|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET
|
Facility
IP
|
$248.90
|
|
|
Service Code
|
NDC 60505-2657-1
|
| Hospital Charge Code |
8134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.52 |
| Max. Negotiated Rate |
$224.01 |
| Rate for Payer: Aetna American Axle |
$161.78
|
| Rate for Payer: Aetna Commercial |
$211.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.78
|
| Rate for Payer: Cash Price |
$199.12
|
| Rate for Payer: Cofinity Commercial |
$174.23
|
| Rate for Payer: Cofinity Commercial |
$214.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$199.12
|
| Rate for Payer: Healthscope Commercial |
$224.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$174.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$211.56
|
| Rate for Payer: PHP Commercial |
$211.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.23
|
| Rate for Payer: Priority Health SBD |
$156.81
|
| Rate for Payer: UMR Bronson Commercial |
$109.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.68
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET
|
Facility
IP
|
$243.36
|
|
|
Service Code
|
NDC 51079-433-20
|
| Hospital Charge Code |
8134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.08 |
| Max. Negotiated Rate |
$219.02 |
| Rate for Payer: Aetna American Axle |
$158.18
|
| Rate for Payer: Aetna Commercial |
$206.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.18
|
| Rate for Payer: Cash Price |
$194.69
|
| Rate for Payer: Cofinity Commercial |
$170.35
|
| Rate for Payer: Cofinity Commercial |
$209.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.69
|
| Rate for Payer: Healthscope Commercial |
$219.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$182.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.86
|
| Rate for Payer: PHP Commercial |
$206.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.35
|
| Rate for Payer: Priority Health SBD |
$153.32
|
| Rate for Payer: UMR Bronson Commercial |
$107.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$182.52
|
|
|
TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET
|
Facility
IP
|
$2.44
|
|
|
Service Code
|
NDC 51079-433-01
|
| Hospital Charge Code |
8134
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Aetna American Axle |
$1.59
|
| Rate for Payer: Aetna Commercial |
$2.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.59
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cofinity Commercial |
$1.71
|
| Rate for Payer: Cofinity Commercial |
$2.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.95
|
| Rate for Payer: Healthscope Commercial |
$2.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.07
|
| Rate for Payer: PHP Commercial |
$2.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.71
|
| Rate for Payer: Priority Health SBD |
$1.54
|
| Rate for Payer: UMR Bronson Commercial |
$1.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.83
|
|
|
TRICHLOROACETIC ACID 100 % TOPICAL POWDER FOR SOLUTION
|
Facility
IP
|
$1,866.00
|
|
|
Service Code
|
NDC 51552-0274-6
|
| Hospital Charge Code |
161607
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$821.04 |
| Max. Negotiated Rate |
$1,679.40 |
| Rate for Payer: Aetna American Axle |
$1,212.90
|
| Rate for Payer: Aetna Commercial |
$1,586.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,212.90
|
| Rate for Payer: Cash Price |
$1,492.80
|
| Rate for Payer: Cofinity Commercial |
$1,306.20
|
| Rate for Payer: Cofinity Commercial |
$1,604.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,492.80
|
| Rate for Payer: Healthscope Commercial |
$1,679.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,306.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,399.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,586.10
|
| Rate for Payer: PHP Commercial |
$1,586.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,306.20
|
| Rate for Payer: Priority Health SBD |
$1,175.58
|
| Rate for Payer: UMR Bronson Commercial |
$821.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,399.50
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
IP
|
$11.64
|
|
|
Service Code
|
NDC 9900-0006-07
|
| Hospital Charge Code |
169208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$10.48 |
| Rate for Payer: Aetna American Axle |
$7.57
|
| Rate for Payer: Aetna Commercial |
$9.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.57
|
| Rate for Payer: Cash Price |
$9.31
|
| Rate for Payer: Cofinity Commercial |
$10.01
|
| Rate for Payer: Cofinity Commercial |
$8.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.31
|
| Rate for Payer: Healthscope Commercial |
$10.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.89
|
| Rate for Payer: PHP Commercial |
$9.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.15
|
| Rate for Payer: Priority Health SBD |
$7.33
|
| Rate for Payer: UMR Bronson Commercial |
$5.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.73
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
IP
|
$9.09
|
|
|
Service Code
|
NDC 72140-85700
|
| Hospital Charge Code |
169208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$8.18 |
| Rate for Payer: Aetna American Axle |
$5.91
|
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.91
|
| Rate for Payer: Cash Price |
$7.27
|
| Rate for Payer: Cofinity Commercial |
$6.36
|
| Rate for Payer: Cofinity Commercial |
$7.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.27
|
| Rate for Payer: Healthscope Commercial |
$8.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.73
|
| Rate for Payer: PHP Commercial |
$7.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.36
|
| Rate for Payer: Priority Health SBD |
$5.73
|
| Rate for Payer: UMR Bronson Commercial |
$4.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.82
|
|
|
TRIFLUOPERAZINE 10 MG TABLET
|
Facility
IP
|
$882.82
|
|
|
Service Code
|
NDC 51079-575-20
|
| Hospital Charge Code |
8162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$388.44 |
| Max. Negotiated Rate |
$794.54 |
| Rate for Payer: Aetna American Axle |
$573.83
|
| Rate for Payer: Aetna Commercial |
$750.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$573.83
|
| Rate for Payer: Cash Price |
$706.26
|
| Rate for Payer: Cofinity Commercial |
$617.97
|
| Rate for Payer: Cofinity Commercial |
$759.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$706.26
|
| Rate for Payer: Healthscope Commercial |
$794.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$617.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$662.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$750.40
|
| Rate for Payer: PHP Commercial |
$750.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$617.97
|
| Rate for Payer: Priority Health SBD |
$556.18
|
| Rate for Payer: UMR Bronson Commercial |
$388.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$662.12
|
|
|
TRIFLUOPERAZINE 10 MG TABLET
|
Facility
IP
|
$8.83
|
|
|
Service Code
|
NDC 51079-575-01
|
| Hospital Charge Code |
8162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$7.95 |
| Rate for Payer: Aetna American Axle |
$5.74
|
| Rate for Payer: Aetna Commercial |
$7.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.74
|
| Rate for Payer: Cash Price |
$7.06
|
| Rate for Payer: Cofinity Commercial |
$6.18
|
| Rate for Payer: Cofinity Commercial |
$7.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.06
|
| Rate for Payer: Healthscope Commercial |
$7.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.51
|
| Rate for Payer: PHP Commercial |
$7.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.18
|
| Rate for Payer: Priority Health SBD |
$5.56
|
| Rate for Payer: UMR Bronson Commercial |
$3.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.62
|
|
|
TRIFLUOPERAZINE 2 MG TABLET
|
Facility
IP
|
$321.60
|
|
|
Service Code
|
NDC 0378-2402-01
|
| Hospital Charge Code |
8163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.50 |
| Max. Negotiated Rate |
$289.44 |
| Rate for Payer: Aetna American Axle |
$209.04
|
| Rate for Payer: Aetna Commercial |
$273.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.04
|
| Rate for Payer: Cash Price |
$257.28
|
| Rate for Payer: Cofinity Commercial |
$225.12
|
| Rate for Payer: Cofinity Commercial |
$276.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.28
|
| Rate for Payer: Healthscope Commercial |
$289.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$273.36
|
| Rate for Payer: PHP Commercial |
$273.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.12
|
| Rate for Payer: Priority Health SBD |
$202.61
|
| Rate for Payer: UMR Bronson Commercial |
$141.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.20
|
|
|
TRIFLUOPERAZINE 2 MG TABLET
|
Facility
IP
|
$7.14
|
|
|
Service Code
|
NDC 51079-573-01
|
| Hospital Charge Code |
8163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna American Axle |
$4.64
|
| Rate for Payer: Aetna Commercial |
$6.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.64
|
| Rate for Payer: Cash Price |
$5.71
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$6.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$6.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.07
|
| Rate for Payer: PHP Commercial |
$6.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.00
|
| Rate for Payer: Priority Health SBD |
$4.50
|
| Rate for Payer: UMR Bronson Commercial |
$3.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.36
|
|
|
TRIFLUOPERAZINE 5 MG TABLET
|
Facility
IP
|
$9.48
|
|
|
Service Code
|
NDC 51079-574-01
|
| Hospital Charge Code |
8164
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.17 |
| Max. Negotiated Rate |
$8.53 |
| Rate for Payer: Aetna American Axle |
$6.16
|
| Rate for Payer: Aetna Commercial |
$8.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.16
|
| Rate for Payer: Cash Price |
$7.58
|
| Rate for Payer: Cofinity Commercial |
$6.64
|
| Rate for Payer: Cofinity Commercial |
$8.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.58
|
| Rate for Payer: Healthscope Commercial |
$8.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.06
|
| Rate for Payer: PHP Commercial |
$8.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.64
|
| Rate for Payer: Priority Health SBD |
$5.97
|
| Rate for Payer: UMR Bronson Commercial |
$4.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.11
|
|
|
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 |
$216.60 |
| Max. Negotiated Rate |
$443.04 |
| Rate for Payer: Aetna American Axle |
$319.98
|
| 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: Encore Health Key Benefits Commercial |
$393.82
|
| Rate for Payer: Healthscope Commercial |
$443.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$344.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$369.20
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$216.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$369.20
|
|
|
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 |
$144.76 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna American Axle |
$213.85
|
| 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: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.75
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$144.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
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 |
$147.86 |
| Max. Negotiated Rate |
$302.44 |
| Rate for Payer: Aetna American Axle |
$218.43
|
| 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: Encore Health Key Benefits Commercial |
$268.84
|
| Rate for Payer: Healthscope Commercial |
$302.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.04
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$147.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.04
|
|
|
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 |
$84.02 |
| Max. Negotiated Rate |
$171.86 |
| Rate for Payer: Aetna American Axle |
$124.12
|
| 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: Encore Health Key Benefits Commercial |
$152.77
|
| Rate for Payer: Healthscope Commercial |
$171.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$143.22
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$84.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$143.22
|
|
|
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 |
$262.10 |
| Max. Negotiated Rate |
$536.11 |
| Rate for Payer: Aetna American Axle |
$387.19
|
| 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: Encore Health Key Benefits Commercial |
$476.54
|
| Rate for Payer: Healthscope Commercial |
$536.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.76
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$262.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.76
|
|
|
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 |
$88.62 |
| Max. Negotiated Rate |
$181.26 |
| Rate for Payer: Aetna American Axle |
$130.91
|
| 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: Encore Health Key Benefits Commercial |
$161.12
|
| Rate for Payer: Healthscope Commercial |
$181.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.05
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$88.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.05
|
|
|
TRIPROLIDINE-PSEUDOEPHEDRINE 2.5 MG-60 MG TABLET
|
Facility
IP
|
$79.90
|
|
|
Service Code
|
NDC 0904-0250-59
|
| Hospital Charge Code |
8213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| Rate for Payer: Cofinity Commercial |
$68.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$71.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.93
|
| Rate for Payer: Priority Health SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$35.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION
|
Facility
IP
|
$14,452.20
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
119655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,358.97 |
| Max. Negotiated Rate |
$13,006.98 |
| Rate for Payer: Aetna American Axle |
$9,393.93
|
| Rate for Payer: Aetna Commercial |
$12,284.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,393.93
|
| 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: Encore Health Key Benefits Commercial |
$11,561.76
|
| Rate for Payer: Healthscope Commercial |
$13,006.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10,116.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,839.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12,284.37
|
| Rate for Payer: PHP Commercial |
$12,284.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,116.54
|
| Rate for Payer: Priority Health SBD |
$9,104.89
|
| Rate for Payer: UMR Bronson Commercial |
$6,358.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,839.15
|
|
|
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 |
$916.61 |
| Max. Negotiated Rate |
$1,874.88 |
| Rate for Payer: Aetna American Axle |
$1,354.08
|
| 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: Encore Health Key Benefits Commercial |
$1,666.56
|
| Rate for Payer: Healthscope Commercial |
$1,874.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,458.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,562.40
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$916.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,562.40
|
|
|
TROPICAMIDE 0.5 % EYE DROPS
|
Facility
IP
|
$69.62
|
|
|
Service Code
|
NDC 61314-354-01
|
| Hospital Charge Code |
8249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.63 |
| Max. Negotiated Rate |
$62.66 |
| Rate for Payer: Aetna American Axle |
$45.25
|
| Rate for Payer: Aetna Commercial |
$59.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.25
|
| Rate for Payer: Cash Price |
$55.70
|
| Rate for Payer: Cofinity Commercial |
$48.73
|
| Rate for Payer: Cofinity Commercial |
$59.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.70
|
| Rate for Payer: Healthscope Commercial |
$62.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.18
|
| Rate for Payer: PHP Commercial |
$59.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: Priority Health SBD |
$43.86
|
| Rate for Payer: UMR Bronson Commercial |
$30.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.22
|
|
|
TROPICAMIDE 0.5 % EYE DROPS
|
Facility
IP
|
$21.84
|
|
|
Service Code
|
NDC 17478-101-12
|
| Hospital Charge Code |
8249
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Aetna American Axle |
$14.20
|
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.20
|
| Rate for Payer: Cash Price |
$17.47
|
| Rate for Payer: Cofinity Commercial |
$15.29
|
| Rate for Payer: Cofinity Commercial |
$18.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.47
|
| Rate for Payer: Healthscope Commercial |
$19.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.56
|
| Rate for Payer: PHP Commercial |
$18.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.29
|
| Rate for Payer: Priority Health SBD |
$13.76
|
| Rate for Payer: UMR Bronson Commercial |
$9.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.38
|
|
|
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 |
$13.68 |
| Max. Negotiated Rate |
$27.97 |
| Rate for Payer: Aetna American Axle |
$20.20
|
| 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: Encore Health Key Benefits Commercial |
$24.86
|
| Rate for Payer: Healthscope Commercial |
$27.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.31
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$13.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.31
|
|
|
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 |
$11.53 |
| Max. Negotiated Rate |
$23.58 |
| Rate for Payer: Aetna American Axle |
$17.03
|
| 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: Encore Health Key Benefits Commercial |
$20.96
|
| Rate for Payer: Healthscope Commercial |
$23.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.65
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$11.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.65
|
|
|
TRYPAN BLUE 0.06 % INTRAOCULAR SYRINGE
|
Facility
IP
|
$182.04
|
|
|
Service Code
|
NDC 68803-612-10
|
| Hospital Charge Code |
88317
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.10 |
| Max. Negotiated Rate |
$163.84 |
| Rate for Payer: Aetna American Axle |
$118.33
|
| Rate for Payer: Aetna Commercial |
$154.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.33
|
| Rate for Payer: Cash Price |
$145.63
|
| Rate for Payer: Cofinity Commercial |
$127.43
|
| Rate for Payer: Cofinity Commercial |
$156.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.63
|
| Rate for Payer: Healthscope Commercial |
$163.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$154.73
|
| Rate for Payer: PHP Commercial |
$154.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$127.43
|
| Rate for Payer: Priority Health SBD |
$114.69
|
| Rate for Payer: UMR Bronson Commercial |
$80.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.53
|
|
