|
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 |
$9.95
|
| 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
|
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
|
|
|
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
|
|
|
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
|
|
|
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: Priority Health Cigna Priority Health |
$795.60
|
|
|
THERMAGE NECK
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00141
|
|
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 THIGH - 1 THIGH
|
Professional
|
Both
|
$1,938.00
|
|
|
Service Code
|
HCPCS 00147
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$775.20 |
| Max. Negotiated Rate |
$1,259.70 |
| Rate for Payer: Aetna Medicare |
$969.00
|
| Rate for Payer: BCBS Complete |
$775.20
|
| Rate for Payer: Cash Price |
$1,550.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,259.70
|
|
|
THERMAGE THIGH - BILATERAL
|
Professional
|
Both
|
$3,162.00
|
|
|
Service Code
|
HCPCS 00148
|
|
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
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$28.23
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$25.41 |
| Rate for Payer: Aetna Commercial |
$24.00
|
| Rate for Payer: Aetna Commercial |
$20.43
|
| Rate for Payer: Aetna Medicare |
$7.34
|
| Rate for Payer: Aetna Medicare |
$6.25
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.51
|
| Rate for Payer: BCBS Complete |
$9.62
|
| Rate for Payer: BCBS Complete |
$11.29
|
| Rate for Payer: BCBS MAPPO |
$6.01
|
| Rate for Payer: BCBS MAPPO |
$7.06
|
| Rate for Payer: BCBS Trust/PPO |
$23.21
|
| Rate for Payer: BCBS Trust/PPO |
$19.76
|
| Rate for Payer: BCN Commercial |
$21.95
|
| Rate for Payer: BCN Commercial |
$18.69
|
| Rate for Payer: BCN Medicare Advantage |
$7.06
|
| Rate for Payer: BCN Medicare Advantage |
$6.01
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Cofinity Commercial |
$24.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.06
|
| Rate for Payer: Healthscope Commercial |
$21.64
|
| Rate for Payer: Healthscope Commercial |
$25.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Nomi Health Commercial |
$23.15
|
| Rate for Payer: Nomi Health Commercial |
$19.71
|
| Rate for Payer: PACE Senior Care Partners |
$6.70
|
| Rate for Payer: PACE Senior Care Partners |
$5.71
|
| Rate for Payer: PACE SWMI |
$7.06
|
| Rate for Payer: PACE SWMI |
$6.01
|
| Rate for Payer: PHP Commercial |
$24.00
|
| Rate for Payer: PHP Commercial |
$20.43
|
| Rate for Payer: PHP Medicare Advantage |
$6.01
|
| Rate for Payer: PHP Medicare Advantage |
$7.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.63
|
| Rate for Payer: Priority Health HMO/PPO |
$20.91
|
| Rate for Payer: Priority Health HMO/PPO |
$24.56
|
| Rate for Payer: Priority Health Medicare |
$7.13
|
| Rate for Payer: Priority Health Medicare |
$6.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.11
|
| Rate for Payer: Railroad Medicare Medicare |
$6.01
|
| Rate for Payer: Railroad Medicare Medicare |
$7.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.84
|
| Rate for Payer: UHC Core |
$23.57
|
| Rate for Payer: UHC Core |
$20.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.01
|
| Rate for Payer: UHC Exchange |
$6.01
|
| Rate for Payer: UHC Exchange |
$7.06
|
| Rate for Payer: UHC Medicare Advantage |
$6.01
|
| Rate for Payer: UHC Medicare Advantage |
$7.06
|
| Rate for Payer: VA VA |
$6.01
|
| Rate for Payer: VA VA |
$7.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.03
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$24.04
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$21.64 |
| Rate for Payer: Aetna Commercial |
$20.43
|
| Rate for Payer: Aetna Commercial |
$24.00
|
| Rate for Payer: BCBS Trust/PPO |
$19.62
|
| Rate for Payer: BCBS Trust/PPO |
$23.04
|
| Rate for Payer: BCN Commercial |
$18.58
|
| Rate for Payer: BCN Commercial |
$21.82
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Cofinity Commercial |
$24.28
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.23
|
| Rate for Payer: Healthscope Commercial |
$21.64
|
| Rate for Payer: Healthscope Commercial |
$25.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.00
|
| Rate for Payer: Nomi Health Commercial |
$19.71
|
| Rate for Payer: Nomi Health Commercial |
$23.15
|
| Rate for Payer: PHP Commercial |
$20.43
|
| Rate for Payer: PHP Commercial |
$24.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.63
|
| Rate for Payer: Priority Health HMO/PPO |
$24.56
|
| Rate for Payer: Priority Health HMO/PPO |
$20.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.84
|
| Rate for Payer: UHC Core |
$20.07
|
| Rate for Payer: UHC Core |
$23.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.17
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$387.75
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$252.04 |
| Max. Negotiated Rate |
$348.98 |
| Rate for Payer: Aetna Commercial |
$329.59
|
| Rate for Payer: BCBS Trust/PPO |
$316.52
|
| Rate for Payer: BCN Commercial |
$299.65
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cofinity Commercial |
$333.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.20
|
| Rate for Payer: Healthscope Commercial |
$348.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.59
|
| Rate for Payer: Nomi Health Commercial |
$317.95
|
| Rate for Payer: PHP Commercial |
$329.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.04
|
| Rate for Payer: Priority Health HMO/PPO |
$337.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$259.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$341.22
|
| Rate for Payer: UHC Core |
$323.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.81
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$387.75
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.09 |
| Max. Negotiated Rate |
$348.98 |
| Rate for Payer: Aetna Commercial |
$329.59
|
| Rate for Payer: Aetna Medicare |
$100.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$121.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$121.17
|
| Rate for Payer: BCBS Complete |
$155.10
|
| Rate for Payer: BCBS MAPPO |
$96.94
|
| Rate for Payer: BCBS Trust/PPO |
$318.77
|
| Rate for Payer: BCN Commercial |
$301.48
|
| Rate for Payer: BCN Medicare Advantage |
$96.94
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cofinity Commercial |
$333.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$310.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$96.94
|
| Rate for Payer: Healthscope Commercial |
$348.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$101.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$111.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.59
|
| Rate for Payer: Nomi Health Commercial |
$317.95
|
| Rate for Payer: PACE Senior Care Partners |
$92.09
|
| Rate for Payer: PACE SWMI |
$96.94
|
| Rate for Payer: PHP Commercial |
$329.59
|
| Rate for Payer: PHP Medicare Advantage |
$96.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.04
|
| Rate for Payer: Priority Health HMO/PPO |
$337.34
|
| Rate for Payer: Priority Health Medicare |
$97.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$259.79
|
| Rate for Payer: Railroad Medicare Medicare |
$96.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$341.22
|
| Rate for Payer: UHC Core |
$323.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$96.94
|
| Rate for Payer: UHC Exchange |
$96.94
|
| Rate for Payer: UHC Medicare Advantage |
$96.94
|
| Rate for Payer: VA VA |
$96.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.81
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$3.88
|
|
|
Service Code
|
NDC 77333093425
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: BCBS Trust/PPO |
$3.17
|
| Rate for Payer: BCN Commercial |
$3.00
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.30
|
| Rate for Payer: Nomi Health Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health HMO/PPO |
$3.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.41
|
| Rate for Payer: UHC Core |
$3.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
