|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
IP
|
$43.07
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.95 |
| Max. Negotiated Rate |
$38.76 |
| Rate for Payer: Aetna American Axle |
$28.00
|
| Rate for Payer: Aetna Commercial |
$36.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.00
|
| Rate for Payer: Cash Price |
$34.46
|
| Rate for Payer: Cofinity Advantage |
$30.15
|
| Rate for Payer: Cofinity Commercial |
$37.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.46
|
| Rate for Payer: Healthscope Commercial |
$38.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.30
|
| Rate for Payer: PHP Commercial |
$36.61
|
| Rate for Payer: Priority Health SBD |
$27.13
|
| Rate for Payer: UMR Bronson Commercial |
$18.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.30
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
OP
|
$43.07
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.94 |
| Max. Negotiated Rate |
$38.76 |
| Rate for Payer: Aetna American Axle |
$28.00
|
| Rate for Payer: Aetna Commercial |
$36.61
|
| Rate for Payer: Aetna Medicare |
$21.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.00
|
| Rate for Payer: BCBS Complete |
$17.23
|
| Rate for Payer: Cash Price |
$34.46
|
| Rate for Payer: Cofinity Advantage |
$30.15
|
| Rate for Payer: Cofinity Commercial |
$37.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.46
|
| Rate for Payer: Healthscope Commercial |
$38.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$32.30
|
| Rate for Payer: PHP Commercial |
$36.61
|
| Rate for Payer: Priority Health SBD |
$27.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.00
|
| Rate for Payer: UHC Core |
$22.44
|
| Rate for Payer: UHC Exchange |
$16.93
|
| Rate for Payer: UMR Bronson Commercial |
$15.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.30
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
OP
|
$187.85
|
|
|
Service Code
|
NDC 54288012701
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.50 |
| Max. Negotiated Rate |
$169.06 |
| Rate for Payer: Aetna American Axle |
$122.10
|
| Rate for Payer: Aetna Commercial |
$159.67
|
| Rate for Payer: Aetna Medicare |
$93.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.10
|
| Rate for Payer: BCBS Complete |
$75.14
|
| Rate for Payer: Cash Price |
$150.28
|
| Rate for Payer: Cofinity Advantage |
$131.50
|
| Rate for Payer: Cofinity Commercial |
$161.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.28
|
| Rate for Payer: Healthscope Commercial |
$169.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$140.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$150.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$140.89
|
| Rate for Payer: PHP Commercial |
$159.67
|
| Rate for Payer: Priority Health SBD |
$118.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.10
|
| Rate for Payer: UHC Core |
$97.87
|
| Rate for Payer: UHC Exchange |
$73.83
|
| Rate for Payer: UMR Bronson Commercial |
$69.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$140.89
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$250.73
|
|
|
Service Code
|
NDC 17478004532
|
| 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 Advantage |
$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 Commercial |
$213.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.05
|
| Rate for Payer: PHP Commercial |
$213.12
|
| 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
|
OP
|
$250.73
|
|
|
Service Code
|
NDC 17478004532
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.77 |
| Max. Negotiated Rate |
$225.66 |
| Rate for Payer: Aetna American Axle |
$162.97
|
| Rate for Payer: Aetna Commercial |
$213.12
|
| Rate for Payer: Aetna Medicare |
$125.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$162.97
|
| Rate for Payer: BCBS Complete |
$100.29
|
| Rate for Payer: Cash Price |
$200.58
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$200.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.05
|
| Rate for Payer: PHP Commercial |
$213.12
|
| Rate for Payer: Priority Health SBD |
$157.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$162.97
|
| Rate for Payer: UHC Core |
$130.63
|
| Rate for Payer: UHC Exchange |
$98.54
|
| Rate for Payer: UMR Bronson Commercial |
$92.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.05
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
OP
|
$187.85
|
|
|
Service Code
|
NDC 54288012710
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.50 |
| Max. Negotiated Rate |
$169.06 |
| Rate for Payer: Aetna American Axle |
$122.10
|
| Rate for Payer: Aetna Commercial |
$159.67
|
| Rate for Payer: Aetna Medicare |
$93.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.10
|
| Rate for Payer: BCBS Complete |
$75.14
|
| Rate for Payer: Cash Price |
$150.28
|
| Rate for Payer: Cofinity Advantage |
$131.50
|
| Rate for Payer: Cofinity Commercial |
$161.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.28
|
| Rate for Payer: Healthscope Commercial |
$169.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$140.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$150.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$140.89
|
| Rate for Payer: PHP Commercial |
$159.67
|
| Rate for Payer: Priority Health SBD |
$118.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.10
|
| Rate for Payer: UHC Core |
$97.87
|
| Rate for Payer: UHC Exchange |
$73.83
|
| Rate for Payer: UMR Bronson Commercial |
$69.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$140.89
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$187.85
|
|
|
Service Code
|
NDC 54288012710
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.65 |
| Max. Negotiated Rate |
$169.06 |
| Rate for Payer: Aetna American Axle |
$122.10
|
| Rate for Payer: Aetna Commercial |
$159.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.10
|
| Rate for Payer: Cash Price |
$150.28
|
| Rate for Payer: Cofinity Advantage |
$131.50
|
| Rate for Payer: Cofinity Commercial |
$161.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.28
|
| Rate for Payer: Healthscope Commercial |
$169.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$140.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$140.89
|
| Rate for Payer: PHP Commercial |
$159.67
|
| Rate for Payer: Priority Health SBD |
$118.35
|
| Rate for Payer: UMR Bronson Commercial |
$82.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$140.89
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$187.85
|
|
|
Service Code
|
NDC 54288012701
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.65 |
| Max. Negotiated Rate |
$169.06 |
| Rate for Payer: Aetna American Axle |
$122.10
|
| Rate for Payer: Aetna Commercial |
$159.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.10
|
| Rate for Payer: Cash Price |
$150.28
|
| Rate for Payer: Cofinity Advantage |
$131.50
|
| Rate for Payer: Cofinity Commercial |
$161.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.28
|
| Rate for Payer: Healthscope Commercial |
$169.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$140.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$140.89
|
| Rate for Payer: PHP Commercial |
$159.67
|
| Rate for Payer: Priority Health SBD |
$118.35
|
| Rate for Payer: UMR Bronson Commercial |
$82.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$140.89
|
|
|
TETRACYCLINE HCL (BULK) POWDER
|
Facility
|
OP
|
$604.80
|
|
|
Service Code
|
NDC 38779005305
|
| Hospital Charge Code |
7799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$223.78 |
| Max. Negotiated Rate |
$544.32 |
| Rate for Payer: Aetna American Axle |
$393.12
|
| Rate for Payer: Aetna Commercial |
$514.08
|
| Rate for Payer: Aetna Medicare |
$302.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.12
|
| Rate for Payer: BCBS Complete |
$241.92
|
| Rate for Payer: Cash Price |
$483.84
|
| Rate for Payer: Cofinity Advantage |
$423.36
|
| Rate for Payer: Cofinity Commercial |
$520.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$483.84
|
| Rate for Payer: Healthscope Commercial |
$544.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$423.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$453.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$483.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$514.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$453.60
|
| Rate for Payer: PHP Commercial |
$514.08
|
| Rate for Payer: Priority Health SBD |
$381.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$393.12
|
| Rate for Payer: UHC Core |
$315.10
|
| Rate for Payer: UHC Exchange |
$237.69
|
| Rate for Payer: UMR Bronson Commercial |
$223.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$453.60
|
|
|
TETRACYCLINE HCL (BULK) POWDER
|
Facility
|
OP
|
$210.60
|
|
|
Service Code
|
NDC 38779005304
|
| Hospital Charge Code |
7799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.92 |
| Max. Negotiated Rate |
$189.54 |
| Rate for Payer: Aetna American Axle |
$136.89
|
| Rate for Payer: Aetna Commercial |
$179.01
|
| Rate for Payer: Aetna Medicare |
$105.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.89
|
| Rate for Payer: BCBS Complete |
$84.24
|
| Rate for Payer: Cash Price |
$168.48
|
| Rate for Payer: Cofinity Advantage |
$147.42
|
| Rate for Payer: Cofinity Commercial |
$181.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.48
|
| Rate for Payer: Healthscope Commercial |
$189.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$168.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.95
|
| Rate for Payer: PHP Commercial |
$179.01
|
| Rate for Payer: Priority Health SBD |
$132.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$136.89
|
| Rate for Payer: UHC Core |
$109.72
|
| Rate for Payer: UHC Exchange |
$82.77
|
| Rate for Payer: UMR Bronson Commercial |
$77.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.95
|
|
|
TETRACYCLINE HCL (BULK) POWDER
|
Facility
|
IP
|
$438.00
|
|
|
Service Code
|
NDC 51552046305
|
| 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 Advantage |
$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 Commercial |
$372.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$328.50
|
| Rate for Payer: PHP Commercial |
$372.30
|
| 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
|
|
|
TETRACYCLINE HCL (BULK) POWDER
|
Facility
|
IP
|
$604.80
|
|
|
Service Code
|
NDC 38779005305
|
| Hospital Charge Code |
7799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.11 |
| Max. Negotiated Rate |
$544.32 |
| Rate for Payer: Aetna American Axle |
$393.12
|
| Rate for Payer: Aetna Commercial |
$514.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$393.12
|
| Rate for Payer: Cash Price |
$483.84
|
| Rate for Payer: Cofinity Advantage |
$423.36
|
| Rate for Payer: Cofinity Commercial |
$520.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$483.84
|
| Rate for Payer: Healthscope Commercial |
$544.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$423.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$453.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$514.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$453.60
|
| Rate for Payer: PHP Commercial |
$514.08
|
| Rate for Payer: Priority Health SBD |
$381.02
|
| Rate for Payer: UMR Bronson Commercial |
$266.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$453.60
|
|
|
TETRACYCLINE HCL (BULK) POWDER
|
Facility
|
OP
|
$438.00
|
|
|
Service Code
|
NDC 51552046305
|
| Hospital Charge Code |
7799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.06 |
| Max. Negotiated Rate |
$394.20 |
| Rate for Payer: Aetna American Axle |
$284.70
|
| Rate for Payer: Aetna Commercial |
$372.30
|
| Rate for Payer: Aetna Medicare |
$219.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.70
|
| Rate for Payer: BCBS Complete |
$175.20
|
| Rate for Payer: Cash Price |
$350.40
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$350.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$372.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$328.50
|
| Rate for Payer: PHP Commercial |
$372.30
|
| Rate for Payer: Priority Health SBD |
$275.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$284.70
|
| Rate for Payer: UHC Core |
$228.20
|
| Rate for Payer: UHC Exchange |
$172.13
|
| Rate for Payer: UMR Bronson Commercial |
$162.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$328.50
|
|
|
TETRACYCLINE HCL (BULK) POWDER
|
Facility
|
IP
|
$210.60
|
|
|
Service Code
|
NDC 38779005304
|
| Hospital Charge Code |
7799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.66 |
| Max. Negotiated Rate |
$189.54 |
| Rate for Payer: Aetna American Axle |
$136.89
|
| Rate for Payer: Aetna Commercial |
$179.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.89
|
| Rate for Payer: Cash Price |
$168.48
|
| Rate for Payer: Cofinity Advantage |
$147.42
|
| Rate for Payer: Cofinity Commercial |
$181.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.48
|
| Rate for Payer: Healthscope Commercial |
$189.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$157.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$157.95
|
| Rate for Payer: PHP Commercial |
$179.01
|
| Rate for Payer: Priority Health SBD |
$132.68
|
| Rate for Payer: UMR Bronson Commercial |
$92.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$157.95
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$11,926.08
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
199104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,247.48 |
| Max. Negotiated Rate |
$10,733.47 |
| Rate for Payer: Aetna American Axle |
$7,751.95
|
| Rate for Payer: Aetna Commercial |
$10,137.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,751.95
|
| Rate for Payer: Cash Price |
$9,540.86
|
| Rate for Payer: Cofinity Advantage |
$8,348.26
|
| Rate for Payer: Cofinity Commercial |
$10,256.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,540.86
|
| Rate for Payer: Healthscope Commercial |
$10,733.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,348.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,944.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,137.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8,944.56
|
| Rate for Payer: PHP Commercial |
$10,137.17
|
| Rate for Payer: Priority Health SBD |
$7,513.43
|
| Rate for Payer: UMR Bronson Commercial |
$5,247.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,944.56
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$11,926.08
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
199104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$10,733.47 |
| Rate for Payer: Aetna American Axle |
$7,751.95
|
| Rate for Payer: Aetna Commercial |
$10,137.17
|
| Rate for Payer: Aetna Medicare |
$18.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,751.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.98
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.98
|
| Rate for Payer: BCBS Complete |
$9.65
|
| Rate for Payer: BCBS MAPPO |
$17.58
|
| Rate for Payer: BCBS Trust/PPO |
$57.76
|
| Rate for Payer: BCN Commercial |
$57.76
|
| Rate for Payer: BCN Medicare Advantage |
$17.58
|
| Rate for Payer: Cash Price |
$9,540.86
|
| Rate for Payer: Cash Price |
$9,540.86
|
| Rate for Payer: Cofinity Advantage |
$8,348.26
|
| Rate for Payer: Cofinity Commercial |
$10,256.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,540.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.58
|
| Rate for Payer: Healthscope Commercial |
$10,733.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,348.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,944.56
|
| Rate for Payer: Mclaren Medicaid |
$17.58
|
| Rate for Payer: Mclaren Medicare |
$17.58
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.46
|
| Rate for Payer: Meridian Medicaid |
$18.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.22
|
| Rate for Payer: Molina Medicare/Medicaid |
$19.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,137.17
|
| Rate for Payer: Nomi Health Commercial |
$52.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8,944.56
|
| Rate for Payer: PACE Medicare |
$16.70
|
| Rate for Payer: PACE SWMI |
$17.58
|
| Rate for Payer: PHP Commercial |
$10,137.17
|
| Rate for Payer: PHP Medicare Advantage |
$17.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.19
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$56.80
|
| Rate for Payer: Priority Health Medicare |
$17.58
|
| Rate for Payer: Priority Health SBD |
$7,513.43
|
| Rate for Payer: Priority Health Tiered Network |
$45.44
|
| Rate for Payer: Railroad Medicare Medicare |
$17.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.40
|
| Rate for Payer: UHC Core |
$29.40
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$17.58
|
| Rate for Payer: UHC Exchange |
$29.40
|
| Rate for Payer: UHC Medicaid |
$9.19
|
| Rate for Payer: UHCCP Medicaid |
$9.19
|
| Rate for Payer: UMR Bronson Commercial |
$4,412.65
|
| Rate for Payer: VA VA |
$17.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,944.56
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$2,037.96
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
27419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$896.70 |
| Max. Negotiated Rate |
$1,834.16 |
| Rate for Payer: Aetna American Axle |
$1,324.67
|
| Rate for Payer: Aetna Commercial |
$1,732.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,324.67
|
| Rate for Payer: Cash Price |
$1,630.37
|
| Rate for Payer: Cofinity Advantage |
$1,426.57
|
| Rate for Payer: Cofinity Commercial |
$1,752.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,630.37
|
| Rate for Payer: Healthscope Commercial |
$1,834.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,426.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,528.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,732.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,528.47
|
| Rate for Payer: PHP Commercial |
$1,732.27
|
| Rate for Payer: Priority Health SBD |
$1,283.91
|
| Rate for Payer: UMR Bronson Commercial |
$896.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,528.47
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$2,037.96
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
27419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$754.05 |
| Max. Negotiated Rate |
$1,834.16 |
| Rate for Payer: Aetna American Axle |
$1,324.67
|
| Rate for Payer: Aetna Commercial |
$1,732.27
|
| Rate for Payer: Aetna Medicare |
$1,018.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,324.67
|
| Rate for Payer: BCBS Complete |
$815.18
|
| Rate for Payer: Cash Price |
$1,630.37
|
| Rate for Payer: Cofinity Advantage |
$1,426.57
|
| Rate for Payer: Cofinity Commercial |
$1,752.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,630.37
|
| Rate for Payer: Healthscope Commercial |
$1,834.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,426.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,528.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,630.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,732.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,528.47
|
| Rate for Payer: PHP Commercial |
$1,732.27
|
| Rate for Payer: Priority Health SBD |
$1,283.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,324.67
|
| Rate for Payer: UHC Core |
$1,061.78
|
| Rate for Payer: UHC Exchange |
$800.92
|
| Rate for Payer: UMR Bronson Commercial |
$754.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,528.47
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$436.32
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.98 |
| Max. Negotiated Rate |
$392.69 |
| Rate for Payer: Aetna American Axle |
$283.61
|
| Rate for Payer: Aetna Commercial |
$370.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$283.61
|
| Rate for Payer: Cash Price |
$349.06
|
| Rate for Payer: Cofinity Advantage |
$305.42
|
| Rate for Payer: Cofinity Commercial |
$375.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.06
|
| Rate for Payer: Healthscope Commercial |
$392.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$305.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$370.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$327.24
|
| Rate for Payer: PHP Commercial |
$370.87
|
| Rate for Payer: Priority Health SBD |
$274.88
|
| Rate for Payer: UMR Bronson Commercial |
$191.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.24
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
OP
|
$579.36
|
|
|
Service Code
|
NDC 68462072101
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$214.36 |
| Max. Negotiated Rate |
$521.42 |
| Rate for Payer: Aetna American Axle |
$376.58
|
| Rate for Payer: Aetna Commercial |
$492.46
|
| Rate for Payer: Aetna Medicare |
$289.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$376.58
|
| Rate for Payer: BCBS Complete |
$231.74
|
| Rate for Payer: Cash Price |
$463.49
|
| Rate for Payer: Cofinity Advantage |
$405.55
|
| Rate for Payer: Cofinity Commercial |
$498.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$463.49
|
| Rate for Payer: Healthscope Commercial |
$521.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$405.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$434.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$463.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$492.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$434.52
|
| Rate for Payer: PHP Commercial |
$492.46
|
| Rate for Payer: Priority Health SBD |
$365.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$376.58
|
| Rate for Payer: UHC Core |
$301.85
|
| Rate for Payer: UHC Exchange |
$227.69
|
| Rate for Payer: UMR Bronson Commercial |
$214.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$434.52
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
OP
|
$436.32
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.44 |
| Max. Negotiated Rate |
$392.69 |
| Rate for Payer: Aetna American Axle |
$283.61
|
| Rate for Payer: Aetna Commercial |
$370.87
|
| Rate for Payer: Aetna Medicare |
$218.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$283.61
|
| Rate for Payer: BCBS Complete |
$174.53
|
| Rate for Payer: Cash Price |
$349.06
|
| Rate for Payer: Cofinity Advantage |
$305.42
|
| Rate for Payer: Cofinity Commercial |
$375.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.06
|
| Rate for Payer: Healthscope Commercial |
$392.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$305.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$349.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$370.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$327.24
|
| Rate for Payer: PHP Commercial |
$370.87
|
| Rate for Payer: Priority Health SBD |
$274.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$283.61
|
| Rate for Payer: UHC Core |
$227.32
|
| Rate for Payer: UHC Exchange |
$171.47
|
| Rate for Payer: UMR Bronson Commercial |
$161.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.24
|
|
|
THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$579.36
|
|
|
Service Code
|
NDC 68462072101
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.92 |
| Max. Negotiated Rate |
$521.42 |
| Rate for Payer: Aetna American Axle |
$376.58
|
| Rate for Payer: Aetna Commercial |
$492.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$376.58
|
| Rate for Payer: Cash Price |
$463.49
|
| Rate for Payer: Cofinity Advantage |
$405.55
|
| Rate for Payer: Cofinity Commercial |
$498.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$463.49
|
| Rate for Payer: Healthscope Commercial |
$521.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$405.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$434.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$492.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$434.52
|
| Rate for Payer: PHP Commercial |
$492.46
|
| Rate for Payer: Priority Health SBD |
$365.00
|
| Rate for Payer: UMR Bronson Commercial |
$254.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$434.52
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$545.28
|
|
|
Service Code
|
NDC 29033000101
|
| Hospital Charge Code |
108325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$201.75 |
| Max. Negotiated Rate |
$490.75 |
| Rate for Payer: Aetna American Axle |
$354.43
|
| Rate for Payer: Aetna Commercial |
$463.49
|
| Rate for Payer: Aetna Medicare |
$272.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$354.43
|
| Rate for Payer: BCBS Complete |
$218.11
|
| Rate for Payer: Cash Price |
$436.22
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$436.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$463.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$408.96
|
| Rate for Payer: PHP Commercial |
$463.49
|
| Rate for Payer: Priority Health SBD |
$343.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$354.43
|
| Rate for Payer: UHC Core |
$284.09
|
| Rate for Payer: UHC Exchange |
$214.30
|
| Rate for Payer: UMR Bronson Commercial |
$201.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$408.96
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$463.68
|
|
|
Service Code
|
NDC 42858070101
|
| Hospital Charge Code |
108325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.56 |
| Max. Negotiated Rate |
$417.31 |
| Rate for Payer: Aetna American Axle |
$301.39
|
| Rate for Payer: Aetna Commercial |
$394.13
|
| Rate for Payer: Aetna Medicare |
$231.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$301.39
|
| Rate for Payer: BCBS Complete |
$185.47
|
| Rate for Payer: Cash Price |
$370.94
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$370.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$394.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$347.76
|
| Rate for Payer: PHP Commercial |
$394.13
|
| Rate for Payer: Priority Health SBD |
$292.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$301.39
|
| Rate for Payer: UHC Core |
$241.58
|
| Rate for Payer: UHC Exchange |
$182.23
|
| Rate for Payer: UMR Bronson Commercial |
$171.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$347.76
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$463.68
|
|
|
Service Code
|
NDC 42858070101
|
| 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 Advantage |
$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 Commercial |
$394.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$347.76
|
| Rate for Payer: PHP Commercial |
$394.13
|
| 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
|
|
