|
TRIFLUOPERAZINE 2 MG TABLET
|
Facility
|
OP
|
$327.84
|
|
|
Service Code
|
NDC 00378240201
|
| Hospital Charge Code |
8163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.30 |
| Max. Negotiated Rate |
$295.06 |
| Rate for Payer: Aetna American Axle |
$213.10
|
| Rate for Payer: Aetna Commercial |
$278.66
|
| Rate for Payer: Aetna Medicare |
$163.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.10
|
| Rate for Payer: BCBS Complete |
$131.14
|
| Rate for Payer: Cash Price |
$262.27
|
| Rate for Payer: Cofinity Commercial |
$229.49
|
| Rate for Payer: Cofinity Commercial |
$281.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$229.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.27
|
| Rate for Payer: Healthscope Commercial |
$295.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.66
|
| Rate for Payer: PHP Commercial |
$278.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.10
|
| Rate for Payer: Priority Health SBD |
$206.54
|
| Rate for Payer: UMR Bronson Commercial |
$121.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.88
|
|
|
TRIFLUOPERAZINE 2 MG TABLET
|
Facility
|
IP
|
$7.14
|
|
|
Service Code
|
NDC 51079057301
|
| Hospital Charge Code |
8163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna American Axle |
$4.64
|
| Rate for Payer: Aetna Commercial |
$6.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.64
|
| Rate for Payer: Cash Price |
$5.71
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$6.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$6.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.07
|
| Rate for Payer: PHP Commercial |
$6.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.64
|
| Rate for Payer: Priority Health SBD |
$4.50
|
| Rate for Payer: UMR Bronson Commercial |
$3.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.36
|
|
|
TRIFLUOPERAZINE 2 MG TABLET
|
Facility
|
IP
|
$327.84
|
|
|
Service Code
|
NDC 00378240201
|
| Hospital Charge Code |
8163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.25 |
| Max. Negotiated Rate |
$295.06 |
| Rate for Payer: Aetna American Axle |
$213.10
|
| Rate for Payer: Aetna Commercial |
$278.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.10
|
| Rate for Payer: Cash Price |
$262.27
|
| Rate for Payer: Cofinity Commercial |
$229.49
|
| Rate for Payer: Cofinity Commercial |
$281.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$229.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.27
|
| Rate for Payer: Healthscope Commercial |
$295.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$229.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$278.66
|
| Rate for Payer: PHP Commercial |
$278.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.10
|
| Rate for Payer: Priority Health SBD |
$206.54
|
| Rate for Payer: UMR Bronson Commercial |
$144.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.88
|
|
|
TRIFLUOPERAZINE 2 MG TABLET
|
Facility
|
OP
|
$7.14
|
|
|
Service Code
|
NDC 51079057301
|
| Hospital Charge Code |
8163
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna American Axle |
$4.64
|
| Rate for Payer: Aetna Commercial |
$6.07
|
| Rate for Payer: Aetna Medicare |
$3.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.64
|
| Rate for Payer: BCBS Complete |
$2.86
|
| Rate for Payer: Cash Price |
$5.71
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$6.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$6.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.07
|
| Rate for Payer: PHP Commercial |
$6.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.64
|
| Rate for Payer: Priority Health SBD |
$4.50
|
| Rate for Payer: UMR Bronson Commercial |
$2.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.36
|
|
|
TRIFLUOPERAZINE 5 MG TABLET
|
Facility
|
IP
|
$9.53
|
|
|
Service Code
|
NDC 51079057401
|
| Hospital Charge Code |
8164
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$8.58 |
| Rate for Payer: Aetna American Axle |
$6.19
|
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.19
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Cofinity Commercial |
$6.67
|
| Rate for Payer: Cofinity Commercial |
$8.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.62
|
| Rate for Payer: Healthscope Commercial |
$8.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.10
|
| Rate for Payer: PHP Commercial |
$8.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.19
|
| Rate for Payer: Priority Health SBD |
$6.00
|
| Rate for Payer: UMR Bronson Commercial |
$4.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.15
|
|
|
TRIFLUOPERAZINE 5 MG TABLET
|
Facility
|
OP
|
$9.53
|
|
|
Service Code
|
NDC 51079057401
|
| Hospital Charge Code |
8164
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.53 |
| Max. Negotiated Rate |
$8.58 |
| Rate for Payer: Aetna American Axle |
$6.19
|
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Medicare |
$4.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.19
|
| Rate for Payer: BCBS Complete |
$3.81
|
| Rate for Payer: Cash Price |
$7.62
|
| Rate for Payer: Cofinity Commercial |
$6.67
|
| Rate for Payer: Cofinity Commercial |
$8.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.62
|
| Rate for Payer: Healthscope Commercial |
$8.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.10
|
| Rate for Payer: PHP Commercial |
$8.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.19
|
| Rate for Payer: Priority Health SBD |
$6.00
|
| Rate for Payer: UMR Bronson Commercial |
$3.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.15
|
|
|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
|
OP
|
$637.98
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
11595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$236.05 |
| Max. Negotiated Rate |
$574.18 |
| Rate for Payer: Aetna American Axle |
$414.69
|
| Rate for Payer: Aetna Commercial |
$542.28
|
| Rate for Payer: Aetna Medicare |
$318.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$414.69
|
| Rate for Payer: BCBS Complete |
$255.19
|
| Rate for Payer: Cash Price |
$510.38
|
| Rate for Payer: Cofinity Commercial |
$446.59
|
| Rate for Payer: Cofinity Commercial |
$548.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$446.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$510.38
|
| Rate for Payer: Healthscope Commercial |
$574.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$446.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$478.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$542.28
|
| Rate for Payer: PHP Commercial |
$542.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$414.69
|
| Rate for Payer: Priority Health SBD |
$401.93
|
| Rate for Payer: UMR Bronson Commercial |
$236.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$478.49
|
|
|
TRIFLURIDINE 1 % EYE DROPS
|
Facility
|
IP
|
$637.98
|
|
|
Service Code
|
NDC 61314004475
|
| Hospital Charge Code |
11595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$280.71 |
| Max. Negotiated Rate |
$574.18 |
| Rate for Payer: Aetna American Axle |
$414.69
|
| Rate for Payer: Aetna Commercial |
$542.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$414.69
|
| Rate for Payer: Cash Price |
$510.38
|
| Rate for Payer: Cofinity Commercial |
$446.59
|
| Rate for Payer: Cofinity Commercial |
$548.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$446.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$510.38
|
| Rate for Payer: Healthscope Commercial |
$574.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$446.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$478.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$542.28
|
| Rate for Payer: PHP Commercial |
$542.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$414.69
|
| Rate for Payer: Priority Health SBD |
$401.93
|
| Rate for Payer: UMR Bronson Commercial |
$280.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$478.49
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
NDC 00591533501
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.76 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna American Axle |
$213.85
|
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$230.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.85
|
| Rate for Payer: Priority Health SBD |
$207.27
|
| Rate for Payer: UMR Bronson Commercial |
$144.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
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 Commercial |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$230.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.85
|
| Rate for Payer: Priority Health SBD |
$207.27
|
| Rate for Payer: UMR Bronson Commercial |
$121.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
TRIHEXYPHENIDYL 2 MG TABLET
|
Facility
|
OP
|
$133.95
|
|
|
Service Code
|
NDC 70954021210
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.56 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna American Axle |
$87.07
|
| Rate for Payer: Aetna Commercial |
$113.86
|
| Rate for Payer: Aetna Medicare |
$66.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.07
|
| Rate for Payer: BCBS Complete |
$53.58
|
| Rate for Payer: Cash Price |
$107.16
|
| Rate for Payer: Cofinity Commercial |
$115.20
|
| Rate for Payer: Cofinity Commercial |
$93.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.16
|
| Rate for Payer: Healthscope Commercial |
$120.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.86
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.07
|
| Rate for Payer: Priority Health SBD |
$84.39
|
| Rate for Payer: UMR Bronson Commercial |
$49.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.46
|
|
|
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 Commercial |
$235.24
|
| Rate for Payer: Cofinity Commercial |
$289.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.24
|
| 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: PHP Commercial |
$285.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.43
|
| 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
|
$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 Commercial |
$235.24
|
| Rate for Payer: Cofinity Commercial |
$289.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.24
|
| 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: PHP Commercial |
$285.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.43
|
| Rate for Payer: Priority Health SBD |
$211.71
|
| 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
|
$133.95
|
|
|
Service Code
|
NDC 70954021210
|
| Hospital Charge Code |
8166
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.94 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna American Axle |
$87.07
|
| Rate for Payer: Aetna Commercial |
$113.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.07
|
| Rate for Payer: Cash Price |
$107.16
|
| Rate for Payer: Cofinity Commercial |
$115.20
|
| Rate for Payer: Cofinity Commercial |
$93.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.16
|
| Rate for Payer: Healthscope Commercial |
$120.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.86
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.07
|
| Rate for Payer: Priority Health SBD |
$84.39
|
| Rate for Payer: UMR Bronson Commercial |
$58.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.46
|
|
|
TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
OP
|
$200.51
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
108755
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$74.19 |
| Max. Negotiated Rate |
$180.46 |
| Rate for Payer: Aetna American Axle |
$130.33
|
| Rate for Payer: Aetna Commercial |
$170.43
|
| Rate for Payer: Aetna Medicare |
$100.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.33
|
| Rate for Payer: BCBS Complete |
$80.20
|
| Rate for Payer: Cash Price |
$160.41
|
| Rate for Payer: Cofinity Commercial |
$140.36
|
| Rate for Payer: Cofinity Commercial |
$172.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.41
|
| Rate for Payer: Healthscope Commercial |
$180.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.43
|
| Rate for Payer: PHP Commercial |
$170.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.33
|
| Rate for Payer: Priority Health SBD |
$126.32
|
| Rate for Payer: UMR Bronson Commercial |
$74.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.38
|
|
|
TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION
|
Facility
|
IP
|
$200.51
|
|
|
Service Code
|
HCPCS J3250
|
| Hospital Charge Code |
108755
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$88.22 |
| Max. Negotiated Rate |
$180.46 |
| Rate for Payer: Aetna American Axle |
$130.33
|
| Rate for Payer: Aetna Commercial |
$170.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.33
|
| Rate for Payer: Cash Price |
$160.41
|
| Rate for Payer: Cofinity Commercial |
$140.36
|
| Rate for Payer: Cofinity Commercial |
$172.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.41
|
| Rate for Payer: Healthscope Commercial |
$180.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.43
|
| Rate for Payer: PHP Commercial |
$170.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.33
|
| Rate for Payer: Priority Health SBD |
$126.32
|
| Rate for Payer: UMR Bronson Commercial |
$88.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.38
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
|
OP
|
$595.68
|
|
|
Service Code
|
NDC 51862048601
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.40 |
| Max. Negotiated Rate |
$536.11 |
| Rate for Payer: Aetna American Axle |
$387.19
|
| Rate for Payer: Aetna Commercial |
$506.33
|
| Rate for Payer: Aetna Medicare |
$297.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.19
|
| Rate for Payer: BCBS Complete |
$238.27
|
| Rate for Payer: Cash Price |
$476.54
|
| Rate for Payer: Cofinity Commercial |
$416.98
|
| Rate for Payer: Cofinity Commercial |
$512.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.54
|
| Rate for Payer: Healthscope Commercial |
$536.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.33
|
| Rate for Payer: PHP Commercial |
$506.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$387.19
|
| Rate for Payer: Priority Health SBD |
$375.28
|
| Rate for Payer: UMR Bronson Commercial |
$220.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.76
|
|
|
TRIMETHOPRIM 100 MG TABLET
|
Facility
|
IP
|
$595.68
|
|
|
Service Code
|
NDC 51862048601
|
| Hospital Charge Code |
8182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.10 |
| Max. Negotiated Rate |
$536.11 |
| Rate for Payer: Aetna American Axle |
$387.19
|
| Rate for Payer: Aetna Commercial |
$506.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$387.19
|
| Rate for Payer: Cash Price |
$476.54
|
| Rate for Payer: Cofinity Commercial |
$416.98
|
| Rate for Payer: Cofinity Commercial |
$512.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$416.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.54
|
| Rate for Payer: Healthscope Commercial |
$536.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$416.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$446.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$506.33
|
| Rate for Payer: PHP Commercial |
$506.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$387.19
|
| Rate for Payer: Priority Health SBD |
$375.28
|
| Rate for Payer: UMR Bronson Commercial |
$262.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$446.76
|
|
|
TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER
|
Facility
|
OP
|
$163.07
|
|
|
Service Code
|
CPT G0127
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$31.05 |
| Max. Negotiated Rate |
$163.07 |
| Rate for Payer: Aetna Medicare |
$60.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$72.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$72.41
|
| Rate for Payer: BCBS Complete |
$32.60
|
| Rate for Payer: BCBS MAPPO |
$57.93
|
| Rate for Payer: BCN Medicare Advantage |
$57.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$57.93
|
| Rate for Payer: Mclaren Medicaid |
$31.05
|
| Rate for Payer: Mclaren Medicare |
$57.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$60.83
|
| Rate for Payer: Meridian Medicaid |
$32.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.62
|
| Rate for Payer: PACE Medicare |
$55.03
|
| Rate for Payer: PACE SWMI |
$57.93
|
| Rate for Payer: PHP Medicare Advantage |
$57.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$31.05
|
| Rate for Payer: Priority Health Medicare |
$57.93
|
| Rate for Payer: Railroad Medicare Medicare |
$57.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$57.93
|
| Rate for Payer: UHC Exchange |
$110.71
|
| Rate for Payer: UHC Medicare Advantage |
$57.93
|
| Rate for Payer: UHCCP Medicaid |
$31.05
|
| Rate for Payer: VA VA |
$57.93
|
|
|
TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER
|
Facility
|
OP
|
$163.07
|
|
|
Service Code
|
CPT 11719
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$31.05 |
| Max. Negotiated Rate |
$163.07 |
| Rate for Payer: Aetna Medicare |
$60.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$72.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$72.41
|
| Rate for Payer: BCBS Complete |
$32.60
|
| Rate for Payer: BCBS MAPPO |
$57.93
|
| Rate for Payer: BCN Medicare Advantage |
$57.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$57.93
|
| Rate for Payer: Mclaren Medicaid |
$31.05
|
| Rate for Payer: Mclaren Medicare |
$57.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$60.83
|
| Rate for Payer: Meridian Medicaid |
$32.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.62
|
| Rate for Payer: PACE Medicare |
$55.03
|
| Rate for Payer: PACE SWMI |
$57.93
|
| Rate for Payer: PHP Medicare Advantage |
$57.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$31.05
|
| Rate for Payer: Priority Health Medicare |
$57.93
|
| Rate for Payer: Railroad Medicare Medicare |
$57.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$57.93
|
| Rate for Payer: UHC Exchange |
$110.71
|
| Rate for Payer: UHC Medicare Advantage |
$57.93
|
| Rate for Payer: UHCCP Medicaid |
$31.05
|
| Rate for Payer: VA VA |
$57.93
|
|
|
TRIPROLIDINE-PSEUDOEPHEDRINE 2.5 MG-60 MG TABLET
|
Facility
|
IP
|
$79.90
|
|
|
Service Code
|
NDC 00904025059
|
| Hospital Charge Code |
8213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| Rate for Payer: Cofinity Commercial |
$68.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$71.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.94
|
| Rate for Payer: Priority Health SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$35.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
TRIPROLIDINE-PSEUDOEPHEDRINE 2.5 MG-60 MG TABLET
|
Facility
|
OP
|
$79.90
|
|
|
Service Code
|
NDC 00904025059
|
| Hospital Charge Code |
8213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna Medicare |
$39.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: BCBS Complete |
$31.96
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| Rate for Payer: Cofinity Commercial |
$68.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$71.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.94
|
| Rate for Payer: Priority Health SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$29.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION
|
Facility
|
IP
|
$17,316.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
119655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,619.04 |
| Max. Negotiated Rate |
$15,584.40 |
| Rate for Payer: Aetna American Axle |
$11,255.40
|
| Rate for Payer: Aetna Commercial |
$14,718.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,255.40
|
| Rate for Payer: Cash Price |
$13,852.80
|
| Rate for Payer: Cofinity Commercial |
$12,121.20
|
| Rate for Payer: Cofinity Commercial |
$14,891.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,121.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,852.80
|
| Rate for Payer: Healthscope Commercial |
$15,584.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,121.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,987.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,718.60
|
| Rate for Payer: PHP Commercial |
$14,718.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,255.40
|
| Rate for Payer: Priority Health SBD |
$10,909.08
|
| Rate for Payer: UMR Bronson Commercial |
$7,619.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,987.00
|
|
|
TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION
|
Facility
|
OP
|
$17,316.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
119655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$254.51 |
| Max. Negotiated Rate |
$15,584.40 |
| Rate for Payer: Aetna American Axle |
$11,255.40
|
| Rate for Payer: Aetna Commercial |
$14,718.60
|
| Rate for Payer: Aetna Medicare |
$493.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,255.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$593.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$593.55
|
| Rate for Payer: BCBS Complete |
$267.24
|
| Rate for Payer: BCBS MAPPO |
$474.84
|
| Rate for Payer: BCN Medicare Advantage |
$474.84
|
| Rate for Payer: Cash Price |
$13,852.80
|
| Rate for Payer: Cash Price |
$13,852.80
|
| Rate for Payer: Cofinity Commercial |
$14,891.76
|
| Rate for Payer: Cofinity Commercial |
$12,121.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$12,121.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,852.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$474.84
|
| Rate for Payer: Healthscope Commercial |
$15,584.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12,121.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12,987.00
|
| Rate for Payer: Mclaren Medicaid |
$254.51
|
| Rate for Payer: Mclaren Medicare |
$474.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$498.58
|
| Rate for Payer: Meridian Medicaid |
$267.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$546.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,718.60
|
| Rate for Payer: PACE Medicare |
$451.10
|
| Rate for Payer: PACE SWMI |
$474.84
|
| Rate for Payer: PHP Commercial |
$14,718.60
|
| Rate for Payer: PHP Medicare Advantage |
$474.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$254.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,255.40
|
| Rate for Payer: Priority Health Medicare |
$474.84
|
| Rate for Payer: Priority Health SBD |
$10,909.08
|
| Rate for Payer: Railroad Medicare Medicare |
$474.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,336.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$474.84
|
| Rate for Payer: UHC Exchange |
$907.47
|
| Rate for Payer: UHC Medicare Advantage |
$474.84
|
| Rate for Payer: UHCCP Medicaid |
$254.51
|
| Rate for Payer: UMR Bronson Commercial |
$6,406.92
|
| Rate for Payer: VA VA |
$474.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12,987.00
|
|
|
TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION
|
Facility
|
OP
|
$2,340.00
|
|
|
Service Code
|
HCPCS J3315
|
| Hospital Charge Code |
28558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$254.51 |
| Max. Negotiated Rate |
$2,106.00 |
| Rate for Payer: Aetna American Axle |
$1,521.00
|
| Rate for Payer: Aetna Commercial |
$1,989.00
|
| Rate for Payer: Aetna Medicare |
$493.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,521.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$593.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$593.55
|
| Rate for Payer: BCBS Complete |
$267.24
|
| Rate for Payer: BCBS MAPPO |
$474.84
|
| Rate for Payer: BCN Medicare Advantage |
$474.84
|
| Rate for Payer: Cash Price |
$1,872.00
|
| Rate for Payer: Cash Price |
$1,872.00
|
| Rate for Payer: Cofinity Commercial |
$2,012.40
|
| Rate for Payer: Cofinity Commercial |
$1,638.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,638.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,872.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$474.84
|
| Rate for Payer: Healthscope Commercial |
$2,106.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,638.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,755.00
|
| Rate for Payer: Mclaren Medicaid |
$254.51
|
| Rate for Payer: Mclaren Medicare |
$474.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$498.58
|
| Rate for Payer: Meridian Medicaid |
$267.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$546.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,989.00
|
| Rate for Payer: PACE Medicare |
$451.10
|
| Rate for Payer: PACE SWMI |
$474.84
|
| Rate for Payer: PHP Commercial |
$1,989.00
|
| Rate for Payer: PHP Medicare Advantage |
$474.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$254.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,521.00
|
| Rate for Payer: Priority Health Medicare |
$474.84
|
| Rate for Payer: Priority Health SBD |
$1,474.20
|
| Rate for Payer: Railroad Medicare Medicare |
$474.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,336.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$474.84
|
| Rate for Payer: UHC Exchange |
$907.47
|
| Rate for Payer: UHC Medicare Advantage |
$474.84
|
| Rate for Payer: UHCCP Medicaid |
$254.51
|
| Rate for Payer: UMR Bronson Commercial |
$865.80
|
| Rate for Payer: VA VA |
$474.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,755.00
|
|
