Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION

Facility

$250.73

Service Code	NDC 17478004532
Hospital Charge Code	11517
Hospital Revenue Code	250
Min. Negotiated Rate	$100.29
Max. Negotiated Rate	$225.66
Rate for Payer: Aetna Commercial	$213.12
Rate for Payer: Aetna Medicare	$125.36
Rate for Payer: Aetna New Business (MI Preferred)	$162.97
Rate for Payer: BCBS Complete	$100.29
Rate for Payer: Cash Price	$200.58
Rate for Payer: Cofinity Commercial	$175.51
Rate for Payer: Cofinity Commercial	$215.63
Rate for Payer: Cofinity Medicare Advantage	$175.51
Rate for Payer: Encore Health Key Benefits Commercial	$200.58
Rate for Payer: Healthscope Commercial	$225.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$213.12
Rate for Payer: PHP Commercial	$213.12
Rate for Payer: Priority Health Cigna Priority Health	$162.97
Rate for Payer: Priority Health SBD	$157.96

TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION

Facility

$250.73

Service Code	NDC 17478004532
Hospital Charge Code	11517
Hospital Revenue Code	250
Min. Negotiated Rate	$157.96
Max. Negotiated Rate	$225.66
Rate for Payer: Aetna Commercial	$213.12
Rate for Payer: Aetna New Business (MI Preferred)	$162.97
Rate for Payer: Cash Price	$200.58
Rate for Payer: Cofinity Commercial	$175.51
Rate for Payer: Cofinity Commercial	$215.63
Rate for Payer: Cofinity Medicare Advantage	$175.51
Rate for Payer: Encore Health Key Benefits Commercial	$200.58
Rate for Payer: Healthscope Commercial	$225.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$213.12
Rate for Payer: PHP Commercial	$213.12
Rate for Payer: Priority Health Cigna Priority Health	$162.97
Rate for Payer: Priority Health SBD	$157.96

TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBCUTANEOUS SYRINGE

Facility

$11,358.16

Service Code	HCPCS J2356
Hospital Charge Code	199104
Hospital Revenue Code	636
Min. Negotiated Rate	$7,155.64
Max. Negotiated Rate	$10,222.34
Rate for Payer: Aetna Commercial	$9,654.44
Rate for Payer: Aetna New Business (MI Preferred)	$7,382.80
Rate for Payer: Cash Price	$9,086.53
Rate for Payer: Cofinity Commercial	$7,950.71
Rate for Payer: Cofinity Commercial	$9,768.02
Rate for Payer: Cofinity Medicare Advantage	$7,950.71
Rate for Payer: Encore Health Key Benefits Commercial	$9,086.53
Rate for Payer: Healthscope Commercial	$10,222.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9,654.44
Rate for Payer: PHP Commercial	$9,654.44
Rate for Payer: Priority Health Cigna Priority Health	$7,382.80
Rate for Payer: Priority Health SBD	$7,155.64

TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBCUTANEOUS SYRINGE

Facility

$11,358.16

Service Code	HCPCS J2356
Hospital Charge Code	199104
Hospital Revenue Code	636
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$10,222.34
Rate for Payer: Aetna Commercial	$9,654.44
Rate for Payer: Aetna Medicare	$18.73
Rate for Payer: Aetna New Business (MI Preferred)	$7,382.80
Rate for Payer: Allen County Amish Medical Aid Commercial	$22.51
Rate for Payer: Amish Plain Church Group Commercial	$22.51
Rate for Payer: BCBS Complete	$10.14
Rate for Payer: BCBS MAPPO	$18.01
Rate for Payer: BCN Medicare Advantage	$18.01
Rate for Payer: Cash Price	$9,086.53
Rate for Payer: Cash Price	$9,086.53
Rate for Payer: Cofinity Commercial	$9,768.02
Rate for Payer: Cofinity Commercial	$7,950.71
Rate for Payer: Cofinity Medicare Advantage	$7,950.71
Rate for Payer: Encore Health Key Benefits Commercial	$9,086.53
Rate for Payer: Health Alliance Plan Medicare Advantage	$18.01
Rate for Payer: Healthscope Commercial	$10,222.34
Rate for Payer: Mclaren Medicaid	$9.65
Rate for Payer: Mclaren Medicare	$18.01
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$18.91
Rate for Payer: Meridian Medicaid	$10.14
Rate for Payer: MI Amish Medical Board Commercial	$20.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9,654.44
Rate for Payer: PACE Medicare	$17.11
Rate for Payer: PACE SWMI	$18.01
Rate for Payer: PHP Commercial	$9,654.44
Rate for Payer: PHP Medicare Advantage	$18.01
Rate for Payer: Priority Health Choice Medicaid	$9.65
Rate for Payer: Priority Health Cigna Priority Health	$7,382.80
Rate for Payer: Priority Health Medicare	$18.01
Rate for Payer: Priority Health SBD	$7,155.64
Rate for Payer: Railroad Medicare Medicare	$18.01
Rate for Payer: UHC All Payor (Choice/PPO)	$50.70
Rate for Payer: UHC Dual Complete DSNP	$18.01
Rate for Payer: UHC Medicare Advantage	$18.01
Rate for Payer: UHCCP Medicaid	$10.14
Rate for Payer: VA VA	$18.01

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR

Facility

$44.64

Service Code	NDC 00121482015
Hospital Charge Code	7820
Hospital Revenue Code	637
Min. Negotiated Rate	$17.86
Max. Negotiated Rate	$40.18
Rate for Payer: Aetna Commercial	$37.94
Rate for Payer: Aetna Medicare	$22.32
Rate for Payer: Aetna New Business (MI Preferred)	$29.02
Rate for Payer: BCBS Complete	$17.86
Rate for Payer: Cash Price	$35.71
Rate for Payer: Cofinity Commercial	$31.25
Rate for Payer: Cofinity Commercial	$38.39
Rate for Payer: Cofinity Medicare Advantage	$31.25
Rate for Payer: Encore Health Key Benefits Commercial	$35.71
Rate for Payer: Healthscope Commercial	$40.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$37.94
Rate for Payer: PHP Commercial	$37.94
Rate for Payer: Priority Health Cigna Priority Health	$29.02
Rate for Payer: Priority Health SBD	$28.12

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR

Facility

$44.64

Service Code	NDC 00121482015
Hospital Charge Code	7820
Hospital Revenue Code	637
Min. Negotiated Rate	$28.12
Max. Negotiated Rate	$40.18
Rate for Payer: Aetna Commercial	$37.94
Rate for Payer: Aetna New Business (MI Preferred)	$29.02
Rate for Payer: Cash Price	$35.71
Rate for Payer: Cofinity Commercial	$31.25
Rate for Payer: Cofinity Commercial	$38.39
Rate for Payer: Cofinity Medicare Advantage	$31.25
Rate for Payer: Encore Health Key Benefits Commercial	$35.71
Rate for Payer: Healthscope Commercial	$40.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$37.94
Rate for Payer: PHP Commercial	$37.94
Rate for Payer: Priority Health Cigna Priority Health	$29.02
Rate for Payer: Priority Health SBD	$28.12

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR

Facility

$44.64

Service Code	NDC 00121482040
Hospital Charge Code	7820
Hospital Revenue Code	637
Min. Negotiated Rate	$28.12
Max. Negotiated Rate	$40.18
Rate for Payer: Aetna Commercial	$37.94
Rate for Payer: Aetna New Business (MI Preferred)	$29.02
Rate for Payer: Cash Price	$35.71
Rate for Payer: Cofinity Commercial	$31.25
Rate for Payer: Cofinity Commercial	$38.39
Rate for Payer: Cofinity Medicare Advantage	$31.25
Rate for Payer: Encore Health Key Benefits Commercial	$35.71
Rate for Payer: Healthscope Commercial	$40.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$37.94
Rate for Payer: PHP Commercial	$37.94
Rate for Payer: Priority Health Cigna Priority Health	$29.02
Rate for Payer: Priority Health SBD	$28.12

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR

Facility

$44.64

Service Code	NDC 00121482040
Hospital Charge Code	7820
Hospital Revenue Code	637
Min. Negotiated Rate	$17.86
Max. Negotiated Rate	$40.18
Rate for Payer: Aetna Commercial	$37.94
Rate for Payer: Aetna Medicare	$22.32
Rate for Payer: Aetna New Business (MI Preferred)	$29.02
Rate for Payer: BCBS Complete	$17.86
Rate for Payer: Cash Price	$35.71
Rate for Payer: Cofinity Commercial	$31.25
Rate for Payer: Cofinity Commercial	$38.39
Rate for Payer: Cofinity Medicare Advantage	$31.25
Rate for Payer: Encore Health Key Benefits Commercial	$35.71
Rate for Payer: Healthscope Commercial	$40.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$37.94
Rate for Payer: PHP Commercial	$37.94
Rate for Payer: Priority Health Cigna Priority Health	$29.02
Rate for Payer: Priority Health SBD	$28.12

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR

Facility

$578.88

Service Code	NDC 62332002531
Hospital Charge Code	12098
Hospital Revenue Code	637
Min. Negotiated Rate	$364.69
Max. Negotiated Rate	$520.99
Rate for Payer: Aetna Commercial	$492.05
Rate for Payer: Aetna New Business (MI Preferred)	$376.27
Rate for Payer: Cash Price	$463.10
Rate for Payer: Cofinity Commercial	$405.22
Rate for Payer: Cofinity Commercial	$497.84
Rate for Payer: Cofinity Medicare Advantage	$405.22
Rate for Payer: Encore Health Key Benefits Commercial	$463.10
Rate for Payer: Healthscope Commercial	$520.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$492.05
Rate for Payer: PHP Commercial	$492.05
Rate for Payer: Priority Health Cigna Priority Health	$376.27
Rate for Payer: Priority Health SBD	$364.69

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR

Facility

$578.88

Service Code	NDC 62332002531
Hospital Charge Code	12098
Hospital Revenue Code	637
Min. Negotiated Rate	$231.55
Max. Negotiated Rate	$520.99
Rate for Payer: Aetna Commercial	$492.05
Rate for Payer: Aetna Medicare	$289.44
Rate for Payer: Aetna New Business (MI Preferred)	$376.27
Rate for Payer: BCBS Complete	$231.55
Rate for Payer: Cash Price	$463.10
Rate for Payer: Cofinity Commercial	$405.22
Rate for Payer: Cofinity Commercial	$497.84
Rate for Payer: Cofinity Medicare Advantage	$405.22
Rate for Payer: Encore Health Key Benefits Commercial	$463.10
Rate for Payer: Healthscope Commercial	$520.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$492.05
Rate for Payer: PHP Commercial	$492.05
Rate for Payer: Priority Health Cigna Priority Health	$376.27
Rate for Payer: Priority Health SBD	$364.69

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$404.16

Service Code	NDC 68462038001
Hospital Charge Code	108325
Hospital Revenue Code	637
Min. Negotiated Rate	$254.62
Max. Negotiated Rate	$363.74
Rate for Payer: Aetna Commercial	$343.54
Rate for Payer: Aetna New Business (MI Preferred)	$262.70
Rate for Payer: Cash Price	$323.33
Rate for Payer: Cofinity Commercial	$282.91
Rate for Payer: Cofinity Commercial	$347.58
Rate for Payer: Cofinity Medicare Advantage	$282.91
Rate for Payer: Encore Health Key Benefits Commercial	$323.33
Rate for Payer: Healthscope Commercial	$363.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$343.54
Rate for Payer: PHP Commercial	$343.54
Rate for Payer: Priority Health Cigna Priority Health	$262.70
Rate for Payer: Priority Health SBD	$254.62

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$404.16

Service Code	NDC 68462038001
Hospital Charge Code	108325
Hospital Revenue Code	637
Min. Negotiated Rate	$161.66
Max. Negotiated Rate	$363.74
Rate for Payer: Aetna Commercial	$343.54
Rate for Payer: Aetna Medicare	$202.08
Rate for Payer: Aetna New Business (MI Preferred)	$262.70
Rate for Payer: BCBS Complete	$161.66
Rate for Payer: Cash Price	$323.33
Rate for Payer: Cofinity Commercial	$282.91
Rate for Payer: Cofinity Commercial	$347.58
Rate for Payer: Cofinity Medicare Advantage	$282.91
Rate for Payer: Encore Health Key Benefits Commercial	$323.33
Rate for Payer: Healthscope Commercial	$363.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$343.54
Rate for Payer: PHP Commercial	$343.54
Rate for Payer: Priority Health Cigna Priority Health	$262.70
Rate for Payer: Priority Health SBD	$254.62

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$463.68

Service Code	NDC 42858070101
Hospital Charge Code	108325
Hospital Revenue Code	637
Min. Negotiated Rate	$185.47
Max. Negotiated Rate	$417.31
Rate for Payer: Aetna Commercial	$394.13
Rate for Payer: Aetna Medicare	$231.84
Rate for Payer: Aetna New Business (MI Preferred)	$301.39
Rate for Payer: BCBS Complete	$185.47
Rate for Payer: Cash Price	$370.94
Rate for Payer: Cofinity Commercial	$324.58
Rate for Payer: Cofinity Commercial	$398.76
Rate for Payer: Cofinity Medicare Advantage	$324.58
Rate for Payer: Encore Health Key Benefits Commercial	$370.94
Rate for Payer: Healthscope Commercial	$417.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$394.13
Rate for Payer: PHP Commercial	$394.13
Rate for Payer: Priority Health Cigna Priority Health	$301.39
Rate for Payer: Priority Health SBD	$292.12

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$463.68

Service Code	NDC 42858070101
Hospital Charge Code	108325
Hospital Revenue Code	637
Min. Negotiated Rate	$292.12
Max. Negotiated Rate	$417.31
Rate for Payer: Aetna Commercial	$394.13
Rate for Payer: Aetna New Business (MI Preferred)	$301.39
Rate for Payer: Cash Price	$370.94
Rate for Payer: Cofinity Commercial	$324.58
Rate for Payer: Cofinity Commercial	$398.76
Rate for Payer: Cofinity Medicare Advantage	$324.58
Rate for Payer: Encore Health Key Benefits Commercial	$370.94
Rate for Payer: Healthscope Commercial	$417.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$394.13
Rate for Payer: PHP Commercial	$394.13
Rate for Payer: Priority Health Cigna Priority Health	$301.39
Rate for Payer: Priority Health SBD	$292.12

THERMAGE

Professional

Both

$1,020.00

Service Code	HCPCS 00167
Hospital Revenue Code	960
Min. Negotiated Rate	$408.00
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Medicare	$510.00
Rate for Payer: BCBS Complete	$408.00
Rate for Payer: Cash Price	$816.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$663.00
Rate for Payer: Priority Health Cigna Priority Health	$663.00

THERMAGE ABDOMEN - ENTIRE

Professional

Both

$3,162.00

Service Code	HCPCS 00150
Hospital Revenue Code	960
Min. Negotiated Rate	$1,264.80
Max. Negotiated Rate	$2,055.30
Rate for Payer: Aetna Medicare	$1,581.00
Rate for Payer: BCBS Complete	$1,264.80
Rate for Payer: Cash Price	$2,529.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,055.30
Rate for Payer: Priority Health Cigna Priority Health	$2,055.30

THERMAGE ABDOMEN - LOWER

Professional

Both

$2,040.00

Service Code	HCPCS 00149
Hospital Revenue Code	960
Min. Negotiated Rate	$816.00
Max. Negotiated Rate	$1,326.00
Rate for Payer: Aetna Medicare	$1,020.00
Rate for Payer: BCBS Complete	$816.00
Rate for Payer: Cash Price	$1,632.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,326.00
Rate for Payer: Priority Health Cigna Priority Health	$1,326.00

THERMAGE ARMS - 1 ARM

Professional

Both

$1,224.00

Service Code	HCPCS 00145
Hospital Revenue Code	960
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$795.60
Rate for Payer: Aetna Medicare	$612.00
Rate for Payer: BCBS Complete	$489.60
Rate for Payer: Cash Price	$979.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$795.60
Rate for Payer: Priority Health Cigna Priority Health	$795.60

THERMAGE ARMS - BILATERAL

Professional

Both

$2,142.00

Service Code	HCPCS 00146
Hospital Revenue Code	960
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,392.30
Rate for Payer: Aetna Medicare	$1,071.00
Rate for Payer: BCBS Complete	$856.80
Rate for Payer: Cash Price	$1,713.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,392.30
Rate for Payer: Priority Health Cigna Priority Health	$1,392.30

THERMAGE EYES

Professional

Both

$969.00

Service Code	HCPCS 00140
Hospital Revenue Code	960
Min. Negotiated Rate	$387.60
Max. Negotiated Rate	$629.85
Rate for Payer: Aetna Medicare	$484.50
Rate for Payer: BCBS Complete	$387.60
Rate for Payer: Cash Price	$775.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$629.85
Rate for Payer: Priority Health Cigna Priority Health	$629.85

THERMAGE FACE

Professional

Both

$2,040.00

Service Code	HCPCS 00139
Hospital Revenue Code	960
Min. Negotiated Rate	$816.00
Max. Negotiated Rate	$1,326.00
Rate for Payer: Aetna Medicare	$1,020.00
Rate for Payer: BCBS Complete	$816.00
Rate for Payer: Cash Price	$1,632.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,326.00
Rate for Payer: Priority Health Cigna Priority Health	$1,326.00

THERMAGE FACE & EYES

Professional

Both

$2,754.00

Service Code	HCPCS 00142
Hospital Revenue Code	960
Min. Negotiated Rate	$1,101.60
Max. Negotiated Rate	$1,790.10
Rate for Payer: Aetna Medicare	$1,377.00
Rate for Payer: BCBS Complete	$1,101.60
Rate for Payer: Cash Price	$2,203.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,790.10
Rate for Payer: Priority Health Cigna Priority Health	$1,790.10

THERMAGE FACE & NECK

Professional

Both

$2,856.00

Service Code	HCPCS 00143
Hospital Revenue Code	960
Min. Negotiated Rate	$1,142.40
Max. Negotiated Rate	$1,856.40
Rate for Payer: Aetna Medicare	$1,428.00
Rate for Payer: BCBS Complete	$1,142.40
Rate for Payer: Cash Price	$2,284.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,856.40
Rate for Payer: Priority Health Cigna Priority Health	$1,856.40

THERMAGE FACE, NECK, & EYES

Professional

Both

$3,570.00

Service Code	HCPCS 00144
Hospital Revenue Code	960
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,320.50
Rate for Payer: Aetna Medicare	$1,785.00
Rate for Payer: BCBS Complete	$1,428.00
Rate for Payer: Cash Price	$2,856.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,320.50
Rate for Payer: Priority Health Cigna Priority Health	$2,320.50

THERMAGE KNEES - BILATERAL

Professional

Both

$1,224.00

Service Code	HCPCS 00151
Hospital Revenue Code	960
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$795.60
Rate for Payer: Aetna Medicare	$612.00
Rate for Payer: BCBS Complete	$489.60
Rate for Payer: Cash Price	$979.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$795.60
Rate for Payer: Priority Health Cigna Priority Health	$795.60

Know your out-of-pocket cost for care.

All Charges