|
THYROID (PORK) 60 MG TABLET
|
Facility
|
OP
|
$552.00
|
|
|
Service Code
|
NDC 00456045901
|
| Hospital Charge Code |
119105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.24 |
| Max. Negotiated Rate |
$496.80 |
| Rate for Payer: Aetna American Axle |
$358.80
|
| Rate for Payer: Aetna Commercial |
$469.20
|
| Rate for Payer: Aetna Medicare |
$276.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$358.80
|
| Rate for Payer: BCBS Complete |
$220.80
|
| Rate for Payer: Cash Price |
$441.60
|
| Rate for Payer: Cofinity Advantage |
$386.40
|
| Rate for Payer: Cofinity Commercial |
$474.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$441.60
|
| Rate for Payer: Healthscope Commercial |
$496.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$386.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$414.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$441.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$469.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$414.00
|
| Rate for Payer: PHP Commercial |
$469.20
|
| Rate for Payer: Priority Health SBD |
$347.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$358.80
|
| Rate for Payer: UHC Core |
$287.59
|
| Rate for Payer: UHC Exchange |
$216.94
|
| Rate for Payer: UMR Bronson Commercial |
$204.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$414.00
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$5,362.69
|
|
|
Service Code
|
HCPCS J3240
|
| Hospital Charge Code |
196901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,359.58 |
| Max. Negotiated Rate |
$4,826.42 |
| Rate for Payer: Aetna American Axle |
$3,485.75
|
| Rate for Payer: Aetna Commercial |
$4,558.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,485.75
|
| Rate for Payer: Cash Price |
$4,290.15
|
| Rate for Payer: Cofinity Advantage |
$3,753.88
|
| Rate for Payer: Cofinity Commercial |
$4,611.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,290.15
|
| Rate for Payer: Healthscope Commercial |
$4,826.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,753.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,022.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,558.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,022.02
|
| Rate for Payer: PHP Commercial |
$4,558.29
|
| Rate for Payer: Priority Health SBD |
$3,378.49
|
| Rate for Payer: UMR Bronson Commercial |
$2,359.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,022.02
|
|
|
THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$5,362.69
|
|
|
Service Code
|
HCPCS J3240
|
| Hospital Charge Code |
196901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,111.55 |
| Max. Negotiated Rate |
$6,892.68 |
| Rate for Payer: Aetna American Axle |
$3,485.75
|
| Rate for Payer: Aetna Commercial |
$4,558.29
|
| Rate for Payer: Aetna Medicare |
$2,210.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,485.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,656.68
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,656.68
|
| Rate for Payer: BCBS Complete |
$1,167.24
|
| Rate for Payer: BCBS MAPPO |
$2,125.34
|
| Rate for Payer: BCBS Trust/PPO |
$6,892.68
|
| Rate for Payer: BCN Commercial |
$6,892.68
|
| Rate for Payer: BCN Medicare Advantage |
$2,125.34
|
| Rate for Payer: Cash Price |
$4,290.15
|
| Rate for Payer: Cash Price |
$4,290.15
|
| Rate for Payer: Cofinity Advantage |
$3,753.88
|
| Rate for Payer: Cofinity Commercial |
$4,611.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,290.15
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,125.34
|
| Rate for Payer: Healthscope Commercial |
$4,826.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,753.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,022.02
|
| Rate for Payer: Mclaren Medicaid |
$2,125.34
|
| Rate for Payer: Mclaren Medicare |
$2,125.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,231.61
|
| Rate for Payer: Meridian Medicaid |
$2,231.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,444.14
|
| Rate for Payer: Molina Medicare/Medicaid |
$2,337.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,558.29
|
| Rate for Payer: Nomi Health Commercial |
$6,376.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,022.02
|
| Rate for Payer: PACE Medicare |
$2,019.07
|
| Rate for Payer: PACE SWMI |
$2,125.34
|
| Rate for Payer: PHP Commercial |
$4,558.29
|
| Rate for Payer: PHP Medicare Advantage |
$2,125.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,111.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$6,674.81
|
| Rate for Payer: Priority Health Medicare |
$2,125.34
|
| Rate for Payer: Priority Health SBD |
$3,378.49
|
| Rate for Payer: Priority Health Tiered Network |
$5,339.85
|
| Rate for Payer: Railroad Medicare Medicare |
$2,125.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,507.31
|
| Rate for Payer: UHC Core |
$3,507.31
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$2,125.34
|
| Rate for Payer: UHC Exchange |
$3,507.31
|
| Rate for Payer: UHC Medicaid |
$1,111.55
|
| Rate for Payer: UHCCP Medicaid |
$1,111.55
|
| Rate for Payer: UMR Bronson Commercial |
$1,984.20
|
| Rate for Payer: VA VA |
$2,125.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,022.02
|
|
|
TIAGABINE 4 MG TABLET
|
Facility
|
IP
|
$1,229.44
|
|
|
Service Code
|
NDC 63459040430
|
| Hospital Charge Code |
21827
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$540.95 |
| Max. Negotiated Rate |
$1,106.50 |
| Rate for Payer: Aetna American Axle |
$799.14
|
| Rate for Payer: Aetna Commercial |
$1,045.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$799.14
|
| Rate for Payer: Cash Price |
$983.55
|
| Rate for Payer: Cofinity Advantage |
$860.61
|
| Rate for Payer: Cofinity Commercial |
$1,057.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$983.55
|
| Rate for Payer: Healthscope Commercial |
$1,106.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$860.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$922.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,045.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$922.08
|
| Rate for Payer: PHP Commercial |
$1,045.02
|
| Rate for Payer: Priority Health SBD |
$774.55
|
| Rate for Payer: UMR Bronson Commercial |
$540.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$922.08
|
|
|
TIAGABINE 4 MG TABLET
|
Facility
|
OP
|
$1,229.44
|
|
|
Service Code
|
NDC 63459040430
|
| Hospital Charge Code |
21827
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$454.89 |
| Max. Negotiated Rate |
$1,106.50 |
| Rate for Payer: Aetna American Axle |
$799.14
|
| Rate for Payer: Aetna Commercial |
$1,045.02
|
| Rate for Payer: Aetna Medicare |
$614.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$799.14
|
| Rate for Payer: BCBS Complete |
$491.78
|
| Rate for Payer: Cash Price |
$983.55
|
| Rate for Payer: Cofinity Advantage |
$860.61
|
| Rate for Payer: Cofinity Commercial |
$1,057.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$983.55
|
| Rate for Payer: Healthscope Commercial |
$1,106.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$860.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$922.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$983.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,045.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$922.08
|
| Rate for Payer: PHP Commercial |
$1,045.02
|
| Rate for Payer: Priority Health SBD |
$774.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$799.14
|
| Rate for Payer: UHC Core |
$640.54
|
| Rate for Payer: UHC Exchange |
$483.17
|
| Rate for Payer: UMR Bronson Commercial |
$454.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$922.08
|
|
|
TIAGABINE 4 MG TABLET
|
Facility
|
OP
|
$655.24
|
|
|
Service Code
|
NDC 62756022483
|
| Hospital Charge Code |
21827
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.44 |
| Max. Negotiated Rate |
$589.72 |
| Rate for Payer: Aetna American Axle |
$425.91
|
| Rate for Payer: Aetna Commercial |
$556.95
|
| Rate for Payer: Aetna Medicare |
$327.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.91
|
| Rate for Payer: BCBS Complete |
$262.10
|
| Rate for Payer: Cash Price |
$524.19
|
| Rate for Payer: Cofinity Advantage |
$458.67
|
| Rate for Payer: Cofinity Commercial |
$563.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$524.19
|
| Rate for Payer: Healthscope Commercial |
$589.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$491.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$524.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$556.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$491.43
|
| Rate for Payer: PHP Commercial |
$556.95
|
| Rate for Payer: Priority Health SBD |
$412.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$425.91
|
| Rate for Payer: UHC Core |
$341.38
|
| Rate for Payer: UHC Exchange |
$257.51
|
| Rate for Payer: UMR Bronson Commercial |
$242.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$491.43
|
|
|
TIAGABINE 4 MG TABLET
|
Facility
|
OP
|
$312.80
|
|
|
Service Code
|
NDC 00093503156
|
| Hospital Charge Code |
21827
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.74 |
| Max. Negotiated Rate |
$281.52 |
| Rate for Payer: Aetna American Axle |
$203.32
|
| Rate for Payer: Aetna Commercial |
$265.88
|
| Rate for Payer: Aetna Medicare |
$156.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.32
|
| Rate for Payer: BCBS Complete |
$125.12
|
| Rate for Payer: Cash Price |
$250.24
|
| Rate for Payer: Cofinity Advantage |
$218.96
|
| Rate for Payer: Cofinity Commercial |
$269.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.24
|
| Rate for Payer: Healthscope Commercial |
$281.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$218.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$250.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.60
|
| Rate for Payer: PHP Commercial |
$265.88
|
| Rate for Payer: Priority Health SBD |
$197.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$203.32
|
| Rate for Payer: UHC Core |
$162.97
|
| Rate for Payer: UHC Exchange |
$122.93
|
| Rate for Payer: UMR Bronson Commercial |
$115.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.60
|
|
|
TIAGABINE 4 MG TABLET
|
Facility
|
IP
|
$312.80
|
|
|
Service Code
|
NDC 00093503156
|
| Hospital Charge Code |
21827
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.63 |
| Max. Negotiated Rate |
$281.52 |
| Rate for Payer: Aetna American Axle |
$203.32
|
| Rate for Payer: Aetna Commercial |
$265.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.32
|
| Rate for Payer: Cash Price |
$250.24
|
| Rate for Payer: Cofinity Advantage |
$218.96
|
| Rate for Payer: Cofinity Commercial |
$269.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.24
|
| Rate for Payer: Healthscope Commercial |
$281.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$218.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.60
|
| Rate for Payer: PHP Commercial |
$265.88
|
| Rate for Payer: Priority Health SBD |
$197.06
|
| Rate for Payer: UMR Bronson Commercial |
$137.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.60
|
|
|
TIAGABINE 4 MG TABLET
|
Facility
|
IP
|
$655.24
|
|
|
Service Code
|
NDC 62756022483
|
| Hospital Charge Code |
21827
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$288.31 |
| Max. Negotiated Rate |
$589.72 |
| Rate for Payer: Aetna American Axle |
$425.91
|
| Rate for Payer: Aetna Commercial |
$556.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$425.91
|
| Rate for Payer: Cash Price |
$524.19
|
| Rate for Payer: Cofinity Advantage |
$458.67
|
| Rate for Payer: Cofinity Commercial |
$563.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$524.19
|
| Rate for Payer: Healthscope Commercial |
$589.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$458.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$491.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$556.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$491.43
|
| Rate for Payer: PHP Commercial |
$556.95
|
| Rate for Payer: Priority Health SBD |
$412.80
|
| Rate for Payer: UMR Bronson Commercial |
$288.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$491.43
|
|
|
TICAGRELOR 60 MG TABLET
|
Facility
|
IP
|
$1,668.33
|
|
|
Service Code
|
NDC 00186077660
|
| Hospital Charge Code |
175597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$734.07 |
| Max. Negotiated Rate |
$1,501.50 |
| Rate for Payer: Aetna American Axle |
$1,084.41
|
| Rate for Payer: Aetna Commercial |
$1,418.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,084.41
|
| Rate for Payer: Cash Price |
$1,334.66
|
| Rate for Payer: Cofinity Advantage |
$1,167.83
|
| Rate for Payer: Cofinity Commercial |
$1,434.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.66
|
| Rate for Payer: Healthscope Commercial |
$1,501.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,167.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,251.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,418.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,251.25
|
| Rate for Payer: PHP Commercial |
$1,418.08
|
| Rate for Payer: Priority Health SBD |
$1,051.05
|
| Rate for Payer: UMR Bronson Commercial |
$734.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,251.25
|
|
|
TICAGRELOR 60 MG TABLET
|
Facility
|
OP
|
$1,668.33
|
|
|
Service Code
|
NDC 00186077660
|
| Hospital Charge Code |
175597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$617.28 |
| Max. Negotiated Rate |
$1,501.50 |
| Rate for Payer: Aetna American Axle |
$1,084.41
|
| Rate for Payer: Aetna Commercial |
$1,418.08
|
| Rate for Payer: Aetna Medicare |
$834.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,084.41
|
| Rate for Payer: BCBS Complete |
$667.33
|
| Rate for Payer: Cash Price |
$1,334.66
|
| Rate for Payer: Cofinity Advantage |
$1,167.83
|
| Rate for Payer: Cofinity Commercial |
$1,434.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.66
|
| Rate for Payer: Healthscope Commercial |
$1,501.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,167.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,251.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,334.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,418.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,251.25
|
| Rate for Payer: PHP Commercial |
$1,418.08
|
| Rate for Payer: Priority Health SBD |
$1,051.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,084.41
|
| Rate for Payer: UHC Core |
$869.20
|
| Rate for Payer: UHC Exchange |
$655.65
|
| Rate for Payer: UMR Bronson Commercial |
$617.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,251.25
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
OP
|
$2,780.18
|
|
|
Service Code
|
NDC 00186077739
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,028.67 |
| Max. Negotiated Rate |
$2,502.16 |
| Rate for Payer: Aetna American Axle |
$1,807.12
|
| Rate for Payer: Aetna Commercial |
$2,363.15
|
| Rate for Payer: Aetna Medicare |
$1,390.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,807.12
|
| Rate for Payer: BCBS Complete |
$1,112.07
|
| Rate for Payer: Cash Price |
$2,224.14
|
| Rate for Payer: Cofinity Advantage |
$1,946.13
|
| Rate for Payer: Cofinity Commercial |
$2,390.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,224.14
|
| Rate for Payer: Healthscope Commercial |
$2,502.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,946.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,085.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,224.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,363.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,085.14
|
| Rate for Payer: PHP Commercial |
$2,363.15
|
| Rate for Payer: Priority Health SBD |
$1,751.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,807.12
|
| Rate for Payer: UHC Core |
$1,448.47
|
| Rate for Payer: UHC Exchange |
$1,092.61
|
| Rate for Payer: UMR Bronson Commercial |
$1,028.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,085.14
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
IP
|
$2,780.18
|
|
|
Service Code
|
NDC 00186077739
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,223.28 |
| Max. Negotiated Rate |
$2,502.16 |
| Rate for Payer: Aetna American Axle |
$1,807.12
|
| Rate for Payer: Aetna Commercial |
$2,363.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,807.12
|
| Rate for Payer: Cash Price |
$2,224.14
|
| Rate for Payer: Cofinity Advantage |
$1,946.13
|
| Rate for Payer: Cofinity Commercial |
$2,390.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,224.14
|
| Rate for Payer: Healthscope Commercial |
$2,502.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,946.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,085.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,363.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,085.14
|
| Rate for Payer: PHP Commercial |
$2,363.15
|
| Rate for Payer: Priority Health SBD |
$1,751.51
|
| Rate for Payer: UMR Bronson Commercial |
$1,223.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,085.14
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
IP
|
$1,668.33
|
|
|
Service Code
|
NDC 00186077760
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$734.07 |
| Max. Negotiated Rate |
$1,501.50 |
| Rate for Payer: Aetna American Axle |
$1,084.41
|
| Rate for Payer: Aetna Commercial |
$1,418.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,084.41
|
| Rate for Payer: Cash Price |
$1,334.66
|
| Rate for Payer: Cofinity Advantage |
$1,167.83
|
| Rate for Payer: Cofinity Commercial |
$1,434.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.66
|
| Rate for Payer: Healthscope Commercial |
$1,501.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,167.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,251.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,418.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,251.25
|
| Rate for Payer: PHP Commercial |
$1,418.08
|
| Rate for Payer: Priority Health SBD |
$1,051.05
|
| Rate for Payer: UMR Bronson Commercial |
$734.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,251.25
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
IP
|
$246.24
|
|
|
Service Code
|
NDC 67877049160
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.35 |
| Max. Negotiated Rate |
$221.62 |
| Rate for Payer: Aetna American Axle |
$160.06
|
| Rate for Payer: Aetna Commercial |
$209.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.06
|
| Rate for Payer: Cash Price |
$196.99
|
| Rate for Payer: Cofinity Advantage |
$172.37
|
| Rate for Payer: Cofinity Commercial |
$211.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.99
|
| Rate for Payer: Healthscope Commercial |
$221.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$184.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$184.68
|
| Rate for Payer: PHP Commercial |
$209.30
|
| Rate for Payer: Priority Health SBD |
$155.13
|
| Rate for Payer: UMR Bronson Commercial |
$108.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$184.68
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
OP
|
$246.24
|
|
|
Service Code
|
NDC 67877049160
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.11 |
| Max. Negotiated Rate |
$221.62 |
| Rate for Payer: Aetna American Axle |
$160.06
|
| Rate for Payer: Aetna Commercial |
$209.30
|
| Rate for Payer: Aetna Medicare |
$123.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.06
|
| Rate for Payer: BCBS Complete |
$98.50
|
| Rate for Payer: Cash Price |
$196.99
|
| Rate for Payer: Cofinity Advantage |
$172.37
|
| Rate for Payer: Cofinity Commercial |
$211.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.99
|
| Rate for Payer: Healthscope Commercial |
$221.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$184.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$196.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$184.68
|
| Rate for Payer: PHP Commercial |
$209.30
|
| Rate for Payer: Priority Health SBD |
$155.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$160.06
|
| Rate for Payer: UHC Core |
$128.29
|
| Rate for Payer: UHC Exchange |
$96.77
|
| Rate for Payer: UMR Bronson Commercial |
$91.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$184.68
|
|
|
TICAGRELOR 90 MG TABLET
|
Facility
|
OP
|
$1,668.33
|
|
|
Service Code
|
NDC 00186077760
|
| Hospital Charge Code |
153169
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$617.28 |
| Max. Negotiated Rate |
$1,501.50 |
| Rate for Payer: Aetna American Axle |
$1,084.41
|
| Rate for Payer: Aetna Commercial |
$1,418.08
|
| Rate for Payer: Aetna Medicare |
$834.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,084.41
|
| Rate for Payer: BCBS Complete |
$667.33
|
| Rate for Payer: Cash Price |
$1,334.66
|
| Rate for Payer: Cofinity Advantage |
$1,167.83
|
| Rate for Payer: Cofinity Commercial |
$1,434.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,334.66
|
| Rate for Payer: Healthscope Commercial |
$1,501.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,167.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,251.25
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,334.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,418.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,251.25
|
| Rate for Payer: PHP Commercial |
$1,418.08
|
| Rate for Payer: Priority Health SBD |
$1,051.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,084.41
|
| Rate for Payer: UHC Core |
$869.20
|
| Rate for Payer: UHC Exchange |
$655.65
|
| Rate for Payer: UMR Bronson Commercial |
$617.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,251.25
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
OP
|
$79.08
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
301711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$71.17 |
| Rate for Payer: Aetna American Axle |
$51.40
|
| Rate for Payer: Aetna Commercial |
$67.22
|
| Rate for Payer: Aetna Medicare |
$39.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.40
|
| Rate for Payer: BCBS Complete |
$31.63
|
| Rate for Payer: BCBS Trust/PPO |
$1.81
|
| Rate for Payer: BCN Commercial |
$1.81
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cofinity Advantage |
$55.36
|
| Rate for Payer: Cofinity Commercial |
$68.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.26
|
| Rate for Payer: Healthscope Commercial |
$71.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.31
|
| Rate for Payer: PHP Commercial |
$67.22
|
| Rate for Payer: Priority Health SBD |
$49.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.92
|
| Rate for Payer: UHC Core |
$0.92
|
| Rate for Payer: UHC Exchange |
$0.92
|
| Rate for Payer: UMR Bronson Commercial |
$29.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.31
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM
|
Facility
|
IP
|
$79.08
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
301711
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$71.17 |
| Rate for Payer: Aetna American Axle |
$51.40
|
| Rate for Payer: Aetna Commercial |
$67.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.40
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cofinity Advantage |
$55.36
|
| Rate for Payer: Cofinity Commercial |
$68.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.26
|
| Rate for Payer: Healthscope Commercial |
$71.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.31
|
| Rate for Payer: PHP Commercial |
$67.22
|
| Rate for Payer: Priority Health SBD |
$49.82
|
| Rate for Payer: UMR Bronson Commercial |
$34.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.31
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$79.08
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
41652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$71.17 |
| Rate for Payer: Aetna American Axle |
$51.40
|
| Rate for Payer: Aetna Commercial |
$67.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.40
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cofinity Advantage |
$55.36
|
| Rate for Payer: Cofinity Commercial |
$68.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.26
|
| Rate for Payer: Healthscope Commercial |
$71.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.31
|
| Rate for Payer: PHP Commercial |
$67.22
|
| Rate for Payer: Priority Health SBD |
$49.82
|
| Rate for Payer: UMR Bronson Commercial |
$34.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.31
|
|
|
TIGECYCLINE 50 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$79.08
|
|
|
Service Code
|
HCPCS J3243
|
| Hospital Charge Code |
41652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$71.17 |
| Rate for Payer: Aetna American Axle |
$51.40
|
| Rate for Payer: Aetna Commercial |
$67.22
|
| Rate for Payer: Aetna Medicare |
$39.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.40
|
| Rate for Payer: BCBS Complete |
$31.63
|
| Rate for Payer: BCBS Trust/PPO |
$1.81
|
| Rate for Payer: BCN Commercial |
$1.81
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cash Price |
$63.26
|
| Rate for Payer: Cofinity Advantage |
$55.36
|
| Rate for Payer: Cofinity Commercial |
$68.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.26
|
| Rate for Payer: Healthscope Commercial |
$71.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.31
|
| Rate for Payer: PHP Commercial |
$67.22
|
| Rate for Payer: Priority Health SBD |
$49.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.92
|
| Rate for Payer: UHC Core |
$0.92
|
| Rate for Payer: UHC Exchange |
$0.92
|
| Rate for Payer: UMR Bronson Commercial |
$29.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.31
|
|
|
TILDRAKIZUMAB-ASMN 100 MG/ML SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$32,184.18
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
188045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.82 |
| Max. Negotiated Rate |
$28,965.76 |
| Rate for Payer: Aetna American Axle |
$20,919.72
|
| Rate for Payer: Aetna Commercial |
$27,356.55
|
| Rate for Payer: Aetna Medicare |
$122.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20,919.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$147.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$147.75
|
| Rate for Payer: BCBS Complete |
$64.92
|
| Rate for Payer: BCBS MAPPO |
$118.20
|
| Rate for Payer: BCBS Trust/PPO |
$401.39
|
| Rate for Payer: BCN Commercial |
$401.39
|
| Rate for Payer: BCN Medicare Advantage |
$118.20
|
| Rate for Payer: Cash Price |
$25,747.34
|
| Rate for Payer: Cash Price |
$25,747.34
|
| Rate for Payer: Cofinity Advantage |
$22,528.93
|
| Rate for Payer: Cofinity Commercial |
$27,678.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25,747.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$118.20
|
| Rate for Payer: Healthscope Commercial |
$28,965.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22,528.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24,138.13
|
| Rate for Payer: Mclaren Medicaid |
$118.20
|
| Rate for Payer: Mclaren Medicare |
$118.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$124.11
|
| Rate for Payer: Meridian Medicaid |
$124.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$135.93
|
| Rate for Payer: Molina Medicare/Medicaid |
$130.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27,356.55
|
| Rate for Payer: Nomi Health Commercial |
$354.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24,138.13
|
| Rate for Payer: PACE Medicare |
$112.29
|
| Rate for Payer: PACE SWMI |
$118.20
|
| Rate for Payer: PHP Commercial |
$27,356.55
|
| Rate for Payer: PHP Medicare Advantage |
$118.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$61.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$401.98
|
| Rate for Payer: Priority Health Medicare |
$118.20
|
| Rate for Payer: Priority Health SBD |
$20,276.03
|
| Rate for Payer: Priority Health Tiered Network |
$321.58
|
| Rate for Payer: Railroad Medicare Medicare |
$118.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$204.25
|
| Rate for Payer: UHC Core |
$204.25
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$118.20
|
| Rate for Payer: UHC Exchange |
$204.25
|
| Rate for Payer: UHC Medicaid |
$61.82
|
| Rate for Payer: UHCCP Medicaid |
$61.82
|
| Rate for Payer: UMR Bronson Commercial |
$11,908.15
|
| Rate for Payer: VA VA |
$118.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24,138.13
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
|
OP
|
$21.78
|
|
|
Service Code
|
NDC 64980051305
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$19.60 |
| Rate for Payer: Aetna American Axle |
$14.16
|
| Rate for Payer: Aetna Commercial |
$18.51
|
| Rate for Payer: Aetna Medicare |
$10.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.16
|
| Rate for Payer: BCBS Complete |
$8.71
|
| Rate for Payer: Cash Price |
$17.42
|
| Rate for Payer: Cofinity Advantage |
$15.25
|
| Rate for Payer: Cofinity Commercial |
$18.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.42
|
| Rate for Payer: Healthscope Commercial |
$19.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.34
|
| Rate for Payer: PHP Commercial |
$18.51
|
| Rate for Payer: Priority Health SBD |
$13.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.16
|
| Rate for Payer: UHC Core |
$11.35
|
| Rate for Payer: UHC Exchange |
$8.56
|
| Rate for Payer: UMR Bronson Commercial |
$8.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.34
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
|
IP
|
$12.47
|
|
|
Service Code
|
NDC 60758080205
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Aetna American Axle |
$8.11
|
| Rate for Payer: Aetna Commercial |
$10.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.11
|
| Rate for Payer: Cash Price |
$9.98
|
| Rate for Payer: Cofinity Advantage |
$8.73
|
| Rate for Payer: Cofinity Commercial |
$10.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.98
|
| Rate for Payer: Healthscope Commercial |
$11.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9.35
|
| Rate for Payer: PHP Commercial |
$10.60
|
| Rate for Payer: Priority Health SBD |
$7.86
|
| Rate for Payer: UMR Bronson Commercial |
$5.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.35
|
|
|
TIMOLOL MALEATE 0.25 % EYE DROPS
|
Facility
|
IP
|
$17.55
|
|
|
Service Code
|
NDC 61314022605
|
| Hospital Charge Code |
11561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$15.79 |
| Rate for Payer: Aetna American Axle |
$11.41
|
| Rate for Payer: Aetna Commercial |
$14.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.41
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cofinity Advantage |
$12.29
|
| Rate for Payer: Cofinity Commercial |
$15.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.04
|
| Rate for Payer: Healthscope Commercial |
$15.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.16
|
| Rate for Payer: PHP Commercial |
$14.92
|
| Rate for Payer: Priority Health SBD |
$11.06
|
| Rate for Payer: UMR Bronson Commercial |
$7.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.16
|
|
