|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 68094011659
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna American Axle |
$2.94
|
| Rate for Payer: Aetna Commercial |
$3.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.94
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cofinity Advantage |
$3.16
|
| Rate for Payer: Cofinity Commercial |
$3.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.62
|
| Rate for Payer: Healthscope Commercial |
$4.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.39
|
| Rate for Payer: PHP Commercial |
$3.84
|
| Rate for Payer: Priority Health SBD |
$2.85
|
| Rate for Payer: UMR Bronson Commercial |
$1.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.39
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$3.88
|
|
|
Service Code
|
NDC 77333093425
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Advantage |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.91
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$65.80
|
|
|
Service Code
|
NDC 96295013892
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.95 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna American Axle |
$42.77
|
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Advantage |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.64
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$49.35
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health SBD |
$41.45
|
| Rate for Payer: UMR Bronson Commercial |
$28.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.35
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$451.20
|
|
|
Service Code
|
NDC 68094011661
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.53 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna American Axle |
$293.28
|
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.28
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Advantage |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.96
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$315.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$338.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$383.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$338.40
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health SBD |
$284.26
|
| Rate for Payer: UMR Bronson Commercial |
$198.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$338.40
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$387.75
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.61 |
| Max. Negotiated Rate |
$348.98 |
| Rate for Payer: Aetna American Axle |
$252.04
|
| Rate for Payer: Aetna Commercial |
$329.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.04
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cofinity Advantage |
$271.43
|
| Rate for Payer: Cofinity Commercial |
$333.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.20
|
| Rate for Payer: Healthscope Commercial |
$348.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$271.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$290.81
|
| Rate for Payer: PHP Commercial |
$329.59
|
| Rate for Payer: Priority Health SBD |
$244.28
|
| Rate for Payer: UMR Bronson Commercial |
$170.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.81
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$451.20
|
|
|
Service Code
|
NDC 68094011661
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.94 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna American Axle |
$293.28
|
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: Aetna Medicare |
$225.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.28
|
| Rate for Payer: BCBS Complete |
$180.48
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Advantage |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.96
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$315.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$338.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$360.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$383.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$338.40
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health SBD |
$284.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$293.28
|
| Rate for Payer: UHC Core |
$235.08
|
| Rate for Payer: UHC Exchange |
$177.32
|
| Rate for Payer: UMR Bronson Commercial |
$166.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$338.40
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$387.75
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.47 |
| Max. Negotiated Rate |
$348.98 |
| Rate for Payer: Aetna American Axle |
$252.04
|
| Rate for Payer: Aetna Commercial |
$329.59
|
| Rate for Payer: Aetna Medicare |
$193.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.04
|
| Rate for Payer: BCBS Complete |
$155.10
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cofinity Advantage |
$271.43
|
| Rate for Payer: Cofinity Commercial |
$333.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.20
|
| Rate for Payer: Healthscope Commercial |
$348.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$271.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$310.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$290.81
|
| Rate for Payer: PHP Commercial |
$329.59
|
| Rate for Payer: Priority Health SBD |
$244.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$252.04
|
| Rate for Payer: UHC Core |
$202.02
|
| Rate for Payer: UHC Exchange |
$152.39
|
| Rate for Payer: UMR Bronson Commercial |
$143.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.81
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 68094011659
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna American Axle |
$2.94
|
| Rate for Payer: Aetna Commercial |
$3.84
|
| Rate for Payer: Aetna Medicare |
$2.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.94
|
| Rate for Payer: BCBS Complete |
$1.81
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cofinity Advantage |
$3.16
|
| Rate for Payer: Cofinity Commercial |
$3.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.62
|
| Rate for Payer: Healthscope Commercial |
$4.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.39
|
| Rate for Payer: PHP Commercial |
$3.84
|
| Rate for Payer: Priority Health SBD |
$2.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.94
|
| Rate for Payer: UHC Core |
$2.35
|
| Rate for Payer: UHC Exchange |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.39
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$65.80
|
|
|
Service Code
|
NDC 96295013892
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna American Axle |
$42.77
|
| Rate for Payer: Aetna Commercial |
$55.93
|
| Rate for Payer: Aetna Medicare |
$32.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.77
|
| Rate for Payer: BCBS Complete |
$26.32
|
| Rate for Payer: Cash Price |
$52.64
|
| Rate for Payer: Cofinity Advantage |
$46.06
|
| Rate for Payer: Cofinity Commercial |
$56.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.64
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$52.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$49.35
|
| Rate for Payer: PHP Commercial |
$55.93
|
| Rate for Payer: Priority Health SBD |
$41.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.77
|
| Rate for Payer: UHC Core |
$34.28
|
| Rate for Payer: UHC Exchange |
$25.86
|
| Rate for Payer: UMR Bronson Commercial |
$24.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.35
|
|
|
THIOGLYCOLIC ACID SALT BODY CREAM (NAIR)
|
Facility
|
OP
|
$21.96
|
|
|
Service Code
|
NDC 09900002059
|
| Hospital Charge Code |
302081
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$19.76 |
| Rate for Payer: Aetna American Axle |
$14.27
|
| Rate for Payer: Aetna Commercial |
$18.67
|
| Rate for Payer: Aetna Medicare |
$10.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.27
|
| Rate for Payer: BCBS Complete |
$8.78
|
| Rate for Payer: Cash Price |
$17.57
|
| Rate for Payer: Cofinity Advantage |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.57
|
| Rate for Payer: Healthscope Commercial |
$19.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.47
|
| Rate for Payer: PHP Commercial |
$18.67
|
| Rate for Payer: Priority Health SBD |
$13.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.27
|
| Rate for Payer: UHC Core |
$11.44
|
| Rate for Payer: UHC Exchange |
$8.63
|
| Rate for Payer: UMR Bronson Commercial |
$8.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.47
|
|
|
THIOGLYCOLIC ACID SALT BODY CREAM (NAIR)
|
Facility
|
IP
|
$21.96
|
|
|
Service Code
|
NDC 09900002059
|
| Hospital Charge Code |
302081
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$19.76 |
| Rate for Payer: Aetna American Axle |
$14.27
|
| Rate for Payer: Aetna Commercial |
$18.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.27
|
| Rate for Payer: Cash Price |
$17.57
|
| Rate for Payer: Cofinity Advantage |
$15.37
|
| Rate for Payer: Cofinity Commercial |
$18.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.57
|
| Rate for Payer: Healthscope Commercial |
$19.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.47
|
| Rate for Payer: PHP Commercial |
$18.67
|
| Rate for Payer: Priority Health SBD |
$13.83
|
| Rate for Payer: UMR Bronson Commercial |
$9.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.47
|
|
|
THIOGUANINE 40 MG TABLET
|
Facility
|
OP
|
$48,758.33
|
|
|
Service Code
|
NDC 80725063025
|
| Hospital Charge Code |
7886
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18,040.58 |
| Max. Negotiated Rate |
$43,882.50 |
| Rate for Payer: Aetna American Axle |
$31,692.91
|
| Rate for Payer: Aetna Commercial |
$41,444.58
|
| Rate for Payer: Aetna Medicare |
$24,379.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31,692.91
|
| Rate for Payer: BCBS Complete |
$19,503.33
|
| Rate for Payer: Cash Price |
$39,006.66
|
| Rate for Payer: Cofinity Advantage |
$34,130.83
|
| Rate for Payer: Cofinity Commercial |
$41,932.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39,006.66
|
| Rate for Payer: Healthscope Commercial |
$43,882.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34,130.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36,568.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$39,006.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41,444.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36,568.75
|
| Rate for Payer: PHP Commercial |
$41,444.58
|
| Rate for Payer: Priority Health SBD |
$30,717.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31,692.91
|
| Rate for Payer: UHC Core |
$25,403.09
|
| Rate for Payer: UHC Exchange |
$19,162.02
|
| Rate for Payer: UMR Bronson Commercial |
$18,040.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36,568.75
|
|
|
THIOGUANINE 40 MG TABLET
|
Facility
|
IP
|
$48,758.33
|
|
|
Service Code
|
NDC 80725063025
|
| Hospital Charge Code |
7886
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21,453.67 |
| Max. Negotiated Rate |
$43,882.50 |
| Rate for Payer: Aetna American Axle |
$31,692.91
|
| Rate for Payer: Aetna Commercial |
$41,444.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31,692.91
|
| Rate for Payer: Cash Price |
$39,006.66
|
| Rate for Payer: Cofinity Advantage |
$34,130.83
|
| Rate for Payer: Cofinity Commercial |
$41,932.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39,006.66
|
| Rate for Payer: Healthscope Commercial |
$43,882.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34,130.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36,568.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41,444.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36,568.75
|
| Rate for Payer: PHP Commercial |
$41,444.58
|
| Rate for Payer: Priority Health SBD |
$30,717.75
|
| Rate for Payer: UMR Bronson Commercial |
$21,453.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36,568.75
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
NDC 51079056620
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.68 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Aetna American Axle |
$171.60
|
| Rate for Payer: Aetna Commercial |
$224.40
|
| Rate for Payer: Aetna Medicare |
$132.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.60
|
| Rate for Payer: BCBS Complete |
$105.60
|
| Rate for Payer: Cash Price |
$211.20
|
| Rate for Payer: Cofinity Advantage |
$184.80
|
| Rate for Payer: Cofinity Commercial |
$227.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.20
|
| Rate for Payer: Healthscope Commercial |
$237.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$211.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$198.00
|
| Rate for Payer: PHP Commercial |
$224.40
|
| Rate for Payer: Priority Health SBD |
$166.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.60
|
| Rate for Payer: UHC Core |
$137.54
|
| Rate for Payer: UHC Exchange |
$103.75
|
| Rate for Payer: UMR Bronson Commercial |
$97.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.00
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
IP
|
$2.64
|
|
|
Service Code
|
NDC 51079056601
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna American Axle |
$1.72
|
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.72
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cofinity Advantage |
$1.85
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.11
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.98
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health SBD |
$1.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.98
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
OP
|
$299.04
|
|
|
Service Code
|
NDC 00378061401
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.64 |
| Max. Negotiated Rate |
$269.14 |
| Rate for Payer: Aetna American Axle |
$194.38
|
| Rate for Payer: Aetna Commercial |
$254.18
|
| Rate for Payer: Aetna Medicare |
$149.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.38
|
| Rate for Payer: BCBS Complete |
$119.62
|
| Rate for Payer: Cash Price |
$239.23
|
| Rate for Payer: Cofinity Advantage |
$209.33
|
| Rate for Payer: Cofinity Commercial |
$257.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.23
|
| Rate for Payer: Healthscope Commercial |
$269.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$209.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$224.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$239.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$254.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$224.28
|
| Rate for Payer: PHP Commercial |
$254.18
|
| Rate for Payer: Priority Health SBD |
$188.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$194.38
|
| Rate for Payer: UHC Core |
$155.80
|
| Rate for Payer: UHC Exchange |
$117.52
|
| Rate for Payer: UMR Bronson Commercial |
$110.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$224.28
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
IP
|
$299.04
|
|
|
Service Code
|
NDC 00378061401
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.58 |
| Max. Negotiated Rate |
$269.14 |
| Rate for Payer: Aetna American Axle |
$194.38
|
| Rate for Payer: Aetna Commercial |
$254.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.38
|
| Rate for Payer: Cash Price |
$239.23
|
| Rate for Payer: Cofinity Advantage |
$209.33
|
| Rate for Payer: Cofinity Commercial |
$257.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.23
|
| Rate for Payer: Healthscope Commercial |
$269.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$209.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$224.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$254.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$224.28
|
| Rate for Payer: PHP Commercial |
$254.18
|
| Rate for Payer: Priority Health SBD |
$188.40
|
| Rate for Payer: UMR Bronson Commercial |
$131.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$224.28
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
NDC 51079056620
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.16 |
| Max. Negotiated Rate |
$237.60 |
| Rate for Payer: Aetna American Axle |
$171.60
|
| Rate for Payer: Aetna Commercial |
$224.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.60
|
| Rate for Payer: Cash Price |
$211.20
|
| Rate for Payer: Cofinity Advantage |
$184.80
|
| Rate for Payer: Cofinity Commercial |
$227.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$211.20
|
| Rate for Payer: Healthscope Commercial |
$237.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$224.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$198.00
|
| Rate for Payer: PHP Commercial |
$224.40
|
| Rate for Payer: Priority Health SBD |
$166.32
|
| Rate for Payer: UMR Bronson Commercial |
$116.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.00
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
OP
|
$2.64
|
|
|
Service Code
|
NDC 51079056601
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna American Axle |
$1.72
|
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.72
|
| Rate for Payer: BCBS Complete |
$1.06
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cofinity Advantage |
$1.85
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.11
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.98
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health SBD |
$1.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.72
|
| Rate for Payer: UHC Core |
$1.38
|
| Rate for Payer: UHC Exchange |
$1.04
|
| Rate for Payer: UMR Bronson Commercial |
$0.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.98
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$473.14
|
|
|
Service Code
|
HCPCS J9342
|
| Hospital Charge Code |
7901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$208.18 |
| Max. Negotiated Rate |
$425.83 |
| Rate for Payer: Aetna American Axle |
$307.54
|
| Rate for Payer: Aetna Commercial |
$402.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.54
|
| Rate for Payer: Cash Price |
$378.51
|
| Rate for Payer: Cofinity Advantage |
$331.20
|
| Rate for Payer: Cofinity Commercial |
$406.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$378.51
|
| Rate for Payer: Healthscope Commercial |
$425.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$331.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$354.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$402.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$354.86
|
| Rate for Payer: PHP Commercial |
$402.17
|
| Rate for Payer: Priority Health SBD |
$298.08
|
| Rate for Payer: UMR Bronson Commercial |
$208.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$354.86
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$473.14
|
|
|
Service Code
|
HCPCS J9342
|
| Hospital Charge Code |
7901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$425.83 |
| Rate for Payer: Aetna American Axle |
$307.54
|
| Rate for Payer: Aetna Commercial |
$402.17
|
| Rate for Payer: Aetna Medicare |
$5.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.17
|
| Rate for Payer: BCBS Complete |
$3.15
|
| Rate for Payer: BCBS MAPPO |
$5.74
|
| Rate for Payer: BCBS Trust/PPO |
$28.74
|
| Rate for Payer: BCN Commercial |
$28.74
|
| Rate for Payer: BCN Medicare Advantage |
$5.74
|
| Rate for Payer: Cash Price |
$378.51
|
| Rate for Payer: Cash Price |
$378.51
|
| Rate for Payer: Cofinity Advantage |
$331.20
|
| Rate for Payer: Cofinity Commercial |
$406.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$378.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.74
|
| Rate for Payer: Healthscope Commercial |
$425.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$331.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$354.86
|
| Rate for Payer: Mclaren Medicaid |
$5.74
|
| Rate for Payer: Mclaren Medicare |
$5.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.03
|
| Rate for Payer: Meridian Medicaid |
$6.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$402.17
|
| Rate for Payer: Nomi Health Commercial |
$17.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$354.86
|
| Rate for Payer: PACE Medicare |
$5.45
|
| Rate for Payer: PACE SWMI |
$5.74
|
| Rate for Payer: PHP Commercial |
$402.17
|
| Rate for Payer: PHP Medicare Advantage |
$5.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$33.24
|
| Rate for Payer: Priority Health Medicare |
$5.74
|
| Rate for Payer: Priority Health SBD |
$298.08
|
| Rate for Payer: Priority Health Tiered Network |
$26.59
|
| Rate for Payer: Railroad Medicare Medicare |
$5.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.62
|
| Rate for Payer: UHC Core |
$14.62
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$5.74
|
| Rate for Payer: UHC Exchange |
$14.62
|
| Rate for Payer: UHC Medicaid |
$3.00
|
| Rate for Payer: UHCCP Medicaid |
$3.00
|
| Rate for Payer: UMR Bronson Commercial |
$175.06
|
| Rate for Payer: VA VA |
$5.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$354.86
|
|
|
THIOTHIXENE 2 MG CAPSULE
|
Facility
|
OP
|
$420.48
|
|
|
Service Code
|
NDC 70954001510
|
| Hospital Charge Code |
7904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.58 |
| Max. Negotiated Rate |
$378.43 |
| Rate for Payer: Aetna American Axle |
$273.31
|
| Rate for Payer: Aetna Commercial |
$357.41
|
| Rate for Payer: Aetna Medicare |
$210.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.31
|
| Rate for Payer: BCBS Complete |
$168.19
|
| Rate for Payer: Cash Price |
$336.38
|
| Rate for Payer: Cofinity Advantage |
$294.34
|
| Rate for Payer: Cofinity Commercial |
$361.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.38
|
| Rate for Payer: Healthscope Commercial |
$378.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$336.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.36
|
| Rate for Payer: PHP Commercial |
$357.41
|
| Rate for Payer: Priority Health SBD |
$264.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$273.31
|
| Rate for Payer: UHC Core |
$219.07
|
| Rate for Payer: UHC Exchange |
$165.25
|
| Rate for Payer: UMR Bronson Commercial |
$155.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.36
|
|
|
THIOTHIXENE 2 MG CAPSULE
|
Facility
|
OP
|
$559.68
|
|
|
Service Code
|
NDC 00378200201
|
| Hospital Charge Code |
7904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.08 |
| Max. Negotiated Rate |
$503.71 |
| Rate for Payer: Aetna American Axle |
$363.79
|
| Rate for Payer: Aetna Commercial |
$475.73
|
| Rate for Payer: Aetna Medicare |
$279.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$363.79
|
| Rate for Payer: BCBS Complete |
$223.87
|
| Rate for Payer: Cash Price |
$447.74
|
| Rate for Payer: Cofinity Advantage |
$391.78
|
| Rate for Payer: Cofinity Commercial |
$481.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$447.74
|
| Rate for Payer: Healthscope Commercial |
$503.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$391.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$419.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$447.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$475.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$419.76
|
| Rate for Payer: PHP Commercial |
$475.73
|
| Rate for Payer: Priority Health SBD |
$352.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$363.79
|
| Rate for Payer: UHC Core |
$291.59
|
| Rate for Payer: UHC Exchange |
$219.95
|
| Rate for Payer: UMR Bronson Commercial |
$207.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$419.76
|
|
|
THIOTHIXENE 2 MG CAPSULE
|
Facility
|
IP
|
$559.68
|
|
|
Service Code
|
NDC 00378200201
|
| Hospital Charge Code |
7904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$246.26 |
| Max. Negotiated Rate |
$503.71 |
| Rate for Payer: Aetna American Axle |
$363.79
|
| Rate for Payer: Aetna Commercial |
$475.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$363.79
|
| Rate for Payer: Cash Price |
$447.74
|
| Rate for Payer: Cofinity Advantage |
$391.78
|
| Rate for Payer: Cofinity Commercial |
$481.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$447.74
|
| Rate for Payer: Healthscope Commercial |
$503.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$391.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$419.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$475.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$419.76
|
| Rate for Payer: PHP Commercial |
$475.73
|
| Rate for Payer: Priority Health SBD |
$352.60
|
| Rate for Payer: UMR Bronson Commercial |
$246.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$419.76
|
|
|
THIOTHIXENE 2 MG CAPSULE
|
Facility
|
IP
|
$420.48
|
|
|
Service Code
|
NDC 70954001510
|
| Hospital Charge Code |
7904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.01 |
| Max. Negotiated Rate |
$378.43 |
| Rate for Payer: Aetna American Axle |
$273.31
|
| Rate for Payer: Aetna Commercial |
$357.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.31
|
| Rate for Payer: Cash Price |
$336.38
|
| Rate for Payer: Cofinity Advantage |
$294.34
|
| Rate for Payer: Cofinity Commercial |
$361.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.38
|
| Rate for Payer: Healthscope Commercial |
$378.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.36
|
| Rate for Payer: PHP Commercial |
$357.41
|
| Rate for Payer: Priority Health SBD |
$264.90
|
| Rate for Payer: UMR Bronson Commercial |
$185.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.36
|
|
