|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
OP
|
$405.50
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$364.95 |
| Rate for Payer: Aetna American Axle |
$263.58
|
| Rate for Payer: Aetna American Axle |
$22.33
|
| Rate for Payer: Aetna American Axle |
$57.23
|
| Rate for Payer: Aetna American Axle |
$42.32
|
| Rate for Payer: Aetna American Axle |
$379.50
|
| Rate for Payer: Aetna Commercial |
$29.20
|
| Rate for Payer: Aetna Commercial |
$55.34
|
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: Aetna Commercial |
$344.68
|
| Rate for Payer: Aetna Commercial |
$496.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$379.50
|
| Rate for Payer: BCBS Complete |
$162.20
|
| Rate for Payer: BCBS Complete |
$26.04
|
| Rate for Payer: BCBS Complete |
$13.74
|
| Rate for Payer: BCBS Complete |
$233.54
|
| Rate for Payer: BCBS Complete |
$35.22
|
| Rate for Payer: BCBS Trust/PPO |
$0.06
|
| Rate for Payer: BCBS Trust/PPO |
$0.06
|
| Rate for Payer: BCBS Trust/PPO |
$0.06
|
| Rate for Payer: BCBS Trust/PPO |
$0.06
|
| Rate for Payer: BCBS Trust/PPO |
$0.06
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cash Price |
$324.40
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cash Price |
$467.08
|
| Rate for Payer: Cash Price |
$324.40
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cash Price |
$467.08
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cofinity Commercial |
$45.57
|
| Rate for Payer: Cofinity Commercial |
$283.85
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Cofinity Commercial |
$61.64
|
| Rate for Payer: Cofinity Commercial |
$24.04
|
| Rate for Payer: Cofinity Commercial |
$29.54
|
| Rate for Payer: Cofinity Commercial |
$55.99
|
| Rate for Payer: Cofinity Commercial |
$408.70
|
| Rate for Payer: Cofinity Commercial |
$502.11
|
| Rate for Payer: Cofinity Commercial |
$348.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$467.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$324.40
|
| Rate for Payer: Healthscope Commercial |
$58.59
|
| Rate for Payer: Healthscope Commercial |
$364.95
|
| Rate for Payer: Healthscope Commercial |
$525.46
|
| Rate for Payer: Healthscope Commercial |
$30.92
|
| Rate for Payer: Healthscope Commercial |
$79.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$408.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$283.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$437.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$496.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$344.68
|
| 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 |
$55.34
|
| Rate for Payer: PHP Commercial |
$74.84
|
| Rate for Payer: PHP Commercial |
$496.27
|
| Rate for Payer: PHP Commercial |
$344.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$283.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$408.70
|
| Rate for Payer: Priority Health SBD |
$367.83
|
| Rate for Payer: Priority Health SBD |
$21.64
|
| Rate for Payer: Priority Health SBD |
$255.46
|
| Rate for Payer: Priority Health SBD |
$41.01
|
| Rate for Payer: Priority Health SBD |
$55.47
|
| Rate for Payer: UMR Bronson Commercial |
$216.02
|
| Rate for Payer: UMR Bronson Commercial |
$24.09
|
| Rate for Payer: UMR Bronson Commercial |
$12.71
|
| Rate for Payer: UMR Bronson Commercial |
$150.04
|
| Rate for Payer: UMR Bronson Commercial |
$32.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$437.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.04
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$34.35
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.11 |
| Max. Negotiated Rate |
$30.92 |
| Rate for Payer: Aetna American Axle |
$22.33
|
| Rate for Payer: Aetna Commercial |
$29.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.33
|
| Rate for Payer: Cash Price |
$27.48
|
| Rate for Payer: Cofinity Commercial |
$24.04
|
| Rate for Payer: Cofinity Commercial |
$29.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.48
|
| Rate for Payer: Healthscope Commercial |
$30.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.76
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$15.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.76
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$1,676.77
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$737.78 |
| Max. Negotiated Rate |
$1,509.09 |
| Rate for Payer: Aetna American Axle |
$1,089.90
|
| 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: Encore Health Key Benefits Commercial |
$1,341.42
|
| Rate for Payer: Healthscope Commercial |
$1,509.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,173.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,257.58
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$737.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,257.58
|
|
|
TETRACAINE 0.5 % EYE DROPS
|
Facility
|
IP
|
$97.62
|
|
|
Service Code
|
NDC 68682-920-05
|
| Hospital Charge Code |
7795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.95 |
| Max. Negotiated Rate |
$87.86 |
| Rate for Payer: Aetna American Axle |
$63.45
|
| Rate for Payer: Aetna Commercial |
$82.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.45
|
| Rate for Payer: Cash Price |
$78.10
|
| Rate for Payer: Cofinity Commercial |
$68.33
|
| Rate for Payer: Cofinity Commercial |
$83.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.10
|
| Rate for Payer: Healthscope Commercial |
$87.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.98
|
| Rate for Payer: PHP Commercial |
$82.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.33
|
| Rate for Payer: Priority Health SBD |
$61.50
|
| Rate for Payer: UMR Bronson Commercial |
$42.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.22
|
|
|
TETRACAINE HCL (BULK) POWDER
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 51552-0269-9
|
| Hospital Charge Code |
13583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Aetna American Axle |
$18.20
|
| Rate for Payer: Aetna Commercial |
$23.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.20
|
| Rate for Payer: Cash Price |
$22.40
|
| Rate for Payer: Cofinity Commercial |
$19.60
|
| Rate for Payer: Cofinity Commercial |
$24.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.40
|
| Rate for Payer: Healthscope Commercial |
$25.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.80
|
| Rate for Payer: PHP Commercial |
$23.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.60
|
| Rate for Payer: Priority Health SBD |
$17.64
|
| Rate for Payer: UMR Bronson Commercial |
$12.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.00
|
|
|
TETRACAINE HCL (BULK) POWDER
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
NDC 62991-2067-2
|
| Hospital Charge Code |
13583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.24 |
| Max. Negotiated Rate |
$356.40 |
| Rate for Payer: Aetna American Axle |
$257.40
|
| Rate for Payer: Aetna Commercial |
$336.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.40
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Cofinity Commercial |
$277.20
|
| Rate for Payer: Cofinity Commercial |
$340.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.80
|
| Rate for Payer: Healthscope Commercial |
$356.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$336.60
|
| Rate for Payer: PHP Commercial |
$336.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$277.20
|
| Rate for Payer: Priority Health SBD |
$249.48
|
| Rate for Payer: UMR Bronson Commercial |
$174.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.00
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
IP
|
$36.43
|
|
|
Service Code
|
NDC 0065-0741-14
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.03 |
| Max. Negotiated Rate |
$32.79 |
| Rate for Payer: Aetna American Axle |
$23.68
|
| 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: Encore Health Key Benefits Commercial |
$29.14
|
| Rate for Payer: Healthscope Commercial |
$32.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.32
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$16.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.32
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$250.73
|
|
|
Service Code
|
NDC 17478-045-32
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.32 |
| Max. Negotiated Rate |
$225.66 |
| Rate for Payer: Aetna American Axle |
$162.97
|
| 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: Encore Health Key Benefits Commercial |
$200.58
|
| Rate for Payer: Healthscope Commercial |
$225.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.05
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$110.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.05
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$155.20
|
|
|
Service Code
|
NDC 54288-127-01
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Aetna American Axle |
$100.88
|
| Rate for Payer: Aetna Commercial |
$131.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.88
|
| Rate for Payer: Cash Price |
$124.16
|
| Rate for Payer: Cofinity Commercial |
$108.64
|
| Rate for Payer: Cofinity Commercial |
$133.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.16
|
| Rate for Payer: Healthscope Commercial |
$139.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$131.92
|
| Rate for Payer: PHP Commercial |
$131.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.64
|
| Rate for Payer: Priority Health SBD |
$97.78
|
| Rate for Payer: UMR Bronson Commercial |
$68.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.40
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$155.20
|
|
|
Service Code
|
NDC 54288-127-10
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Aetna American Axle |
$100.88
|
| Rate for Payer: Aetna Commercial |
$131.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.88
|
| Rate for Payer: Cash Price |
$124.16
|
| Rate for Payer: Cofinity Commercial |
$108.64
|
| Rate for Payer: Cofinity Commercial |
$133.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.16
|
| Rate for Payer: Healthscope Commercial |
$139.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$131.92
|
| Rate for Payer: PHP Commercial |
$131.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.64
|
| Rate for Payer: Priority Health SBD |
$97.78
|
| Rate for Payer: UMR Bronson Commercial |
$68.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.40
|
|
|
TETRACYCLINE HCL (BULK) POWDER
|
Facility
|
IP
|
$567.00
|
|
|
Service Code
|
NDC 38779-0053-5
|
| Hospital Charge Code |
7799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$249.48 |
| Max. Negotiated Rate |
$510.30 |
| Rate for Payer: Aetna American Axle |
$368.55
|
| Rate for Payer: Aetna Commercial |
$481.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$368.55
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cofinity Commercial |
$396.90
|
| Rate for Payer: Cofinity Commercial |
$487.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$453.60
|
| Rate for Payer: Healthscope Commercial |
$510.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$396.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$425.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$481.95
|
| Rate for Payer: PHP Commercial |
$481.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$396.90
|
| Rate for Payer: Priority Health SBD |
$357.21
|
| Rate for Payer: UMR Bronson Commercial |
$249.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$425.25
|
|
|
TETRACYCLINE HCL (BULK) POWDER
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
NDC 51552-0463-5
|
| Hospital Charge Code |
7799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.72 |
| Max. Negotiated Rate |
$394.20 |
| Rate for Payer: Aetna American Axle |
$284.70
|
| Rate for Payer: Aetna Commercial |
$372.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.70
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cofinity Commercial |
$306.60
|
| Rate for Payer: Cofinity Commercial |
$376.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$350.40
|
| Rate for Payer: Healthscope Commercial |
$394.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$306.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$328.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$372.30
|
| Rate for Payer: PHP Commercial |
$372.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$306.60
|
| Rate for Payer: Priority Health SBD |
$275.94
|
| Rate for Payer: UMR Bronson Commercial |
$192.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$328.50
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$10,502.24
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
199104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.17 |
| Max. Negotiated Rate |
$9,452.02 |
| Rate for Payer: Aetna American Axle |
$6,826.46
|
| Rate for Payer: Aetna Commercial |
$8,926.90
|
| Rate for Payer: Aetna Medicare |
$19.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,826.46
|
| 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 |
$10.68
|
| Rate for Payer: BCBS MAPPO |
$18.59
|
| Rate for Payer: BCBS Trust/PPO |
$60.04
|
| Rate for Payer: BCN Medicare Advantage |
$18.59
|
| Rate for Payer: Cash Price |
$8,401.79
|
| 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: Encore Health Key Benefits Commercial |
$8,401.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.59
|
| Rate for Payer: Healthscope Commercial |
$9,452.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,351.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,876.68
|
| Rate for Payer: Mclaren Medicaid |
$10.17
|
| Rate for Payer: Mclaren Medicare |
$18.59
|
| Rate for Payer: Meridian Medicaid |
$10.68
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$19.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8,926.90
|
| Rate for Payer: PACE Medicare |
$17.66
|
| Rate for Payer: PACE SWMI |
$18.59
|
| Rate for Payer: PHP Commercial |
$8,926.90
|
| Rate for Payer: PHP Medicare Advantage |
$18.59
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,351.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$54.56
|
| Rate for Payer: Priority Health Medicare |
$18.59
|
| Rate for Payer: Priority Health Narrow Network |
$43.65
|
| Rate for Payer: Priority Health SBD |
$6,616.41
|
| Rate for Payer: Railroad Medicare Medicare |
$18.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.59
|
| Rate for Payer: UHC Medicare Advantage |
$19.14
|
| Rate for Payer: UMR Bronson Commercial |
$3,885.83
|
| Rate for Payer: VA VA |
$18.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,876.68
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$10,502.24
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
199104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,620.99 |
| Max. Negotiated Rate |
$9,452.02 |
| Rate for Payer: Aetna American Axle |
$6,826.46
|
| 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: Encore Health Key Benefits Commercial |
$8,401.79
|
| Rate for Payer: Healthscope Commercial |
$9,452.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,351.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,876.68
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$4,620.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,876.68
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$934.08
|
|
|
Service Code
|
NDC 50474-200-01
|
| Hospital Charge Code |
27419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$411.00 |
| Max. Negotiated Rate |
$840.67 |
| Rate for Payer: Aetna American Axle |
$607.15
|
| Rate for Payer: Aetna Commercial |
$793.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$607.15
|
| Rate for Payer: Cash Price |
$747.26
|
| Rate for Payer: Cofinity Commercial |
$803.31
|
| Rate for Payer: Cofinity Commercial |
$653.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$747.26
|
| Rate for Payer: Healthscope Commercial |
$840.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$653.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$700.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$793.97
|
| Rate for Payer: PHP Commercial |
$793.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$653.86
|
| Rate for Payer: Priority Health SBD |
$588.47
|
| Rate for Payer: UMR Bronson Commercial |
$411.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$700.56
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,800.42
|
|
|
Service Code
|
NDC 52244-200-10
|
| Hospital Charge Code |
27419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$792.18 |
| Max. Negotiated Rate |
$1,620.38 |
| Rate for Payer: Aetna American Axle |
$1,170.27
|
| Rate for Payer: Aetna Commercial |
$1,530.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,170.27
|
| Rate for Payer: Cash Price |
$1,440.34
|
| Rate for Payer: Cofinity Commercial |
$1,260.29
|
| Rate for Payer: Cofinity Commercial |
$1,548.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,440.34
|
| Rate for Payer: Healthscope Commercial |
$1,620.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,260.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,350.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,530.36
|
| Rate for Payer: PHP Commercial |
$1,530.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,260.29
|
| Rate for Payer: Priority Health SBD |
$1,134.26
|
| Rate for Payer: UMR Bronson Commercial |
$792.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,350.32
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$882.45
|
|
|
Service Code
|
NDC 62332-025-31
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$388.28 |
| Max. Negotiated Rate |
$794.20 |
| Rate for Payer: Aetna American Axle |
$573.59
|
| 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: Encore Health Key Benefits Commercial |
$705.96
|
| Rate for Payer: Healthscope Commercial |
$794.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$617.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$661.84
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$388.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$661.84
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$1,182.52
|
|
|
Service Code
|
NDC 68462-721-01
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$520.31 |
| Max. Negotiated Rate |
$1,064.27 |
| Rate for Payer: Aetna American Axle |
$768.64
|
| Rate for Payer: Aetna Commercial |
$1,005.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.64
|
| Rate for Payer: Cash Price |
$946.02
|
| Rate for Payer: Cofinity Commercial |
$1,016.97
|
| Rate for Payer: Cofinity Commercial |
$827.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$946.02
|
| Rate for Payer: Healthscope Commercial |
$1,064.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$827.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$886.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,005.14
|
| Rate for Payer: PHP Commercial |
$1,005.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$827.76
|
| Rate for Payer: Priority Health SBD |
$744.99
|
| Rate for Payer: UMR Bronson Commercial |
$520.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$886.89
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$463.68
|
|
|
Service Code
|
NDC 42858-701-01
|
| Hospital Charge Code |
108325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.02 |
| Max. Negotiated Rate |
$417.31 |
| Rate for Payer: Aetna American Axle |
$301.39
|
| 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: Encore Health Key Benefits Commercial |
$370.94
|
| Rate for Payer: Healthscope Commercial |
$417.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$324.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$347.76
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$204.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$347.76
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$397.44
|
|
|
Service Code
|
NDC 68462-380-01
|
| Hospital Charge Code |
108325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.87 |
| Max. Negotiated Rate |
$357.70 |
| Rate for Payer: Aetna American Axle |
$258.34
|
| 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: Encore Health Key Benefits Commercial |
$317.95
|
| Rate for Payer: Healthscope Commercial |
$357.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$278.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$298.08
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$174.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$298.08
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$545.28
|
|
|
Service Code
|
NDC 29033-001-01
|
| Hospital Charge Code |
108325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$239.92 |
| Max. Negotiated Rate |
$490.75 |
| Rate for Payer: Aetna American Axle |
$354.43
|
| Rate for Payer: Aetna Commercial |
$463.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$354.43
|
| Rate for Payer: Cash Price |
$436.22
|
| Rate for Payer: Cofinity Commercial |
$381.70
|
| Rate for Payer: Cofinity Commercial |
$468.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$436.22
|
| Rate for Payer: Healthscope Commercial |
$490.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$381.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$408.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$463.49
|
| Rate for Payer: PHP Commercial |
$463.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$381.70
|
| Rate for Payer: Priority Health SBD |
$343.53
|
| Rate for Payer: UMR Bronson Commercial |
$239.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$408.96
|
|
|
THERAPEUTIC APHERESIS; FOR PLASMA PHERESIS
|
Facility
|
OP
|
$4,293.39
|
|
|
Service Code
|
CPT 36514
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$90.05 |
| Max. Negotiated Rate |
$4,293.39 |
| Rate for Payer: Aetna Medicare |
$1,418.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,704.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,704.79
|
| Rate for Payer: BCBS Complete |
$783.38
|
| Rate for Payer: BCBS MAPPO |
$1,363.83
|
| Rate for Payer: BCBS Trust/PPO |
$1,864.63
|
| Rate for Payer: BCN Medicare Advantage |
$1,363.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,363.83
|
| Rate for Payer: Mclaren Medicaid |
$746.02
|
| Rate for Payer: Mclaren Medicare |
$1,363.83
|
| Rate for Payer: Meridian Medicaid |
$783.38
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$1,432.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,568.40
|
| Rate for Payer: PACE Medicare |
$1,295.64
|
| Rate for Payer: PACE SWMI |
$1,363.83
|
| Rate for Payer: PHP Medicare Advantage |
$1,363.83
|
| Rate for Payer: Priority Health Choice Medicaid |
$746.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,293.39
|
| Rate for Payer: Priority Health Medicare |
$1,363.83
|
| Rate for Payer: Priority Health Narrow Network |
$3,434.71
|
| Rate for Payer: Railroad Medicare Medicare |
$1,363.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$99.06
|
| Rate for Payer: UHC Core |
$2,014.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,363.83
|
| Rate for Payer: UHC Exchange |
$90.05
|
| Rate for Payer: UHC Medicare Advantage |
$1,404.74
|
| Rate for Payer: VA VA |
$1,363.83
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
NDC 904053961
|
| Hospital Charge Code |
7857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Aetna American Axle |
$91.00
|
| Rate for Payer: Aetna Commercial |
$119.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.00
|
| Rate for Payer: Cash Price |
$112.00
|
| Rate for Payer: Cofinity Commercial |
$120.40
|
| Rate for Payer: Cofinity Commercial |
$98.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.00
|
| Rate for Payer: Healthscope Commercial |
$126.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.00
|
| Rate for Payer: PHP Commercial |
$119.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.00
|
| Rate for Payer: Priority Health SBD |
$88.20
|
| Rate for Payer: UMR Bronson Commercial |
$61.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.00
|
|
|
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
|
| Rate for Payer: UMR Bronson Commercial |
$460.00
|
|
|
THERMAGE ABDOMEN - ENTIRE
|
Professional
|
Both
|
$3,100.00
|
|
|
Service Code
|
HCPCS 00150
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,240.00 |
| Max. Negotiated Rate |
$2,170.00 |
| Rate for Payer: BCBS Complete |
$1,240.00
|
| Rate for Payer: Cash Price |
$2,480.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,170.00
|
| Rate for Payer: UMR Bronson Commercial |
$1,426.00
|
|
