Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

TRAZODONE 150 MG TABLET

Facility

$350.15

Service Code	NDC 50111-450-01
Hospital Charge Code	8084
Hospital Revenue Code	637
Min. Negotiated Rate	$220.59
Max. Negotiated Rate	$315.14
Rate for Payer: Aetna Commercial	$297.63
Rate for Payer: Aetna New Business (MI Preferred)	$227.60
Rate for Payer: Cash Price	$280.12
Rate for Payer: Cofinity Commercial	$301.13
Rate for Payer: Cofinity Commercial	$245.10
Rate for Payer: Healthscope Commercial	$315.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$297.63
Rate for Payer: PHP Commercial	$297.63
Rate for Payer: Priority Health Cigna Priority Health	$245.10
Rate for Payer: Priority Health SBD	$220.59

TRAZODONE 150 MG TABLET

Facility

$3.55

Service Code	NDC 68084-608-11
Hospital Charge Code	8084
Hospital Revenue Code	637
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$3.20
Rate for Payer: Aetna Commercial	$3.02
Rate for Payer: Aetna New Business (MI Preferred)	$2.31
Rate for Payer: Cash Price	$2.84
Rate for Payer: Cofinity Commercial	$2.48
Rate for Payer: Cofinity Commercial	$3.05
Rate for Payer: Healthscope Commercial	$3.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.02
Rate for Payer: PHP Commercial	$3.02
Rate for Payer: Priority Health Cigna Priority Health	$2.48
Rate for Payer: Priority Health SBD	$2.24

TRAZODONE 50 MG TABLET

Facility

$2.61

Service Code	NDC 60687-443-11
Hospital Charge Code	8085
Hospital Revenue Code	637
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna Commercial	$2.22
Rate for Payer: Aetna New Business (MI Preferred)	$1.70
Rate for Payer: Cash Price	$2.09
Rate for Payer: Cofinity Commercial	$1.83
Rate for Payer: Cofinity Commercial	$2.24
Rate for Payer: Healthscope Commercial	$2.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.22
Rate for Payer: PHP Commercial	$2.22
Rate for Payer: Priority Health Cigna Priority Health	$1.83
Rate for Payer: Priority Health SBD	$1.64

TRAZODONE 50 MG TABLET

Facility

$242.05

Service Code	NDC 0904-6868-61
Hospital Charge Code	8085
Hospital Revenue Code	637
Min. Negotiated Rate	$152.49
Max. Negotiated Rate	$217.84
Rate for Payer: Aetna Commercial	$205.74
Rate for Payer: Aetna New Business (MI Preferred)	$157.33
Rate for Payer: Cash Price	$193.64
Rate for Payer: Cofinity Commercial	$208.16
Rate for Payer: Cofinity Commercial	$169.44
Rate for Payer: Healthscope Commercial	$217.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$205.74
Rate for Payer: PHP Commercial	$205.74
Rate for Payer: Priority Health Cigna Priority Health	$169.44
Rate for Payer: Priority Health SBD	$152.49

TRAZODONE 50 MG TABLET

Facility

$260.85

Service Code	NDC 60687-443-01
Hospital Charge Code	8085
Hospital Revenue Code	637
Min. Negotiated Rate	$164.34
Max. Negotiated Rate	$234.76
Rate for Payer: Aetna Commercial	$221.72
Rate for Payer: Aetna New Business (MI Preferred)	$169.55
Rate for Payer: Cash Price	$208.68
Rate for Payer: Cofinity Commercial	$182.60
Rate for Payer: Cofinity Commercial	$224.33
Rate for Payer: Healthscope Commercial	$234.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$221.72
Rate for Payer: PHP Commercial	$221.72
Rate for Payer: Priority Health Cigna Priority Health	$182.60
Rate for Payer: Priority Health SBD	$164.34

TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS

Facility

$39,125.19

Service Code	CPT 24516
Hospital Revenue Code	360
Min. Negotiated Rate	$852.33
Max. Negotiated Rate	$39,125.19
Rate for Payer: Aetna Medicare	$12,179.12
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,638.36
Rate for Payer: Amish Plain Church Group Commercial	$14,638.36
Rate for Payer: BCBS Complete	$6,726.62
Rate for Payer: BCBS MAPPO	$11,710.69
Rate for Payer: BCBS Trust/PPO	$4,321.68
Rate for Payer: BCN Medicare Advantage	$11,710.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,710.69
Rate for Payer: Mclaren Medicaid	$6,405.75
Rate for Payer: Mclaren Medicare	$11,710.69
Rate for Payer: Meridian Medicaid	$6,726.62
Rate for Payer: Meridian Wellcare - Medicare Advantage	$12,296.22
Rate for Payer: MI Amish Medical Board Commercial	$13,467.29
Rate for Payer: PACE Medicare	$11,125.16
Rate for Payer: PACE SWMI	$11,710.69
Rate for Payer: PHP Medicare Advantage	$11,710.69
Rate for Payer: Priority Health Choice Medicaid	$6,405.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$39,125.19
Rate for Payer: Priority Health Medicare	$11,710.69
Rate for Payer: Priority Health Narrow Network	$31,300.15
Rate for Payer: Railroad Medicare Medicare	$11,710.69
Rate for Payer: UHC All Payor (Choice/PPO)	$937.56
Rate for Payer: UHC Core	$7,632.00
Rate for Payer: UHC Dual Complete DSNP	$11,710.69
Rate for Payer: UHC Exchange	$852.33
Rate for Payer: UHC Medicare Advantage	$12,062.01
Rate for Payer: VA VA	$11,710.69

TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY

Facility

$8,478.18

Service Code	CPT 59812
Hospital Revenue Code	360
Min. Negotiated Rate	$306.16
Max. Negotiated Rate	$8,478.18
Rate for Payer: Aetna Medicare	$2,893.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,477.26
Rate for Payer: Amish Plain Church Group Commercial	$3,477.26
Rate for Payer: BCBS Complete	$1,597.87
Rate for Payer: BCBS MAPPO	$2,781.81
Rate for Payer: BCBS Trust/PPO	$1,417.50
Rate for Payer: BCN Medicare Advantage	$2,781.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,781.81
Rate for Payer: Mclaren Medicaid	$1,521.65
Rate for Payer: Mclaren Medicare	$2,781.81
Rate for Payer: Meridian Medicaid	$1,597.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,920.90
Rate for Payer: MI Amish Medical Board Commercial	$3,199.08
Rate for Payer: PACE Medicare	$2,642.72
Rate for Payer: PACE SWMI	$2,781.81
Rate for Payer: PHP Medicare Advantage	$2,781.81
Rate for Payer: Priority Health Choice Medicaid	$1,521.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,478.18
Rate for Payer: Priority Health Medicare	$2,781.81
Rate for Payer: Priority Health Narrow Network	$6,782.54
Rate for Payer: Railroad Medicare Medicare	$2,781.81
Rate for Payer: UHC All Payor (Choice/PPO)	$336.78
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$2,781.81
Rate for Payer: UHC Exchange	$306.16
Rate for Payer: UHC Medicare Advantage	$2,865.26
Rate for Payer: VA VA	$2,781.81

TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE

Facility

$6,837.00

Service Code	CPT 27245
Hospital Revenue Code	360
Min. Negotiated Rate	$1,209.90
Max. Negotiated Rate	$6,837.00
Rate for Payer: BCBS Trust/PPO	$2,499.10
Rate for Payer: UHC All Payor (Choice/PPO)	$1,330.89
Rate for Payer: UHC Core	$6,837.00
Rate for Payer: UHC Exchange	$1,209.90

TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST TRIMESTER

Facility

$8,478.18

Service Code	CPT 59820
Hospital Revenue Code	360
Min. Negotiated Rate	$385.40
Max. Negotiated Rate	$8,478.18
Rate for Payer: Aetna Medicare	$2,893.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,477.26
Rate for Payer: Amish Plain Church Group Commercial	$3,477.26
Rate for Payer: BCBS Complete	$1,597.87
Rate for Payer: BCBS MAPPO	$2,781.81
Rate for Payer: BCBS Trust/PPO	$1,299.88
Rate for Payer: BCN Medicare Advantage	$2,781.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,781.81
Rate for Payer: Mclaren Medicaid	$1,521.65
Rate for Payer: Mclaren Medicare	$2,781.81
Rate for Payer: Meridian Medicaid	$1,597.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,920.90
Rate for Payer: MI Amish Medical Board Commercial	$3,199.08
Rate for Payer: PACE Medicare	$2,642.72
Rate for Payer: PACE SWMI	$2,781.81
Rate for Payer: PHP Medicare Advantage	$2,781.81
Rate for Payer: Priority Health Choice Medicaid	$1,521.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,478.18
Rate for Payer: Priority Health Medicare	$2,781.81
Rate for Payer: Priority Health Narrow Network	$6,782.54
Rate for Payer: Railroad Medicare Medicare	$2,781.81
Rate for Payer: UHC All Payor (Choice/PPO)	$423.94
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$2,781.81
Rate for Payer: UHC Exchange	$385.40
Rate for Payer: UHC Medicare Advantage	$2,865.26
Rate for Payer: VA VA	$2,781.81

TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND TRIMESTER

Facility

$8,478.18

Service Code	CPT 59821
Hospital Revenue Code	360
Min. Negotiated Rate	$376.56
Max. Negotiated Rate	$8,478.18
Rate for Payer: Aetna Medicare	$2,893.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,477.26
Rate for Payer: Amish Plain Church Group Commercial	$3,477.26
Rate for Payer: BCBS Complete	$1,597.87
Rate for Payer: BCBS MAPPO	$2,781.81
Rate for Payer: BCBS Trust/PPO	$1,896.27
Rate for Payer: BCN Medicare Advantage	$2,781.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,781.81
Rate for Payer: Mclaren Medicaid	$1,521.65
Rate for Payer: Mclaren Medicare	$2,781.81
Rate for Payer: Meridian Medicaid	$1,597.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,920.90
Rate for Payer: MI Amish Medical Board Commercial	$3,199.08
Rate for Payer: PACE Medicare	$2,642.72
Rate for Payer: PACE SWMI	$2,781.81
Rate for Payer: PHP Medicare Advantage	$2,781.81
Rate for Payer: Priority Health Choice Medicaid	$1,521.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,478.18
Rate for Payer: Priority Health Medicare	$2,781.81
Rate for Payer: Priority Health Narrow Network	$6,782.54
Rate for Payer: Railroad Medicare Medicare	$2,781.81
Rate for Payer: UHC All Payor (Choice/PPO)	$414.22
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$2,781.81
Rate for Payer: UHC Exchange	$376.56
Rate for Payer: UHC Medicare Advantage	$2,865.26
Rate for Payer: VA VA	$2,781.81

TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE

Facility

$1,757.43

Service Code	CPT 12020
Hospital Revenue Code	361
Min. Negotiated Rate	$185.33
Max. Negotiated Rate	$1,757.43
Rate for Payer: Aetna Medicare	$581.18
Rate for Payer: Allen County Amish Medical Aid Commercial	$698.54
Rate for Payer: Amish Plain Church Group Commercial	$698.54
Rate for Payer: BCBS Complete	$320.99
Rate for Payer: BCBS MAPPO	$558.83
Rate for Payer: BCBS Trust/PPO	$363.15
Rate for Payer: BCN Medicare Advantage	$558.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$558.83
Rate for Payer: Mclaren Medicaid	$305.68
Rate for Payer: Mclaren Medicare	$558.83
Rate for Payer: Meridian Medicaid	$320.99
Rate for Payer: Meridian Wellcare - Medicare Advantage	$586.77
Rate for Payer: MI Amish Medical Board Commercial	$642.65
Rate for Payer: PACE Medicare	$530.89
Rate for Payer: PACE SWMI	$558.83
Rate for Payer: PHP Medicare Advantage	$558.83
Rate for Payer: Priority Health Choice Medicaid	$305.68
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,757.43
Rate for Payer: Priority Health Medicare	$558.83
Rate for Payer: Priority Health Narrow Network	$1,405.94
Rate for Payer: Railroad Medicare Medicare	$558.83
Rate for Payer: UHC All Payor (Choice/PPO)	$203.86
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Dual Complete DSNP	$558.83
Rate for Payer: UHC Exchange	$185.33
Rate for Payer: UHC Medicare Advantage	$575.59
Rate for Payer: VA VA	$558.83

TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE

Facility

$1,757.43

Service Code	CPT 12020
Hospital Revenue Code	360
Min. Negotiated Rate	$185.33
Max. Negotiated Rate	$1,757.43
Rate for Payer: Aetna Medicare	$581.18
Rate for Payer: Allen County Amish Medical Aid Commercial	$698.54
Rate for Payer: Amish Plain Church Group Commercial	$698.54
Rate for Payer: BCBS Complete	$320.99
Rate for Payer: BCBS MAPPO	$558.83
Rate for Payer: BCBS Trust/PPO	$363.15
Rate for Payer: BCN Medicare Advantage	$558.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$558.83
Rate for Payer: Mclaren Medicaid	$305.68
Rate for Payer: Mclaren Medicare	$558.83
Rate for Payer: Meridian Medicaid	$320.99
Rate for Payer: Meridian Wellcare - Medicare Advantage	$586.77
Rate for Payer: MI Amish Medical Board Commercial	$642.65
Rate for Payer: PACE Medicare	$530.89
Rate for Payer: PACE SWMI	$558.83
Rate for Payer: PHP Medicare Advantage	$558.83
Rate for Payer: Priority Health Choice Medicaid	$305.68
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,757.43
Rate for Payer: Priority Health Medicare	$558.83
Rate for Payer: Priority Health Narrow Network	$1,405.94
Rate for Payer: Railroad Medicare Medicare	$558.83
Rate for Payer: UHC All Payor (Choice/PPO)	$203.86
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Dual Complete DSNP	$558.83
Rate for Payer: UHC Exchange	$185.33
Rate for Payer: UHC Medicare Advantage	$575.59
Rate for Payer: VA VA	$558.83

TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE

Facility

$38,393.11

Service Code	CPT 27759
Hospital Revenue Code	360
Min. Negotiated Rate	$986.58
Max. Negotiated Rate	$38,393.11
Rate for Payer: Aetna Medicare	$12,179.12
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,638.36
Rate for Payer: Amish Plain Church Group Commercial	$14,638.36
Rate for Payer: BCBS Complete	$6,726.62
Rate for Payer: BCBS MAPPO	$11,710.69
Rate for Payer: BCBS Trust/PPO	$4,383.67
Rate for Payer: BCN Medicare Advantage	$11,710.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,710.69
Rate for Payer: Mclaren Medicaid	$6,405.75
Rate for Payer: Mclaren Medicare	$11,710.69
Rate for Payer: Meridian Medicaid	$6,726.62
Rate for Payer: Meridian Wellcare - Medicare Advantage	$12,296.22
Rate for Payer: MI Amish Medical Board Commercial	$13,467.29
Rate for Payer: PACE Medicare	$11,125.16
Rate for Payer: PACE SWMI	$11,710.69
Rate for Payer: PHP Medicare Advantage	$11,710.69
Rate for Payer: Priority Health Choice Medicaid	$6,405.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$38,393.11
Rate for Payer: Priority Health Medicare	$11,710.69
Rate for Payer: Priority Health Narrow Network	$30,714.49
Rate for Payer: Railroad Medicare Medicare	$11,710.69
Rate for Payer: UHC All Payor (Choice/PPO)	$1,085.24
Rate for Payer: UHC Core	$7,632.00
Rate for Payer: UHC Dual Complete DSNP	$11,710.69
Rate for Payer: UHC Exchange	$986.58
Rate for Payer: UHC Medicare Advantage	$12,062.01
Rate for Payer: VA VA	$11,710.69

TRIAMCINOLONE ACETONIDE 0.147 MG/GRAM TOPICAL AEROSOL

Facility

$1,735.12

Service Code	NDC 10631-093-62
Hospital Charge Code	19770
Hospital Revenue Code	637
Min. Negotiated Rate	$1,093.13
Max. Negotiated Rate	$1,561.61
Rate for Payer: Aetna Commercial	$1,474.85
Rate for Payer: Aetna New Business (MI Preferred)	$1,127.83
Rate for Payer: Cash Price	$1,388.10
Rate for Payer: Cofinity Commercial	$1,214.58
Rate for Payer: Cofinity Commercial	$1,492.20
Rate for Payer: Healthscope Commercial	$1,561.61
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,474.85
Rate for Payer: PHP Commercial	$1,474.85
Rate for Payer: Priority Health Cigna Priority Health	$1,214.58
Rate for Payer: Priority Health SBD	$1,093.13

TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM

Facility

$10.08

Service Code	NDC 67877-251-15
Hospital Charge Code	8113
Hospital Revenue Code	637
Min. Negotiated Rate	$6.35
Max. Negotiated Rate	$9.07
Rate for Payer: Aetna Commercial	$8.57
Rate for Payer: Aetna New Business (MI Preferred)	$6.55
Rate for Payer: Cash Price	$8.06
Rate for Payer: Cofinity Commercial	$7.06
Rate for Payer: Cofinity Commercial	$8.67
Rate for Payer: Healthscope Commercial	$9.07
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8.57
Rate for Payer: PHP Commercial	$8.57
Rate for Payer: Priority Health Cigna Priority Health	$7.06
Rate for Payer: Priority Health SBD	$6.35

TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM

Facility

$12.63

Service Code	NDC 52565-056-15
Hospital Charge Code	8113
Hospital Revenue Code	637
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$11.37
Rate for Payer: Aetna Commercial	$10.74
Rate for Payer: Aetna New Business (MI Preferred)	$8.21
Rate for Payer: Cash Price	$10.10
Rate for Payer: Cofinity Commercial	$10.86
Rate for Payer: Cofinity Commercial	$8.84
Rate for Payer: Healthscope Commercial	$11.37
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.74
Rate for Payer: PHP Commercial	$10.74
Rate for Payer: Priority Health Cigna Priority Health	$8.84
Rate for Payer: Priority Health SBD	$7.96

TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT

Facility

$19.44

Service Code	NDC 0168-0006-15
Hospital Charge Code	8118
Hospital Revenue Code	637
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$16.52
Rate for Payer: Aetna New Business (MI Preferred)	$12.64
Rate for Payer: Cash Price	$15.55
Rate for Payer: Cofinity Commercial	$16.72
Rate for Payer: Cofinity Commercial	$13.61
Rate for Payer: Healthscope Commercial	$17.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.52
Rate for Payer: PHP Commercial	$16.52
Rate for Payer: Priority Health Cigna Priority Health	$13.61
Rate for Payer: Priority Health SBD	$12.25

TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT

Facility

$17.96

Service Code	NDC 51672-1284-1
Hospital Charge Code	8118
Hospital Revenue Code	637
Min. Negotiated Rate	$11.31
Max. Negotiated Rate	$16.16
Rate for Payer: Aetna Commercial	$15.27
Rate for Payer: Aetna New Business (MI Preferred)	$11.67
Rate for Payer: Cash Price	$14.37
Rate for Payer: Cofinity Commercial	$12.57
Rate for Payer: Cofinity Commercial	$15.45
Rate for Payer: Healthscope Commercial	$16.16
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.27
Rate for Payer: PHP Commercial	$15.27
Rate for Payer: Priority Health Cigna Priority Health	$12.57
Rate for Payer: Priority Health SBD	$11.31

TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT

Facility

$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

$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	$20.38
Rate for Payer: Aetna Commercial	$20.20
Rate for Payer: Aetna Commercial	$249.61
Rate for Payer: Aetna New Business (MI Preferred)	$25.17
Rate for Payer: Aetna New Business (MI Preferred)	$15.45
Rate for Payer: Aetna New Business (MI Preferred)	$15.59
Rate for Payer: Aetna New Business (MI Preferred)	$190.88
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	$33.30
Rate for Payer: Cofinity Commercial	$16.79
Rate for Payer: Cofinity Commercial	$20.62
Rate for Payer: Cofinity Commercial	$20.44
Rate for Payer: Cofinity Commercial	$27.10
Rate for Payer: Cofinity Commercial	$16.64
Rate for Payer: Cofinity Commercial	$205.56
Rate for Payer: Cofinity Commercial	$252.55
Rate for Payer: Healthscope Commercial	$264.29
Rate for Payer: Healthscope Commercial	$21.39
Rate for Payer: Healthscope Commercial	$21.58
Rate for Payer: Healthscope Commercial	$34.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$20.38
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	$32.91
Rate for Payer: PHP Commercial	$20.38
Rate for Payer: PHP Commercial	$20.20
Rate for Payer: PHP Commercial	$249.61
Rate for Payer: PHP Commercial	$32.91
Rate for Payer: Priority Health Cigna Priority Health	$16.64
Rate for Payer: Priority Health Cigna Priority Health	$205.56
Rate for Payer: Priority Health Cigna Priority Health	$27.10
Rate for Payer: Priority Health Cigna Priority Health	$16.79
Rate for Payer: Priority Health SBD	$185.01
Rate for Payer: Priority Health SBD	$15.11
Rate for Payer: Priority Health SBD	$14.98
Rate for Payer: Priority Health SBD	$24.39

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE

Facility

$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

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE

Facility

$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

$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

$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

TRIFLURIDINE 1 % EYE DROPS

Facility

$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

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