|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT
|
Facility
IP
|
$19.24
|
|
|
Service Code
|
NDC 45802-055-35
|
| Hospital Charge Code |
8118
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.12 |
| Max. Negotiated Rate |
$17.32 |
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.51
|
| Rate for Payer: Cash Price |
$15.39
|
| Rate for Payer: Cofinity Commercial |
$13.47
|
| Rate for Payer: Cofinity Commercial |
$16.55
|
| Rate for Payer: Healthscope Commercial |
$17.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.35
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.47
|
| Rate for Payer: Priority Health SBD |
$12.12
|
|
|
TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION
|
Facility
IP
|
$38.72
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
8120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.39 |
| Max. Negotiated Rate |
$34.85 |
| Rate for Payer: Aetna Commercial |
$32.91
|
| Rate for Payer: Aetna Commercial |
$20.20
|
| Rate for Payer: Aetna Commercial |
$20.38
|
| Rate for Payer: Aetna Commercial |
$249.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.17
|
| Rate for Payer: Cash Price |
$19.18
|
| Rate for Payer: Cash Price |
$30.98
|
| Rate for Payer: Cash Price |
$234.93
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cofinity Commercial |
$205.56
|
| Rate for Payer: Cofinity Commercial |
$20.44
|
| Rate for Payer: Cofinity Commercial |
$33.30
|
| Rate for Payer: Cofinity Commercial |
$27.10
|
| Rate for Payer: Cofinity Commercial |
$16.64
|
| Rate for Payer: Cofinity Commercial |
$16.79
|
| Rate for Payer: Cofinity Commercial |
$20.62
|
| Rate for Payer: Cofinity Commercial |
$252.55
|
| Rate for Payer: Healthscope Commercial |
$21.58
|
| Rate for Payer: Healthscope Commercial |
$34.85
|
| Rate for Payer: Healthscope Commercial |
$264.29
|
| Rate for Payer: Healthscope Commercial |
$21.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$249.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.91
|
| Rate for Payer: PHP Commercial |
$20.38
|
| Rate for Payer: PHP Commercial |
$20.20
|
| Rate for Payer: PHP Commercial |
$32.91
|
| Rate for Payer: PHP Commercial |
$249.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$205.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.10
|
| Rate for Payer: Priority Health SBD |
$14.98
|
| Rate for Payer: Priority Health SBD |
$15.11
|
| Rate for Payer: Priority Health SBD |
$185.01
|
| Rate for Payer: Priority Health SBD |
$24.39
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
IP
|
$200.45
|
|
|
Service Code
|
NDC 0378-2537-01
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.28 |
| Max. Negotiated Rate |
$180.40 |
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.29
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$140.32
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Healthscope Commercial |
$180.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.38
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.32
|
| Rate for Payer: Priority Health SBD |
$126.28
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
IP
|
$251.45
|
|
|
Service Code
|
NDC 0527-1632-01
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.41 |
| Max. Negotiated Rate |
$226.30 |
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.02
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Healthscope Commercial |
$226.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.02
|
| Rate for Payer: Priority Health SBD |
$158.41
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
IP
|
$2.60
|
|
|
Service Code
|
NDC 51079-935-01
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.69
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.21
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.82
|
| Rate for Payer: Priority Health SBD |
$1.64
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE
|
Facility
IP
|
$259.35
|
|
|
Service Code
|
NDC 51079-935-20
|
| Hospital Charge Code |
12729
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.39 |
| Max. Negotiated Rate |
$233.42 |
| Rate for Payer: Aetna Commercial |
$220.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.58
|
| Rate for Payer: Cash Price |
$207.48
|
| Rate for Payer: Cofinity Commercial |
$181.54
|
| Rate for Payer: Cofinity Commercial |
$223.04
|
| Rate for Payer: Healthscope Commercial |
$233.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$220.45
|
| Rate for Payer: PHP Commercial |
$220.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$181.54
|
| Rate for Payer: Priority Health SBD |
$163.39
|
|
|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
IP
|
$492.27
|
|
|
Service Code
|
NDC 61314-044-75
|
| Hospital Charge Code |
11595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$310.13 |
| Max. Negotiated Rate |
$443.04 |
| Rate for Payer: Aetna Commercial |
$418.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$319.98
|
| Rate for Payer: Cash Price |
$393.82
|
| Rate for Payer: Cofinity Commercial |
$344.59
|
| Rate for Payer: Cofinity Commercial |
$423.35
|
| Rate for Payer: Healthscope Commercial |
$443.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$418.43
|
| Rate for Payer: PHP Commercial |
$418.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$344.59
|
| Rate for Payer: Priority Health SBD |
$310.13
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
IP
|
$329.00
|
|
|
Service Code
|
NDC 0591-5335-01
|
| 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: Healthscope Commercial |
$296.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$279.65
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.30
|
| Rate for Payer: Priority Health SBD |
$207.27
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
IP
|
$336.05
|
|
|
Service Code
|
NDC 69452-241-20
|
| 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: Healthscope Commercial |
$302.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$285.64
|
| Rate for Payer: PHP Commercial |
$285.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.24
|
| Rate for Payer: Priority Health SBD |
$211.71
|
|
|
TRILACICLIB 300 MG INTRAVENOUS SOLUTION
|
Facility
OP
|
$6,833.78
|
|
|
Service Code
|
HCPCS J1448
|
| Hospital Charge Code |
196299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$6,150.40 |
| Rate for Payer: Aetna Commercial |
$5,808.71
|
| Rate for Payer: Aetna Medicare |
$5.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,441.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.50
|
| Rate for Payer: BCBS Complete |
$2.99
|
| Rate for Payer: BCBS MAPPO |
$5.20
|
| Rate for Payer: BCBS Trust/PPO |
$15.37
|
| Rate for Payer: BCN Medicare Advantage |
$5.20
|
| Rate for Payer: Cash Price |
$5,467.02
|
| Rate for Payer: Cash Price |
$5,467.02
|
| Rate for Payer: Cofinity Commercial |
$4,783.65
|
| Rate for Payer: Cofinity Commercial |
$5,877.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.20
|
| Rate for Payer: Healthscope Commercial |
$6,150.40
|
| Rate for Payer: Mclaren Medicaid |
$2.84
|
| Rate for Payer: Mclaren Medicare |
$5.20
|
| Rate for Payer: Meridian Medicaid |
$2.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,808.71
|
| Rate for Payer: PACE Medicare |
$4.94
|
| Rate for Payer: PACE SWMI |
$5.20
|
| Rate for Payer: PHP Commercial |
$5,808.71
|
| Rate for Payer: PHP Medicare Advantage |
$5.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,783.65
|
| Rate for Payer: Priority Health Medicare |
$5.20
|
| Rate for Payer: Priority Health SBD |
$4,305.28
|
| Rate for Payer: Railroad Medicare Medicare |
$5.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.20
|
| Rate for Payer: UHC Medicare Advantage |
$5.36
|
| Rate for Payer: VA VA |
$5.20
|
|
|
TRILACICLIB 300 MG INTRAVENOUS SOLUTION
|
Facility
IP
|
$6,833.78
|
|
|
Service Code
|
HCPCS J1448
|
| Hospital Charge Code |
196299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,305.28 |
| Max. Negotiated Rate |
$6,150.40 |
| Rate for Payer: Aetna Commercial |
$5,808.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,441.96
|
| Rate for Payer: Cash Price |
$5,467.02
|
| Rate for Payer: Cofinity Commercial |
$4,783.65
|
| Rate for Payer: Cofinity Commercial |
$5,877.05
|
| Rate for Payer: Healthscope Commercial |
$6,150.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5,808.71
|
| Rate for Payer: PHP Commercial |
$5,808.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,783.65
|
| Rate for Payer: Priority Health SBD |
$4,305.28
|
|
|
TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
IP
|
$190.96
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
108755
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.30 |
| Max. Negotiated Rate |
$171.86 |
| Rate for Payer: Aetna Commercial |
$162.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$124.12
|
| Rate for Payer: Cash Price |
$152.77
|
| Rate for Payer: Cofinity Commercial |
$133.67
|
| Rate for Payer: Cofinity Commercial |
$164.23
|
| Rate for Payer: Healthscope Commercial |
$171.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$162.32
|
| Rate for Payer: PHP Commercial |
$162.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.67
|
| Rate for Payer: Priority Health SBD |
$120.30
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
IP
|
$595.68
|
|
|
Service Code
|
NDC 51862-486-01
|
| 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: Healthscope Commercial |
$536.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$506.33
|
| Rate for Payer: PHP Commercial |
$506.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$416.98
|
| Rate for Payer: Priority Health SBD |
$375.28
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
IP
|
$201.40
|
|
|
Service Code
|
NDC 43386-330-01
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.88 |
| Max. Negotiated Rate |
$181.26 |
| Rate for Payer: Aetna Commercial |
$171.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.91
|
| Rate for Payer: Cash Price |
$161.12
|
| Rate for Payer: Cofinity Commercial |
$140.98
|
| Rate for Payer: Cofinity Commercial |
$173.20
|
| Rate for Payer: Healthscope Commercial |
$181.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.19
|
| Rate for Payer: PHP Commercial |
$171.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.98
|
| Rate for Payer: Priority Health SBD |
$126.88
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION
|
Facility
OP
|
$8,768.97
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$226.23 |
| Max. Negotiated Rate |
$7,892.07 |
| Rate for Payer: Aetna Commercial |
$7,453.62
|
| Rate for Payer: Aetna Medicare |
$430.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,699.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$516.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$516.98
|
| Rate for Payer: BCBS Complete |
$237.56
|
| Rate for Payer: BCBS MAPPO |
$413.58
|
| Rate for Payer: BCBS Trust/PPO |
$1,224.40
|
| Rate for Payer: BCN Medicare Advantage |
$413.58
|
| Rate for Payer: Cash Price |
$7,015.18
|
| Rate for Payer: Cash Price |
$7,015.18
|
| Rate for Payer: Cofinity Commercial |
$7,541.31
|
| Rate for Payer: Cofinity Commercial |
$6,138.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$413.58
|
| Rate for Payer: Healthscope Commercial |
$7,892.07
|
| Rate for Payer: Mclaren Medicaid |
$226.23
|
| Rate for Payer: Mclaren Medicare |
$413.58
|
| Rate for Payer: Meridian Medicaid |
$237.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$434.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$475.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,453.62
|
| Rate for Payer: PACE Medicare |
$392.91
|
| Rate for Payer: PACE SWMI |
$413.58
|
| Rate for Payer: PHP Commercial |
$7,453.62
|
| Rate for Payer: PHP Medicare Advantage |
$413.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$226.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,138.28
|
| Rate for Payer: Priority Health Medicare |
$413.58
|
| Rate for Payer: Priority Health SBD |
$5,524.45
|
| Rate for Payer: Railroad Medicare Medicare |
$413.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$413.58
|
| Rate for Payer: UHC Medicare Advantage |
$425.99
|
| Rate for Payer: VA VA |
$413.58
|
|
|
TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION
|
Facility
IP
|
$8,768.97
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
31708
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,524.45 |
| Max. Negotiated Rate |
$7,892.07 |
| Rate for Payer: Aetna Commercial |
$7,453.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,699.83
|
| Rate for Payer: Cash Price |
$7,015.18
|
| Rate for Payer: Cofinity Commercial |
$6,138.28
|
| Rate for Payer: Cofinity Commercial |
$7,541.31
|
| Rate for Payer: Healthscope Commercial |
$7,892.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,453.62
|
| Rate for Payer: PHP Commercial |
$7,453.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,138.28
|
| Rate for Payer: Priority Health SBD |
$5,524.45
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION
|
Facility
OP
|
$14,452.20
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
119655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$226.23 |
| Max. Negotiated Rate |
$13,006.98 |
| Rate for Payer: Aetna Commercial |
$12,284.37
|
| Rate for Payer: Aetna Medicare |
$430.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,393.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$516.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$516.98
|
| Rate for Payer: BCBS Complete |
$237.56
|
| Rate for Payer: BCBS MAPPO |
$413.58
|
| Rate for Payer: BCBS Trust/PPO |
$1,224.40
|
| Rate for Payer: BCN Medicare Advantage |
$413.58
|
| Rate for Payer: Cash Price |
$11,561.76
|
| Rate for Payer: Cash Price |
$11,561.76
|
| Rate for Payer: Cofinity Commercial |
$10,116.54
|
| Rate for Payer: Cofinity Commercial |
$12,428.89
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$413.58
|
| Rate for Payer: Healthscope Commercial |
$13,006.98
|
| Rate for Payer: Mclaren Medicaid |
$226.23
|
| Rate for Payer: Mclaren Medicare |
$413.58
|
| Rate for Payer: Meridian Medicaid |
$237.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$434.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$475.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,284.37
|
| Rate for Payer: PACE Medicare |
$392.91
|
| Rate for Payer: PACE SWMI |
$413.58
|
| Rate for Payer: PHP Commercial |
$12,284.37
|
| Rate for Payer: PHP Medicare Advantage |
$413.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$226.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,116.54
|
| Rate for Payer: Priority Health Medicare |
$413.58
|
| Rate for Payer: Priority Health SBD |
$9,104.89
|
| Rate for Payer: Railroad Medicare Medicare |
$413.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$413.58
|
| Rate for Payer: UHC Medicare Advantage |
$425.99
|
| Rate for Payer: VA VA |
$413.58
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
OP
|
$2,083.20
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
28558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$226.23 |
| Max. Negotiated Rate |
$1,874.88 |
| Rate for Payer: Aetna Commercial |
$1,770.72
|
| Rate for Payer: Aetna Medicare |
$430.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,354.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$516.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$516.98
|
| Rate for Payer: BCBS Complete |
$237.56
|
| Rate for Payer: BCBS MAPPO |
$413.58
|
| Rate for Payer: BCBS Trust/PPO |
$1,224.40
|
| Rate for Payer: BCN Medicare Advantage |
$413.58
|
| Rate for Payer: Cash Price |
$1,666.56
|
| Rate for Payer: Cash Price |
$1,666.56
|
| Rate for Payer: Cofinity Commercial |
$1,458.24
|
| Rate for Payer: Cofinity Commercial |
$1,791.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$413.58
|
| Rate for Payer: Healthscope Commercial |
$1,874.88
|
| Rate for Payer: Mclaren Medicaid |
$226.23
|
| Rate for Payer: Mclaren Medicare |
$413.58
|
| Rate for Payer: Meridian Medicaid |
$237.56
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$434.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$475.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,770.72
|
| Rate for Payer: PACE Medicare |
$392.91
|
| Rate for Payer: PACE SWMI |
$413.58
|
| Rate for Payer: PHP Commercial |
$1,770.72
|
| Rate for Payer: PHP Medicare Advantage |
$413.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$226.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,458.24
|
| Rate for Payer: Priority Health Medicare |
$413.58
|
| Rate for Payer: Priority Health SBD |
$1,312.42
|
| Rate for Payer: Railroad Medicare Medicare |
$413.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$413.58
|
| Rate for Payer: UHC Medicare Advantage |
$425.99
|
| Rate for Payer: VA VA |
$413.58
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
IP
|
$2,083.20
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
28558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,312.42 |
| Max. Negotiated Rate |
$1,874.88 |
| Rate for Payer: Aetna Commercial |
$1,770.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,354.08
|
| Rate for Payer: Cash Price |
$1,666.56
|
| Rate for Payer: Cofinity Commercial |
$1,458.24
|
| Rate for Payer: Cofinity Commercial |
$1,791.55
|
| Rate for Payer: Healthscope Commercial |
$1,874.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,770.72
|
| Rate for Payer: PHP Commercial |
$1,770.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,458.24
|
| Rate for Payer: Priority Health SBD |
$1,312.42
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
IP
|
$26.20
|
|
|
Service Code
|
NDC 17478-102-12
|
| 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: Healthscope Commercial |
$23.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.27
|
| Rate for Payer: PHP Commercial |
$22.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.34
|
| Rate for Payer: Priority Health SBD |
$16.51
|
|
|
TROPICAMIDE 1 % EYE DROPS
|
Facility
IP
|
$31.08
|
|
|
Service Code
|
NDC 61314-355-01
|
| Hospital Charge Code |
8250
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.58 |
| Max. Negotiated Rate |
$27.97 |
| Rate for Payer: Aetna Commercial |
$26.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.20
|
| Rate for Payer: Cash Price |
$24.86
|
| Rate for Payer: Cofinity Commercial |
$21.76
|
| Rate for Payer: Cofinity Commercial |
$26.73
|
| Rate for Payer: Healthscope Commercial |
$27.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.42
|
| Rate for Payer: PHP Commercial |
$26.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.76
|
| Rate for Payer: Priority Health SBD |
$19.58
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION
|
Facility
IP
|
$267.99
|
|
|
Service Code
|
NDC 42023-104-01
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$168.83 |
| Max. Negotiated Rate |
$241.19 |
| Rate for Payer: Aetna Commercial |
$227.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.19
|
| Rate for Payer: Cash Price |
$214.39
|
| Rate for Payer: Cofinity Commercial |
$187.59
|
| Rate for Payer: Cofinity Commercial |
$230.47
|
| Rate for Payer: Healthscope Commercial |
$241.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.79
|
| Rate for Payer: PHP Commercial |
$227.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.59
|
| Rate for Payer: Priority Health SBD |
$168.83
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION
|
Facility
IP
|
$232.42
|
|
|
Service Code
|
NDC 49281-752-21
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.42 |
| Max. Negotiated Rate |
$209.18 |
| Rate for Payer: Aetna Commercial |
$197.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.07
|
| Rate for Payer: Cash Price |
$185.94
|
| Rate for Payer: Cofinity Commercial |
$162.69
|
| Rate for Payer: Cofinity Commercial |
$199.88
|
| Rate for Payer: Healthscope Commercial |
$209.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.56
|
| Rate for Payer: PHP Commercial |
$197.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.69
|
| Rate for Payer: Priority Health SBD |
$146.42
|
|
|
TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION
|
Facility
IP
|
$232.42
|
|
|
Service Code
|
NDC 49281-752-78
|
| Hospital Charge Code |
8259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$146.42 |
| Max. Negotiated Rate |
$209.18 |
| Rate for Payer: Aetna Commercial |
$197.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.07
|
| Rate for Payer: Cash Price |
$185.94
|
| Rate for Payer: Cofinity Commercial |
$162.69
|
| Rate for Payer: Cofinity Commercial |
$199.88
|
| Rate for Payer: Healthscope Commercial |
$209.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.56
|
| Rate for Payer: PHP Commercial |
$197.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.69
|
| Rate for Payer: Priority Health SBD |
$146.42
|
|
|
TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION
|
Facility
OP
|
$6,837.00
|
|
|
Service Code
|
CPT 69631
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$880.49 |
| Max. Negotiated Rate |
$6,837.00 |
| Rate for Payer: Aetna Medicare |
$5,419.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,513.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,513.48
|
| Rate for Payer: BCBS Complete |
$2,993.07
|
| Rate for Payer: BCBS MAPPO |
$5,210.78
|
| Rate for Payer: BCBS Trust/PPO |
$3,362.67
|
| Rate for Payer: BCN Medicare Advantage |
$5,210.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,210.78
|
| Rate for Payer: Mclaren Medicaid |
$2,850.30
|
| Rate for Payer: Mclaren Medicare |
$5,210.78
|
| Rate for Payer: Meridian Medicaid |
$2,993.07
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,471.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,992.40
|
| Rate for Payer: PACE Medicare |
$4,950.24
|
| Rate for Payer: PACE SWMI |
$5,210.78
|
| Rate for Payer: PHP Medicare Advantage |
$5,210.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,850.30
|
| Rate for Payer: Priority Health Medicare |
$5,210.78
|
| Rate for Payer: Railroad Medicare Medicare |
$5,210.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$968.54
|
| Rate for Payer: UHC Core |
$6,837.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,210.78
|
| Rate for Payer: UHC Exchange |
$880.49
|
| Rate for Payer: UHC Medicare Advantage |
$5,367.10
|
| Rate for Payer: VA VA |
$5,210.78
|
|
