|
THERMAGE ABDOMEN - LOWER
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 00149
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$800.00 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: BCBS Complete |
$800.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,400.00
|
| Rate for Payer: UMR Bronson Commercial |
$920.00
|
|
|
THERMAGE ARMS - 1 ARM
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 00145
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: BCBS Complete |
$480.00
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$840.00
|
| Rate for Payer: UMR Bronson Commercial |
$552.00
|
|
|
THERMAGE ARMS - BILATERAL
|
Professional
|
Both
|
$2,100.00
|
|
|
Service Code
|
HCPCS 00146
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$1,470.00 |
| Rate for Payer: BCBS Complete |
$840.00
|
| Rate for Payer: Cash Price |
$1,680.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,470.00
|
| Rate for Payer: UMR Bronson Commercial |
$966.00
|
|
|
THERMAGE EYES
|
Professional
|
Both
|
$950.00
|
|
|
Service Code
|
HCPCS 00140
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$380.00 |
| Max. Negotiated Rate |
$665.00 |
| Rate for Payer: BCBS Complete |
$380.00
|
| Rate for Payer: Cash Price |
$760.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$665.00
|
| Rate for Payer: UMR Bronson Commercial |
$437.00
|
|
|
THERMAGE FACE
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 00139
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$800.00 |
| Max. Negotiated Rate |
$1,400.00 |
| Rate for Payer: BCBS Complete |
$800.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,400.00
|
| Rate for Payer: UMR Bronson Commercial |
$920.00
|
|
|
THERMAGE FACE & EYES
|
Professional
|
Both
|
$2,700.00
|
|
|
Service Code
|
HCPCS 00142
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,080.00 |
| Max. Negotiated Rate |
$1,890.00 |
| Rate for Payer: BCBS Complete |
$1,080.00
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,890.00
|
| Rate for Payer: UMR Bronson Commercial |
$1,242.00
|
|
|
THERMAGE FACE & NECK
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 00143
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$1,960.00 |
| Rate for Payer: BCBS Complete |
$1,120.00
|
| Rate for Payer: Cash Price |
$2,240.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,960.00
|
| Rate for Payer: UMR Bronson Commercial |
$1,288.00
|
|
|
THERMAGE FACE, NECK, & EYES
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 00144
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,400.00 |
| Max. Negotiated Rate |
$2,450.00 |
| Rate for Payer: BCBS Complete |
$1,400.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,450.00
|
| Rate for Payer: UMR Bronson Commercial |
$1,610.00
|
|
|
THERMAGE KNEES - BILATERAL
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 00151
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: BCBS Complete |
$480.00
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$840.00
|
| Rate for Payer: UMR Bronson Commercial |
$552.00
|
|
|
THERMAGE NECK
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 00141
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: BCBS Complete |
$480.00
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$840.00
|
| Rate for Payer: UMR Bronson Commercial |
$552.00
|
|
|
THERMAGE THIGH - 1 THIGH
|
Professional
|
Both
|
$1,900.00
|
|
|
Service Code
|
HCPCS 00147
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$760.00 |
| Max. Negotiated Rate |
$1,330.00 |
| Rate for Payer: BCBS Complete |
$760.00
|
| Rate for Payer: Cash Price |
$1,520.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,330.00
|
| Rate for Payer: UMR Bronson Commercial |
$874.00
|
|
|
THERMAGE THIGH - BILATERAL
|
Professional
|
Both
|
$3,100.00
|
|
|
Service Code
|
HCPCS 00148
|
|
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
|
|
|
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 |
$7.93 |
| Max. Negotiated Rate |
$25.41 |
| Rate for Payer: Aetna American Axle |
$18.35
|
| Rate for Payer: Aetna Commercial |
$24.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.35
|
| Rate for Payer: BCBS Complete |
$11.29
|
| Rate for Payer: BCBS Trust/PPO |
$7.93
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Cofinity Commercial |
$19.76
|
| Rate for Payer: Cofinity Commercial |
$24.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.58
|
| Rate for Payer: Healthscope Commercial |
$25.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.00
|
| Rate for Payer: PHP Commercial |
$24.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.76
|
| Rate for Payer: Priority Health SBD |
$17.78
|
| Rate for Payer: UMR Bronson Commercial |
$10.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.17
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$22.84
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna American Axle |
$14.85
|
| Rate for Payer: Aetna American Axle |
$17.63
|
| Rate for Payer: Aetna American Axle |
$18.35
|
| Rate for Payer: Aetna American Axle |
$17.89
|
| Rate for Payer: Aetna Commercial |
$19.41
|
| Rate for Payer: Aetna Commercial |
$23.05
|
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Commercial |
$24.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.63
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cofinity Commercial |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$24.28
|
| Rate for Payer: Cofinity Commercial |
$18.98
|
| Rate for Payer: Cofinity Commercial |
$23.32
|
| Rate for Payer: Cofinity Commercial |
$23.68
|
| Rate for Payer: Cofinity Commercial |
$19.27
|
| Rate for Payer: Cofinity Commercial |
$19.76
|
| Rate for Payer: Cofinity Commercial |
$19.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$24.41
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Healthscope Commercial |
$24.78
|
| Rate for Payer: Healthscope Commercial |
$25.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.05
|
| Rate for Payer: PHP Commercial |
$24.00
|
| Rate for Payer: PHP Commercial |
$19.41
|
| Rate for Payer: PHP Commercial |
$23.05
|
| Rate for Payer: PHP Commercial |
$23.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.98
|
| Rate for Payer: Priority Health SBD |
$17.78
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: Priority Health SBD |
$14.39
|
| Rate for Payer: Priority Health SBD |
$17.09
|
| Rate for Payer: UMR Bronson Commercial |
$10.05
|
| Rate for Payer: UMR Bronson Commercial |
$11.93
|
| Rate for Payer: UMR Bronson Commercial |
$12.42
|
| Rate for Payer: UMR Bronson Commercial |
$12.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.17
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 7985420010
|
| Hospital Charge Code |
7877
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.02
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$46.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$3.88
|
|
|
Service Code
|
NDC 7733393425
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$2.72
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$2.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.30
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$4.12
|
|
|
Service Code
|
NDC 6809411659
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna American Axle |
$2.68
|
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.68
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Commercial |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.50
|
| Rate for Payer: PHP Commercial |
$3.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.88
|
| Rate for Payer: Priority Health SBD |
$2.60
|
| Rate for Payer: UMR Bronson Commercial |
$1.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.09
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
NDC 9629513892
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.36 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna American Axle |
$61.10
|
| Rate for Payer: Aetna Commercial |
$79.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.10
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$80.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.20
|
| Rate for Payer: Healthscope Commercial |
$84.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.90
|
| Rate for Payer: PHP Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.80
|
| Rate for Payer: Priority Health SBD |
$59.22
|
| Rate for Payer: UMR Bronson Commercial |
$41.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.50
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$411.25
|
|
|
Service Code
|
NDC 6809411661
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.95 |
| Max. Negotiated Rate |
$370.12 |
| Rate for Payer: Aetna American Axle |
$267.31
|
| Rate for Payer: Aetna Commercial |
$349.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$267.31
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$287.88
|
| Rate for Payer: Cofinity Commercial |
$353.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.00
|
| Rate for Payer: Healthscope Commercial |
$370.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$308.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$349.56
|
| Rate for Payer: PHP Commercial |
$349.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.88
|
| Rate for Payer: Priority Health SBD |
$259.09
|
| Rate for Payer: UMR Bronson Commercial |
$180.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$308.44
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$387.75
|
|
|
Service Code
|
NDC 7733393410
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.61 |
| Max. Negotiated Rate |
$348.98 |
| Rate for Payer: Aetna American Axle |
$252.04
|
| Rate for Payer: Aetna Commercial |
$329.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$252.04
|
| Rate for Payer: Cash Price |
$310.20
|
| Rate for Payer: Cofinity Commercial |
$271.42
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$271.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$329.59
|
| Rate for Payer: PHP Commercial |
$329.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.42
|
| Rate for Payer: Priority Health SBD |
$244.28
|
| Rate for Payer: UMR Bronson Commercial |
$170.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.81
|
|
|
THIOGUANINE 40 MG TABLET
|
Facility
|
IP
|
$2,256.91
|
|
|
Service Code
|
NDC 76388-880-25
|
| Hospital Charge Code |
7886
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$993.04 |
| Max. Negotiated Rate |
$2,031.22 |
| Rate for Payer: Aetna American Axle |
$1,466.99
|
| Rate for Payer: Aetna Commercial |
$1,918.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,466.99
|
| Rate for Payer: Cash Price |
$1,805.53
|
| Rate for Payer: Cofinity Commercial |
$1,579.84
|
| Rate for Payer: Cofinity Commercial |
$1,940.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,805.53
|
| Rate for Payer: Healthscope Commercial |
$2,031.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,579.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,692.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,918.37
|
| Rate for Payer: PHP Commercial |
$1,918.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,579.84
|
| Rate for Payer: Priority Health SBD |
$1,421.85
|
| Rate for Payer: UMR Bronson Commercial |
$993.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,692.68
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
IP
|
$299.04
|
|
|
Service Code
|
NDC 0378-0614-01
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.58 |
| Max. Negotiated Rate |
$269.14 |
| Rate for Payer: Aetna American Axle |
$194.38
|
| Rate for Payer: Aetna Commercial |
$254.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.38
|
| Rate for Payer: Cash Price |
$239.23
|
| Rate for Payer: Cofinity Commercial |
$209.33
|
| Rate for Payer: Cofinity Commercial |
$257.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.23
|
| Rate for Payer: Healthscope Commercial |
$269.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$209.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$224.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$254.18
|
| Rate for Payer: PHP Commercial |
$254.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$209.33
|
| Rate for Payer: Priority Health SBD |
$188.40
|
| Rate for Payer: UMR Bronson Commercial |
$131.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$224.28
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 51079-566-01
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna American Axle |
$3.05
|
| Rate for Payer: Aetna Commercial |
$3.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.05
|
| Rate for Payer: Cash Price |
$3.75
|
| Rate for Payer: Cofinity Commercial |
$3.28
|
| Rate for Payer: Cofinity Commercial |
$4.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.75
|
| Rate for Payer: Healthscope Commercial |
$4.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.99
|
| Rate for Payer: PHP Commercial |
$3.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.28
|
| Rate for Payer: Priority Health SBD |
$2.95
|
| Rate for Payer: UMR Bronson Commercial |
$2.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.52
|
|
|
THIORIDAZINE 25 MG TABLET
|
Facility
|
IP
|
$468.35
|
|
|
Service Code
|
NDC 51079-566-20
|
| Hospital Charge Code |
7899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.07 |
| Max. Negotiated Rate |
$421.52 |
| Rate for Payer: Aetna American Axle |
$304.43
|
| Rate for Payer: Aetna Commercial |
$398.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$304.43
|
| Rate for Payer: Cash Price |
$374.68
|
| Rate for Payer: Cofinity Commercial |
$327.84
|
| Rate for Payer: Cofinity Commercial |
$402.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$374.68
|
| Rate for Payer: Healthscope Commercial |
$421.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$327.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$351.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$398.10
|
| Rate for Payer: PHP Commercial |
$398.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$327.84
|
| Rate for Payer: Priority Health SBD |
$295.06
|
| Rate for Payer: UMR Bronson Commercial |
$206.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$351.26
|
|
|
THIOTEPA 15 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$861.90
|
|
|
Service Code
|
HCPCS J9340
|
| Hospital Charge Code |
7901
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$379.24 |
| Max. Negotiated Rate |
$775.71 |
| Rate for Payer: Aetna American Axle |
$560.24
|
| Rate for Payer: Aetna Commercial |
$732.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$560.24
|
| Rate for Payer: Cash Price |
$689.52
|
| Rate for Payer: Cofinity Commercial |
$741.23
|
| Rate for Payer: Cofinity Commercial |
$603.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$689.52
|
| Rate for Payer: Healthscope Commercial |
$775.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$603.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$646.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$732.62
|
| Rate for Payer: PHP Commercial |
$732.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$603.33
|
| Rate for Payer: Priority Health SBD |
$543.00
|
| Rate for Payer: UMR Bronson Commercial |
$379.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$646.42
|
|
