Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

TIZANIDINE 4 MG TABLET

Facility

$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

$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

$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

TIZANIDINE 4 MG TABLET

Facility

$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	$198.07
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

$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

TIZANIDINE 4 MG TABLET

Facility

$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

$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

$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

$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

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION

Facility

$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

$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

$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

$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

$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 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION

Facility

$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 % EYE DROPS

Facility

$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

$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

$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 DROPS

Facility

$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

$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

$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 OINTMENT

Facility

$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 0.3 % EYE OINTMENT

Facility

$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 1.2 GRAM SOLUTION FOR INJECTION

Facility

$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

TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION

Facility

$141.84

Service Code	HCPCS J3260
Hospital Charge Code	11565
Hospital Revenue Code	636
Min. Negotiated Rate	$56.74
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: 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	$124.28
Rate for Payer: Priority Health Narrow Network	$99.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$124.82

Know your out-of-pocket cost for care.

All Charges