|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
OP
|
$155.20
|
|
|
Service Code
|
NDC 54288012710
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.42 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Aetna American Axle |
$100.88
|
| Rate for Payer: Aetna Commercial |
$131.92
|
| Rate for Payer: Aetna Medicare |
$77.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.88
|
| Rate for Payer: BCBS Complete |
$62.08
|
| Rate for Payer: Cash Price |
$124.16
|
| Rate for Payer: Cofinity Commercial |
$108.64
|
| Rate for Payer: Cofinity Commercial |
$133.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.64
|
| 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 Commercial |
$131.92
|
| Rate for Payer: PHP Commercial |
$131.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.88
|
| Rate for Payer: Priority Health SBD |
$97.78
|
| Rate for Payer: UMR Bronson Commercial |
$57.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.40
|
|
|
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 Commercial |
$306.60
|
| Rate for Payer: Cofinity Commercial |
$376.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$306.60
|
| 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: PHP Commercial |
$372.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.70
|
| Rate for Payer: Priority Health SBD |
$275.94
|
| 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
|
$567.00
|
|
|
Service Code
|
NDC 38779005305
|
| 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: Cofinity Medicare Advantage |
$396.90
|
| 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 Commercial |
$481.95
|
| Rate for Payer: PHP Commercial |
$481.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$368.55
|
| 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 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 Commercial |
$306.60
|
| Rate for Payer: Cofinity Commercial |
$376.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$306.60
|
| 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: PHP Commercial |
$372.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$284.70
|
| 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
|
OP
|
$567.00
|
|
|
Service Code
|
NDC 38779005305
|
| Hospital Charge Code |
7799
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$209.79 |
| Max. Negotiated Rate |
$510.30 |
| Rate for Payer: Aetna American Axle |
$368.55
|
| Rate for Payer: Aetna Commercial |
$481.95
|
| Rate for Payer: Aetna Medicare |
$283.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$368.55
|
| Rate for Payer: BCBS Complete |
$226.80
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cofinity Commercial |
$396.90
|
| Rate for Payer: Cofinity Commercial |
$487.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$396.90
|
| 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 Commercial |
$481.95
|
| Rate for Payer: PHP Commercial |
$481.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$368.55
|
| Rate for Payer: Priority Health SBD |
$357.21
|
| Rate for Payer: UMR Bronson Commercial |
$209.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$425.25
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$11,358.16
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
199104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.65 |
| Max. Negotiated Rate |
$10,222.34 |
| Rate for Payer: Aetna American Axle |
$7,382.80
|
| Rate for Payer: Aetna Commercial |
$9,654.44
|
| Rate for Payer: Aetna Medicare |
$18.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,382.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.51
|
| Rate for Payer: BCBS Complete |
$10.14
|
| Rate for Payer: BCBS MAPPO |
$18.01
|
| Rate for Payer: BCN Medicare Advantage |
$18.01
|
| Rate for Payer: Cash Price |
$9,086.53
|
| Rate for Payer: Cash Price |
$9,086.53
|
| Rate for Payer: Cofinity Commercial |
$9,768.02
|
| Rate for Payer: Cofinity Commercial |
$7,950.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,950.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,086.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.01
|
| Rate for Payer: Healthscope Commercial |
$10,222.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,950.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,518.62
|
| Rate for Payer: Mclaren Medicaid |
$9.65
|
| Rate for Payer: Mclaren Medicare |
$18.01
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.91
|
| Rate for Payer: Meridian Medicaid |
$10.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,654.44
|
| Rate for Payer: PACE Medicare |
$17.11
|
| Rate for Payer: PACE SWMI |
$18.01
|
| Rate for Payer: PHP Commercial |
$9,654.44
|
| Rate for Payer: PHP Medicare Advantage |
$18.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,382.80
|
| Rate for Payer: Priority Health Medicare |
$18.01
|
| Rate for Payer: Priority Health SBD |
$7,155.64
|
| Rate for Payer: Railroad Medicare Medicare |
$18.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.01
|
| Rate for Payer: UHC Exchange |
$34.42
|
| Rate for Payer: UHC Medicare Advantage |
$18.01
|
| Rate for Payer: UHCCP Medicaid |
$9.65
|
| Rate for Payer: UMR Bronson Commercial |
$4,202.52
|
| Rate for Payer: VA VA |
$18.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,518.62
|
|
|
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$11,358.16
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
199104
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,997.59 |
| Max. Negotiated Rate |
$10,222.34 |
| Rate for Payer: Aetna American Axle |
$7,382.80
|
| Rate for Payer: Aetna Commercial |
$9,654.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,382.80
|
| Rate for Payer: Cash Price |
$9,086.53
|
| Rate for Payer: Cofinity Commercial |
$7,950.71
|
| Rate for Payer: Cofinity Commercial |
$9,768.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,950.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,086.53
|
| Rate for Payer: Healthscope Commercial |
$10,222.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,950.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,518.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,654.44
|
| Rate for Payer: PHP Commercial |
$9,654.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,382.80
|
| Rate for Payer: Priority Health SBD |
$7,155.64
|
| Rate for Payer: UMR Bronson Commercial |
$4,997.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,518.62
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$934.08
|
|
|
Service Code
|
NDC 50474020001
|
| Hospital Charge Code |
27419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$345.61 |
| Max. Negotiated Rate |
$840.67 |
| Rate for Payer: Aetna American Axle |
$607.15
|
| Rate for Payer: Aetna Commercial |
$793.97
|
| Rate for Payer: Aetna Medicare |
$467.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$607.15
|
| Rate for Payer: BCBS Complete |
$373.63
|
| Rate for Payer: Cash Price |
$747.26
|
| Rate for Payer: Cofinity Commercial |
$653.86
|
| Rate for Payer: Cofinity Commercial |
$803.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$793.97
|
| Rate for Payer: PHP Commercial |
$793.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$607.15
|
| Rate for Payer: Priority Health SBD |
$588.47
|
| Rate for Payer: UMR Bronson Commercial |
$345.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$700.56
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$934.08
|
|
|
Service Code
|
NDC 50474020001
|
| 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 |
$653.86
|
| Rate for Payer: Cofinity Commercial |
$803.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$793.97
|
| Rate for Payer: PHP Commercial |
$793.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$607.15
|
| 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
|
OP
|
$1,978.76
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
27419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$732.14 |
| Max. Negotiated Rate |
$1,780.88 |
| Rate for Payer: Aetna American Axle |
$1,286.19
|
| Rate for Payer: Aetna Commercial |
$1,681.95
|
| Rate for Payer: Aetna Medicare |
$989.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,286.19
|
| Rate for Payer: BCBS Complete |
$791.50
|
| Rate for Payer: Cash Price |
$1,583.01
|
| Rate for Payer: Cofinity Commercial |
$1,385.13
|
| Rate for Payer: Cofinity Commercial |
$1,701.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,385.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,583.01
|
| Rate for Payer: Healthscope Commercial |
$1,780.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,385.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,484.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,681.95
|
| Rate for Payer: PHP Commercial |
$1,681.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,286.19
|
| Rate for Payer: Priority Health SBD |
$1,246.62
|
| Rate for Payer: UMR Bronson Commercial |
$732.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,484.07
|
|
|
THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$1,978.76
|
|
|
Service Code
|
NDC 52244020010
|
| Hospital Charge Code |
27419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$870.65 |
| Max. Negotiated Rate |
$1,780.88 |
| Rate for Payer: Aetna American Axle |
$1,286.19
|
| Rate for Payer: Aetna Commercial |
$1,681.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,286.19
|
| Rate for Payer: Cash Price |
$1,583.01
|
| Rate for Payer: Cofinity Commercial |
$1,385.13
|
| Rate for Payer: Cofinity Commercial |
$1,701.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,385.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,583.01
|
| Rate for Payer: Healthscope Commercial |
$1,780.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,385.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,484.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,681.95
|
| Rate for Payer: PHP Commercial |
$1,681.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,286.19
|
| Rate for Payer: Priority Health SBD |
$1,246.62
|
| Rate for Payer: UMR Bronson Commercial |
$870.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,484.07
|
|
|
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 Commercial |
$405.55
|
| Rate for Payer: Cofinity Commercial |
$498.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$405.55
|
| 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: PHP Commercial |
$492.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$376.58
|
| 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 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 |
$214.19 |
| Max. Negotiated Rate |
$520.99 |
| Rate for Payer: Aetna American Axle |
$376.27
|
| Rate for Payer: Aetna Commercial |
$492.05
|
| Rate for Payer: Aetna Medicare |
$289.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$376.27
|
| Rate for Payer: BCBS Complete |
$231.55
|
| Rate for Payer: Cash Price |
$463.10
|
| Rate for Payer: Cofinity Commercial |
$405.22
|
| Rate for Payer: Cofinity Commercial |
$497.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$405.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$463.10
|
| Rate for Payer: Healthscope Commercial |
$520.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$405.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$434.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$492.05
|
| Rate for Payer: PHP Commercial |
$492.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$376.27
|
| Rate for Payer: Priority Health SBD |
$364.69
|
| Rate for Payer: UMR Bronson Commercial |
$214.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$434.16
|
|
|
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 Commercial |
$405.55
|
| Rate for Payer: Cofinity Commercial |
$498.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$405.55
|
| 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: PHP Commercial |
$492.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$376.58
|
| Rate for Payer: Priority Health SBD |
$365.00
|
| 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
|
IP
|
$578.88
|
|
|
Service Code
|
NDC 62332002531
|
| Hospital Charge Code |
12098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$254.71 |
| Max. Negotiated Rate |
$520.99 |
| Rate for Payer: Aetna American Axle |
$376.27
|
| Rate for Payer: Aetna Commercial |
$492.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$376.27
|
| Rate for Payer: Cash Price |
$463.10
|
| Rate for Payer: Cofinity Commercial |
$405.22
|
| Rate for Payer: Cofinity Commercial |
$497.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$405.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$463.10
|
| Rate for Payer: Healthscope Commercial |
$520.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$405.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$434.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$492.05
|
| Rate for Payer: PHP Commercial |
$492.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$376.27
|
| Rate for Payer: Priority Health SBD |
$364.69
|
| Rate for Payer: UMR Bronson Commercial |
$254.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$434.16
|
|
|
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 Commercial |
$381.70
|
| Rate for Payer: Cofinity Commercial |
$468.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$381.70
|
| 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 Commercial |
$463.49
|
| Rate for Payer: PHP Commercial |
$463.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$354.43
|
| Rate for Payer: Priority Health SBD |
$343.53
|
| 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
|
IP
|
$404.16
|
|
|
Service Code
|
NDC 68462038001
|
| Hospital Charge Code |
108325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.83 |
| Max. Negotiated Rate |
$363.74 |
| Rate for Payer: Aetna American Axle |
$262.70
|
| Rate for Payer: Aetna Commercial |
$343.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.70
|
| Rate for Payer: Cash Price |
$323.33
|
| Rate for Payer: Cofinity Commercial |
$282.91
|
| Rate for Payer: Cofinity Commercial |
$347.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$282.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.33
|
| Rate for Payer: Healthscope Commercial |
$363.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.54
|
| Rate for Payer: PHP Commercial |
$343.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.70
|
| Rate for Payer: Priority Health SBD |
$254.62
|
| Rate for Payer: UMR Bronson Commercial |
$177.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.12
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$545.28
|
|
|
Service Code
|
NDC 29033000101
|
| 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: Cofinity Medicare Advantage |
$381.70
|
| 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 Commercial |
$463.49
|
| Rate for Payer: PHP Commercial |
$463.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$354.43
|
| 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
|
|
|
THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$404.16
|
|
|
Service Code
|
NDC 68462038001
|
| Hospital Charge Code |
108325
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.54 |
| Max. Negotiated Rate |
$363.74 |
| Rate for Payer: Aetna American Axle |
$262.70
|
| Rate for Payer: Aetna Commercial |
$343.54
|
| Rate for Payer: Aetna Medicare |
$202.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$262.70
|
| Rate for Payer: BCBS Complete |
$161.66
|
| Rate for Payer: Cash Price |
$323.33
|
| Rate for Payer: Cofinity Commercial |
$282.91
|
| Rate for Payer: Cofinity Commercial |
$347.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$282.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.33
|
| Rate for Payer: Healthscope Commercial |
$363.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$282.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$343.54
|
| Rate for Payer: PHP Commercial |
$343.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$262.70
|
| Rate for Payer: Priority Health SBD |
$254.62
|
| Rate for Payer: UMR Bronson Commercial |
$149.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.12
|
|
|
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 Commercial |
$324.58
|
| Rate for Payer: Cofinity Commercial |
$398.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$324.58
|
| 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: PHP Commercial |
$394.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$301.39
|
| Rate for Payer: Priority Health SBD |
$292.12
|
| 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 Commercial |
$324.58
|
| Rate for Payer: Cofinity Commercial |
$398.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$324.58
|
| 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: PHP Commercial |
$394.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$301.39
|
| 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
|
|
|
THERAPEUTIC APHERESIS; FOR PLASMA PHERESIS
|
Facility
|
OP
|
$4,500.35
|
|
|
Service Code
|
CPT 36514
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$856.94 |
| Max. Negotiated Rate |
$4,500.35 |
| Rate for Payer: Aetna Medicare |
$1,662.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1,998.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1,998.45
|
| Rate for Payer: BCBS Complete |
$899.78
|
| Rate for Payer: BCBS MAPPO |
$1,598.76
|
| Rate for Payer: BCN Medicare Advantage |
$1,598.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,598.76
|
| Rate for Payer: Mclaren Medicaid |
$856.94
|
| Rate for Payer: Mclaren Medicare |
$1,598.76
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,678.70
|
| Rate for Payer: Meridian Medicaid |
$899.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,838.57
|
| Rate for Payer: PACE Medicare |
$1,518.82
|
| Rate for Payer: PACE SWMI |
$1,598.76
|
| Rate for Payer: PHP Medicare Advantage |
$1,598.76
|
| Rate for Payer: Priority Health Choice Medicaid |
$856.94
|
| Rate for Payer: Priority Health Medicare |
$1,598.76
|
| Rate for Payer: Railroad Medicare Medicare |
$1,598.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,500.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,598.76
|
| Rate for Payer: UHC Exchange |
$3,055.39
|
| Rate for Payer: UHC Medicare Advantage |
$1,598.76
|
| Rate for Payer: UHCCP Medicaid |
$856.94
|
| Rate for Payer: VA VA |
$1,598.76
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
NDC 00904053961
|
| Hospital Charge Code |
7857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.12 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna American Axle |
$96.20
|
| Rate for Payer: Aetna Commercial |
$125.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cofinity Commercial |
$103.60
|
| Rate for Payer: Cofinity Commercial |
$127.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.40
|
| Rate for Payer: Healthscope Commercial |
$133.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.80
|
| Rate for Payer: PHP Commercial |
$125.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.20
|
| Rate for Payer: Priority Health SBD |
$93.24
|
| Rate for Payer: UMR Bronson Commercial |
$65.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.00
|
|
|
THERAPEUTIC MULTIVITAMIN TABLET
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
NDC 00904053961
|
| Hospital Charge Code |
7857
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.76 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna American Axle |
$96.20
|
| Rate for Payer: Aetna Commercial |
$125.80
|
| Rate for Payer: Aetna Medicare |
$74.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.20
|
| Rate for Payer: BCBS Complete |
$59.20
|
| Rate for Payer: Cash Price |
$118.40
|
| Rate for Payer: Cofinity Commercial |
$103.60
|
| Rate for Payer: Cofinity Commercial |
$127.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.40
|
| Rate for Payer: Healthscope Commercial |
$133.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$125.80
|
| Rate for Payer: PHP Commercial |
$125.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$96.20
|
| Rate for Payer: Priority Health SBD |
$93.24
|
| Rate for Payer: UMR Bronson Commercial |
$54.76
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$469.20
|
|
