|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
|
IP
|
$9.90
|
|
|
Service Code
|
NDC 61314-226-05
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$8.91 |
| Rate for Payer: Aetna American Axle |
$6.44
|
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.44
|
| Rate for Payer: Cash Price |
$7.92
|
| Rate for Payer: Cofinity Commercial |
$6.93
|
| Rate for Payer: Cofinity Commercial |
$8.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.92
|
| Rate for Payer: Healthscope Commercial |
$8.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.42
|
| Rate for Payer: PHP Commercial |
$8.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.93
|
| Rate for Payer: Priority Health SBD |
$6.24
|
| Rate for Payer: UMR Bronson Commercial |
$4.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.42
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$46.24
|
|
|
Service Code
|
NDC 64980-514-01
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.35 |
| Max. Negotiated Rate |
$41.62 |
| Rate for Payer: Aetna American Axle |
$30.06
|
| Rate for Payer: Aetna Commercial |
$39.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.06
|
| Rate for Payer: Cash Price |
$36.99
|
| Rate for Payer: Cofinity Commercial |
$32.37
|
| Rate for Payer: Cofinity Commercial |
$39.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.99
|
| Rate for Payer: Healthscope Commercial |
$41.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.30
|
| Rate for Payer: PHP Commercial |
$39.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.37
|
| Rate for Payer: Priority Health SBD |
$29.13
|
| Rate for Payer: UMR Bronson Commercial |
$20.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.68
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$40.39
|
|
|
Service Code
|
NDC 17478-288-11
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.77 |
| Max. Negotiated Rate |
$36.35 |
| Rate for Payer: Aetna American Axle |
$26.25
|
| Rate for Payer: Aetna Commercial |
$34.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.25
|
| Rate for Payer: Cash Price |
$32.31
|
| Rate for Payer: Cofinity Commercial |
$28.27
|
| Rate for Payer: Cofinity Commercial |
$34.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.31
|
| Rate for Payer: Healthscope Commercial |
$36.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$28.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.33
|
| Rate for Payer: PHP Commercial |
$34.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.27
|
| Rate for Payer: Priority Health SBD |
$25.45
|
| Rate for Payer: UMR Bronson Commercial |
$17.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.29
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$28.25
|
|
|
Service Code
|
NDC 17478-288-10
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$25.42 |
| Rate for Payer: Aetna American Axle |
$18.36
|
| Rate for Payer: Aetna Commercial |
$24.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.36
|
| Rate for Payer: Cash Price |
$22.60
|
| Rate for Payer: Cofinity Commercial |
$19.78
|
| Rate for Payer: Cofinity Commercial |
$24.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.60
|
| Rate for Payer: Healthscope Commercial |
$25.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.01
|
| Rate for Payer: PHP Commercial |
$24.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.78
|
| Rate for Payer: Priority Health SBD |
$17.80
|
| Rate for Payer: UMR Bronson Commercial |
$12.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.19
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$688.84
|
|
|
Service Code
|
NDC 24208-813-05
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$303.09 |
| Max. Negotiated Rate |
$619.96 |
| Rate for Payer: Aetna American Axle |
$447.75
|
| Rate for Payer: Aetna Commercial |
$585.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$447.75
|
| Rate for Payer: Cash Price |
$551.07
|
| Rate for Payer: Cofinity Commercial |
$482.19
|
| Rate for Payer: Cofinity Commercial |
$592.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$551.07
|
| Rate for Payer: Healthscope Commercial |
$619.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$482.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$516.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$585.51
|
| Rate for Payer: PHP Commercial |
$585.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$482.19
|
| Rate for Payer: Priority Health SBD |
$433.97
|
| Rate for Payer: UMR Bronson Commercial |
$303.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$516.63
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$19.71
|
|
|
Service Code
|
NDC 61314-227-05
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.67 |
| Max. Negotiated Rate |
$17.74 |
| Rate for Payer: Aetna American Axle |
$12.81
|
| Rate for Payer: Aetna Commercial |
$16.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.81
|
| Rate for Payer: Cash Price |
$15.77
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Commercial |
$16.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.77
|
| Rate for Payer: Healthscope Commercial |
$17.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.75
|
| Rate for Payer: PHP Commercial |
$16.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.80
|
| Rate for Payer: Priority Health SBD |
$12.42
|
| Rate for Payer: UMR Bronson Commercial |
$8.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.78
|
|
|
TIMOLOL MALEATE 0.5 % EYE DROPS
|
Facility
|
IP
|
$31.57
|
|
|
Service Code
|
NDC 64980-514-05
|
| Hospital Charge Code |
11562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.89 |
| Max. Negotiated Rate |
$28.41 |
| Rate for Payer: Aetna American Axle |
$20.52
|
| Rate for Payer: Aetna Commercial |
$26.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.52
|
| Rate for Payer: Cash Price |
$25.26
|
| Rate for Payer: Cofinity Commercial |
$27.15
|
| Rate for Payer: Cofinity Commercial |
$22.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.26
|
| Rate for Payer: Healthscope Commercial |
$28.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.83
|
| Rate for Payer: PHP Commercial |
$26.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.10
|
| Rate for Payer: Priority Health SBD |
$19.89
|
| Rate for Payer: UMR Bronson Commercial |
$13.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.68
|
|
|
TIMOLOL MALEATE 0.5 % EYE GEL FORMING SOLUTION
|
Facility
|
IP
|
$399.53
|
|
|
Service Code
|
NDC 24208-819-05
|
| Hospital Charge Code |
24576
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.79 |
| Max. Negotiated Rate |
$359.58 |
| Rate for Payer: Aetna American Axle |
$259.69
|
| Rate for Payer: Aetna Commercial |
$339.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$259.69
|
| Rate for Payer: Cash Price |
$319.62
|
| Rate for Payer: Cofinity Commercial |
$279.67
|
| Rate for Payer: Cofinity Commercial |
$343.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$319.62
|
| Rate for Payer: Healthscope Commercial |
$359.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$279.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$299.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$339.60
|
| Rate for Payer: PHP Commercial |
$339.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.67
|
| Rate for Payer: Priority Health SBD |
$251.70
|
| Rate for Payer: UMR Bronson Commercial |
$175.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$299.65
|
|
|
TIMOLOL MALEATE 0.5 % EYE GEL FORMING SOLUTION
|
Facility
|
IP
|
$565.74
|
|
|
Service Code
|
NDC 61314-225-05
|
| Hospital Charge Code |
24576
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$248.93 |
| Max. Negotiated Rate |
$509.17 |
| Rate for Payer: Aetna American Axle |
$367.73
|
| Rate for Payer: Aetna Commercial |
$480.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$367.73
|
| Rate for Payer: Cash Price |
$452.59
|
| Rate for Payer: Cofinity Commercial |
$396.02
|
| Rate for Payer: Cofinity Commercial |
$486.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$452.59
|
| Rate for Payer: Healthscope Commercial |
$509.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$396.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$424.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$480.88
|
| Rate for Payer: PHP Commercial |
$480.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$396.02
|
| Rate for Payer: Priority Health SBD |
$356.42
|
| Rate for Payer: UMR Bronson Commercial |
$248.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$424.30
|
|
|
TIOTROPIUM BROMIDE 1.25 MCG/ACTUATION MIST FOR INHALATION
|
Facility
|
IP
|
$1,201.67
|
|
|
Service Code
|
NDC 0597-0160-61
|
| Hospital Charge Code |
175691
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$528.73 |
| Max. Negotiated Rate |
$1,081.50 |
| Rate for Payer: Aetna American Axle |
$781.09
|
| Rate for Payer: Aetna Commercial |
$1,021.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$781.09
|
| Rate for Payer: Cash Price |
$961.34
|
| Rate for Payer: Cofinity Commercial |
$1,033.44
|
| Rate for Payer: Cofinity Commercial |
$841.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$961.34
|
| Rate for Payer: Healthscope Commercial |
$1,081.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$841.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$901.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,021.42
|
| Rate for Payer: PHP Commercial |
$1,021.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$841.17
|
| Rate for Payer: Priority Health SBD |
$757.05
|
| Rate for Payer: UMR Bronson Commercial |
$528.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$901.25
|
|
|
TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE
|
Facility
|
IP
|
$177.23
|
|
|
Service Code
|
NDC 0597-0075-75
|
| Hospital Charge Code |
38315
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.98 |
| Max. Negotiated Rate |
$159.51 |
| Rate for Payer: Aetna American Axle |
$115.20
|
| Rate for Payer: Aetna Commercial |
$150.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.20
|
| Rate for Payer: Cash Price |
$141.78
|
| Rate for Payer: Cofinity Commercial |
$124.06
|
| Rate for Payer: Cofinity Commercial |
$152.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.78
|
| Rate for Payer: Healthscope Commercial |
$159.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$124.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$150.65
|
| Rate for Payer: PHP Commercial |
$150.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.06
|
| Rate for Payer: Priority Health SBD |
$111.65
|
| Rate for Payer: UMR Bronson Commercial |
$77.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.92
|
|
|
TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$29,629.51
|
|
|
Service Code
|
HCPCS J9273
|
| Hospital Charge Code |
198323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.07 |
| Max. Negotiated Rate |
$26,666.56 |
| Rate for Payer: Aetna American Axle |
$19,259.18
|
| Rate for Payer: Aetna Commercial |
$25,185.08
|
| Rate for Payer: Aetna Medicare |
$175.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,259.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$210.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$210.39
|
| Rate for Payer: BCBS Complete |
$96.68
|
| Rate for Payer: BCBS MAPPO |
$168.31
|
| Rate for Payer: BCBS Trust/PPO |
$543.88
|
| Rate for Payer: BCN Medicare Advantage |
$168.31
|
| Rate for Payer: Cash Price |
$23,703.61
|
| Rate for Payer: Cash Price |
$23,703.61
|
| Rate for Payer: Cofinity Commercial |
$20,740.66
|
| Rate for Payer: Cofinity Commercial |
$25,481.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,703.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$168.31
|
| Rate for Payer: Healthscope Commercial |
$26,666.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20,740.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22,222.13
|
| Rate for Payer: Mclaren Medicaid |
$92.07
|
| Rate for Payer: Mclaren Medicare |
$168.31
|
| Rate for Payer: Meridian Medicaid |
$96.68
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$176.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$193.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25,185.08
|
| Rate for Payer: PACE Medicare |
$159.89
|
| Rate for Payer: PACE SWMI |
$168.31
|
| Rate for Payer: PHP Commercial |
$25,185.08
|
| Rate for Payer: PHP Medicare Advantage |
$168.31
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20,740.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$494.17
|
| Rate for Payer: Priority Health Medicare |
$168.31
|
| Rate for Payer: Priority Health Narrow Network |
$395.34
|
| Rate for Payer: Priority Health SBD |
$18,666.59
|
| Rate for Payer: Railroad Medicare Medicare |
$168.31
|
| Rate for Payer: UHC Dual Complete DSNP |
$168.31
|
| Rate for Payer: UHC Medicare Advantage |
$173.36
|
| Rate for Payer: UMR Bronson Commercial |
$10,962.92
|
| Rate for Payer: VA VA |
$168.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22,222.13
|
|
|
TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
|
Facility
|
OP
|
$49,310.17
|
|
|
Service Code
|
CPT 19357
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,143.10 |
| Max. Negotiated Rate |
$49,310.17 |
| Rate for Payer: Aetna Medicare |
$16,290.29
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19,579.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19,579.68
|
| Rate for Payer: BCBS Complete |
$8,997.25
|
| Rate for Payer: BCBS MAPPO |
$15,663.74
|
| Rate for Payer: BCBS Trust/PPO |
$9,032.30
|
| Rate for Payer: BCN Medicare Advantage |
$15,663.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15,663.74
|
| Rate for Payer: Mclaren Medicaid |
$8,568.07
|
| Rate for Payer: Mclaren Medicare |
$15,663.74
|
| Rate for Payer: Meridian Medicaid |
$8,997.25
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$16,446.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18,013.30
|
| Rate for Payer: PACE Medicare |
$14,880.55
|
| Rate for Payer: PACE SWMI |
$15,663.74
|
| Rate for Payer: PHP Medicare Advantage |
$15,663.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,568.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49,310.17
|
| Rate for Payer: Priority Health Medicare |
$15,663.74
|
| Rate for Payer: Priority Health Narrow Network |
$39,448.14
|
| Rate for Payer: Railroad Medicare Medicare |
$15,663.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,257.41
|
| Rate for Payer: UHC Core |
$8,596.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$15,663.74
|
| Rate for Payer: UHC Exchange |
$1,143.10
|
| Rate for Payer: UHC Medicare Advantage |
$16,133.65
|
| Rate for Payer: VA VA |
$15,663.74
|
|
|
TIZANIDINE 2 MG TABLET
|
Facility
|
IP
|
$137.48
|
|
|
Service Code
|
NDC 57664-502-89
|
| Hospital Charge Code |
14792
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.49 |
| Max. Negotiated Rate |
$123.73 |
| Rate for Payer: Aetna American Axle |
$89.36
|
| Rate for Payer: Aetna Commercial |
$116.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$89.36
|
| Rate for Payer: Cash Price |
$109.98
|
| Rate for Payer: Cofinity Commercial |
$118.23
|
| Rate for Payer: Cofinity Commercial |
$96.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.98
|
| Rate for Payer: Healthscope Commercial |
$123.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$96.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$116.86
|
| Rate for Payer: PHP Commercial |
$116.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.24
|
| Rate for Payer: Priority Health SBD |
$86.61
|
| Rate for Payer: UMR Bronson Commercial |
$60.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.11
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$389.50
|
|
|
Service Code
|
NDC 0904-6418-61
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.38 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna American Axle |
$253.18
|
| Rate for Payer: Aetna Commercial |
$331.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.18
|
| Rate for Payer: Cash Price |
$311.60
|
| Rate for Payer: Cofinity Commercial |
$272.65
|
| Rate for Payer: Cofinity Commercial |
$334.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.60
|
| Rate for Payer: Healthscope Commercial |
$350.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$272.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$331.08
|
| Rate for Payer: PHP Commercial |
$331.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$272.65
|
| Rate for Payer: Priority Health SBD |
$245.38
|
| Rate for Payer: UMR Bronson Commercial |
$171.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.12
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$334.88
|
|
|
Service Code
|
NDC 55111-180-15
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.35 |
| Max. Negotiated Rate |
$301.39 |
| Rate for Payer: Aetna American Axle |
$217.67
|
| Rate for Payer: Aetna Commercial |
$284.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.67
|
| Rate for Payer: Cash Price |
$267.90
|
| Rate for Payer: Cofinity Commercial |
$234.42
|
| Rate for Payer: Cofinity Commercial |
$288.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.90
|
| Rate for Payer: Healthscope Commercial |
$301.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$234.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$251.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$284.65
|
| Rate for Payer: PHP Commercial |
$284.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.42
|
| Rate for Payer: Priority Health SBD |
$210.97
|
| Rate for Payer: UMR Bronson Commercial |
$147.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$251.16
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$334.88
|
|
|
Service Code
|
NDC 29300-169-15
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.35 |
| Max. Negotiated Rate |
$301.39 |
| Rate for Payer: Aetna American Axle |
$217.67
|
| Rate for Payer: Aetna Commercial |
$284.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.67
|
| Rate for Payer: Cash Price |
$267.90
|
| Rate for Payer: Cofinity Commercial |
$234.42
|
| Rate for Payer: Cofinity Commercial |
$288.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.90
|
| Rate for Payer: Healthscope Commercial |
$301.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$234.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$251.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$284.65
|
| Rate for Payer: PHP Commercial |
$284.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.42
|
| Rate for Payer: Priority Health SBD |
$210.97
|
| Rate for Payer: UMR Bronson Commercial |
$147.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$251.16
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$260.64
|
|
|
Service Code
|
NDC 51079-998-20
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.68 |
| Max. Negotiated Rate |
$234.58 |
| Rate for Payer: Aetna American Axle |
$169.42
|
| Rate for Payer: Aetna Commercial |
$221.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.42
|
| Rate for Payer: Cash Price |
$208.51
|
| Rate for Payer: Cofinity Commercial |
$182.45
|
| Rate for Payer: Cofinity Commercial |
$224.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.51
|
| Rate for Payer: Healthscope Commercial |
$234.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$221.54
|
| Rate for Payer: PHP Commercial |
$221.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.45
|
| Rate for Payer: Priority Health SBD |
$164.20
|
| Rate for Payer: UMR Bronson Commercial |
$114.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.48
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$171.00
|
|
|
Service Code
|
NDC 50268-760-15
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.24 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna American Axle |
$111.15
|
| Rate for Payer: Aetna Commercial |
$145.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$111.15
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cofinity Commercial |
$119.70
|
| Rate for Payer: Cofinity Commercial |
$147.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.80
|
| Rate for Payer: Healthscope Commercial |
$153.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$128.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$145.35
|
| Rate for Payer: PHP Commercial |
$145.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.70
|
| Rate for Payer: Priority Health SBD |
$107.73
|
| Rate for Payer: UMR Bronson Commercial |
$75.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$128.25
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$2.61
|
|
|
Service Code
|
NDC 51079-998-01
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna American Axle |
$1.70
|
| 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: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
TIZANIDINE 4 MG TABLET
|
Facility
|
IP
|
$3.42
|
|
|
Service Code
|
NDC 50268-760-11
|
| Hospital Charge Code |
14793
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna American Axle |
$2.22
|
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.22
|
| Rate for Payer: Cash Price |
$2.74
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.74
|
| Rate for Payer: Healthscope Commercial |
$3.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.91
|
| Rate for Payer: PHP Commercial |
$2.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.39
|
| Rate for Payer: Priority Health SBD |
$2.15
|
| Rate for Payer: UMR Bronson Commercial |
$1.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.56
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$270.80
|
|
|
Service Code
|
NDC 0065-0647-25
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.15 |
| Max. Negotiated Rate |
$243.72 |
| Rate for Payer: Aetna American Axle |
$176.02
|
| Rate for Payer: Aetna Commercial |
$230.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.02
|
| Rate for Payer: Cash Price |
$216.64
|
| Rate for Payer: Cofinity Commercial |
$189.56
|
| Rate for Payer: Cofinity Commercial |
$232.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.64
|
| Rate for Payer: Healthscope Commercial |
$243.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$230.18
|
| Rate for Payer: PHP Commercial |
$230.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.56
|
| Rate for Payer: Priority Health SBD |
$170.60
|
| Rate for Payer: UMR Bronson Commercial |
$119.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.10
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$123.45
|
|
|
Service Code
|
NDC 61314-647-25
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$111.10 |
| Rate for Payer: Aetna American Axle |
$80.24
|
| Rate for Payer: Aetna Commercial |
$104.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$80.24
|
| Rate for Payer: Cash Price |
$98.76
|
| Rate for Payer: Cofinity Commercial |
$106.17
|
| Rate for Payer: Cofinity Commercial |
$86.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$98.76
|
| Rate for Payer: Healthscope Commercial |
$111.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$86.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$92.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$104.93
|
| Rate for Payer: PHP Commercial |
$104.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.42
|
| Rate for Payer: Priority Health SBD |
$77.77
|
| Rate for Payer: UMR Bronson Commercial |
$54.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$92.59
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION
|
Facility
|
IP
|
$164.61
|
|
|
Service Code
|
NDC 24208-295-25
|
| Hospital Charge Code |
11567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.43 |
| Max. Negotiated Rate |
$148.15 |
| Rate for Payer: Aetna American Axle |
$107.00
|
| Rate for Payer: Aetna Commercial |
$139.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.00
|
| Rate for Payer: Cash Price |
$131.69
|
| Rate for Payer: Cofinity Commercial |
$115.23
|
| Rate for Payer: Cofinity Commercial |
$141.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.69
|
| Rate for Payer: Healthscope Commercial |
$148.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.92
|
| Rate for Payer: PHP Commercial |
$139.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.23
|
| Rate for Payer: Priority Health SBD |
$103.70
|
| Rate for Payer: UMR Bronson Commercial |
$72.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.46
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS
|
Facility
|
IP
|
$37.84
|
|
|
Service Code
|
NDC 17478-290-10
|
| Hospital Charge Code |
7995
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$34.06 |
| Rate for Payer: Aetna American Axle |
$24.60
|
| Rate for Payer: Aetna Commercial |
$32.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.60
|
| Rate for Payer: Cash Price |
$30.27
|
| Rate for Payer: Cofinity Commercial |
$26.49
|
| Rate for Payer: Cofinity Commercial |
$32.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.27
|
| Rate for Payer: Healthscope Commercial |
$34.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.16
|
| Rate for Payer: PHP Commercial |
$32.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.49
|
| Rate for Payer: Priority Health SBD |
$23.84
|
| Rate for Payer: UMR Bronson Commercial |
$16.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.38
|
|
