Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

TRIFLURIDINE 1 % EYE DROPS

Facility

$637.98

Service Code	NDC 61314004475
Hospital Charge Code	11595
Hospital Revenue Code	637
Min. Negotiated Rate	$255.19
Max. Negotiated Rate	$574.18
Rate for Payer: Aetna Commercial	$542.28
Rate for Payer: Aetna Medicare	$318.99
Rate for Payer: Aetna New Business (MI Preferred)	$414.69
Rate for Payer: BCBS Complete	$255.19
Rate for Payer: Cash Price	$510.38
Rate for Payer: Cofinity Commercial	$446.59
Rate for Payer: Cofinity Commercial	$548.66
Rate for Payer: Cofinity Medicare Advantage	$446.59
Rate for Payer: Encore Health Key Benefits Commercial	$510.38
Rate for Payer: Healthscope Commercial	$574.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$542.28
Rate for Payer: PHP Commercial	$542.28
Rate for Payer: Priority Health Cigna Priority Health	$414.69
Rate for Payer: Priority Health SBD	$401.93

TRIFLURIDINE 1 % EYE DROPS

Facility

$637.98

Service Code	NDC 61314004475
Hospital Charge Code	11595
Hospital Revenue Code	637
Min. Negotiated Rate	$401.93
Max. Negotiated Rate	$574.18
Rate for Payer: Aetna Commercial	$542.28
Rate for Payer: Aetna New Business (MI Preferred)	$414.69
Rate for Payer: Cash Price	$510.38
Rate for Payer: Cofinity Commercial	$446.59
Rate for Payer: Cofinity Commercial	$548.66
Rate for Payer: Cofinity Medicare Advantage	$446.59
Rate for Payer: Encore Health Key Benefits Commercial	$510.38
Rate for Payer: Healthscope Commercial	$574.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$542.28
Rate for Payer: PHP Commercial	$542.28
Rate for Payer: Priority Health Cigna Priority Health	$414.69
Rate for Payer: Priority Health SBD	$401.93

TRIHEXYPHENIDYL 2 MG TABLET

Facility

$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 Commercial	$235.24
Rate for Payer: Cofinity Commercial	$289.00
Rate for Payer: Cofinity Medicare Advantage	$235.24
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: PHP Commercial	$285.64
Rate for Payer: Priority Health Cigna Priority Health	$218.43
Rate for Payer: Priority Health SBD	$211.71

TRIHEXYPHENIDYL 2 MG TABLET

Facility

$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 Commercial	$230.30
Rate for Payer: Cofinity Commercial	$282.94
Rate for Payer: Cofinity Medicare Advantage	$230.30
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: PHP Commercial	$279.65
Rate for Payer: Priority Health Cigna Priority Health	$213.85
Rate for Payer: Priority Health SBD	$207.27

TRIHEXYPHENIDYL 2 MG TABLET

Facility

$329.00

Service Code	NDC 00591533501
Hospital Charge Code	8166
Hospital Revenue Code	637
Min. Negotiated Rate	$131.60
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 Commercial	$230.30
Rate for Payer: Cofinity Commercial	$282.94
Rate for Payer: Cofinity Medicare Advantage	$230.30
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: PHP Commercial	$279.65
Rate for Payer: Priority Health Cigna Priority Health	$213.85
Rate for Payer: Priority Health SBD	$207.27

TRIHEXYPHENIDYL 2 MG TABLET

Facility

$336.05

Service Code	NDC 69452024120
Hospital Charge Code	8166
Hospital Revenue Code	637
Min. Negotiated Rate	$134.42
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 Commercial	$235.24
Rate for Payer: Cofinity Commercial	$289.00
Rate for Payer: Cofinity Medicare Advantage	$235.24
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: PHP Commercial	$285.64
Rate for Payer: Priority Health Cigna Priority Health	$218.43
Rate for Payer: Priority Health SBD	$211.71

TRILACICLIB 300 MG INTRAVENOUS SOLUTION

Facility

$7,022.36

Service Code	HCPCS J1448
Hospital Charge Code	196299
Hospital Revenue Code	636
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$6,320.12
Rate for Payer: Aetna Commercial	$5,969.01
Rate for Payer: Aetna Medicare	$5.68
Rate for Payer: Aetna New Business (MI Preferred)	$4,564.53
Rate for Payer: Allen County Amish Medical Aid Commercial	$6.83
Rate for Payer: Amish Plain Church Group Commercial	$6.83
Rate for Payer: BCBS Complete	$3.07
Rate for Payer: BCBS MAPPO	$5.46
Rate for Payer: BCN Medicare Advantage	$5.46
Rate for Payer: Cash Price	$5,617.89
Rate for Payer: Cash Price	$5,617.89
Rate for Payer: Cofinity Commercial	$6,039.23
Rate for Payer: Cofinity Commercial	$4,915.65
Rate for Payer: Cofinity Medicare Advantage	$4,915.65
Rate for Payer: Encore Health Key Benefits Commercial	$5,617.89
Rate for Payer: Health Alliance Plan Medicare Advantage	$5.46
Rate for Payer: Healthscope Commercial	$6,320.12
Rate for Payer: Mclaren Medicaid	$2.93
Rate for Payer: Mclaren Medicare	$5.46
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5.73
Rate for Payer: Meridian Medicaid	$3.07
Rate for Payer: MI Amish Medical Board Commercial	$6.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,969.01
Rate for Payer: PACE Medicare	$5.19
Rate for Payer: PACE SWMI	$5.46
Rate for Payer: PHP Commercial	$5,969.01
Rate for Payer: PHP Medicare Advantage	$5.46
Rate for Payer: Priority Health Choice Medicaid	$2.93
Rate for Payer: Priority Health Cigna Priority Health	$4,564.53
Rate for Payer: Priority Health Medicare	$5.46
Rate for Payer: Priority Health SBD	$4,424.09
Rate for Payer: Railroad Medicare Medicare	$5.46
Rate for Payer: UHC All Payor (Choice/PPO)	$15.37
Rate for Payer: UHC Dual Complete DSNP	$5.46
Rate for Payer: UHC Medicare Advantage	$5.46
Rate for Payer: UHCCP Medicaid	$3.07
Rate for Payer: VA VA	$5.46

TRILACICLIB 300 MG INTRAVENOUS SOLUTION

Facility

$7,022.36

Service Code	HCPCS J1448
Hospital Charge Code	196299
Hospital Revenue Code	636
Min. Negotiated Rate	$4,424.09
Max. Negotiated Rate	$6,320.12
Rate for Payer: Aetna Commercial	$5,969.01
Rate for Payer: Aetna New Business (MI Preferred)	$4,564.53
Rate for Payer: Cash Price	$5,617.89
Rate for Payer: Cofinity Commercial	$4,915.65
Rate for Payer: Cofinity Commercial	$6,039.23
Rate for Payer: Cofinity Medicare Advantage	$4,915.65
Rate for Payer: Encore Health Key Benefits Commercial	$5,617.89
Rate for Payer: Healthscope Commercial	$6,320.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,969.01
Rate for Payer: PHP Commercial	$5,969.01
Rate for Payer: Priority Health Cigna Priority Health	$4,564.53
Rate for Payer: Priority Health SBD	$4,424.09

TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION

Facility

$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: Cash Price	$160.41
Rate for Payer: Cofinity Commercial	$140.36
Rate for Payer: Cofinity Commercial	$172.44
Rate for Payer: Cofinity Medicare Advantage	$140.36
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: PHP Commercial	$170.43
Rate for Payer: Priority Health Cigna Priority Health	$130.33
Rate for Payer: Priority Health SBD	$126.32

TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION

Facility

$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 Commercial	$140.36
Rate for Payer: Cofinity Commercial	$172.44
Rate for Payer: Cofinity Medicare Advantage	$140.36
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: PHP Commercial	$170.43
Rate for Payer: Priority Health Cigna Priority Health	$130.33
Rate for Payer: Priority Health SBD	$126.32

TRIMETHOPRIM 100 MG TABLET

Facility

$595.68

Service Code	NDC 75907004301
Hospital Charge Code	8182
Hospital Revenue Code	637
Min. Negotiated Rate	$238.27
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 Commercial	$416.98
Rate for Payer: Cofinity Commercial	$512.28
Rate for Payer: Cofinity Medicare Advantage	$416.98
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: PHP Commercial	$506.33
Rate for Payer: Priority Health Cigna Priority Health	$387.19
Rate for Payer: Priority Health SBD	$375.28

TRIMETHOPRIM 100 MG TABLET

Facility

$595.68

Service Code	NDC 51862048601
Hospital Charge Code	8182
Hospital Revenue Code	637
Min. Negotiated Rate	$238.27
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 Commercial	$416.98
Rate for Payer: Cofinity Commercial	$512.28
Rate for Payer: Cofinity Medicare Advantage	$416.98
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: PHP Commercial	$506.33
Rate for Payer: Priority Health Cigna Priority Health	$387.19
Rate for Payer: Priority Health SBD	$375.28

TRIMETHOPRIM 100 MG TABLET

Facility

$595.68

Service Code	NDC 75907004301
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 Commercial	$416.98
Rate for Payer: Cofinity Commercial	$512.28
Rate for Payer: Cofinity Medicare Advantage	$416.98
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: PHP Commercial	$506.33
Rate for Payer: Priority Health Cigna Priority Health	$387.19
Rate for Payer: Priority Health SBD	$375.28

TRIMETHOPRIM 100 MG TABLET

Facility

$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 Commercial	$416.98
Rate for Payer: Cofinity Commercial	$512.28
Rate for Payer: Cofinity Medicare Advantage	$416.98
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: PHP Commercial	$506.33
Rate for Payer: Priority Health Cigna Priority Health	$387.19
Rate for Payer: Priority Health SBD	$375.28

TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION

Facility

$10,506.60

Service Code	HCPCS J3315
Hospital Charge Code	31708
Hospital Revenue Code	636
Min. Negotiated Rate	$254.51
Max. Negotiated Rate	$9,455.94
Rate for Payer: Aetna Commercial	$8,930.61
Rate for Payer: Aetna Medicare	$493.83
Rate for Payer: Aetna New Business (MI Preferred)	$6,829.29
Rate for Payer: Allen County Amish Medical Aid Commercial	$593.55
Rate for Payer: Amish Plain Church Group Commercial	$593.55
Rate for Payer: BCBS Complete	$267.24
Rate for Payer: BCBS MAPPO	$474.84
Rate for Payer: BCN Medicare Advantage	$474.84
Rate for Payer: Cash Price	$8,405.28
Rate for Payer: Cash Price	$8,405.28
Rate for Payer: Cofinity Commercial	$9,035.68
Rate for Payer: Cofinity Commercial	$7,354.62
Rate for Payer: Cofinity Medicare Advantage	$7,354.62
Rate for Payer: Encore Health Key Benefits Commercial	$8,405.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$474.84
Rate for Payer: Healthscope Commercial	$9,455.94
Rate for Payer: Mclaren Medicaid	$254.51
Rate for Payer: Mclaren Medicare	$474.84
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$498.58
Rate for Payer: Meridian Medicaid	$267.24
Rate for Payer: MI Amish Medical Board Commercial	$546.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8,930.61
Rate for Payer: PACE Medicare	$451.10
Rate for Payer: PACE SWMI	$474.84
Rate for Payer: PHP Commercial	$8,930.61
Rate for Payer: PHP Medicare Advantage	$474.84
Rate for Payer: Priority Health Choice Medicaid	$254.51
Rate for Payer: Priority Health Cigna Priority Health	$6,829.29
Rate for Payer: Priority Health Medicare	$474.84
Rate for Payer: Priority Health SBD	$6,619.16
Rate for Payer: Railroad Medicare Medicare	$474.84
Rate for Payer: UHC All Payor (Choice/PPO)	$1,336.63
Rate for Payer: UHC Dual Complete DSNP	$474.84
Rate for Payer: UHC Medicare Advantage	$474.84
Rate for Payer: UHCCP Medicaid	$267.33
Rate for Payer: VA VA	$474.84

TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION

Facility

$10,506.60

Service Code	HCPCS J3315
Hospital Charge Code	31708
Hospital Revenue Code	636
Min. Negotiated Rate	$6,619.16
Max. Negotiated Rate	$9,455.94
Rate for Payer: Aetna Commercial	$8,930.61
Rate for Payer: Aetna New Business (MI Preferred)	$6,829.29
Rate for Payer: Cash Price	$8,405.28
Rate for Payer: Cofinity Commercial	$7,354.62
Rate for Payer: Cofinity Commercial	$9,035.68
Rate for Payer: Cofinity Medicare Advantage	$7,354.62
Rate for Payer: Encore Health Key Benefits Commercial	$8,405.28
Rate for Payer: Healthscope Commercial	$9,455.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8,930.61
Rate for Payer: PHP Commercial	$8,930.61
Rate for Payer: Priority Health Cigna Priority Health	$6,829.29
Rate for Payer: Priority Health SBD	$6,619.16

TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION

Facility

$17,316.00

Service Code	HCPCS J3315
Hospital Charge Code	119655
Hospital Revenue Code	636
Min. Negotiated Rate	$254.51
Max. Negotiated Rate	$15,584.40
Rate for Payer: Aetna Commercial	$14,718.60
Rate for Payer: Aetna Medicare	$493.83
Rate for Payer: Aetna New Business (MI Preferred)	$11,255.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$593.55
Rate for Payer: Amish Plain Church Group Commercial	$593.55
Rate for Payer: BCBS Complete	$267.24
Rate for Payer: BCBS MAPPO	$474.84
Rate for Payer: BCN Medicare Advantage	$474.84
Rate for Payer: Cash Price	$13,852.80
Rate for Payer: Cash Price	$13,852.80
Rate for Payer: Cofinity Commercial	$12,121.20
Rate for Payer: Cofinity Commercial	$14,891.76
Rate for Payer: Cofinity Medicare Advantage	$12,121.20
Rate for Payer: Encore Health Key Benefits Commercial	$13,852.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$474.84
Rate for Payer: Healthscope Commercial	$15,584.40
Rate for Payer: Mclaren Medicaid	$254.51
Rate for Payer: Mclaren Medicare	$474.84
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$498.58
Rate for Payer: Meridian Medicaid	$267.24
Rate for Payer: MI Amish Medical Board Commercial	$546.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$14,718.60
Rate for Payer: PACE Medicare	$451.10
Rate for Payer: PACE SWMI	$474.84
Rate for Payer: PHP Commercial	$14,718.60
Rate for Payer: PHP Medicare Advantage	$474.84
Rate for Payer: Priority Health Choice Medicaid	$254.51
Rate for Payer: Priority Health Cigna Priority Health	$11,255.40
Rate for Payer: Priority Health Medicare	$474.84
Rate for Payer: Priority Health SBD	$10,909.08
Rate for Payer: Railroad Medicare Medicare	$474.84
Rate for Payer: UHC All Payor (Choice/PPO)	$1,336.63
Rate for Payer: UHC Dual Complete DSNP	$474.84
Rate for Payer: UHC Medicare Advantage	$474.84
Rate for Payer: UHCCP Medicaid	$267.33
Rate for Payer: VA VA	$474.84

TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION

Facility

$2,340.00

Service Code	HCPCS J3315
Hospital Charge Code	28558
Hospital Revenue Code	636
Min. Negotiated Rate	$254.51
Max. Negotiated Rate	$2,106.00
Rate for Payer: Aetna Commercial	$1,989.00
Rate for Payer: Aetna Medicare	$493.83
Rate for Payer: Aetna New Business (MI Preferred)	$1,521.00
Rate for Payer: Allen County Amish Medical Aid Commercial	$593.55
Rate for Payer: Amish Plain Church Group Commercial	$593.55
Rate for Payer: BCBS Complete	$267.24
Rate for Payer: BCBS MAPPO	$474.84
Rate for Payer: BCN Medicare Advantage	$474.84
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Cofinity Commercial	$1,638.00
Rate for Payer: Cofinity Commercial	$2,012.40
Rate for Payer: Cofinity Medicare Advantage	$1,638.00
Rate for Payer: Encore Health Key Benefits Commercial	$1,872.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$474.84
Rate for Payer: Healthscope Commercial	$2,106.00
Rate for Payer: Mclaren Medicaid	$254.51
Rate for Payer: Mclaren Medicare	$474.84
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$498.58
Rate for Payer: Meridian Medicaid	$267.24
Rate for Payer: MI Amish Medical Board Commercial	$546.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,989.00
Rate for Payer: PACE Medicare	$451.10
Rate for Payer: PACE SWMI	$474.84
Rate for Payer: PHP Commercial	$1,989.00
Rate for Payer: PHP Medicare Advantage	$474.84
Rate for Payer: Priority Health Choice Medicaid	$254.51
Rate for Payer: Priority Health Cigna Priority Health	$1,521.00
Rate for Payer: Priority Health Medicare	$474.84
Rate for Payer: Priority Health SBD	$1,474.20
Rate for Payer: Railroad Medicare Medicare	$474.84
Rate for Payer: UHC All Payor (Choice/PPO)	$1,336.63
Rate for Payer: UHC Dual Complete DSNP	$474.84
Rate for Payer: UHC Medicare Advantage	$474.84
Rate for Payer: UHCCP Medicaid	$267.33
Rate for Payer: VA VA	$474.84

TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION

Facility

$2,340.00

Service Code	HCPCS J3315
Hospital Charge Code	28558
Hospital Revenue Code	636
Min. Negotiated Rate	$1,474.20
Max. Negotiated Rate	$2,106.00
Rate for Payer: Aetna Commercial	$1,989.00
Rate for Payer: Aetna New Business (MI Preferred)	$1,521.00
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Cofinity Commercial	$1,638.00
Rate for Payer: Cofinity Commercial	$2,012.40
Rate for Payer: Cofinity Medicare Advantage	$1,638.00
Rate for Payer: Encore Health Key Benefits Commercial	$1,872.00
Rate for Payer: Healthscope Commercial	$2,106.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,989.00
Rate for Payer: PHP Commercial	$1,989.00
Rate for Payer: Priority Health Cigna Priority Health	$1,521.00
Rate for Payer: Priority Health SBD	$1,474.20

TROPICAMIDE 1 % EYE DROPS

Facility

$26.20

Service Code	NDC 17478010212
Hospital Charge Code	8250
Hospital Revenue Code	637
Min. Negotiated Rate	$10.48
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 Commercial	$18.34
Rate for Payer: Cofinity Commercial	$22.53
Rate for Payer: Cofinity Medicare Advantage	$18.34
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: PHP Commercial	$22.27
Rate for Payer: Priority Health Cigna Priority Health	$17.03
Rate for Payer: Priority Health SBD	$16.51

TROPICAMIDE 1 % EYE DROPS

Facility

$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 Commercial	$18.34
Rate for Payer: Cofinity Commercial	$22.53
Rate for Payer: Cofinity Medicare Advantage	$18.34
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: PHP Commercial	$22.27
Rate for Payer: Priority Health Cigna Priority Health	$17.03
Rate for Payer: Priority Health SBD	$16.51

TROPICAMIDE 1 % EYE DROPS

Facility

$33.18

Service Code	NDC 61314035501
Hospital Charge Code	8250
Hospital Revenue Code	637
Min. Negotiated Rate	$13.27
Max. Negotiated Rate	$29.86
Rate for Payer: Aetna Commercial	$28.20
Rate for Payer: Aetna Medicare	$16.59
Rate for Payer: Aetna New Business (MI Preferred)	$21.57
Rate for Payer: BCBS Complete	$13.27
Rate for Payer: Cash Price	$26.54
Rate for Payer: Cofinity Commercial	$23.23
Rate for Payer: Cofinity Commercial	$28.53
Rate for Payer: Cofinity Medicare Advantage	$23.23
Rate for Payer: Encore Health Key Benefits Commercial	$26.54
Rate for Payer: Healthscope Commercial	$29.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$28.20
Rate for Payer: PHP Commercial	$28.20
Rate for Payer: Priority Health Cigna Priority Health	$21.57
Rate for Payer: Priority Health SBD	$20.90

TROPICAMIDE 1 % EYE DROPS

Facility

$33.18

Service Code	NDC 61314035501
Hospital Charge Code	8250
Hospital Revenue Code	637
Min. Negotiated Rate	$20.90
Max. Negotiated Rate	$29.86
Rate for Payer: Aetna Commercial	$28.20
Rate for Payer: Aetna New Business (MI Preferred)	$21.57
Rate for Payer: Cash Price	$26.54
Rate for Payer: Cofinity Commercial	$23.23
Rate for Payer: Cofinity Commercial	$28.53
Rate for Payer: Cofinity Medicare Advantage	$23.23
Rate for Payer: Encore Health Key Benefits Commercial	$26.54
Rate for Payer: Healthscope Commercial	$29.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$28.20
Rate for Payer: PHP Commercial	$28.20
Rate for Payer: Priority Health Cigna Priority Health	$21.57
Rate for Payer: Priority Health SBD	$20.90

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION

Facility

$16,240.34

Service Code	CPT 69631
Hospital Revenue Code	360
Min. Negotiated Rate	$3,092.41
Max. Negotiated Rate	$16,240.34
Rate for Payer: Aetna Medicare	$6,000.20
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,211.77
Rate for Payer: Amish Plain Church Group Commercial	$7,211.77
Rate for Payer: BCBS Complete	$3,247.03
Rate for Payer: BCBS MAPPO	$5,769.42
Rate for Payer: BCN Medicare Advantage	$5,769.42
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,769.42
Rate for Payer: Mclaren Medicaid	$3,092.41
Rate for Payer: Mclaren Medicare	$5,769.42
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,057.89
Rate for Payer: Meridian Medicaid	$3,247.03
Rate for Payer: MI Amish Medical Board Commercial	$6,634.83
Rate for Payer: PACE Medicare	$5,480.95
Rate for Payer: PACE SWMI	$5,769.42
Rate for Payer: PHP Medicare Advantage	$5,769.42
Rate for Payer: Priority Health Choice Medicaid	$3,092.41
Rate for Payer: Priority Health Medicare	$5,769.42
Rate for Payer: Railroad Medicare Medicare	$5,769.42
Rate for Payer: UHC All Payor (Choice/PPO)	$16,240.34
Rate for Payer: UHC Dual Complete DSNP	$5,769.42
Rate for Payer: UHC Medicare Advantage	$5,769.42
Rate for Payer: UHCCP Medicaid	$3,248.18
Rate for Payer: VA VA	$5,769.42

TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA

Facility

$4,066.57

Service Code	CPT 69436
Hospital Revenue Code	360
Min. Negotiated Rate	$774.34
Max. Negotiated Rate	$4,066.57
Rate for Payer: Aetna Medicare	$1,502.45
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,805.83
Rate for Payer: Amish Plain Church Group Commercial	$1,805.83
Rate for Payer: BCBS Complete	$813.05
Rate for Payer: BCBS MAPPO	$1,444.66
Rate for Payer: BCN Medicare Advantage	$1,444.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,444.66
Rate for Payer: Mclaren Medicaid	$774.34
Rate for Payer: Mclaren Medicare	$1,444.66
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,516.89
Rate for Payer: Meridian Medicaid	$813.05
Rate for Payer: MI Amish Medical Board Commercial	$1,661.36
Rate for Payer: PACE Medicare	$1,372.43
Rate for Payer: PACE SWMI	$1,444.66
Rate for Payer: PHP Medicare Advantage	$1,444.66
Rate for Payer: Priority Health Choice Medicaid	$774.34
Rate for Payer: Priority Health Medicare	$1,444.66
Rate for Payer: Railroad Medicare Medicare	$1,444.66
Rate for Payer: UHC All Payor (Choice/PPO)	$4,066.57
Rate for Payer: UHC Dual Complete DSNP	$1,444.66
Rate for Payer: UHC Medicare Advantage	$1,444.66
Rate for Payer: UHCCP Medicaid	$813.34
Rate for Payer: VA VA	$1,444.66

Know your out-of-pocket cost for care.

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