Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

TENECTEPLASE 50 MG INTRAVENOUS SOLUTION

Facility

$26,150.27

Service Code	HCPCS J3101
Hospital Charge Code	186094
Hospital Revenue Code	636
Min. Negotiated Rate	$16,474.67
Max. Negotiated Rate	$23,535.24
Rate for Payer: Aetna Commercial	$22,227.73
Rate for Payer: Aetna New Business (MI Preferred)	$16,997.68
Rate for Payer: Cash Price	$20,920.22
Rate for Payer: Cofinity Commercial	$18,305.19
Rate for Payer: Cofinity Commercial	$22,489.23
Rate for Payer: Healthscope Commercial	$23,535.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22,227.73
Rate for Payer: PHP Commercial	$22,227.73
Rate for Payer: Priority Health Cigna Priority Health	$18,305.19
Rate for Payer: Priority Health SBD	$16,474.67

TENODESIS OF LONG TENDON OF BICEPS

Facility

$19,834.21

Service Code	CPT 23430
Hospital Revenue Code	360
Min. Negotiated Rate	$741.00
Max. Negotiated Rate	$19,834.21
Rate for Payer: Aetna Medicare	$6,620.26
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,957.04
Rate for Payer: Amish Plain Church Group Commercial	$7,957.04
Rate for Payer: BCBS Complete	$3,656.42
Rate for Payer: BCBS MAPPO	$6,365.63
Rate for Payer: BCBS Trust/PPO	$2,909.12
Rate for Payer: BCN Medicare Advantage	$6,365.63
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,365.63
Rate for Payer: Mclaren Medicaid	$3,482.00
Rate for Payer: Mclaren Medicare	$6,365.63
Rate for Payer: Meridian Medicaid	$3,656.42
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6,683.91
Rate for Payer: MI Amish Medical Board Commercial	$7,320.47
Rate for Payer: PACE Medicare	$6,047.35
Rate for Payer: PACE SWMI	$6,365.63
Rate for Payer: PHP Medicare Advantage	$6,365.63
Rate for Payer: Priority Health Choice Medicaid	$3,482.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19,834.21
Rate for Payer: Priority Health Medicare	$6,365.63
Rate for Payer: Priority Health Narrow Network	$15,867.37
Rate for Payer: Railroad Medicare Medicare	$6,365.63
Rate for Payer: UHC All Payor (Choice/PPO)	$815.10
Rate for Payer: UHC Core	$6,837.00
Rate for Payer: UHC Dual Complete DSNP	$6,365.63
Rate for Payer: UHC Exchange	$741.00
Rate for Payer: UHC Medicare Advantage	$6,556.60
Rate for Payer: VA VA	$6,365.63

TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; SINGLE, EACH TENDON

Facility

$8,925.64

Service Code	CPT 27680
Hospital Revenue Code	360
Min. Negotiated Rate	$419.13
Max. Negotiated Rate	$8,925.64
Rate for Payer: Aetna Medicare	$2,995.31
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,600.14
Rate for Payer: Amish Plain Church Group Commercial	$3,600.14
Rate for Payer: BCBS Complete	$1,654.34
Rate for Payer: BCBS MAPPO	$2,880.11
Rate for Payer: BCBS Trust/PPO	$1,234.36
Rate for Payer: BCN Medicare Advantage	$2,880.11
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,880.11
Rate for Payer: Mclaren Medicaid	$1,575.42
Rate for Payer: Mclaren Medicare	$2,880.11
Rate for Payer: Meridian Medicaid	$1,654.34
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,024.12
Rate for Payer: MI Amish Medical Board Commercial	$3,312.13
Rate for Payer: PACE Medicare	$2,736.10
Rate for Payer: PACE SWMI	$2,880.11
Rate for Payer: PHP Medicare Advantage	$2,880.11
Rate for Payer: Priority Health Choice Medicaid	$1,575.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,925.64
Rate for Payer: Priority Health Medicare	$2,880.11
Rate for Payer: Priority Health Narrow Network	$7,140.51
Rate for Payer: Railroad Medicare Medicare	$2,880.11
Rate for Payer: UHC All Payor (Choice/PPO)	$461.04
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$2,880.11
Rate for Payer: UHC Exchange	$419.13
Rate for Payer: UHC Medicare Advantage	$2,966.51
Rate for Payer: VA VA	$2,880.11

TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN

Facility

$8,925.64

Service Code	CPT 24358
Hospital Revenue Code	360
Min. Negotiated Rate	$531.44
Max. Negotiated Rate	$8,925.64
Rate for Payer: Aetna Medicare	$2,995.31
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,600.14
Rate for Payer: Amish Plain Church Group Commercial	$3,600.14
Rate for Payer: BCBS Complete	$1,654.34
Rate for Payer: BCBS MAPPO	$2,880.11
Rate for Payer: BCBS Trust/PPO	$1,234.36
Rate for Payer: BCN Medicare Advantage	$2,880.11
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,880.11
Rate for Payer: Mclaren Medicaid	$1,575.42
Rate for Payer: Mclaren Medicare	$2,880.11
Rate for Payer: Meridian Medicaid	$1,654.34
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,024.12
Rate for Payer: MI Amish Medical Board Commercial	$3,312.13
Rate for Payer: PACE Medicare	$2,736.10
Rate for Payer: PACE SWMI	$2,880.11
Rate for Payer: PHP Medicare Advantage	$2,880.11
Rate for Payer: Priority Health Choice Medicaid	$1,575.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,925.64
Rate for Payer: Priority Health Medicare	$2,880.11
Rate for Payer: Priority Health Narrow Network	$7,140.51
Rate for Payer: Railroad Medicare Medicare	$2,880.11
Rate for Payer: UHC All Payor (Choice/PPO)	$584.58
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$2,880.11
Rate for Payer: UHC Exchange	$531.44
Rate for Payer: UHC Medicare Advantage	$2,966.51
Rate for Payer: VA VA	$2,880.11

TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT

Facility

$8,925.64

Service Code	CPT 24359
Hospital Revenue Code	360
Min. Negotiated Rate	$662.74
Max. Negotiated Rate	$8,925.64
Rate for Payer: Aetna Medicare	$2,995.31
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,600.14
Rate for Payer: Amish Plain Church Group Commercial	$3,600.14
Rate for Payer: BCBS Complete	$1,654.34
Rate for Payer: BCBS MAPPO	$2,880.11
Rate for Payer: BCBS Trust/PPO	$1,893.15
Rate for Payer: BCN Medicare Advantage	$2,880.11
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,880.11
Rate for Payer: Mclaren Medicaid	$1,575.42
Rate for Payer: Mclaren Medicare	$2,880.11
Rate for Payer: Meridian Medicaid	$1,654.34
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,024.12
Rate for Payer: MI Amish Medical Board Commercial	$3,312.13
Rate for Payer: PACE Medicare	$2,736.10
Rate for Payer: PACE SWMI	$2,880.11
Rate for Payer: PHP Medicare Advantage	$2,880.11
Rate for Payer: Priority Health Choice Medicaid	$1,575.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,925.64
Rate for Payer: Priority Health Medicare	$2,880.11
Rate for Payer: Priority Health Narrow Network	$7,140.51
Rate for Payer: Railroad Medicare Medicare	$2,880.11
Rate for Payer: UHC All Payor (Choice/PPO)	$729.01
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$2,880.11
Rate for Payer: UHC Exchange	$662.74
Rate for Payer: UHC Medicare Advantage	$2,966.51
Rate for Payer: VA VA	$2,880.11

TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON

Facility

$4,155.00

Service Code	CPT 28234
Hospital Revenue Code	360
Min. Negotiated Rate	$268.50
Max. Negotiated Rate	$4,155.00
Rate for Payer: Aetna Medicare	$1,487.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,787.60
Rate for Payer: Amish Plain Church Group Commercial	$1,787.60
Rate for Payer: BCBS Complete	$821.44
Rate for Payer: BCBS MAPPO	$1,430.08
Rate for Payer: BCBS Trust/PPO	$804.96
Rate for Payer: BCN Medicare Advantage	$1,430.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,430.08
Rate for Payer: Mclaren Medicaid	$782.25
Rate for Payer: Mclaren Medicare	$1,430.08
Rate for Payer: Meridian Medicaid	$821.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,501.58
Rate for Payer: MI Amish Medical Board Commercial	$1,644.59
Rate for Payer: PACE Medicare	$1,358.58
Rate for Payer: PACE SWMI	$1,430.08
Rate for Payer: PHP Medicare Advantage	$1,430.08
Rate for Payer: Priority Health Choice Medicaid	$782.25
Rate for Payer: Priority Health Medicare	$1,430.08
Rate for Payer: Railroad Medicare Medicare	$1,430.08
Rate for Payer: UHC All Payor (Choice/PPO)	$295.35
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,430.08
Rate for Payer: UHC Exchange	$268.50
Rate for Payer: UHC Medicare Advantage	$1,472.98
Rate for Payer: VA VA	$1,430.08

TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON

Facility

$8,817.68

Service Code	CPT 25290
Hospital Revenue Code	360
Min. Negotiated Rate	$438.77
Max. Negotiated Rate	$8,817.68
Rate for Payer: Aetna Medicare	$2,995.31
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,600.14
Rate for Payer: Amish Plain Church Group Commercial	$3,600.14
Rate for Payer: BCBS Complete	$1,654.34
Rate for Payer: BCBS MAPPO	$2,880.11
Rate for Payer: BCBS Trust/PPO	$1,234.36
Rate for Payer: BCN Medicare Advantage	$2,880.11
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,880.11
Rate for Payer: Mclaren Medicaid	$1,575.42
Rate for Payer: Mclaren Medicare	$2,880.11
Rate for Payer: Meridian Medicaid	$1,654.34
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,024.12
Rate for Payer: MI Amish Medical Board Commercial	$3,312.13
Rate for Payer: PACE Medicare	$2,736.10
Rate for Payer: PACE SWMI	$2,880.11
Rate for Payer: PHP Medicare Advantage	$2,880.11
Rate for Payer: Priority Health Choice Medicaid	$1,575.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,817.68
Rate for Payer: Priority Health Medicare	$2,880.11
Rate for Payer: Priority Health Narrow Network	$7,054.14
Rate for Payer: Railroad Medicare Medicare	$2,880.11
Rate for Payer: UHC All Payor (Choice/PPO)	$482.65
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$2,880.11
Rate for Payer: UHC Exchange	$438.77
Rate for Payer: UHC Medicare Advantage	$2,966.51
Rate for Payer: VA VA	$2,880.11

TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE PROCEDURE)

Facility

$4,155.00

Service Code	CPT 28232
Hospital Revenue Code	360
Min. Negotiated Rate	$195.58
Max. Negotiated Rate	$4,155.00
Rate for Payer: Aetna Medicare	$1,487.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,787.60
Rate for Payer: Amish Plain Church Group Commercial	$1,787.60
Rate for Payer: BCBS Complete	$821.44
Rate for Payer: BCBS MAPPO	$1,430.08
Rate for Payer: BCBS Trust/PPO	$195.58
Rate for Payer: BCN Medicare Advantage	$1,430.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,430.08
Rate for Payer: Mclaren Medicaid	$782.25
Rate for Payer: Mclaren Medicare	$1,430.08
Rate for Payer: Meridian Medicaid	$821.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,501.58
Rate for Payer: MI Amish Medical Board Commercial	$1,644.59
Rate for Payer: PACE Medicare	$1,358.58
Rate for Payer: PACE SWMI	$1,430.08
Rate for Payer: PHP Medicare Advantage	$1,430.08
Rate for Payer: Priority Health Choice Medicaid	$782.25
Rate for Payer: Priority Health Medicare	$1,430.08
Rate for Payer: Railroad Medicare Medicare	$1,430.08
Rate for Payer: UHC All Payor (Choice/PPO)	$263.66
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,430.08
Rate for Payer: UHC Exchange	$239.69
Rate for Payer: UHC Medicare Advantage	$1,472.98
Rate for Payer: VA VA	$1,430.08

TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION

Facility

$41,392.78

Service Code	HCPCS J3241
Hospital Charge Code	192660
Hospital Revenue Code	636
Min. Negotiated Rate	$26,077.45
Max. Negotiated Rate	$37,253.50
Rate for Payer: Aetna Commercial	$35,183.86
Rate for Payer: Aetna New Business (MI Preferred)	$26,905.31
Rate for Payer: Cash Price	$33,114.22
Rate for Payer: Cofinity Commercial	$28,974.95
Rate for Payer: Cofinity Commercial	$35,597.79
Rate for Payer: Healthscope Commercial	$37,253.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$35,183.86
Rate for Payer: PHP Commercial	$35,183.86
Rate for Payer: Priority Health Cigna Priority Health	$28,974.95
Rate for Payer: Priority Health SBD	$26,077.45

TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION

Facility

$21.32

Service Code	HCPCS J3105
Hospital Charge Code	11507
Hospital Revenue Code	636
Min. Negotiated Rate	$13.43
Max. Negotiated Rate	$19.19
Rate for Payer: Aetna Commercial	$18.12
Rate for Payer: Aetna Commercial	$14.37
Rate for Payer: Aetna New Business (MI Preferred)	$13.86
Rate for Payer: Aetna New Business (MI Preferred)	$10.99
Rate for Payer: Cash Price	$17.06
Rate for Payer: Cash Price	$13.53
Rate for Payer: Cofinity Commercial	$14.92
Rate for Payer: Cofinity Commercial	$11.84
Rate for Payer: Cofinity Commercial	$14.54
Rate for Payer: Cofinity Commercial	$18.34
Rate for Payer: Healthscope Commercial	$15.22
Rate for Payer: Healthscope Commercial	$19.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.37
Rate for Payer: PHP Commercial	$14.37
Rate for Payer: PHP Commercial	$18.12
Rate for Payer: Priority Health Cigna Priority Health	$11.84
Rate for Payer: Priority Health Cigna Priority Health	$14.92
Rate for Payer: Priority Health SBD	$13.43
Rate for Payer: Priority Health SBD	$10.65

TERCONAZOLE 0.8 % VAGINAL CREAM

Facility

$117.25

Service Code	NDC 51672-1302-0
Hospital Charge Code	11511
Hospital Revenue Code	637
Min. Negotiated Rate	$73.87
Max. Negotiated Rate	$105.52
Rate for Payer: Aetna Commercial	$99.66
Rate for Payer: Aetna New Business (MI Preferred)	$76.21
Rate for Payer: Cash Price	$93.80
Rate for Payer: Cofinity Commercial	$100.84
Rate for Payer: Cofinity Commercial	$82.08
Rate for Payer: Healthscope Commercial	$105.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$99.66
Rate for Payer: PHP Commercial	$99.66
Rate for Payer: Priority Health Cigna Priority Health	$82.08
Rate for Payer: Priority Health SBD	$73.87

TESTES PROCEDURES WITH CC/MCC

Facility

$32,382.72

Service Code	MS-DRG 711
Min. Negotiated Rate	$14,992.35
Max. Negotiated Rate	$32,382.72
Rate for Payer: Aetna Medicare	$16,412.68
Rate for Payer: Allen County Amish Medical Aid Commercial	$19,726.78
Rate for Payer: Amish Plain Church Group Commercial	$19,726.78
Rate for Payer: BCBS MAPPO	$15,781.42
Rate for Payer: BCBS Trust/PPO	$31,208.13
Rate for Payer: BCN Medicare Advantage	$15,781.42
Rate for Payer: Health Alliance Plan Medicare Advantage	$15,781.42
Rate for Payer: Mclaren Medicare	$15,781.42
Rate for Payer: Meridian Wellcare - Medicare Advantage	$16,570.49
Rate for Payer: MI Amish Medical Board Commercial	$18,148.63
Rate for Payer: PACE Medicare	$14,992.35
Rate for Payer: PACE SWMI	$15,781.42
Rate for Payer: PHP Medicare Advantage	$15,781.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$30,463.45
Rate for Payer: Priority Health Medicare	$15,781.42
Rate for Payer: Priority Health Narrow Network	$24,370.76
Rate for Payer: Railroad Medicare Medicare	$15,781.42
Rate for Payer: UHC All Payor (Choice/PPO)	$32,382.72
Rate for Payer: UHC Core	$19,870.34
Rate for Payer: UHC Dual Complete DSNP	$15,781.42
Rate for Payer: UHC Exchange	$21,282.07
Rate for Payer: UHC Medicare Advantage	$16,254.86
Rate for Payer: VA VA	$15,781.42

TESTES PROCEDURES WITHOUT CC/MCC

Facility

$18,127.85

Service Code	MS-DRG 712
Min. Negotiated Rate	$8,598.76
Max. Negotiated Rate	$18,127.85
Rate for Payer: Aetna Medicare	$9,413.38
Rate for Payer: Allen County Amish Medical Aid Commercial	$11,314.16
Rate for Payer: Amish Plain Church Group Commercial	$11,314.16
Rate for Payer: BCBS MAPPO	$9,051.33
Rate for Payer: BCBS Trust/PPO	$17,202.68
Rate for Payer: BCN Medicare Advantage	$9,051.33
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,051.33
Rate for Payer: Mclaren Medicare	$9,051.33
Rate for Payer: Meridian Wellcare - Medicare Advantage	$9,503.90
Rate for Payer: MI Amish Medical Board Commercial	$10,409.03
Rate for Payer: PACE Medicare	$8,598.76
Rate for Payer: PACE SWMI	$9,051.33
Rate for Payer: PHP Medicare Advantage	$9,051.33
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17,053.44
Rate for Payer: Priority Health Medicare	$9,051.33
Rate for Payer: Priority Health Narrow Network	$13,642.75
Rate for Payer: Railroad Medicare Medicare	$9,051.33
Rate for Payer: UHC All Payor (Choice/PPO)	$18,127.85
Rate for Payer: UHC Core	$11,123.42
Rate for Payer: UHC Dual Complete DSNP	$9,051.33
Rate for Payer: UHC Exchange	$11,913.71
Rate for Payer: UHC Medicare Advantage	$9,322.87
Rate for Payer: VA VA	$9,051.33

TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL

Facility

$34.35

Service Code	HCPCS J1071
Hospital Charge Code	7784
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$30.92
Rate for Payer: Aetna Commercial	$29.20
Rate for Payer: Aetna New Business (MI Preferred)	$22.33
Rate for Payer: BCBS Complete	$13.74
Rate for Payer: BCBS Trust/PPO	$0.06
Rate for Payer: Cash Price	$27.48
Rate for Payer: Cash Price	$27.48
Rate for Payer: Cofinity Commercial	$24.04
Rate for Payer: Cofinity Commercial	$29.54
Rate for Payer: Healthscope Commercial	$30.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$29.20
Rate for Payer: PHP Commercial	$29.20
Rate for Payer: Priority Health Cigna Priority Health	$24.04
Rate for Payer: Priority Health SBD	$21.64

TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL

Facility

$34.35

Service Code	HCPCS J1071
Hospital Charge Code	7784
Hospital Revenue Code	636
Min. Negotiated Rate	$21.64
Max. Negotiated Rate	$30.92
Rate for Payer: Aetna Commercial	$29.20
Rate for Payer: Aetna Commercial	$74.84
Rate for Payer: Aetna New Business (MI Preferred)	$22.33
Rate for Payer: Aetna New Business (MI Preferred)	$57.23
Rate for Payer: Cash Price	$27.48
Rate for Payer: Cash Price	$70.44
Rate for Payer: Cofinity Commercial	$29.54
Rate for Payer: Cofinity Commercial	$75.72
Rate for Payer: Cofinity Commercial	$61.64
Rate for Payer: Cofinity Commercial	$24.04
Rate for Payer: Healthscope Commercial	$30.92
Rate for Payer: Healthscope Commercial	$79.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$29.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$74.84
Rate for Payer: PHP Commercial	$29.20
Rate for Payer: PHP Commercial	$74.84
Rate for Payer: Priority Health Cigna Priority Health	$61.64
Rate for Payer: Priority Health Cigna Priority Health	$24.04
Rate for Payer: Priority Health SBD	$21.64
Rate for Payer: Priority Health SBD	$55.47

TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE

Facility

$1,676.77

Service Code	HCPCS J1670
Hospital Charge Code	118208
Hospital Revenue Code	636
Min. Negotiated Rate	$1,056.37
Max. Negotiated Rate	$1,509.09
Rate for Payer: Aetna Commercial	$1,425.25
Rate for Payer: Aetna New Business (MI Preferred)	$1,089.90
Rate for Payer: Cash Price	$1,341.42
Rate for Payer: Cofinity Commercial	$1,173.74
Rate for Payer: Cofinity Commercial	$1,442.02
Rate for Payer: Healthscope Commercial	$1,509.09
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,425.25
Rate for Payer: PHP Commercial	$1,425.25
Rate for Payer: Priority Health Cigna Priority Health	$1,173.74
Rate for Payer: Priority Health SBD	$1,056.37

TETRACAINE HCL (PF) 0.5 % EYE DROPS

Facility

$36.43

Service Code	NDC 0065-0741-14
Hospital Charge Code	151946
Hospital Revenue Code	637
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$32.79
Rate for Payer: Aetna Commercial	$30.97
Rate for Payer: Aetna New Business (MI Preferred)	$23.68
Rate for Payer: Cash Price	$29.14
Rate for Payer: Cofinity Commercial	$25.50
Rate for Payer: Cofinity Commercial	$31.33
Rate for Payer: Healthscope Commercial	$32.79
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.97
Rate for Payer: PHP Commercial	$30.97
Rate for Payer: Priority Health Cigna Priority Health	$25.50
Rate for Payer: Priority Health SBD	$22.95

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

Facility

$250.73

Service Code	NDC 17478-045-32
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: Healthscope Commercial	$225.66
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$213.12
Rate for Payer: PHP Commercial	$213.12
Rate for Payer: Priority Health Cigna Priority Health	$175.51
Rate for Payer: Priority Health SBD	$157.96

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

Facility

$10,502.24

Service Code	HCPCS J2356
Hospital Charge Code	199104
Hospital Revenue Code	636
Min. Negotiated Rate	$6,616.41
Max. Negotiated Rate	$9,452.02
Rate for Payer: Aetna Commercial	$8,926.90
Rate for Payer: Aetna New Business (MI Preferred)	$6,826.46
Rate for Payer: Cash Price	$8,401.79
Rate for Payer: Cofinity Commercial	$7,351.57
Rate for Payer: Cofinity Commercial	$9,031.93
Rate for Payer: Healthscope Commercial	$9,452.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8,926.90
Rate for Payer: PHP Commercial	$8,926.90
Rate for Payer: Priority Health Cigna Priority Health	$7,351.57
Rate for Payer: Priority Health SBD	$6,616.41

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR

Facility

$44.64

Service Code	NDC 0121-4820-40
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: Healthscope Commercial	$40.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$37.94
Rate for Payer: PHP Commercial	$37.94
Rate for Payer: Priority Health Cigna Priority Health	$31.25
Rate for Payer: Priority Health SBD	$28.12

THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR

Facility

$44.64

Service Code	NDC 0121-4820-15
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: Healthscope Commercial	$40.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$37.94
Rate for Payer: PHP Commercial	$37.94
Rate for Payer: Priority Health Cigna Priority Health	$31.25
Rate for Payer: Priority Health SBD	$28.12

THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR

Facility

$882.45

Service Code	NDC 62332-025-31
Hospital Charge Code	12098
Hospital Revenue Code	637
Min. Negotiated Rate	$555.94
Max. Negotiated Rate	$794.20
Rate for Payer: Aetna Commercial	$750.08
Rate for Payer: Aetna New Business (MI Preferred)	$573.59
Rate for Payer: Cash Price	$705.96
Rate for Payer: Cofinity Commercial	$617.72
Rate for Payer: Cofinity Commercial	$758.91
Rate for Payer: Healthscope Commercial	$794.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$750.08
Rate for Payer: PHP Commercial	$750.08
Rate for Payer: Priority Health Cigna Priority Health	$617.72
Rate for Payer: Priority Health SBD	$555.94

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$397.44

Service Code	NDC 68462-380-01
Hospital Charge Code	108325
Hospital Revenue Code	637
Min. Negotiated Rate	$250.39
Max. Negotiated Rate	$357.70
Rate for Payer: Aetna Commercial	$337.82
Rate for Payer: Aetna New Business (MI Preferred)	$258.34
Rate for Payer: Cash Price	$317.95
Rate for Payer: Cofinity Commercial	$278.21
Rate for Payer: Cofinity Commercial	$341.80
Rate for Payer: Healthscope Commercial	$357.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$337.82
Rate for Payer: PHP Commercial	$337.82
Rate for Payer: Priority Health Cigna Priority Health	$278.21
Rate for Payer: Priority Health SBD	$250.39

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$463.68

Service Code	NDC 42858-701-01
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: Healthscope Commercial	$417.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$394.13
Rate for Payer: PHP Commercial	$394.13
Rate for Payer: Priority Health Cigna Priority Health	$324.58
Rate for Payer: Priority Health SBD	$292.12

THERMAGE

Professional

Both

$1,000.00

Service Code	HCPCS 00167
Hospital Revenue Code	960
Min. Negotiated Rate	$400.00
Max. Negotiated Rate	$700.00
Rate for Payer: BCBS Complete	$400.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Priority Health Cigna Priority Health	$700.00

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