|
TRIAMCINOLONE ACETONIDE (PF) 40 MG/ML INTRAOCULAR SUSPENSION
|
Facility
|
IP
|
$3,072.72
|
|
|
Service Code
|
HCPCS J3300
|
| Hospital Charge Code |
89128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,352.00 |
| Max. Negotiated Rate |
$2,765.45 |
| Rate for Payer: Aetna American Axle |
$1,997.27
|
| Rate for Payer: Aetna Commercial |
$2,611.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,997.27
|
| Rate for Payer: Cash Price |
$2,458.18
|
| Rate for Payer: Cofinity Advantage |
$2,150.90
|
| Rate for Payer: Cofinity Commercial |
$2,642.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,458.18
|
| Rate for Payer: Healthscope Commercial |
$2,765.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,150.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,304.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,611.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,304.54
|
| Rate for Payer: PHP Commercial |
$2,611.81
|
| Rate for Payer: Priority Health SBD |
$1,935.81
|
| Rate for Payer: UMR Bronson Commercial |
$1,352.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,304.54
|
|
|
TRIAMCINOLONE ACETONIDE (PF) 40 MG/ML INTRAOCULAR SUSPENSION
|
Facility
|
OP
|
$3,072.72
|
|
|
Service Code
|
HCPCS J3300
|
| Hospital Charge Code |
89128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.82 |
| Max. Negotiated Rate |
$2,765.45 |
| Rate for Payer: Aetna American Axle |
$1,997.27
|
| Rate for Payer: Aetna Commercial |
$2,611.81
|
| Rate for Payer: Aetna Medicare |
$19.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,997.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.48
|
| Rate for Payer: BCBS Complete |
$10.31
|
| Rate for Payer: BCBS MAPPO |
$18.78
|
| Rate for Payer: BCBS Trust/PPO |
$79.41
|
| Rate for Payer: BCN Commercial |
$79.41
|
| Rate for Payer: BCN Medicare Advantage |
$18.78
|
| Rate for Payer: Cash Price |
$2,458.18
|
| Rate for Payer: Cash Price |
$2,458.18
|
| Rate for Payer: Cofinity Advantage |
$2,150.90
|
| Rate for Payer: Cofinity Commercial |
$2,642.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,458.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.78
|
| Rate for Payer: Healthscope Commercial |
$2,765.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,150.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,304.54
|
| Rate for Payer: Mclaren Medicaid |
$18.78
|
| Rate for Payer: Mclaren Medicare |
$18.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.72
|
| Rate for Payer: Meridian Medicaid |
$19.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.60
|
| Rate for Payer: Molina Medicare/Medicaid |
$20.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,611.81
|
| Rate for Payer: Nomi Health Commercial |
$56.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,304.54
|
| Rate for Payer: PACE Medicare |
$17.84
|
| Rate for Payer: PACE SWMI |
$18.78
|
| Rate for Payer: PHP Commercial |
$2,611.81
|
| Rate for Payer: PHP Medicare Advantage |
$18.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$77.27
|
| Rate for Payer: Priority Health Medicare |
$18.78
|
| Rate for Payer: Priority Health SBD |
$1,935.81
|
| Rate for Payer: Priority Health Tiered Network |
$61.82
|
| Rate for Payer: Railroad Medicare Medicare |
$18.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.41
|
| Rate for Payer: UHC Core |
$40.41
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$18.78
|
| Rate for Payer: UHC Exchange |
$40.41
|
| Rate for Payer: UHC Medicaid |
$9.82
|
| Rate for Payer: UHCCP Medicaid |
$9.82
|
| Rate for Payer: UMR Bronson Commercial |
$1,136.91
|
| Rate for Payer: VA VA |
$18.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,304.54
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$243.20
|
|
|
Service Code
|
NDC 60505265601
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.01 |
| Max. Negotiated Rate |
$218.88 |
| Rate for Payer: Aetna American Axle |
$158.08
|
| Rate for Payer: Aetna Commercial |
$206.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.08
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Advantage |
$170.24
|
| Rate for Payer: Cofinity Commercial |
$209.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$218.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$182.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$182.40
|
| Rate for Payer: PHP Commercial |
$206.72
|
| Rate for Payer: Priority Health SBD |
$153.22
|
| Rate for Payer: UMR Bronson Commercial |
$107.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$182.40
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$243.20
|
|
|
Service Code
|
NDC 60505265601
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.98 |
| Max. Negotiated Rate |
$218.88 |
| Rate for Payer: Aetna American Axle |
$158.08
|
| Rate for Payer: Aetna Commercial |
$206.72
|
| Rate for Payer: Aetna Medicare |
$121.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.08
|
| Rate for Payer: BCBS Complete |
$97.28
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cofinity Advantage |
$170.24
|
| Rate for Payer: Cofinity Commercial |
$209.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.56
|
| Rate for Payer: Healthscope Commercial |
$218.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$182.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$194.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$206.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$182.40
|
| Rate for Payer: PHP Commercial |
$206.72
|
| Rate for Payer: Priority Health SBD |
$153.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$158.08
|
| Rate for Payer: UHC Core |
$126.71
|
| Rate for Payer: UHC Exchange |
$95.58
|
| Rate for Payer: UMR Bronson Commercial |
$89.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$182.40
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
OP
|
$108.10
|
|
|
Service Code
|
NDC 72888009401
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.27
|
| Rate for Payer: Aetna Commercial |
$91.89
|
| Rate for Payer: Aetna Medicare |
$54.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.27
|
| Rate for Payer: BCBS Complete |
$43.24
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Advantage |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$86.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.08
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.27
|
| Rate for Payer: UHC Core |
$56.32
|
| Rate for Payer: UHC Exchange |
$42.48
|
| Rate for Payer: UMR Bronson Commercial |
$40.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
|
TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 72888009401
|
| Hospital Charge Code |
8132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.56 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.27
|
| Rate for Payer: Aetna Commercial |
$91.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.27
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Advantage |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.08
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UMR Bronson Commercial |
$47.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
|
TRICHLOROACETIC ACID 100 % TOPICAL POWDER FOR SOLUTION
|
Facility
|
IP
|
$1,866.00
|
|
|
Service Code
|
NDC 51552027406
|
| 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 Advantage |
$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 Commercial |
$1,586.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,399.50
|
| Rate for Payer: PHP Commercial |
$1,586.10
|
| 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
|
|
|
TRICHLOROACETIC ACID 100 % TOPICAL POWDER FOR SOLUTION
|
Facility
|
OP
|
$1,866.00
|
|
|
Service Code
|
NDC 51552027406
|
| Hospital Charge Code |
161607
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$690.42 |
| 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 Medicare |
$933.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,212.90
|
| Rate for Payer: BCBS Complete |
$746.40
|
| Rate for Payer: Cash Price |
$1,492.80
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$1,492.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,586.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,399.50
|
| Rate for Payer: PHP Commercial |
$1,586.10
|
| Rate for Payer: Priority Health SBD |
$1,175.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,212.90
|
| Rate for Payer: UHC Core |
$972.19
|
| Rate for Payer: UHC Exchange |
$733.34
|
| Rate for Payer: UMR Bronson Commercial |
$690.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,399.50
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
|
OP
|
$9.09
|
|
|
Service Code
|
NDC 72140085700
|
| Hospital Charge Code |
169208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.36 |
| Max. Negotiated Rate |
$8.18 |
| Rate for Payer: Aetna American Axle |
$5.91
|
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Aetna Medicare |
$4.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.91
|
| Rate for Payer: BCBS Complete |
$3.64
|
| Rate for Payer: Cash Price |
$7.27
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$7.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.82
|
| Rate for Payer: PHP Commercial |
$7.73
|
| Rate for Payer: Priority Health SBD |
$5.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.91
|
| Rate for Payer: UHC Core |
$4.74
|
| Rate for Payer: UHC Exchange |
$3.57
|
| Rate for Payer: UMR Bronson Commercial |
$3.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.82
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
|
IP
|
$9.09
|
|
|
Service Code
|
NDC 72140085700
|
| 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 Advantage |
$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 Commercial |
$7.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.82
|
| Rate for Payer: PHP Commercial |
$7.73
|
| 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
|
|
|
TRICLOSAN TOPICAL BAR
|
Facility
|
IP
|
$11.64
|
|
|
Service Code
|
NDC 09900000607
|
| 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 Advantage |
$8.15
|
| Rate for Payer: Cofinity Commercial |
$10.01
|
| 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 Commercial |
$9.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.73
|
| Rate for Payer: PHP Commercial |
$9.89
|
| 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
|
OP
|
$11.64
|
|
|
Service Code
|
NDC 09900000607
|
| Hospital Charge Code |
169208
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.31 |
| Max. Negotiated Rate |
$10.48 |
| Rate for Payer: Aetna American Axle |
$7.57
|
| Rate for Payer: Aetna Commercial |
$9.89
|
| Rate for Payer: Aetna Medicare |
$5.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.57
|
| Rate for Payer: BCBS Complete |
$4.66
|
| Rate for Payer: Cash Price |
$9.31
|
| Rate for Payer: Cofinity Advantage |
$8.15
|
| Rate for Payer: Cofinity Commercial |
$10.01
|
| 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: MI Amish Medical Board Commercial |
$9.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.73
|
| Rate for Payer: PHP Commercial |
$9.89
|
| Rate for Payer: Priority Health SBD |
$7.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.57
|
| Rate for Payer: UHC Core |
$6.06
|
| Rate for Payer: UHC Exchange |
$4.57
|
| Rate for Payer: UMR Bronson Commercial |
$4.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.73
|
|
|
TRIFLUOPERAZINE 10 MG TABLET
|
Facility
|
OP
|
$8.83
|
|
|
Service Code
|
NDC 51079057501
|
| Hospital Charge Code |
8162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$7.95 |
| Rate for Payer: Aetna American Axle |
$5.74
|
| Rate for Payer: Aetna Commercial |
$7.51
|
| Rate for Payer: Aetna Medicare |
$4.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.74
|
| Rate for Payer: BCBS Complete |
$3.53
|
| Rate for Payer: Cash Price |
$7.06
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$7.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.62
|
| Rate for Payer: PHP Commercial |
$7.51
|
| Rate for Payer: Priority Health SBD |
$5.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.74
|
| Rate for Payer: UHC Core |
$4.60
|
| Rate for Payer: UHC Exchange |
$3.47
|
| Rate for Payer: UMR Bronson Commercial |
$3.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.62
|
|
|
TRIFLUOPERAZINE 10 MG TABLET
|
Facility
|
OP
|
$882.82
|
|
|
Service Code
|
NDC 51079057520
|
| Hospital Charge Code |
8162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$326.64 |
| Max. Negotiated Rate |
$794.54 |
| Rate for Payer: Aetna American Axle |
$573.83
|
| Rate for Payer: Aetna Commercial |
$750.40
|
| Rate for Payer: Aetna Medicare |
$441.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$573.83
|
| Rate for Payer: BCBS Complete |
$353.13
|
| Rate for Payer: Cash Price |
$706.26
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$706.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$750.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$662.12
|
| Rate for Payer: PHP Commercial |
$750.40
|
| Rate for Payer: Priority Health SBD |
$556.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$573.83
|
| Rate for Payer: UHC Core |
$459.95
|
| Rate for Payer: UHC Exchange |
$346.95
|
| Rate for Payer: UMR Bronson Commercial |
$326.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$662.12
|
|
|
TRIFLUOPERAZINE 10 MG TABLET
|
Facility
|
IP
|
$882.82
|
|
|
Service Code
|
NDC 51079057520
|
| 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 Advantage |
$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 Commercial |
$750.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$662.12
|
| Rate for Payer: PHP Commercial |
$750.40
|
| 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 51079057501
|
| 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 Advantage |
$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 Commercial |
$7.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.62
|
| Rate for Payer: PHP Commercial |
$7.51
|
| 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 5 MG TABLET
|
Facility
|
IP
|
$8.43
|
|
|
Service Code
|
NDC 51079057401
|
| Hospital Charge Code |
8164
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$7.59 |
| Rate for Payer: Aetna American Axle |
$5.48
|
| Rate for Payer: Aetna Commercial |
$7.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.48
|
| Rate for Payer: Cash Price |
$6.74
|
| Rate for Payer: Cofinity Advantage |
$5.90
|
| Rate for Payer: Cofinity Commercial |
$7.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.74
|
| Rate for Payer: Healthscope Commercial |
$7.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.32
|
| Rate for Payer: PHP Commercial |
$7.17
|
| Rate for Payer: Priority Health SBD |
$5.31
|
| Rate for Payer: UMR Bronson Commercial |
$3.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.32
|
|
|
TRIFLUOPERAZINE 5 MG TABLET
|
Facility
|
OP
|
$8.43
|
|
|
Service Code
|
NDC 51079057401
|
| Hospital Charge Code |
8164
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$7.59 |
| Rate for Payer: Aetna American Axle |
$5.48
|
| Rate for Payer: Aetna Commercial |
$7.17
|
| Rate for Payer: Aetna Medicare |
$4.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.48
|
| Rate for Payer: BCBS Complete |
$3.37
|
| Rate for Payer: Cash Price |
$6.74
|
| Rate for Payer: Cofinity Advantage |
$5.90
|
| Rate for Payer: Cofinity Commercial |
$7.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.74
|
| Rate for Payer: Healthscope Commercial |
$7.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.32
|
| Rate for Payer: PHP Commercial |
$7.17
|
| Rate for Payer: Priority Health SBD |
$5.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.48
|
| Rate for Payer: UHC Core |
$4.39
|
| Rate for Payer: UHC Exchange |
$3.31
|
| Rate for Payer: UMR Bronson Commercial |
$3.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.32
|
|
|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
|
IP
|
$695.08
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
11595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$305.84 |
| Max. Negotiated Rate |
$625.57 |
| Rate for Payer: Aetna American Axle |
$451.80
|
| Rate for Payer: Aetna Commercial |
$590.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$451.80
|
| Rate for Payer: Cash Price |
$556.06
|
| Rate for Payer: Cofinity Advantage |
$486.56
|
| Rate for Payer: Cofinity Commercial |
$597.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$556.06
|
| Rate for Payer: Healthscope Commercial |
$625.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$486.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$521.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$590.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$521.31
|
| Rate for Payer: PHP Commercial |
$590.82
|
| Rate for Payer: Priority Health SBD |
$437.90
|
| Rate for Payer: UMR Bronson Commercial |
$305.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$521.31
|
|
|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
|
OP
|
$695.08
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
11595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.18 |
| Max. Negotiated Rate |
$625.57 |
| Rate for Payer: Aetna American Axle |
$451.80
|
| Rate for Payer: Aetna Commercial |
$590.82
|
| Rate for Payer: Aetna Medicare |
$347.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$451.80
|
| Rate for Payer: BCBS Complete |
$278.03
|
| Rate for Payer: Cash Price |
$556.06
|
| Rate for Payer: Cofinity Advantage |
$486.56
|
| Rate for Payer: Cofinity Commercial |
$597.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$556.06
|
| Rate for Payer: Healthscope Commercial |
$625.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$486.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$521.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$556.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$590.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$521.31
|
| Rate for Payer: PHP Commercial |
$590.82
|
| Rate for Payer: Priority Health SBD |
$437.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$451.80
|
| Rate for Payer: UHC Core |
$362.14
|
| Rate for Payer: UHC Exchange |
$273.17
|
| Rate for Payer: UMR Bronson Commercial |
$257.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$521.31
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
OP
|
$105.75
|
|
|
Service Code
|
NDC 70954021210
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$95.17 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna Medicare |
$52.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: BCBS Complete |
$42.30
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Advantage |
$74.03
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$84.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$79.31
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.74
|
| Rate for Payer: UHC Core |
$55.10
|
| Rate for Payer: UHC Exchange |
$41.56
|
| Rate for Payer: UMR Bronson Commercial |
$39.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
OP
|
$336.05
|
|
|
Service Code
|
NDC 69452024120
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.34 |
| Max. Negotiated Rate |
$302.44 |
| Rate for Payer: Aetna American Axle |
$218.43
|
| Rate for Payer: Aetna Commercial |
$285.64
|
| Rate for Payer: Aetna Medicare |
$168.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.43
|
| Rate for Payer: BCBS Complete |
$134.42
|
| Rate for Payer: Cash Price |
$268.84
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$268.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.04
|
| Rate for Payer: PHP Commercial |
$285.64
|
| Rate for Payer: Priority Health SBD |
$211.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$218.43
|
| Rate for Payer: UHC Core |
$175.08
|
| Rate for Payer: UHC Exchange |
$132.07
|
| Rate for Payer: UMR Bronson Commercial |
$124.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.04
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 70954021210
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.17 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Advantage |
$74.03
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$79.31
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$46.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
IP
|
$336.05
|
|
|
Service Code
|
NDC 69452024120
|
| 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 Advantage |
$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 Commercial |
$285.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$252.04
|
| Rate for Payer: PHP Commercial |
$285.64
|
| 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
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
NDC 00591533501
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.73 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna American Axle |
$213.85
|
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna Medicare |
$164.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: BCBS Complete |
$131.60
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$263.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.75
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health SBD |
$207.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.85
|
| Rate for Payer: UHC Core |
$171.41
|
| Rate for Payer: UHC Exchange |
$129.30
|
| Rate for Payer: UMR Bronson Commercial |
$121.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
