|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION
|
Facility
|
OP
|
$38.72
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
8120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$34.85 |
| Rate for Payer: Aetna Commercial |
$32.91
|
| Rate for Payer: Aetna Commercial |
$249.61
|
| Rate for Payer: Aetna Commercial |
$21.77
|
| Rate for Payer: Aetna Commercial |
$28.45
|
| Rate for Payer: Aetna Commercial |
$13.84
|
| Rate for Payer: Aetna Medicare |
$8.14
|
| Rate for Payer: Aetna Medicare |
$12.80
|
| Rate for Payer: Aetna Medicare |
$146.83
|
| Rate for Payer: Aetna Medicare |
$19.36
|
| Rate for Payer: Aetna Medicare |
$16.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.58
|
| Rate for Payer: BCBS Complete |
$15.49
|
| Rate for Payer: BCBS Complete |
$10.24
|
| Rate for Payer: BCBS Complete |
$117.46
|
| Rate for Payer: BCBS Complete |
$6.51
|
| Rate for Payer: BCBS Complete |
$13.39
|
| Rate for Payer: BCBS Trust/PPO |
$1.85
|
| Rate for Payer: BCBS Trust/PPO |
$1.85
|
| Rate for Payer: BCBS Trust/PPO |
$1.85
|
| Rate for Payer: BCBS Trust/PPO |
$1.85
|
| Rate for Payer: BCBS Trust/PPO |
$1.85
|
| Rate for Payer: BCN Commercial |
$1.85
|
| Rate for Payer: BCN Commercial |
$1.85
|
| Rate for Payer: BCN Commercial |
$1.85
|
| Rate for Payer: BCN Commercial |
$1.85
|
| Rate for Payer: BCN Commercial |
$1.85
|
| Rate for Payer: Cash Price |
$26.78
|
| Rate for Payer: Cash Price |
$20.49
|
| Rate for Payer: Cash Price |
$13.02
|
| Rate for Payer: Cash Price |
$13.02
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Cash Price |
$20.49
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Cash Price |
$26.78
|
| Rate for Payer: Cash Price |
$30.98
|
| Rate for Payer: Cash Price |
$30.98
|
| Rate for Payer: Cofinity Advantage |
$27.10
|
| Rate for Payer: Cofinity Advantage |
$23.43
|
| Rate for Payer: Cofinity Advantage |
$17.93
|
| Rate for Payer: Cofinity Advantage |
$11.40
|
| Rate for Payer: Cofinity Advantage |
$205.56
|
| Rate for Payer: Cofinity Commercial |
$252.55
|
| Rate for Payer: Cofinity Commercial |
$22.02
|
| Rate for Payer: Cofinity Commercial |
$28.78
|
| Rate for Payer: Cofinity Commercial |
$33.30
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.49
|
| Rate for Payer: Healthscope Commercial |
$23.05
|
| Rate for Payer: Healthscope Commercial |
$34.85
|
| Rate for Payer: Healthscope Commercial |
$30.12
|
| Rate for Payer: Healthscope Commercial |
$264.29
|
| Rate for Payer: Healthscope Commercial |
$14.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$234.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$220.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.10
|
| Rate for Payer: PHP Commercial |
$249.61
|
| Rate for Payer: PHP Commercial |
$21.77
|
| Rate for Payer: PHP Commercial |
$13.84
|
| Rate for Payer: PHP Commercial |
$32.91
|
| Rate for Payer: PHP Commercial |
$28.45
|
| Rate for Payer: Priority Health SBD |
$185.01
|
| Rate for Payer: Priority Health SBD |
$21.09
|
| Rate for Payer: Priority Health SBD |
$24.39
|
| Rate for Payer: Priority Health SBD |
$16.13
|
| Rate for Payer: Priority Health SBD |
$10.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.22
|
| Rate for Payer: UHC Core |
$1.22
|
| Rate for Payer: UHC Core |
$1.22
|
| Rate for Payer: UHC Core |
$1.22
|
| Rate for Payer: UHC Core |
$1.22
|
| Rate for Payer: UHC Core |
$1.22
|
| Rate for Payer: UHC Exchange |
$1.22
|
| Rate for Payer: UHC Exchange |
$1.22
|
| Rate for Payer: UHC Exchange |
$1.22
|
| Rate for Payer: UHC Exchange |
$1.22
|
| Rate for Payer: UHC Exchange |
$1.22
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
NDC 00527163201
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.30 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna Medicare |
$164.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: BCBS Complete |
$131.60
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Advantage |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$263.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.75
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health SBD |
$207.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.85
|
| Rate for Payer: UHC Core |
$171.41
|
| Rate for Payer: UHC Exchange |
$129.30
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
NDC 00527163201
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.27 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Advantage |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.75
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health SBD |
$207.27
|
|
|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
|
OP
|
$695.08
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
11595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.17 |
| Max. Negotiated Rate |
$625.57 |
| Rate for Payer: Aetna Commercial |
$590.82
|
| Rate for Payer: Aetna Medicare |
$347.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$451.80
|
| Rate for Payer: BCBS Complete |
$278.03
|
| Rate for Payer: Cash Price |
$556.06
|
| Rate for Payer: Cofinity Advantage |
$486.56
|
| Rate for Payer: Cofinity Commercial |
$597.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$556.06
|
| Rate for Payer: Healthscope Commercial |
$625.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$556.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$590.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$521.31
|
| Rate for Payer: PHP Commercial |
$590.82
|
| Rate for Payer: Priority Health SBD |
$437.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$451.80
|
| Rate for Payer: UHC Core |
$362.14
|
| Rate for Payer: UHC Exchange |
$273.17
|
|
|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
|
IP
|
$695.08
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
11595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$437.90 |
| Max. Negotiated Rate |
$625.57 |
| Rate for Payer: Aetna Commercial |
$590.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$451.80
|
| Rate for Payer: Cash Price |
$556.06
|
| Rate for Payer: Cofinity Advantage |
$486.56
|
| Rate for Payer: Cofinity Commercial |
$597.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$556.06
|
| Rate for Payer: Healthscope Commercial |
$625.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$590.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$521.31
|
| Rate for Payer: PHP Commercial |
$590.82
|
| Rate for Payer: Priority Health SBD |
$437.90
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
NDC 00591533501
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.30 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna Medicare |
$164.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: BCBS Complete |
$131.60
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Advantage |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$263.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.75
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health SBD |
$207.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.85
|
| Rate for Payer: UHC Core |
$171.41
|
| Rate for Payer: UHC Exchange |
$129.30
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
NDC 00591533501
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.27 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Advantage |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.75
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health SBD |
$207.27
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
OP
|
$336.05
|
|
|
Service Code
|
NDC 69452024120
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.07 |
| Max. Negotiated Rate |
$302.44 |
| Rate for Payer: Aetna Commercial |
$285.64
|
| Rate for Payer: Aetna Medicare |
$168.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.43
|
| Rate for Payer: BCBS Complete |
$134.42
|
| Rate for Payer: Cash Price |
$268.84
|
| Rate for Payer: Cofinity Advantage |
$235.24
|
| Rate for Payer: Cofinity Commercial |
$289.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.84
|
| Rate for Payer: Healthscope Commercial |
$302.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$268.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.04
|
| Rate for Payer: PHP Commercial |
$285.64
|
| Rate for Payer: Priority Health SBD |
$211.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$218.43
|
| Rate for Payer: UHC Core |
$175.08
|
| Rate for Payer: UHC Exchange |
$132.07
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
IP
|
$336.05
|
|
|
Service Code
|
NDC 69452024120
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$211.71 |
| Max. Negotiated Rate |
$302.44 |
| Rate for Payer: Aetna Commercial |
$285.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.43
|
| Rate for Payer: Cash Price |
$268.84
|
| Rate for Payer: Cofinity Advantage |
$235.24
|
| Rate for Payer: Cofinity Commercial |
$289.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.84
|
| Rate for Payer: Healthscope Commercial |
$302.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.04
|
| Rate for Payer: PHP Commercial |
$285.64
|
| Rate for Payer: Priority Health SBD |
$211.71
|
|
|
TRILACICLIB 300 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$7,242.51
|
|
|
Service Code
|
HCPCS J1448
|
| Hospital Charge Code |
196299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$6,518.26 |
| Rate for Payer: Aetna Commercial |
$6,156.13
|
| Rate for Payer: Aetna Medicare |
$5.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,707.63
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.86
|
| Rate for Payer: BCBS Complete |
$3.02
|
| Rate for Payer: BCBS MAPPO |
$5.49
|
| Rate for Payer: BCBS Trust/PPO |
$13.59
|
| Rate for Payer: BCN Commercial |
$13.59
|
| Rate for Payer: BCN Medicare Advantage |
$5.49
|
| Rate for Payer: Cash Price |
$5,794.01
|
| Rate for Payer: Cash Price |
$5,794.01
|
| Rate for Payer: Cofinity Advantage |
$5,069.76
|
| Rate for Payer: Cofinity Commercial |
$6,228.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,794.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.49
|
| Rate for Payer: Healthscope Commercial |
$6,518.26
|
| Rate for Payer: Mclaren Medicaid |
$2.87
|
| Rate for Payer: Mclaren Medicare |
$5.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.76
|
| Rate for Payer: Meridian Medicaid |
$5.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.31
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,156.13
|
| Rate for Payer: Nomi Health Commercial |
$16.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,431.88
|
| Rate for Payer: PACE Medicare |
$5.22
|
| Rate for Payer: PACE SWMI |
$5.49
|
| Rate for Payer: PHP Commercial |
$6,156.13
|
| Rate for Payer: PHP Medicare Advantage |
$5.49
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$17.24
|
| Rate for Payer: Priority Health Medicare |
$5.49
|
| Rate for Payer: Priority Health SBD |
$4,562.78
|
| Rate for Payer: Priority Health Tiered Network |
$13.79
|
| Rate for Payer: Railroad Medicare Medicare |
$5.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.94
|
| Rate for Payer: UHC Core |
$8.94
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5.49
|
| Rate for Payer: UHC Exchange |
$8.94
|
| Rate for Payer: UHC Medicaid |
$2.87
|
| Rate for Payer: UHCCP Medicaid |
$2.87
|
| Rate for Payer: VA VA |
$5.49
|
|
|
TRILACICLIB 300 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$7,242.51
|
|
|
Service Code
|
HCPCS J1448
|
| Hospital Charge Code |
196299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,562.78 |
| Max. Negotiated Rate |
$6,518.26 |
| Rate for Payer: Aetna Commercial |
$6,156.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,707.63
|
| Rate for Payer: Cash Price |
$5,794.01
|
| Rate for Payer: Cofinity Advantage |
$5,069.76
|
| Rate for Payer: Cofinity Commercial |
$6,228.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,794.01
|
| Rate for Payer: Healthscope Commercial |
$6,518.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,156.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,431.88
|
| Rate for Payer: PHP Commercial |
$6,156.13
|
| Rate for Payer: Priority Health SBD |
$4,562.78
|
|
|
TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$200.51
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
108755
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.20 |
| Max. Negotiated Rate |
$180.46 |
| Rate for Payer: Aetna Commercial |
$170.43
|
| Rate for Payer: Aetna Medicare |
$100.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.33
|
| Rate for Payer: BCBS Complete |
$80.20
|
| Rate for Payer: BCBS Trust/PPO |
$144.49
|
| Rate for Payer: BCN Commercial |
$144.49
|
| Rate for Payer: Cash Price |
$160.41
|
| Rate for Payer: Cash Price |
$160.41
|
| Rate for Payer: Cofinity Advantage |
$140.36
|
| Rate for Payer: Cofinity Commercial |
$172.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.41
|
| Rate for Payer: Healthscope Commercial |
$180.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$160.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$150.38
|
| Rate for Payer: PHP Commercial |
$170.43
|
| Rate for Payer: Priority Health SBD |
$126.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$95.04
|
| Rate for Payer: UHC Core |
$95.04
|
| Rate for Payer: UHC Exchange |
$95.04
|
|
|
TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$200.51
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
108755
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.32 |
| Max. Negotiated Rate |
$180.46 |
| Rate for Payer: Aetna Commercial |
$170.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.33
|
| Rate for Payer: Cash Price |
$160.41
|
| Rate for Payer: Cofinity Advantage |
$140.36
|
| Rate for Payer: Cofinity Commercial |
$172.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.41
|
| Rate for Payer: Healthscope Commercial |
$180.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$150.38
|
| Rate for Payer: PHP Commercial |
$170.43
|
| Rate for Payer: Priority Health SBD |
$126.32
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
|
OP
|
$630.72
|
|
|
Service Code
|
NDC 75907004301
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.87 |
| Max. Negotiated Rate |
$567.65 |
| Rate for Payer: Aetna Commercial |
$536.11
|
| Rate for Payer: Aetna Medicare |
$315.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.97
|
| Rate for Payer: BCBS Complete |
$252.29
|
| Rate for Payer: Cash Price |
$504.58
|
| Rate for Payer: Cofinity Advantage |
$441.50
|
| Rate for Payer: Cofinity Commercial |
$542.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$504.58
|
| Rate for Payer: Healthscope Commercial |
$567.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$504.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$473.04
|
| Rate for Payer: PHP Commercial |
$536.11
|
| Rate for Payer: Priority Health SBD |
$397.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$409.97
|
| Rate for Payer: UHC Core |
$328.61
|
| Rate for Payer: UHC Exchange |
$247.87
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
|
IP
|
$630.72
|
|
|
Service Code
|
NDC 75907004301
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$397.35 |
| Max. Negotiated Rate |
$567.65 |
| Rate for Payer: Aetna Commercial |
$536.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.97
|
| Rate for Payer: Cash Price |
$504.58
|
| Rate for Payer: Cofinity Advantage |
$441.50
|
| Rate for Payer: Cofinity Commercial |
$542.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$504.58
|
| Rate for Payer: Healthscope Commercial |
$567.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$473.04
|
| Rate for Payer: PHP Commercial |
$536.11
|
| Rate for Payer: Priority Health SBD |
$397.35
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
|
OP
|
$595.68
|
|
|
Service Code
|
NDC 51862048601
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.10 |
| Max. Negotiated Rate |
$536.11 |
| Rate for Payer: Aetna Commercial |
$506.33
|
| Rate for Payer: Aetna Medicare |
$297.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.19
|
| Rate for Payer: BCBS Complete |
$238.27
|
| Rate for Payer: Cash Price |
$476.54
|
| Rate for Payer: Cofinity Advantage |
$416.98
|
| Rate for Payer: Cofinity Commercial |
$512.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.54
|
| Rate for Payer: Healthscope Commercial |
$536.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$476.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$446.76
|
| Rate for Payer: PHP Commercial |
$506.33
|
| Rate for Payer: Priority Health SBD |
$375.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$387.19
|
| Rate for Payer: UHC Core |
$310.35
|
| Rate for Payer: UHC Exchange |
$234.10
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
|
IP
|
$595.68
|
|
|
Service Code
|
NDC 51862048601
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$375.28 |
| Max. Negotiated Rate |
$536.11 |
| Rate for Payer: Aetna Commercial |
$506.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.19
|
| Rate for Payer: Cash Price |
$476.54
|
| Rate for Payer: Cofinity Advantage |
$416.98
|
| Rate for Payer: Cofinity Commercial |
$512.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.54
|
| Rate for Payer: Healthscope Commercial |
$536.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$446.76
|
| Rate for Payer: PHP Commercial |
$506.33
|
| Rate for Payer: Priority Health SBD |
$375.28
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION
|
Facility
|
OP
|
$11,294.60
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$245.49 |
| Max. Negotiated Rate |
$10,165.14 |
| Rate for Payer: Aetna Commercial |
$9,600.41
|
| Rate for Payer: Aetna Medicare |
$488.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,341.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$586.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$586.73
|
| Rate for Payer: BCBS Complete |
$257.78
|
| Rate for Payer: BCBS MAPPO |
$469.38
|
| Rate for Payer: BCBS Trust/PPO |
$1,162.08
|
| Rate for Payer: BCN Commercial |
$1,162.08
|
| Rate for Payer: BCN Medicare Advantage |
$469.38
|
| Rate for Payer: Cash Price |
$9,035.68
|
| Rate for Payer: Cash Price |
$9,035.68
|
| Rate for Payer: Cofinity Advantage |
$7,906.22
|
| Rate for Payer: Cofinity Commercial |
$9,713.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,035.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$469.38
|
| Rate for Payer: Healthscope Commercial |
$10,165.14
|
| Rate for Payer: Mclaren Medicaid |
$245.49
|
| Rate for Payer: Mclaren Medicare |
$469.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$492.85
|
| Rate for Payer: Meridian Medicaid |
$492.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$539.79
|
| Rate for Payer: Molina Medicare/Medicaid |
$516.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,600.41
|
| Rate for Payer: Nomi Health Commercial |
$1,408.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8,470.95
|
| Rate for Payer: PACE Medicare |
$445.91
|
| Rate for Payer: PACE SWMI |
$469.38
|
| Rate for Payer: PHP Commercial |
$9,600.41
|
| Rate for Payer: PHP Medicare Advantage |
$469.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$245.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,497.62
|
| Rate for Payer: Priority Health Medicare |
$469.38
|
| Rate for Payer: Priority Health SBD |
$7,115.60
|
| Rate for Payer: Priority Health Tiered Network |
$1,198.10
|
| Rate for Payer: Railroad Medicare Medicare |
$469.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$764.28
|
| Rate for Payer: UHC Core |
$764.28
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$469.38
|
| Rate for Payer: UHC Exchange |
$764.28
|
| Rate for Payer: UHC Medicaid |
$245.49
|
| Rate for Payer: UHCCP Medicaid |
$245.49
|
| Rate for Payer: VA VA |
$469.38
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION
|
Facility
|
IP
|
$11,294.60
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,115.60 |
| Max. Negotiated Rate |
$10,165.14 |
| Rate for Payer: Aetna Commercial |
$9,600.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,341.49
|
| Rate for Payer: Cash Price |
$9,035.68
|
| Rate for Payer: Cofinity Advantage |
$7,906.22
|
| Rate for Payer: Cofinity Commercial |
$9,713.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,035.68
|
| Rate for Payer: Healthscope Commercial |
$10,165.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,600.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8,470.95
|
| Rate for Payer: PHP Commercial |
$9,600.41
|
| Rate for Payer: Priority Health SBD |
$7,115.60
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION
|
Facility
|
OP
|
$18,614.70
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
119655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$245.49 |
| Max. Negotiated Rate |
$16,753.23 |
| Rate for Payer: Aetna Commercial |
$15,822.50
|
| Rate for Payer: Aetna Medicare |
$488.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,099.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$586.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$586.73
|
| Rate for Payer: BCBS Complete |
$257.78
|
| Rate for Payer: BCBS MAPPO |
$469.38
|
| Rate for Payer: BCBS Trust/PPO |
$1,162.08
|
| Rate for Payer: BCN Commercial |
$1,162.08
|
| Rate for Payer: BCN Medicare Advantage |
$469.38
|
| Rate for Payer: Cash Price |
$14,891.76
|
| Rate for Payer: Cash Price |
$14,891.76
|
| Rate for Payer: Cofinity Advantage |
$13,030.29
|
| Rate for Payer: Cofinity Commercial |
$16,008.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14,891.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$469.38
|
| Rate for Payer: Healthscope Commercial |
$16,753.23
|
| Rate for Payer: Mclaren Medicaid |
$245.49
|
| Rate for Payer: Mclaren Medicare |
$469.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$492.85
|
| Rate for Payer: Meridian Medicaid |
$492.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$539.79
|
| Rate for Payer: Molina Medicare/Medicaid |
$516.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15,822.50
|
| Rate for Payer: Nomi Health Commercial |
$1,408.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13,961.02
|
| Rate for Payer: PACE Medicare |
$445.91
|
| Rate for Payer: PACE SWMI |
$469.38
|
| Rate for Payer: PHP Commercial |
$15,822.50
|
| Rate for Payer: PHP Medicare Advantage |
$469.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$245.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,497.62
|
| Rate for Payer: Priority Health Medicare |
$469.38
|
| Rate for Payer: Priority Health SBD |
$11,727.26
|
| Rate for Payer: Priority Health Tiered Network |
$1,198.10
|
| Rate for Payer: Railroad Medicare Medicare |
$469.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$764.28
|
| Rate for Payer: UHC Core |
$764.28
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$469.38
|
| Rate for Payer: UHC Exchange |
$764.28
|
| Rate for Payer: UHC Medicaid |
$245.49
|
| Rate for Payer: UHCCP Medicaid |
$245.49
|
| Rate for Payer: VA VA |
$469.38
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
|
IP
|
$2,683.20
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
28558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,690.42 |
| Max. Negotiated Rate |
$2,414.88 |
| Rate for Payer: Aetna Commercial |
$2,280.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,744.08
|
| Rate for Payer: Cash Price |
$2,146.56
|
| Rate for Payer: Cofinity Advantage |
$1,878.24
|
| Rate for Payer: Cofinity Commercial |
$2,307.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,146.56
|
| Rate for Payer: Healthscope Commercial |
$2,414.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,280.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,012.40
|
| Rate for Payer: PHP Commercial |
$2,280.72
|
| Rate for Payer: Priority Health SBD |
$1,690.42
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
|
OP
|
$2,683.20
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
28558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$245.49 |
| Max. Negotiated Rate |
$2,414.88 |
| Rate for Payer: Aetna Commercial |
$2,280.72
|
| Rate for Payer: Aetna Medicare |
$488.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,744.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$586.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$586.73
|
| Rate for Payer: BCBS Complete |
$257.78
|
| Rate for Payer: BCBS MAPPO |
$469.38
|
| Rate for Payer: BCBS Trust/PPO |
$1,162.08
|
| Rate for Payer: BCN Commercial |
$1,162.08
|
| Rate for Payer: BCN Medicare Advantage |
$469.38
|
| Rate for Payer: Cash Price |
$2,146.56
|
| Rate for Payer: Cash Price |
$2,146.56
|
| Rate for Payer: Cofinity Advantage |
$1,878.24
|
| Rate for Payer: Cofinity Commercial |
$2,307.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,146.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$469.38
|
| Rate for Payer: Healthscope Commercial |
$2,414.88
|
| Rate for Payer: Mclaren Medicaid |
$245.49
|
| Rate for Payer: Mclaren Medicare |
$469.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$492.85
|
| Rate for Payer: Meridian Medicaid |
$492.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$539.79
|
| Rate for Payer: Molina Medicare/Medicaid |
$516.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,280.72
|
| Rate for Payer: Nomi Health Commercial |
$1,408.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,012.40
|
| Rate for Payer: PACE Medicare |
$445.91
|
| Rate for Payer: PACE SWMI |
$469.38
|
| Rate for Payer: PHP Commercial |
$2,280.72
|
| Rate for Payer: PHP Medicare Advantage |
$469.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$245.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,497.62
|
| Rate for Payer: Priority Health Medicare |
$469.38
|
| Rate for Payer: Priority Health SBD |
$1,690.42
|
| Rate for Payer: Priority Health Tiered Network |
$1,198.10
|
| Rate for Payer: Railroad Medicare Medicare |
$469.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$764.28
|
| Rate for Payer: UHC Core |
$764.28
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$469.38
|
| Rate for Payer: UHC Exchange |
$764.28
|
| Rate for Payer: UHC Medicaid |
$245.49
|
| Rate for Payer: UHCCP Medicaid |
$245.49
|
| Rate for Payer: VA VA |
$469.38
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
IP
|
$26.20
|
|
|
Service Code
|
NDC 17478010212
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Advantage |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.65
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health SBD |
$16.51
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$26.20
|
|
|
Service Code
|
NDC 17478010212
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.30 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna Commercial |
$22.27
|
| Rate for Payer: Aetna Medicare |
$13.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.03
|
| Rate for Payer: BCBS Complete |
$10.48
|
| Rate for Payer: Cash Price |
$20.96
|
| Rate for Payer: Cofinity Advantage |
$18.34
|
| Rate for Payer: Cofinity Commercial |
$22.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.65
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health SBD |
$16.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.03
|
| Rate for Payer: UHC Core |
$13.65
|
| Rate for Payer: UHC Exchange |
$10.30
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$33.71
|
|
|
Service Code
|
NDC 61314035501
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$30.34 |
| Rate for Payer: Aetna Commercial |
$28.65
|
| Rate for Payer: Aetna Medicare |
$16.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.91
|
| Rate for Payer: BCBS Complete |
$13.48
|
| Rate for Payer: Cash Price |
$26.97
|
| Rate for Payer: Cofinity Advantage |
$23.60
|
| Rate for Payer: Cofinity Commercial |
$28.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.97
|
| Rate for Payer: Healthscope Commercial |
$30.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.28
|
| Rate for Payer: PHP Commercial |
$28.65
|
| Rate for Payer: Priority Health SBD |
$21.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.91
|
| Rate for Payer: UHC Core |
$17.56
|
| Rate for Payer: UHC Exchange |
$13.25
|
|
