
$21.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.33
|
| Rate for Payer: Healthscope Commercial |
$22.91
|
| Rate for Payer: Healthscope Whirlpool |
$22.22
|
| Rate for Payer: Mclaren Commercial |
$20.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.47
|
| Rate for Payer: Nomi Health Commercial |
$18.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.89
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.07
|
| Rate for Payer: Priority Health Narrow Network |
$16.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.16
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$30.76
|
|
|
Service Code
|
NDC 61314022710
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$30.76 |
| Rate for Payer: Aetna Commercial |
$27.68
|
| Rate for Payer: Aetna Medicare |
$15.38
|
| Rate for Payer: ASR ASR |
$29.84
|
| Rate for Payer: ASR Commercial |
$29.84
|
| Rate for Payer: BCBS Complete |
$12.30
|
| Rate for Payer: BCBS Trust/PPO |
$25.19
|
| Rate for Payer: BCN Commercial |
$23.85
|
| Rate for Payer: Cash Price |
$24.61
|
| Rate for Payer: Cofinity Commercial |
$28.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.61
|
| Rate for Payer: Healthscope Commercial |
$30.76
|
| Rate for Payer: Healthscope Whirlpool |
$29.84
|
| Rate for Payer: Mclaren Commercial |
$27.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.15
|
| Rate for Payer: Nomi Health Commercial |
$25.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26.95
|
| Rate for Payer: Priority Health Narrow Network |
$21.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.07
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$20.20
|
|
|
Service Code
|
NDC 61314022705
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$20.20 |
| Rate for Payer: Aetna Commercial |
$18.18
|
| Rate for Payer: Aetna Medicare |
$10.10
|
| Rate for Payer: ASR ASR |
$19.59
|
| Rate for Payer: ASR Commercial |
$19.59
|
| Rate for Payer: BCBS Complete |
$8.08
|
| Rate for Payer: BCBS Trust/PPO |
$16.54
|
| Rate for Payer: BCN Commercial |
$15.66
|
| Rate for Payer: Cash Price |
$16.16
|
| Rate for Payer: Cofinity Commercial |
$18.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.16
|
| Rate for Payer: Healthscope Commercial |
$20.20
|
| Rate for Payer: Healthscope Whirlpool |
$19.59
|
| Rate for Payer: Mclaren Commercial |
$18.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.17
|
| Rate for Payer: Nomi Health Commercial |
$16.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.13
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.70
|
| Rate for Payer: Priority Health Narrow Network |
$14.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.78
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$22.82
|
|
|
Service Code
|
NDC 17478028810
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$22.82 |
| Rate for Payer: Aetna Commercial |
$20.54
|
| Rate for Payer: Aetna Medicare |
$11.41
|
| Rate for Payer: ASR ASR |
$22.14
|
| Rate for Payer: ASR Commercial |
$22.14
|
| Rate for Payer: BCBS Complete |
$9.13
|
| Rate for Payer: BCBS Trust/PPO |
$18.69
|
| Rate for Payer: BCN Commercial |
$17.69
|
| Rate for Payer: Cash Price |
$18.26
|
| Rate for Payer: Cofinity Commercial |
$21.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.26
|
| Rate for Payer: Healthscope Commercial |
$22.82
|
| Rate for Payer: Healthscope Whirlpool |
$22.14
|
| Rate for Payer: Mclaren Commercial |
$20.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.40
|
| Rate for Payer: Nomi Health Commercial |
$18.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.99
|
| Rate for Payer: Priority Health Narrow Network |
$16.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.08
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$22.82
|
|
|
Service Code
|
NDC 17478028810
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.83 |
| Max. Negotiated Rate |
$22.82 |
| Rate for Payer: Aetna Commercial |
$20.54
|
| Rate for Payer: ASR ASR |
$22.14
|
| Rate for Payer: ASR Commercial |
$22.14
|
| Rate for Payer: BCBS Trust/PPO |
$18.60
|
| Rate for Payer: BCN Commercial |
$17.69
|
| Rate for Payer: Cash Price |
$18.26
|
| Rate for Payer: Cofinity Commercial |
$21.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.26
|
| Rate for Payer: Healthscope Commercial |
$22.82
|
| Rate for Payer: Healthscope Whirlpool |
$22.14
|
| Rate for Payer: Mclaren Commercial |
$20.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.40
|
| Rate for Payer: Nomi Health Commercial |
$18.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.08
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$35.80
|
|
|
Service Code
|
NDC 68682081305
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.27 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$32.22
|
| Rate for Payer: ASR ASR |
$34.73
|
| Rate for Payer: ASR Commercial |
$34.73
|
| Rate for Payer: BCBS Trust/PPO |
$29.17
|
| Rate for Payer: BCN Commercial |
$27.76
|
| Rate for Payer: Cash Price |
$28.64
|
| Rate for Payer: Cofinity Commercial |
$33.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.64
|
| Rate for Payer: Healthscope Commercial |
$35.80
|
| Rate for Payer: Healthscope Whirlpool |
$34.73
|
| Rate for Payer: Mclaren Commercial |
$32.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.43
|
| Rate for Payer: Nomi Health Commercial |
$29.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.50
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$22.91
|
|
|
Service Code
|
NDC 60758080105
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.89 |
| Max. Negotiated Rate |
$22.91 |
| Rate for Payer: Aetna Commercial |
$20.62
|
| Rate for Payer: ASR ASR |
$22.22
|
| Rate for Payer: ASR Commercial |
$22.22
|
| Rate for Payer: BCBS Trust/PPO |
$18.67
|
| Rate for Payer: BCN Commercial |
$17.76
|
| Rate for Payer: Cash Price |
$18.32
|
| Rate for Payer: Cofinity Commercial |
$21.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.33
|
| Rate for Payer: Healthscope Commercial |
$22.91
|
| Rate for Payer: Healthscope Whirlpool |
$22.22
|
| Rate for Payer: Mclaren Commercial |
$20.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.47
|
| Rate for Payer: Nomi Health Commercial |
$18.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.16
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$30.76
|
|
|
Service Code
|
NDC 61314022710
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.99 |
| Max. Negotiated Rate |
$30.76 |
| Rate for Payer: Aetna Commercial |
$27.68
|
| Rate for Payer: ASR ASR |
$29.84
|
| Rate for Payer: ASR Commercial |
$29.84
|
| Rate for Payer: BCBS Trust/PPO |
$25.07
|
| Rate for Payer: BCN Commercial |
$23.85
|
| Rate for Payer: Cash Price |
$24.61
|
| Rate for Payer: Cofinity Commercial |
$28.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.61
|
| Rate for Payer: Healthscope Commercial |
$30.76
|
| Rate for Payer: Healthscope Whirlpool |
$29.84
|
| Rate for Payer: Mclaren Commercial |
$27.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.15
|
| Rate for Payer: Nomi Health Commercial |
$25.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$27.07
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
OP
|
$35.80
|
|
|
Service Code
|
NDC 68682081305
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$32.22
|
| Rate for Payer: Aetna Medicare |
$17.90
|
| Rate for Payer: ASR ASR |
$34.73
|
| Rate for Payer: ASR Commercial |
$34.73
|
| Rate for Payer: BCBS Complete |
$14.32
|
| Rate for Payer: BCBS Trust/PPO |
$29.32
|
| Rate for Payer: BCN Commercial |
$27.76
|
| Rate for Payer: Cash Price |
$28.64
|
| Rate for Payer: Cofinity Commercial |
$33.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.64
|
| Rate for Payer: Healthscope Commercial |
$35.80
|
| Rate for Payer: Healthscope Whirlpool |
$34.73
|
| Rate for Payer: Mclaren Commercial |
$32.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.43
|
| Rate for Payer: Nomi Health Commercial |
$29.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31.37
|
| Rate for Payer: Priority Health Narrow Network |
$25.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.50
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$206.62
|
|
|
Service Code
|
NDC 50268076015
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.30 |
| Max. Negotiated Rate |
$206.62 |
| Rate for Payer: Aetna Commercial |
$185.96
|
| Rate for Payer: ASR ASR |
$200.42
|
| Rate for Payer: ASR Commercial |
$200.42
|
| Rate for Payer: BCBS Trust/PPO |
$168.37
|
| Rate for Payer: BCN Commercial |
$160.19
|
| Rate for Payer: Cash Price |
$165.30
|
| Rate for Payer: Cofinity Commercial |
$194.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.30
|
| Rate for Payer: Healthscope Commercial |
$206.62
|
| Rate for Payer: Healthscope Whirlpool |
$200.42
|
| Rate for Payer: Mclaren Commercial |
$185.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.63
|
| Rate for Payer: Nomi Health Commercial |
$169.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.83
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
OP
|
$165.68
|
|
|
Service Code
|
NDC 57664050389
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.27 |
| Max. Negotiated Rate |
$165.68 |
| Rate for Payer: Aetna Commercial |
$149.11
|
| Rate for Payer: Aetna Medicare |
$82.84
|
| Rate for Payer: ASR ASR |
$160.71
|
| Rate for Payer: ASR Commercial |
$160.71
|
| Rate for Payer: BCBS Complete |
$66.27
|
| Rate for Payer: BCBS Trust/PPO |
$135.68
|
| Rate for Payer: BCN Commercial |
$128.45
|
| Rate for Payer: Cash Price |
$132.54
|
| Rate for Payer: Cofinity Commercial |
$155.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.54
|
| Rate for Payer: Healthscope Commercial |
$165.68
|
| Rate for Payer: Healthscope Whirlpool |
$160.71
|
| Rate for Payer: Mclaren Commercial |
$149.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.83
|
| Rate for Payer: Nomi Health Commercial |
$135.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$145.17
|
| Rate for Payer: Priority Health Narrow Network |
$116.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$145.80
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
OP
|
$428.45
|
|
|
Service Code
|
NDC 68084064501
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.38 |
| Max. Negotiated Rate |
$428.45 |
| Rate for Payer: Aetna Commercial |
$385.60
|
| Rate for Payer: Aetna Medicare |
$214.22
|
| Rate for Payer: ASR ASR |
$415.60
|
| Rate for Payer: ASR Commercial |
$415.60
|
| Rate for Payer: BCBS Complete |
$171.38
|
| Rate for Payer: BCBS Trust/PPO |
$350.86
|
| Rate for Payer: BCN Commercial |
$332.18
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$402.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$428.45
|
| Rate for Payer: Healthscope Whirlpool |
$415.60
|
| Rate for Payer: Mclaren Commercial |
$385.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.18
|
| Rate for Payer: Nomi Health Commercial |
$351.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$375.41
|
| Rate for Payer: Priority Health Narrow Network |
$300.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$377.04
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$165.68
|
|
|
Service Code
|
NDC 57664050389
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.69 |
| Max. Negotiated Rate |
$165.68 |
| Rate for Payer: Aetna Commercial |
$149.11
|
| Rate for Payer: ASR ASR |
$160.71
|
| Rate for Payer: ASR Commercial |
$160.71
|
| Rate for Payer: BCBS Trust/PPO |
$135.01
|
| Rate for Payer: BCN Commercial |
$128.45
|
| Rate for Payer: Cash Price |
$132.54
|
| Rate for Payer: Cofinity Commercial |
$155.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.54
|
| Rate for Payer: Healthscope Commercial |
$165.68
|
| Rate for Payer: Healthscope Whirlpool |
$160.71
|
| Rate for Payer: Mclaren Commercial |
$149.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.83
|
| Rate for Payer: Nomi Health Commercial |
$135.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$145.80
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
OP
|
$396.15
|
|
|
Service Code
|
NDC 00904641861
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.46 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna Commercial |
$356.54
|
| Rate for Payer: Aetna Medicare |
$198.08
|
| Rate for Payer: ASR ASR |
$384.27
|
| Rate for Payer: ASR Commercial |
$384.27
|
| Rate for Payer: BCBS Complete |
$158.46
|
| Rate for Payer: BCBS Trust/PPO |
$324.41
|
| Rate for Payer: BCN Commercial |
$307.14
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$372.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$396.15
|
| Rate for Payer: Healthscope Whirlpool |
$384.27
|
| Rate for Payer: Mclaren Commercial |
$356.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$347.11
|
| Rate for Payer: Priority Health Narrow Network |
$277.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$348.61
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
OP
|
$4.28
|
|
|
Service Code
|
NDC 68084064511
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.85
|
| Rate for Payer: Aetna Medicare |
$2.14
|
| Rate for Payer: ASR ASR |
$4.15
|
| Rate for Payer: ASR Commercial |
$4.15
|
| Rate for Payer: BCBS Complete |
$1.71
|
| Rate for Payer: BCBS Trust/PPO |
$3.50
|
| Rate for Payer: BCN Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cofinity Commercial |
$4.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.42
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Healthscope Whirlpool |
$4.15
|
| Rate for Payer: Mclaren Commercial |
$3.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.64
|
| Rate for Payer: Nomi Health Commercial |
$3.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.75
|
| Rate for Payer: Priority Health Narrow Network |
$3.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.77
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$428.45
|
|
|
Service Code
|
NDC 68084064501
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.49 |
| Max. Negotiated Rate |
$428.45 |
| Rate for Payer: Aetna Commercial |
$385.60
|
| Rate for Payer: ASR ASR |
$415.60
|
| Rate for Payer: ASR Commercial |
$415.60
|
| Rate for Payer: BCBS Trust/PPO |
$349.14
|
| Rate for Payer: BCN Commercial |
$332.18
|
| Rate for Payer: Cash Price |
$342.76
|
| Rate for Payer: Cofinity Commercial |
$402.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.76
|
| Rate for Payer: Healthscope Commercial |
$428.45
|
| Rate for Payer: Healthscope Whirlpool |
$415.60
|
| Rate for Payer: Mclaren Commercial |
$385.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.18
|
| Rate for Payer: Nomi Health Commercial |
$351.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$377.04
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$4.13
|
|
|
Service Code
|
NDC 50268076011
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: ASR ASR |
$4.01
|
| Rate for Payer: ASR Commercial |
$4.01
|
| Rate for Payer: BCBS Trust/PPO |
$3.37
|
| Rate for Payer: BCN Commercial |
$3.20
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cofinity Commercial |
$3.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$4.13
|
| Rate for Payer: Healthscope Whirlpool |
$4.01
|
| Rate for Payer: Mclaren Commercial |
$3.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.51
|
| Rate for Payer: Nomi Health Commercial |
$3.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.63
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
OP
|
$206.62
|
|
|
Service Code
|
NDC 50268076015
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.65 |
| Max. Negotiated Rate |
$206.62 |
| Rate for Payer: Aetna Commercial |
$185.96
|
| Rate for Payer: Aetna Medicare |
$103.31
|
| Rate for Payer: ASR ASR |
$200.42
|
| Rate for Payer: ASR Commercial |
$200.42
|
| Rate for Payer: BCBS Complete |
$82.65
|
| Rate for Payer: BCBS Trust/PPO |
$169.20
|
| Rate for Payer: BCN Commercial |
$160.19
|
| Rate for Payer: Cash Price |
$165.30
|
| Rate for Payer: Cofinity Commercial |
$194.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.30
|
| Rate for Payer: Healthscope Commercial |
$206.62
|
| Rate for Payer: Healthscope Whirlpool |
$200.42
|
| Rate for Payer: Mclaren Commercial |
$185.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.63
|
| Rate for Payer: Nomi Health Commercial |
$169.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$181.04
|
| Rate for Payer: Priority Health Narrow Network |
$144.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$181.83
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 68084064511
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.85
|
| Rate for Payer: ASR ASR |
$4.15
|
| Rate for Payer: ASR Commercial |
$4.15
|
| Rate for Payer: BCBS Trust/PPO |
$3.49
|
| Rate for Payer: BCN Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$3.43
|
| Rate for Payer: Cofinity Commercial |
$4.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.42
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Healthscope Whirlpool |
$4.15
|
| Rate for Payer: Mclaren Commercial |
$3.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.64
|
| Rate for Payer: Nomi Health Commercial |
$3.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.77
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
OP
|
$4.13
|
|
|
Service Code
|
NDC 50268076011
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Aetna Medicare |
$2.06
|
| Rate for Payer: ASR ASR |
$4.01
|
| Rate for Payer: ASR Commercial |
$4.01
|
| Rate for Payer: BCBS Complete |
$1.65
|
| Rate for Payer: BCBS Trust/PPO |
$3.38
|
| Rate for Payer: BCN Commercial |
$3.20
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cofinity Commercial |
$3.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$4.13
|
| Rate for Payer: Healthscope Whirlpool |
$4.01
|
| Rate for Payer: Mclaren Commercial |
$3.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.51
|
| Rate for Payer: Nomi Health Commercial |
$3.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.62
|
| Rate for Payer: Priority Health Narrow Network |
$2.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.63
|
|
