|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$396.15
|
|
|
Service Code
|
NDC 00904641861
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.50 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna Commercial |
$356.54
|
| Rate for Payer: ASR ASR |
$384.27
|
| Rate for Payer: ASR Commercial |
$384.27
|
| Rate for Payer: BCBS Trust/PPO |
$322.82
|
| 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: UHC All Payor (Choice/PPO) + Core |
$348.61
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$78.44
|
|
|
Service Code
|
NDC 00574403125
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.99 |
| Max. Negotiated Rate |
$78.44 |
| Rate for Payer: Aetna Commercial |
$70.60
|
| Rate for Payer: ASR ASR |
$76.09
|
| Rate for Payer: ASR Commercial |
$76.09
|
| Rate for Payer: BCBS Trust/PPO |
$63.92
|
| Rate for Payer: BCN Commercial |
$60.81
|
| Rate for Payer: Cash Price |
$62.75
|
| Rate for Payer: Cofinity Commercial |
$73.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.75
|
| Rate for Payer: Healthscope Commercial |
$78.44
|
| Rate for Payer: Healthscope Whirlpool |
$76.09
|
| Rate for Payer: Mclaren Commercial |
$70.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.67
|
| Rate for Payer: Nomi Health Commercial |
$64.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$69.03
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
OP
|
$272.16
|
|
|
Service Code
|
NDC 00065064725
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.86 |
| Max. Negotiated Rate |
$272.16 |
| Rate for Payer: Aetna Commercial |
$244.94
|
| Rate for Payer: Aetna Medicare |
$136.08
|
| Rate for Payer: ASR ASR |
$264.00
|
| Rate for Payer: ASR Commercial |
$264.00
|
| Rate for Payer: BCBS Complete |
$108.86
|
| Rate for Payer: BCBS Trust/PPO |
$222.87
|
| Rate for Payer: BCN Commercial |
$211.01
|
| Rate for Payer: Cash Price |
$217.73
|
| Rate for Payer: Cofinity Commercial |
$255.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.73
|
| Rate for Payer: Healthscope Commercial |
$272.16
|
| Rate for Payer: Healthscope Whirlpool |
$264.00
|
| Rate for Payer: Mclaren Commercial |
$244.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$231.34
|
| Rate for Payer: Nomi Health Commercial |
$223.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$238.47
|
| Rate for Payer: Priority Health Narrow Network |
$190.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$239.50
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
OP
|
$164.60
|
|
|
Service Code
|
NDC 24208029525
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.84 |
| Max. Negotiated Rate |
$164.60 |
| Rate for Payer: Aetna Commercial |
$148.14
|
| Rate for Payer: Aetna Medicare |
$82.30
|
| Rate for Payer: ASR ASR |
$159.66
|
| Rate for Payer: ASR Commercial |
$159.66
|
| Rate for Payer: BCBS Complete |
$65.84
|
| Rate for Payer: BCBS Trust/PPO |
$134.79
|
| Rate for Payer: BCN Commercial |
$127.61
|
| Rate for Payer: Cash Price |
$131.68
|
| Rate for Payer: Cofinity Commercial |
$154.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.68
|
| Rate for Payer: Healthscope Commercial |
$164.60
|
| Rate for Payer: Healthscope Whirlpool |
$159.66
|
| Rate for Payer: Mclaren Commercial |
$148.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.91
|
| Rate for Payer: Nomi Health Commercial |
$134.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$144.22
|
| Rate for Payer: Priority Health Narrow Network |
$115.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$144.85
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$164.60
|
|
|
Service Code
|
NDC 24208029525
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.99 |
| Max. Negotiated Rate |
$164.60 |
| Rate for Payer: Aetna Commercial |
$148.14
|
| Rate for Payer: ASR ASR |
$159.66
|
| Rate for Payer: ASR Commercial |
$159.66
|
| Rate for Payer: BCBS Trust/PPO |
$134.13
|
| Rate for Payer: BCN Commercial |
$127.61
|
| Rate for Payer: Cash Price |
$131.68
|
| Rate for Payer: Cofinity Commercial |
$154.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.68
|
| Rate for Payer: Healthscope Commercial |
$164.60
|
| Rate for Payer: Healthscope Whirlpool |
$159.66
|
| Rate for Payer: Mclaren Commercial |
$148.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.91
|
| Rate for Payer: Nomi Health Commercial |
$134.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$144.85
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
OP
|
$78.44
|
|
|
Service Code
|
NDC 00574403125
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.38 |
| Max. Negotiated Rate |
$78.44 |
| Rate for Payer: Aetna Commercial |
$70.60
|
| Rate for Payer: Aetna Medicare |
$39.22
|
| Rate for Payer: ASR ASR |
$76.09
|
| Rate for Payer: ASR Commercial |
$76.09
|
| Rate for Payer: BCBS Complete |
$31.38
|
| Rate for Payer: BCBS Trust/PPO |
$64.23
|
| Rate for Payer: BCN Commercial |
$60.81
|
| Rate for Payer: Cash Price |
$62.75
|
| Rate for Payer: Cofinity Commercial |
$73.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.75
|
| Rate for Payer: Healthscope Commercial |
$78.44
|
| Rate for Payer: Healthscope Whirlpool |
$76.09
|
| Rate for Payer: Mclaren Commercial |
$70.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.67
|
| Rate for Payer: Nomi Health Commercial |
$64.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$68.73
|
| Rate for Payer: Priority Health Narrow Network |
$54.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$69.03
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$272.16
|
|
|
Service Code
|
NDC 00065064725
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.90 |
| Max. Negotiated Rate |
$272.16 |
| Rate for Payer: Aetna Commercial |
$244.94
|
| Rate for Payer: ASR ASR |
$264.00
|
| Rate for Payer: ASR Commercial |
$264.00
|
| Rate for Payer: BCBS Trust/PPO |
$221.78
|
| Rate for Payer: BCN Commercial |
$211.01
|
| Rate for Payer: Cash Price |
$217.73
|
| Rate for Payer: Cofinity Commercial |
$255.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.73
|
| Rate for Payer: Healthscope Commercial |
$272.16
|
| Rate for Payer: Healthscope Whirlpool |
$264.00
|
| Rate for Payer: Mclaren Commercial |
$244.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$231.34
|
| Rate for Payer: Nomi Health Commercial |
$223.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$239.50
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$24.92
|
|
|
Service Code
|
NDC 62332051805
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$24.92 |
| Rate for Payer: Aetna Commercial |
$22.43
|
| Rate for Payer: Aetna Medicare |
$12.46
|
| Rate for Payer: ASR ASR |
$24.17
|
| Rate for Payer: ASR Commercial |
$24.17
|
| Rate for Payer: BCBS Complete |
$9.97
|
| Rate for Payer: BCBS Trust/PPO |
$20.41
|
| Rate for Payer: BCN Commercial |
$19.32
|
| Rate for Payer: Cash Price |
$19.94
|
| Rate for Payer: Cofinity Commercial |
$23.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.94
|
| Rate for Payer: Healthscope Commercial |
$24.92
|
| Rate for Payer: Healthscope Whirlpool |
$24.17
|
| Rate for Payer: Mclaren Commercial |
$22.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.18
|
| Rate for Payer: Nomi Health Commercial |
$20.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.83
|
| Rate for Payer: Priority Health Narrow Network |
$17.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.93
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$20.92
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$20.92 |
| Rate for Payer: Aetna Commercial |
$18.83
|
| Rate for Payer: ASR ASR |
$20.29
|
| Rate for Payer: ASR Commercial |
$20.29
|
| Rate for Payer: BCBS Trust/PPO |
$17.05
|
| Rate for Payer: BCN Commercial |
$16.22
|
| Rate for Payer: Cash Price |
$16.74
|
| Rate for Payer: Cofinity Commercial |
$19.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.74
|
| Rate for Payer: Healthscope Commercial |
$20.92
|
| Rate for Payer: Healthscope Whirlpool |
$20.29
|
| Rate for Payer: Mclaren Commercial |
$18.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.78
|
| Rate for Payer: Nomi Health Commercial |
$17.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.41
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$37.84
|
|
|
Service Code
|
NDC 17478029010
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.60 |
| Max. Negotiated Rate |
$37.84 |
| Rate for Payer: Aetna Commercial |
$34.06
|
| Rate for Payer: ASR ASR |
$36.70
|
| Rate for Payer: ASR Commercial |
$36.70
|
| Rate for Payer: BCBS Trust/PPO |
$30.84
|
| Rate for Payer: BCN Commercial |
$29.34
|
| Rate for Payer: Cash Price |
$30.27
|
| Rate for Payer: Cofinity Commercial |
$35.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.27
|
| Rate for Payer: Healthscope Commercial |
$37.84
|
| Rate for Payer: Healthscope Whirlpool |
$36.70
|
| Rate for Payer: Mclaren Commercial |
$34.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.16
|
| Rate for Payer: Nomi Health Commercial |
$31.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.30
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$24.92
|
|
|
Service Code
|
NDC 62332051805
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$24.92 |
| Rate for Payer: Aetna Commercial |
$22.43
|
| Rate for Payer: ASR ASR |
$24.17
|
| Rate for Payer: ASR Commercial |
$24.17
|
| Rate for Payer: BCBS Trust/PPO |
$20.31
|
| Rate for Payer: BCN Commercial |
$19.32
|
| Rate for Payer: Cash Price |
$19.94
|
| Rate for Payer: Cofinity Commercial |
$23.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.94
|
| Rate for Payer: Healthscope Commercial |
$24.92
|
| Rate for Payer: Healthscope Whirlpool |
$24.17
|
| Rate for Payer: Mclaren Commercial |
$22.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.18
|
| Rate for Payer: Nomi Health Commercial |
$20.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.93
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$20.92
|
|
|
Service Code
|
NDC 70069013101
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$20.92 |
| Rate for Payer: Aetna Commercial |
$18.83
|
| Rate for Payer: Aetna Medicare |
$10.46
|
| Rate for Payer: ASR ASR |
$20.29
|
| Rate for Payer: ASR Commercial |
$20.29
|
| Rate for Payer: BCBS Complete |
$8.37
|
| Rate for Payer: BCBS Trust/PPO |
$17.13
|
| Rate for Payer: BCN Commercial |
$16.22
|
| Rate for Payer: Cash Price |
$16.74
|
| Rate for Payer: Cofinity Commercial |
$19.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.74
|
| Rate for Payer: Healthscope Commercial |
$20.92
|
| Rate for Payer: Healthscope Whirlpool |
$20.29
|
| Rate for Payer: Mclaren Commercial |
$18.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.78
|
| Rate for Payer: Nomi Health Commercial |
$17.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.33
|
| Rate for Payer: Priority Health Narrow Network |
$14.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.41
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
|
OP
|
$37.84
|
|
|
Service Code
|
NDC 17478029010
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$37.84 |
| Rate for Payer: Aetna Commercial |
$34.06
|
| Rate for Payer: Aetna Medicare |
$18.92
|
| Rate for Payer: ASR ASR |
$36.70
|
| Rate for Payer: ASR Commercial |
$36.70
|
| Rate for Payer: BCBS Complete |
$15.14
|
| Rate for Payer: BCBS Trust/PPO |
$30.99
|
| Rate for Payer: BCN Commercial |
$29.34
|
| Rate for Payer: Cash Price |
$30.27
|
| Rate for Payer: Cofinity Commercial |
$35.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.27
|
| Rate for Payer: Healthscope Commercial |
$37.84
|
| Rate for Payer: Healthscope Whirlpool |
$36.70
|
| Rate for Payer: Mclaren Commercial |
$34.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.16
|
| Rate for Payer: Nomi Health Commercial |
$31.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33.16
|
| Rate for Payer: Priority Health Narrow Network |
$26.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.30
|
|
|
TOBRAMYCIN 0.3 % EYE OINTMENT
|
Facility
|
IP
|
$696.46
|
|
|
Service Code
|
NDC 00065064435
|
| Hospital Charge Code |
19769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$452.70 |
| Max. Negotiated Rate |
$696.46 |
| Rate for Payer: Aetna Commercial |
$626.81
|
| Rate for Payer: ASR ASR |
$675.57
|
| Rate for Payer: ASR Commercial |
$675.57
|
| Rate for Payer: BCBS Trust/PPO |
$567.55
|
| Rate for Payer: BCN Commercial |
$539.97
|
| Rate for Payer: Cash Price |
$557.17
|
| Rate for Payer: Cofinity Commercial |
$654.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.17
|
| Rate for Payer: Healthscope Commercial |
$696.46
|
| Rate for Payer: Healthscope Whirlpool |
$675.57
|
| Rate for Payer: Mclaren Commercial |
$626.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$591.99
|
| Rate for Payer: Nomi Health Commercial |
$571.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$452.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$612.88
|
|
|
TOBRAMYCIN 0.3 % EYE OINTMENT
|
Facility
|
OP
|
$696.46
|
|
|
Service Code
|
NDC 00065064435
|
| Hospital Charge Code |
19769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.58 |
| Max. Negotiated Rate |
$696.46 |
| Rate for Payer: Aetna Commercial |
$626.81
|
| Rate for Payer: Aetna Medicare |
$348.23
|
| Rate for Payer: ASR ASR |
$675.57
|
| Rate for Payer: ASR Commercial |
$675.57
|
| Rate for Payer: BCBS Complete |
$278.58
|
| Rate for Payer: BCBS Trust/PPO |
$570.33
|
| Rate for Payer: BCN Commercial |
$539.97
|
| Rate for Payer: Cash Price |
$557.17
|
| Rate for Payer: Cofinity Commercial |
$654.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.17
|
| Rate for Payer: Healthscope Commercial |
$696.46
|
| Rate for Payer: Healthscope Whirlpool |
$675.57
|
| Rate for Payer: Mclaren Commercial |
$626.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$591.99
|
| Rate for Payer: Nomi Health Commercial |
$571.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$452.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$610.24
|
| Rate for Payer: Priority Health Narrow Network |
$488.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$612.88
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION
|
Facility
|
OP
|
$141.84
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$141.84 |
| Rate for Payer: Aetna Commercial |
$127.66
|
| Rate for Payer: Aetna Medicare |
$70.92
|
| Rate for Payer: ASR ASR |
$137.58
|
| Rate for Payer: ASR Commercial |
$137.58
|
| Rate for Payer: BCBS Complete |
$56.74
|
| Rate for Payer: BCBS Trust/PPO |
$116.15
|
| Rate for Payer: BCN Commercial |
$109.97
|
| Rate for Payer: Cash Price |
$113.48
|
| Rate for Payer: Cash Price |
$113.48
|
| Rate for Payer: Cofinity Commercial |
$133.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.47
|
| Rate for Payer: Healthscope Commercial |
$141.84
|
| Rate for Payer: Healthscope Whirlpool |
$137.58
|
| Rate for Payer: Mclaren Commercial |
$127.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.56
|
| Rate for Payer: Nomi Health Commercial |
$116.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.66
|
| Rate for Payer: Priority Health Narrow Network |
$1.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.82
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$141.84
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.20 |
| Max. Negotiated Rate |
$141.84 |
| Rate for Payer: Aetna Commercial |
$127.66
|
| Rate for Payer: ASR ASR |
$137.58
|
| Rate for Payer: ASR Commercial |
$137.58
|
| Rate for Payer: BCBS Trust/PPO |
$115.59
|
| Rate for Payer: BCN Commercial |
$109.97
|
| Rate for Payer: Cash Price |
$113.48
|
| Rate for Payer: Cofinity Commercial |
$133.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.47
|
| Rate for Payer: Healthscope Commercial |
$141.84
|
| Rate for Payer: Healthscope Whirlpool |
$137.58
|
| Rate for Payer: Mclaren Commercial |
$127.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.56
|
| Rate for Payer: Nomi Health Commercial |
$116.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.82
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
OP
|
$215.65
|
|
|
Service Code
|
NDC 68084034211
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.26 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Aetna Commercial |
$194.08
|
| Rate for Payer: Aetna Medicare |
$107.82
|
| Rate for Payer: ASR ASR |
$209.18
|
| Rate for Payer: ASR Commercial |
$209.18
|
| Rate for Payer: BCBS Complete |
$86.26
|
| Rate for Payer: BCBS Trust/PPO |
$176.60
|
| Rate for Payer: BCN Commercial |
$167.19
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$202.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.52
|
| Rate for Payer: Healthscope Commercial |
$215.65
|
| Rate for Payer: Healthscope Whirlpool |
$209.18
|
| Rate for Payer: Mclaren Commercial |
$194.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$183.30
|
| Rate for Payer: Nomi Health Commercial |
$176.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$188.95
|
| Rate for Payer: Priority Health Narrow Network |
$151.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$189.77
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$195.70
|
|
|
Service Code
|
NDC 00904692861
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.20 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Aetna Commercial |
$176.13
|
| Rate for Payer: ASR ASR |
$189.83
|
| Rate for Payer: ASR Commercial |
$189.83
|
| Rate for Payer: BCBS Trust/PPO |
$159.48
|
| Rate for Payer: BCN Commercial |
$151.73
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Commercial |
$183.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Healthscope Commercial |
$195.70
|
| Rate for Payer: Healthscope Whirlpool |
$189.83
|
| Rate for Payer: Mclaren Commercial |
$176.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.34
|
| Rate for Payer: Nomi Health Commercial |
$160.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$127.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.22
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$215.65
|
|
|
Service Code
|
NDC 68084034211
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.17 |
| Max. Negotiated Rate |
$215.65 |
| Rate for Payer: Aetna Commercial |
$194.08
|
| Rate for Payer: ASR ASR |
$209.18
|
| Rate for Payer: ASR Commercial |
$209.18
|
| Rate for Payer: BCBS Trust/PPO |
$175.73
|
| Rate for Payer: BCN Commercial |
$167.19
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$202.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.52
|
| Rate for Payer: Healthscope Commercial |
$215.65
|
| Rate for Payer: Healthscope Whirlpool |
$209.18
|
| Rate for Payer: Mclaren Commercial |
$194.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$183.30
|
| Rate for Payer: Nomi Health Commercial |
$176.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$189.77
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
OP
|
$195.70
|
|
|
Service Code
|
NDC 00904692861
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.28 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Aetna Commercial |
$176.13
|
| Rate for Payer: Aetna Medicare |
$97.85
|
| Rate for Payer: ASR ASR |
$189.83
|
| Rate for Payer: ASR Commercial |
$189.83
|
| Rate for Payer: BCBS Complete |
$78.28
|
| Rate for Payer: BCBS Trust/PPO |
$160.26
|
| Rate for Payer: BCN Commercial |
$151.73
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Commercial |
$183.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Healthscope Commercial |
$195.70
|
| Rate for Payer: Healthscope Whirlpool |
$189.83
|
| Rate for Payer: Mclaren Commercial |
$176.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.34
|
| Rate for Payer: Nomi Health Commercial |
$160.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$127.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$171.47
|
| Rate for Payer: Priority Health Narrow Network |
$137.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.22
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
|
OP
|
$345.45
|
|
|
Service Code
|
NDC 31722053001
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.18 |
| Max. Negotiated Rate |
$345.45 |
| Rate for Payer: Aetna Commercial |
$310.90
|
| Rate for Payer: Aetna Medicare |
$172.72
|
| Rate for Payer: ASR ASR |
$335.09
|
| Rate for Payer: ASR Commercial |
$335.09
|
| Rate for Payer: BCBS Complete |
$138.18
|
| Rate for Payer: BCBS Trust/PPO |
$282.89
|
| Rate for Payer: BCN Commercial |
$267.83
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$324.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$345.45
|
| Rate for Payer: Healthscope Whirlpool |
$335.09
|
| Rate for Payer: Mclaren Commercial |
$310.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.63
|
| Rate for Payer: Nomi Health Commercial |
$283.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$302.68
|
| Rate for Payer: Priority Health Narrow Network |
$242.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$304.00
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
NDC 50111091601
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.00 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Aetna Commercial |
$427.50
|
| Rate for Payer: Aetna Medicare |
$237.50
|
| Rate for Payer: ASR ASR |
$460.75
|
| Rate for Payer: ASR Commercial |
$460.75
|
| Rate for Payer: BCBS Complete |
$190.00
|
| Rate for Payer: BCBS Trust/PPO |
$388.98
|
| Rate for Payer: BCN Commercial |
$368.27
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cofinity Commercial |
$446.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.00
|
| Rate for Payer: Healthscope Commercial |
$475.00
|
| Rate for Payer: Healthscope Whirlpool |
$460.75
|
| Rate for Payer: Mclaren Commercial |
$427.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.75
|
| Rate for Payer: Nomi Health Commercial |
$389.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$416.20
|
| Rate for Payer: Priority Health Narrow Network |
$332.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$418.00
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
|
OP
|
$2.09
|
|
|
Service Code
|
NDC 50268075511
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Aetna Commercial |
$1.88
|
| Rate for Payer: Aetna Medicare |
$1.04
|
| Rate for Payer: ASR ASR |
$2.03
|
| Rate for Payer: ASR Commercial |
$2.03
|
| Rate for Payer: BCBS Complete |
$0.84
|
| Rate for Payer: BCBS Trust/PPO |
$1.71
|
| Rate for Payer: BCN Commercial |
$1.62
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cofinity Commercial |
$1.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.67
|
| Rate for Payer: Healthscope Commercial |
$2.09
|
| Rate for Payer: Healthscope Whirlpool |
$2.03
|
| Rate for Payer: Mclaren Commercial |
$1.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.78
|
| Rate for Payer: Nomi Health Commercial |
$1.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.83
|
| Rate for Payer: Priority Health Narrow Network |
$1.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.84
|
|
|
TORSEMIDE 10 MG TABLET
|
Facility
|
IP
|
$104.50
|
|
|
Service Code
|
NDC 50268075515
|
| Hospital Charge Code |
18292
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.92 |
| Max. Negotiated Rate |
$104.50 |
| Rate for Payer: Aetna Commercial |
$94.05
|
| Rate for Payer: ASR ASR |
$101.36
|
| Rate for Payer: ASR Commercial |
$101.36
|
| Rate for Payer: BCBS Trust/PPO |
$85.16
|
| Rate for Payer: BCN Commercial |
$81.02
|
| Rate for Payer: Cash Price |
$83.60
|
| Rate for Payer: Cofinity Commercial |
$98.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.60
|
| Rate for Payer: Healthscope Commercial |
$104.50
|
| Rate for Payer: Healthscope Whirlpool |
$101.36
|
| Rate for Payer: Mclaren Commercial |
$94.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.82
|
| Rate for Payer: Nomi Health Commercial |
$85.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$91.96
|
|
