|
TERBINAFINE HCL 1 % TOPICAL CREAM
|
Facility
|
IP
|
$30.03
|
|
|
Service Code
|
NDC 00067399842
|
| Hospital Charge Code |
27023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.52 |
| Max. Negotiated Rate |
$27.03 |
| Rate for Payer: Aetna Commercial |
$25.53
|
| Rate for Payer: BCBS Trust/PPO |
$24.51
|
| Rate for Payer: BCN Commercial |
$23.21
|
| Rate for Payer: Cash Price |
$24.02
|
| Rate for Payer: Cofinity Commercial |
$25.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.02
|
| Rate for Payer: Healthscope Commercial |
$27.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.53
|
| Rate for Payer: Nomi Health Commercial |
$24.62
|
| Rate for Payer: PHP Commercial |
$25.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.52
|
| Rate for Payer: Priority Health HMO/PPO |
$26.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.43
|
| Rate for Payer: UHC Core |
$25.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.52
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM
|
Facility
|
OP
|
$23.90
|
|
|
Service Code
|
NDC 51672208001
|
| Hospital Charge Code |
27023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.68 |
| Max. Negotiated Rate |
$21.51 |
| Rate for Payer: Aetna Commercial |
$20.32
|
| Rate for Payer: Aetna Medicare |
$6.21
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.47
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.47
|
| Rate for Payer: BCBS Complete |
$9.56
|
| Rate for Payer: BCBS MAPPO |
$5.98
|
| Rate for Payer: BCBS Trust/PPO |
$19.65
|
| Rate for Payer: BCN Commercial |
$18.58
|
| Rate for Payer: BCN Medicare Advantage |
$5.98
|
| Rate for Payer: Cash Price |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$20.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.98
|
| Rate for Payer: Healthscope Commercial |
$21.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.32
|
| Rate for Payer: Nomi Health Commercial |
$19.60
|
| Rate for Payer: PACE Senior Care Partners |
$5.68
|
| Rate for Payer: PACE SWMI |
$5.98
|
| Rate for Payer: PHP Commercial |
$20.32
|
| Rate for Payer: PHP Medicare Advantage |
$5.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.54
|
| Rate for Payer: Priority Health HMO/PPO |
$20.79
|
| Rate for Payer: Priority Health Medicare |
$6.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.01
|
| Rate for Payer: Railroad Medicare Medicare |
$5.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.03
|
| Rate for Payer: UHC Core |
$19.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.98
|
| Rate for Payer: UHC Exchange |
$5.98
|
| Rate for Payer: UHC Medicare Advantage |
$5.98
|
| Rate for Payer: VA VA |
$5.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.92
|
|
|
TERBINAFINE HCL 1 % TOPICAL CREAM
|
Facility
|
OP
|
$30.03
|
|
|
Service Code
|
NDC 00067399842
|
| Hospital Charge Code |
27023
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.13 |
| Max. Negotiated Rate |
$27.03 |
| Rate for Payer: Aetna Commercial |
$25.53
|
| Rate for Payer: Aetna Medicare |
$7.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.38
|
| Rate for Payer: BCBS Complete |
$12.01
|
| Rate for Payer: BCBS MAPPO |
$7.51
|
| Rate for Payer: BCBS Trust/PPO |
$24.69
|
| Rate for Payer: BCN Commercial |
$23.35
|
| Rate for Payer: BCN Medicare Advantage |
$7.51
|
| Rate for Payer: Cash Price |
$24.02
|
| Rate for Payer: Cofinity Commercial |
$25.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.51
|
| Rate for Payer: Healthscope Commercial |
$27.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.53
|
| Rate for Payer: Nomi Health Commercial |
$24.62
|
| Rate for Payer: PACE Senior Care Partners |
$7.13
|
| Rate for Payer: PACE SWMI |
$7.51
|
| Rate for Payer: PHP Commercial |
$25.53
|
| Rate for Payer: PHP Medicare Advantage |
$7.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.52
|
| Rate for Payer: Priority Health HMO/PPO |
$26.13
|
| Rate for Payer: Priority Health Medicare |
$7.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.12
|
| Rate for Payer: Railroad Medicare Medicare |
$7.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.43
|
| Rate for Payer: UHC Core |
$25.08
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.51
|
| Rate for Payer: UHC Exchange |
$7.51
|
| Rate for Payer: UHC Medicare Advantage |
$7.51
|
| Rate for Payer: VA VA |
$7.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.52
|
|
|
TERCONAZOLE 0.4 % VAGINAL CREAM
|
Facility
|
OP
|
$74.34
|
|
|
Service Code
|
NDC 51672130406
|
| Hospital Charge Code |
11510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.66 |
| Max. Negotiated Rate |
$66.91 |
| Rate for Payer: Aetna Commercial |
$63.19
|
| Rate for Payer: Aetna Medicare |
$19.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.23
|
| Rate for Payer: BCBS Complete |
$29.74
|
| Rate for Payer: BCBS MAPPO |
$18.58
|
| Rate for Payer: BCBS Trust/PPO |
$61.11
|
| Rate for Payer: BCN Commercial |
$57.80
|
| Rate for Payer: BCN Medicare Advantage |
$18.58
|
| Rate for Payer: Cash Price |
$59.47
|
| Rate for Payer: Cofinity Commercial |
$63.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.58
|
| Rate for Payer: Healthscope Commercial |
$66.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.76
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.19
|
| Rate for Payer: Nomi Health Commercial |
$60.96
|
| Rate for Payer: PACE Senior Care Partners |
$17.66
|
| Rate for Payer: PACE SWMI |
$18.58
|
| Rate for Payer: PHP Commercial |
$63.19
|
| Rate for Payer: PHP Medicare Advantage |
$18.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.32
|
| Rate for Payer: Priority Health HMO/PPO |
$64.68
|
| Rate for Payer: Priority Health Medicare |
$18.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$49.81
|
| Rate for Payer: Railroad Medicare Medicare |
$18.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.42
|
| Rate for Payer: UHC Core |
$62.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.58
|
| Rate for Payer: UHC Exchange |
$18.58
|
| Rate for Payer: UHC Medicare Advantage |
$18.58
|
| Rate for Payer: VA VA |
$18.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.76
|
|
|
TERCONAZOLE 0.4 % VAGINAL CREAM
|
Facility
|
IP
|
$74.34
|
|
|
Service Code
|
NDC 51672130406
|
| Hospital Charge Code |
11510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.32 |
| Max. Negotiated Rate |
$66.91 |
| Rate for Payer: Aetna Commercial |
$63.19
|
| Rate for Payer: BCBS Trust/PPO |
$60.68
|
| Rate for Payer: BCN Commercial |
$57.45
|
| Rate for Payer: Cash Price |
$59.47
|
| Rate for Payer: Cofinity Commercial |
$63.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.47
|
| Rate for Payer: Healthscope Commercial |
$66.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.19
|
| Rate for Payer: Nomi Health Commercial |
$60.96
|
| Rate for Payer: PHP Commercial |
$63.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.32
|
| Rate for Payer: Priority Health HMO/PPO |
$64.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$49.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.42
|
| Rate for Payer: UHC Core |
$62.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.76
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$110.40
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.76 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$93.84
|
| Rate for Payer: Aetna Commercial |
$83.00
|
| Rate for Payer: BCBS Trust/PPO |
$90.12
|
| Rate for Payer: BCBS Trust/PPO |
$79.71
|
| Rate for Payer: BCN Commercial |
$85.32
|
| Rate for Payer: BCN Commercial |
$75.46
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cofinity Commercial |
$83.98
|
| Rate for Payer: Cofinity Commercial |
$94.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.32
|
| Rate for Payer: Healthscope Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$87.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: Nomi Health Commercial |
$90.53
|
| Rate for Payer: Nomi Health Commercial |
$80.07
|
| Rate for Payer: PHP Commercial |
$93.84
|
| Rate for Payer: PHP Commercial |
$83.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.76
|
| Rate for Payer: Priority Health HMO/PPO |
$84.96
|
| Rate for Payer: Priority Health HMO/PPO |
$96.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$73.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$65.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$85.93
|
| Rate for Payer: UHC Core |
$92.18
|
| Rate for Payer: UHC Core |
$81.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.24
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
OP
|
$97.65
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$87.88 |
| Rate for Payer: Aetna Commercial |
$83.00
|
| Rate for Payer: Aetna Commercial |
$93.84
|
| Rate for Payer: Aetna Medicare |
$25.39
|
| Rate for Payer: Aetna Medicare |
$28.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$34.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$30.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$30.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$34.50
|
| Rate for Payer: BCBS Complete |
$44.16
|
| Rate for Payer: BCBS Complete |
$39.06
|
| Rate for Payer: BCBS MAPPO |
$27.60
|
| Rate for Payer: BCBS MAPPO |
$24.41
|
| Rate for Payer: BCBS Trust/PPO |
$80.28
|
| Rate for Payer: BCBS Trust/PPO |
$90.76
|
| Rate for Payer: BCN Commercial |
$75.92
|
| Rate for Payer: BCN Commercial |
$85.84
|
| Rate for Payer: BCN Medicare Advantage |
$24.41
|
| Rate for Payer: BCN Medicare Advantage |
$27.60
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cofinity Commercial |
$94.94
|
| Rate for Payer: Cofinity Commercial |
$83.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$24.41
|
| Rate for Payer: Healthscope Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$87.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.98
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$25.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.84
|
| Rate for Payer: Nomi Health Commercial |
$80.07
|
| Rate for Payer: Nomi Health Commercial |
$90.53
|
| Rate for Payer: PACE Senior Care Partners |
$23.19
|
| Rate for Payer: PACE Senior Care Partners |
$26.22
|
| Rate for Payer: PACE SWMI |
$24.41
|
| Rate for Payer: PACE SWMI |
$27.60
|
| Rate for Payer: PHP Commercial |
$83.00
|
| Rate for Payer: PHP Commercial |
$93.84
|
| Rate for Payer: PHP Medicare Advantage |
$27.60
|
| Rate for Payer: PHP Medicare Advantage |
$24.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.76
|
| Rate for Payer: Priority Health HMO/PPO |
$96.05
|
| Rate for Payer: Priority Health HMO/PPO |
$84.96
|
| Rate for Payer: Priority Health Medicare |
$24.66
|
| Rate for Payer: Priority Health Medicare |
$27.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$65.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$73.97
|
| Rate for Payer: Railroad Medicare Medicare |
$27.60
|
| Rate for Payer: Railroad Medicare Medicare |
$24.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$85.93
|
| Rate for Payer: UHC Core |
$81.54
|
| Rate for Payer: UHC Core |
$92.18
|
| Rate for Payer: UHC Dual Complete DSNP |
$24.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$27.60
|
| Rate for Payer: UHC Exchange |
$27.60
|
| Rate for Payer: UHC Exchange |
$24.41
|
| Rate for Payer: UHC Medicare Advantage |
$27.60
|
| Rate for Payer: UHC Medicare Advantage |
$24.41
|
| Rate for Payer: VA VA |
$27.60
|
| Rate for Payer: VA VA |
$24.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.80
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$1,678.15
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,090.80 |
| Max. Negotiated Rate |
$1,510.34 |
| Rate for Payer: Aetna Commercial |
$1,426.43
|
| Rate for Payer: BCBS Trust/PPO |
$1,369.87
|
| Rate for Payer: BCN Commercial |
$1,296.87
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cofinity Commercial |
$1,443.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,342.52
|
| Rate for Payer: Healthscope Commercial |
$1,510.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,258.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,426.43
|
| Rate for Payer: Nomi Health Commercial |
$1,376.08
|
| Rate for Payer: PHP Commercial |
$1,426.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,090.80
|
| Rate for Payer: Priority Health HMO/PPO |
$1,459.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,124.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,476.77
|
| Rate for Payer: UHC Core |
$1,401.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,258.61
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$1,678.15
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$398.56 |
| Max. Negotiated Rate |
$1,510.34 |
| Rate for Payer: Aetna Commercial |
$1,426.43
|
| Rate for Payer: Aetna Medicare |
$436.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$524.42
|
| Rate for Payer: Amish Plain Church Group Commercial |
$524.42
|
| Rate for Payer: BCBS Complete |
$434.32
|
| Rate for Payer: BCBS MAPPO |
$419.54
|
| Rate for Payer: BCBS Trust/PPO |
$1,379.61
|
| Rate for Payer: BCN Commercial |
$1,304.76
|
| Rate for Payer: BCN Medicare Advantage |
$419.54
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cofinity Commercial |
$1,443.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,342.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$419.54
|
| Rate for Payer: Healthscope Commercial |
$1,510.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,258.61
|
| Rate for Payer: Mclaren Medicaid |
$413.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$440.51
|
| Rate for Payer: Meridian Medicaid |
$434.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$482.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,426.43
|
| Rate for Payer: Nomi Health Commercial |
$1,376.08
|
| Rate for Payer: PACE Senior Care Partners |
$398.56
|
| Rate for Payer: PACE SWMI |
$419.54
|
| Rate for Payer: PHP Commercial |
$1,426.43
|
| Rate for Payer: PHP Medicare Advantage |
$419.54
|
| Rate for Payer: Priority Health Choice Medicaid |
$413.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,090.80
|
| Rate for Payer: Priority Health HMO/PPO |
$1,459.99
|
| Rate for Payer: Priority Health Medicare |
$423.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,124.36
|
| Rate for Payer: Railroad Medicare Medicare |
$419.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,476.77
|
| Rate for Payer: UHC Core |
$1,401.26
|
| Rate for Payer: UHC Dual Complete DSNP |
$419.54
|
| Rate for Payer: UHC Exchange |
$419.54
|
| Rate for Payer: UHC Medicare Advantage |
$419.54
|
| Rate for Payer: UHCCP Medicaid |
$413.61
|
| Rate for Payer: VA VA |
$419.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,258.61
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
OP
|
$38.25
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$34.42 |
| Rate for Payer: Aetna Commercial |
$32.51
|
| Rate for Payer: Aetna Medicare |
$9.94
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.95
|
| Rate for Payer: BCBS Complete |
$15.30
|
| Rate for Payer: BCBS MAPPO |
$9.56
|
| Rate for Payer: BCBS Trust/PPO |
$31.45
|
| Rate for Payer: BCN Commercial |
$29.74
|
| Rate for Payer: BCN Medicare Advantage |
$9.56
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cofinity Commercial |
$32.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.56
|
| Rate for Payer: Healthscope Commercial |
$34.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.69
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.51
|
| Rate for Payer: Nomi Health Commercial |
$31.36
|
| Rate for Payer: PACE Senior Care Partners |
$9.08
|
| Rate for Payer: PACE SWMI |
$9.56
|
| Rate for Payer: PHP Commercial |
$32.51
|
| Rate for Payer: PHP Medicare Advantage |
$9.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.86
|
| Rate for Payer: Priority Health HMO/PPO |
$33.28
|
| Rate for Payer: Priority Health Medicare |
$9.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.63
|
| Rate for Payer: Railroad Medicare Medicare |
$9.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.66
|
| Rate for Payer: UHC Core |
$31.94
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.56
|
| Rate for Payer: UHC Exchange |
$9.56
|
| Rate for Payer: UHC Medicare Advantage |
$9.56
|
| Rate for Payer: VA VA |
$9.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.69
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
IP
|
$38.25
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.86 |
| Max. Negotiated Rate |
$34.42 |
| Rate for Payer: Aetna Commercial |
$32.51
|
| Rate for Payer: BCBS Trust/PPO |
$31.22
|
| Rate for Payer: BCN Commercial |
$29.56
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cofinity Commercial |
$32.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.60
|
| Rate for Payer: Healthscope Commercial |
$34.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.51
|
| Rate for Payer: Nomi Health Commercial |
$31.36
|
| Rate for Payer: PHP Commercial |
$32.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.86
|
| Rate for Payer: Priority Health HMO/PPO |
$33.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.66
|
| Rate for Payer: UHC Core |
$31.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.69
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$578.88
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$376.27 |
| Max. Negotiated Rate |
$520.99 |
| Rate for Payer: Aetna Commercial |
$492.05
|
| Rate for Payer: BCBS Trust/PPO |
$472.54
|
| Rate for Payer: BCN Commercial |
$447.36
|
| Rate for Payer: Cash Price |
$463.10
|
| Rate for Payer: Cofinity Commercial |
$497.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$463.10
|
| Rate for Payer: Healthscope Commercial |
$520.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$434.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$492.05
|
| Rate for Payer: Nomi Health Commercial |
$474.68
|
| Rate for Payer: PHP Commercial |
$492.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$376.27
|
| Rate for Payer: Priority Health HMO/PPO |
$503.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$387.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$509.41
|
| Rate for Payer: UHC Core |
$483.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$434.16
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
OP
|
$578.88
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.48 |
| Max. Negotiated Rate |
$520.99 |
| Rate for Payer: Aetna Commercial |
$492.05
|
| Rate for Payer: Aetna Medicare |
$150.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$180.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$180.90
|
| Rate for Payer: BCBS Complete |
$231.55
|
| Rate for Payer: BCBS MAPPO |
$144.72
|
| Rate for Payer: BCBS Trust/PPO |
$475.90
|
| Rate for Payer: BCN Commercial |
$450.08
|
| Rate for Payer: BCN Medicare Advantage |
$144.72
|
| Rate for Payer: Cash Price |
$463.10
|
| Rate for Payer: Cofinity Commercial |
$497.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$463.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$144.72
|
| Rate for Payer: Healthscope Commercial |
$520.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$434.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$151.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$166.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$492.05
|
| Rate for Payer: Nomi Health Commercial |
$474.68
|
| Rate for Payer: PACE Senior Care Partners |
$137.48
|
| Rate for Payer: PACE SWMI |
$144.72
|
| Rate for Payer: PHP Commercial |
$492.05
|
| Rate for Payer: PHP Medicare Advantage |
$144.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$376.27
|
| Rate for Payer: Priority Health HMO/PPO |
$503.63
|
| Rate for Payer: Priority Health Medicare |
$146.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$387.85
|
| Rate for Payer: Railroad Medicare Medicare |
$144.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$509.41
|
| Rate for Payer: UHC Core |
$483.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$144.72
|
| Rate for Payer: UHC Exchange |
$144.72
|
| Rate for Payer: UHC Medicare Advantage |
$144.72
|
| Rate for Payer: VA VA |
$144.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$434.16
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
NDC 00904053961
|
| Hospital Charge Code |
7857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.15 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna Commercial |
$125.80
|
| Rate for Payer: Aetna Medicare |
$38.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.25
|
| Rate for Payer: BCBS Complete |
$59.20
|
| Rate for Payer: BCBS MAPPO |
$37.00
|
| Rate for Payer: BCBS Trust/PPO |
$121.67
|
| Rate for Payer: BCN Commercial |
$115.07
|
| Rate for Payer: BCN Medicare Advantage |
$37.00
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cofinity Commercial |
$127.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.00
|
| Rate for Payer: Healthscope Commercial |
$133.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$38.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.80
|
| Rate for Payer: Nomi Health Commercial |
$121.36
|
| Rate for Payer: PACE Senior Care Partners |
$35.15
|
| Rate for Payer: PACE SWMI |
$37.00
|
| Rate for Payer: PHP Commercial |
$125.80
|
| Rate for Payer: PHP Medicare Advantage |
$37.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.20
|
| Rate for Payer: Priority Health HMO/PPO |
$128.76
|
| Rate for Payer: Priority Health Medicare |
$37.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.16
|
| Rate for Payer: Railroad Medicare Medicare |
$37.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.24
|
| Rate for Payer: UHC Core |
$123.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$37.00
|
| Rate for Payer: UHC Exchange |
$37.00
|
| Rate for Payer: UHC Medicare Advantage |
$37.00
|
| Rate for Payer: VA VA |
$37.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.00
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
NDC 00904053961
|
| Hospital Charge Code |
7857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.20 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna Commercial |
$125.80
|
| Rate for Payer: BCBS Trust/PPO |
$120.81
|
| Rate for Payer: BCN Commercial |
$114.37
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cofinity Commercial |
$127.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.40
|
| Rate for Payer: Healthscope Commercial |
$133.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.80
|
| Rate for Payer: Nomi Health Commercial |
$121.36
|
| Rate for Payer: PHP Commercial |
$125.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.20
|
| Rate for Payer: Priority Health HMO/PPO |
$128.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.24
|
| Rate for Payer: UHC Core |
$123.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.00
|
|
|
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: 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: 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: 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: 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: 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: 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: 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: 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: 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: Priority Health Cigna Priority Health |
$2,320.50
|
|
