|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
|
OP
|
$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
|
|
|
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 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
|
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 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
|
OP
|
$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
|
OP
|
$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 |
$168.02
|
| 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
|
OP
|
$7,022.36
|
|
|
Service Code
|
HCPCS J1448
|
| Hospital Charge Code |
196299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$6,320.12 |
| Rate for Payer: Aetna Commercial |
$5,969.01
|
| Rate for Payer: Aetna Medicare |
$5.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,564.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.71
|
| Rate for Payer: BCBS Complete |
$3.02
|
| Rate for Payer: BCBS MAPPO |
$5.37
|
| Rate for Payer: BCBS Trust/PPO |
$15.14
|
| Rate for Payer: BCN Commercial |
$15.14
|
| Rate for Payer: BCN Medicare Advantage |
$5.37
|
| Rate for Payer: Cash Price |
$5,617.89
|
| 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: Health Alliance Plan Medicare Advantage |
$5.37
|
| Rate for Payer: Healthscope Commercial |
$6,320.12
|
| Rate for Payer: Mclaren Medicaid |
$2.88
|
| Rate for Payer: Mclaren Medicare |
$5.37
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.64
|
| Rate for Payer: Meridian Medicaid |
$3.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,969.01
|
| Rate for Payer: Nomi Health Commercial |
$16.11
|
| Rate for Payer: PACE Medicare |
$5.10
|
| Rate for Payer: PACE SWMI |
$5.37
|
| Rate for Payer: PHP Commercial |
$5,969.01
|
| Rate for Payer: PHP Medicare Advantage |
$5.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,564.53
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.42
|
| Rate for Payer: Priority Health Medicare |
$5.37
|
| Rate for Payer: Priority Health Narrow Network |
$12.34
|
| Rate for Payer: Priority Health SBD |
$4,424.09
|
| Rate for Payer: Railroad Medicare Medicare |
$5.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.37
|
| Rate for Payer: UHC Medicare Advantage |
$5.37
|
| Rate for Payer: UHCCP Medicaid |
$3.02
|
| Rate for Payer: VA VA |
$5.37
|
|
|
TRILACICLIB 300 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$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
|
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 |
$100.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.33
|
| Rate for Payer: BCBS Complete |
$80.20
|
| Rate for Payer: BCBS Trust/PPO |
$144.70
|
| Rate for Payer: BCN Commercial |
$144.70
|
| Rate for Payer: Cash Price |
$160.41
|
| 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
|
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 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
|
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 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
|
OP
|
$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
|
IP
|
$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
|
OP
|
$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
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION
|
Facility
|
OP
|
$10,506.60
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.97 |
| Max. Negotiated Rate |
$9,455.94 |
| Rate for Payer: Aetna Commercial |
$8,930.61
|
| Rate for Payer: Aetna Medicare |
$500.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,829.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$601.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$601.61
|
| Rate for Payer: BCBS Complete |
$270.87
|
| Rate for Payer: BCBS MAPPO |
$481.29
|
| Rate for Payer: BCBS Trust/PPO |
$1,359.55
|
| Rate for Payer: BCN Commercial |
$1,359.55
|
| Rate for Payer: BCN Medicare Advantage |
$481.29
|
| 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 |
$481.29
|
| Rate for Payer: Healthscope Commercial |
$9,455.94
|
| Rate for Payer: Mclaren Medicaid |
$257.97
|
| Rate for Payer: Mclaren Medicare |
$481.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$505.35
|
| Rate for Payer: Meridian Medicaid |
$270.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$553.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,930.61
|
| Rate for Payer: Nomi Health Commercial |
$1,443.87
|
| Rate for Payer: PACE Medicare |
$457.23
|
| Rate for Payer: PACE SWMI |
$481.29
|
| Rate for Payer: PHP Commercial |
$8,930.61
|
| Rate for Payer: PHP Medicare Advantage |
$481.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$257.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,829.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,343.25
|
| Rate for Payer: Priority Health Medicare |
$481.29
|
| Rate for Payer: Priority Health Narrow Network |
$1,074.60
|
| Rate for Payer: Priority Health SBD |
$6,619.16
|
| Rate for Payer: Railroad Medicare Medicare |
$481.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,354.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$481.29
|
| Rate for Payer: UHC Medicare Advantage |
$481.29
|
| Rate for Payer: UHCCP Medicaid |
$270.97
|
| Rate for Payer: VA VA |
$481.29
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION
|
Facility
|
IP
|
$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
|
OP
|
$17,316.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
119655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.97 |
| Max. Negotiated Rate |
$15,584.40 |
| Rate for Payer: Aetna Commercial |
$14,718.60
|
| Rate for Payer: Aetna Medicare |
$500.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,255.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$601.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$601.61
|
| Rate for Payer: BCBS Complete |
$270.87
|
| Rate for Payer: BCBS MAPPO |
$481.29
|
| Rate for Payer: BCBS Trust/PPO |
$1,359.55
|
| Rate for Payer: BCN Commercial |
$1,359.55
|
| Rate for Payer: BCN Medicare Advantage |
$481.29
|
| 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 |
$481.29
|
| Rate for Payer: Healthscope Commercial |
$15,584.40
|
| Rate for Payer: Mclaren Medicaid |
$257.97
|
| Rate for Payer: Mclaren Medicare |
$481.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$505.35
|
| Rate for Payer: Meridian Medicaid |
$270.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$553.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,718.60
|
| Rate for Payer: Nomi Health Commercial |
$1,443.87
|
| Rate for Payer: PACE Medicare |
$457.23
|
| Rate for Payer: PACE SWMI |
$481.29
|
| Rate for Payer: PHP Commercial |
$14,718.60
|
| Rate for Payer: PHP Medicare Advantage |
$481.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$257.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,255.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,343.25
|
| Rate for Payer: Priority Health Medicare |
$481.29
|
| Rate for Payer: Priority Health Narrow Network |
$1,074.60
|
| Rate for Payer: Priority Health SBD |
$10,909.08
|
| Rate for Payer: Railroad Medicare Medicare |
$481.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,354.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$481.29
|
| Rate for Payer: UHC Medicare Advantage |
$481.29
|
| Rate for Payer: UHCCP Medicaid |
$270.97
|
| Rate for Payer: VA VA |
$481.29
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
|
IP
|
$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
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
|
OP
|
$2,340.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
28558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.97 |
| Max. Negotiated Rate |
$2,106.00 |
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Medicare |
$500.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,521.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$601.61
|
| Rate for Payer: Amish Plain Church Group Commercial |
$601.61
|
| Rate for Payer: BCBS Complete |
$270.87
|
| Rate for Payer: BCBS MAPPO |
$481.29
|
| Rate for Payer: BCBS Trust/PPO |
$1,359.55
|
| Rate for Payer: BCN Commercial |
$1,359.55
|
| Rate for Payer: BCN Medicare Advantage |
$481.29
|
| Rate for Payer: Cash Price |
$1,872.00
|
| Rate for Payer: Cash Price |
$1,872.00
|
| Rate for Payer: Cofinity Commercial |
$2,012.40
|
| Rate for Payer: Cofinity Commercial |
$1,638.00
|
| 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 |
$481.29
|
| Rate for Payer: Healthscope Commercial |
$2,106.00
|
| Rate for Payer: Mclaren Medicaid |
$257.97
|
| Rate for Payer: Mclaren Medicare |
$481.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$505.35
|
| Rate for Payer: Meridian Medicaid |
$270.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$553.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,989.00
|
| Rate for Payer: Nomi Health Commercial |
$1,443.87
|
| Rate for Payer: PACE Medicare |
$457.23
|
| Rate for Payer: PACE SWMI |
$481.29
|
| Rate for Payer: PHP Commercial |
$1,989.00
|
| Rate for Payer: PHP Medicare Advantage |
$481.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$257.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,521.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,343.25
|
| Rate for Payer: Priority Health Medicare |
$481.29
|
| Rate for Payer: Priority Health Narrow Network |
$1,074.60
|
| Rate for Payer: Priority Health SBD |
$1,474.20
|
| Rate for Payer: Railroad Medicare Medicare |
$481.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,354.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$481.29
|
| Rate for Payer: UHC Medicare Advantage |
$481.29
|
| Rate for Payer: UHCCP Medicaid |
$270.97
|
| Rate for Payer: VA VA |
$481.29
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$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
|
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 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
|
IP
|
$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
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
|
OP
|
$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
|
|
|
TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION
|
Facility
|
OP
|
$18,216.88
|
|
|
Service Code
|
CPT 69631
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$928.62 |
| Max. Negotiated Rate |
$18,216.88 |
| Rate for Payer: Aetna Medicare |
$6,027.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,245.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,245.06
|
| Rate for Payer: BCBS Complete |
$3,262.02
|
| Rate for Payer: BCBS MAPPO |
$5,796.05
|
| Rate for Payer: BCBS Trust/PPO |
$3,462.73
|
| Rate for Payer: BCN Commercial |
$3,462.73
|
| Rate for Payer: BCN Medicare Advantage |
$5,796.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,796.05
|
| Rate for Payer: Mclaren Medicaid |
$3,106.68
|
| Rate for Payer: Mclaren Medicare |
$5,796.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,085.85
|
| Rate for Payer: Meridian Medicaid |
$3,262.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,665.46
|
| Rate for Payer: Nomi Health Commercial |
$12,171.70
|
| Rate for Payer: PACE Medicare |
$5,506.25
|
| Rate for Payer: PACE SWMI |
$5,796.05
|
| Rate for Payer: PHP Medicare Advantage |
$5,796.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,106.68
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18,216.88
|
| Rate for Payer: Priority Health Medicare |
$5,796.05
|
| Rate for Payer: Priority Health Narrow Network |
$14,573.50
|
| Rate for Payer: Railroad Medicare Medicare |
$5,796.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$928.62
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,796.05
|
| Rate for Payer: UHC Exchange |
$7,322.00
|
| Rate for Payer: UHC Medicare Advantage |
$5,796.05
|
| Rate for Payer: UHCCP Medicaid |
$3,263.18
|
| Rate for Payer: VA VA |
$5,796.05
|
|
|
TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA
|
Facility
|
OP
|
$4,561.52
|
|
|
Service Code
|
CPT 69436
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$167.99 |
| Max. Negotiated Rate |
$4,561.52 |
| Rate for Payer: Aetna Medicare |
$1,509.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,814.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,814.16
|
| Rate for Payer: BCBS Complete |
$816.81
|
| Rate for Payer: BCBS MAPPO |
$1,451.33
|
| Rate for Payer: BCBS Trust/PPO |
$1,050.74
|
| Rate for Payer: BCN Commercial |
$1,050.74
|
| Rate for Payer: BCN Medicare Advantage |
$1,451.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,451.33
|
| Rate for Payer: Mclaren Medicaid |
$777.91
|
| Rate for Payer: Mclaren Medicare |
$1,451.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,523.90
|
| Rate for Payer: Meridian Medicaid |
$816.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,669.03
|
| Rate for Payer: Nomi Health Commercial |
$3,047.79
|
| Rate for Payer: PACE Medicare |
$1,378.76
|
| Rate for Payer: PACE SWMI |
$1,451.33
|
| Rate for Payer: PHP Medicare Advantage |
$1,451.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$777.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,561.52
|
| Rate for Payer: Priority Health Medicare |
$1,451.33
|
| Rate for Payer: Priority Health Narrow Network |
$3,649.22
|
| Rate for Payer: Railroad Medicare Medicare |
$1,451.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$167.99
|
| Rate for Payer: UHC Core |
$3,138.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,451.33
|
| Rate for Payer: UHC Exchange |
$3,362.00
|
| Rate for Payer: UHC Medicare Advantage |
$1,451.33
|
| Rate for Payer: UHCCP Medicaid |
$817.10
|
| Rate for Payer: VA VA |
$1,451.33
|
|
|
ULIPRISTAL 30 MG TABLET
|
Facility
|
IP
|
$123.70
|
|
|
Service Code
|
NDC 50102091101
|
| Hospital Charge Code |
106079
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.93 |
| Max. Negotiated Rate |
$111.33 |
| Rate for Payer: Aetna Commercial |
$105.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.40
|
| Rate for Payer: Cash Price |
$98.96
|
| Rate for Payer: Cofinity Commercial |
$86.59
|
| Rate for Payer: Cofinity Commercial |
$106.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$86.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.96
|
| Rate for Payer: Healthscope Commercial |
$111.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$105.14
|
| Rate for Payer: PHP Commercial |
$105.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.40
|
| Rate for Payer: Priority Health SBD |
$77.93
|
|
