|
THERMAGE ABDOMEN - ENTIRE
|
Professional
|
Both
|
$3,162.00
|
|
|
Service Code
|
HCPCS 00150
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,264.80 |
| Max. Negotiated Rate |
$2,055.30 |
| Rate for Payer: Aetna Medicare |
$1,581.00
|
| Rate for Payer: BCBS Complete |
$1,264.80
|
| Rate for Payer: Cash Price |
$2,529.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,055.30
|
| Rate for Payer: UMR Bronson Commercial |
$1,454.52
|
|
|
THERMAGE ABDOMEN - LOWER
|
Professional
|
Both
|
$2,040.00
|
|
|
Service Code
|
HCPCS 00149
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$816.00 |
| Max. Negotiated Rate |
$1,326.00 |
| Rate for Payer: Aetna Medicare |
$1,020.00
|
| Rate for Payer: BCBS Complete |
$816.00
|
| Rate for Payer: Cash Price |
$1,632.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,326.00
|
| Rate for Payer: UMR Bronson Commercial |
$938.40
|
|
|
THERMAGE ARMS - 1 ARM
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00145
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna Medicare |
$612.00
|
| Rate for Payer: BCBS Complete |
$489.60
|
| Rate for Payer: Cash Price |
$979.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.60
|
| Rate for Payer: UMR Bronson Commercial |
$563.04
|
|
|
THERMAGE ARMS - BILATERAL
|
Professional
|
Both
|
$2,142.00
|
|
|
Service Code
|
HCPCS 00146
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$856.80 |
| Max. Negotiated Rate |
$1,392.30 |
| Rate for Payer: Aetna Medicare |
$1,071.00
|
| Rate for Payer: BCBS Complete |
$856.80
|
| Rate for Payer: Cash Price |
$1,713.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,392.30
|
| Rate for Payer: UMR Bronson Commercial |
$985.32
|
|
|
THERMAGE EYES
|
Professional
|
Both
|
$969.00
|
|
|
Service Code
|
HCPCS 00140
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$387.60 |
| Max. Negotiated Rate |
$629.85 |
| Rate for Payer: Aetna Medicare |
$484.50
|
| Rate for Payer: BCBS Complete |
$387.60
|
| Rate for Payer: Cash Price |
$775.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$629.85
|
| Rate for Payer: UMR Bronson Commercial |
$445.74
|
|
|
THERMAGE FACE
|
Professional
|
Both
|
$2,040.00
|
|
|
Service Code
|
HCPCS 00139
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$816.00 |
| Max. Negotiated Rate |
$1,326.00 |
| Rate for Payer: Aetna Medicare |
$1,020.00
|
| Rate for Payer: BCBS Complete |
$816.00
|
| Rate for Payer: Cash Price |
$1,632.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,326.00
|
| Rate for Payer: UMR Bronson Commercial |
$938.40
|
|
|
THERMAGE FACE & EYES
|
Professional
|
Both
|
$2,754.00
|
|
|
Service Code
|
HCPCS 00142
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,101.60 |
| Max. Negotiated Rate |
$1,790.10 |
| Rate for Payer: Aetna Medicare |
$1,377.00
|
| Rate for Payer: BCBS Complete |
$1,101.60
|
| Rate for Payer: Cash Price |
$2,203.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,790.10
|
| Rate for Payer: UMR Bronson Commercial |
$1,266.84
|
|
|
THERMAGE FACE & NECK
|
Professional
|
Both
|
$2,856.00
|
|
|
Service Code
|
HCPCS 00143
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,142.40 |
| Max. Negotiated Rate |
$1,856.40 |
| Rate for Payer: Aetna Medicare |
$1,428.00
|
| Rate for Payer: BCBS Complete |
$1,142.40
|
| Rate for Payer: Cash Price |
$2,284.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,856.40
|
| Rate for Payer: UMR Bronson Commercial |
$1,313.76
|
|
|
THERMAGE FACE, NECK, & EYES
|
Professional
|
Both
|
$3,570.00
|
|
|
Service Code
|
HCPCS 00144
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,428.00 |
| Max. Negotiated Rate |
$2,320.50 |
| Rate for Payer: Aetna Medicare |
$1,785.00
|
| Rate for Payer: BCBS Complete |
$1,428.00
|
| Rate for Payer: Cash Price |
$2,856.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,320.50
|
| Rate for Payer: UMR Bronson Commercial |
$1,642.20
|
|
|
THERMAGE KNEES - BILATERAL
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00151
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna Medicare |
$612.00
|
| Rate for Payer: BCBS Complete |
$489.60
|
| Rate for Payer: Cash Price |
$979.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.60
|
| Rate for Payer: UMR Bronson Commercial |
$563.04
|
|
|
THERMAGE NECK
|
Professional
|
Both
|
$1,224.00
|
|
|
Service Code
|
HCPCS 00141
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$489.60 |
| Max. Negotiated Rate |
$795.60 |
| Rate for Payer: Aetna Medicare |
$612.00
|
| Rate for Payer: BCBS Complete |
$489.60
|
| Rate for Payer: Cash Price |
$979.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$795.60
|
| Rate for Payer: UMR Bronson Commercial |
$563.04
|
|
|
THERMAGE THIGH - 1 THIGH
|
Professional
|
Both
|
$1,938.00
|
|
|
Service Code
|
HCPCS 00147
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$775.20 |
| Max. Negotiated Rate |
$1,259.70 |
| Rate for Payer: Aetna Medicare |
$969.00
|
| Rate for Payer: BCBS Complete |
$775.20
|
| Rate for Payer: Cash Price |
$1,550.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,259.70
|
| Rate for Payer: UMR Bronson Commercial |
$891.48
|
|
|
THERMAGE THIGH - BILATERAL
|
Professional
|
Both
|
$3,162.00
|
|
|
Service Code
|
HCPCS 00148
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$1,264.80 |
| Max. Negotiated Rate |
$2,055.30 |
| Rate for Payer: Aetna Medicare |
$1,581.00
|
| Rate for Payer: BCBS Complete |
$1,264.80
|
| Rate for Payer: Cash Price |
$2,529.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,055.30
|
| Rate for Payer: UMR Bronson Commercial |
$1,454.52
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$27.12
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$24.41 |
| Rate for Payer: Aetna American Axle |
$17.63
|
| Rate for Payer: Aetna American Axle |
$18.35
|
| Rate for Payer: Aetna American Axle |
$14.85
|
| Rate for Payer: Aetna American Axle |
$17.89
|
| Rate for Payer: Aetna Commercial |
$24.00
|
| Rate for Payer: Aetna Commercial |
$23.05
|
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Commercial |
$19.41
|
| Rate for Payer: Aetna Medicare |
$13.77
|
| Rate for Payer: Aetna Medicare |
$11.42
|
| Rate for Payer: Aetna Medicare |
$14.12
|
| Rate for Payer: Aetna Medicare |
$13.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.85
|
| Rate for Payer: BCBS Complete |
$9.14
|
| Rate for Payer: BCBS Complete |
$11.29
|
| Rate for Payer: BCBS Complete |
$11.01
|
| Rate for Payer: BCBS Complete |
$10.85
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Cofinity Commercial |
$23.32
|
| Rate for Payer: Cofinity Commercial |
$24.28
|
| Rate for Payer: Cofinity Commercial |
$15.99
|
| 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: Cofinity Commercial |
$18.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| 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: Healthscope Commercial |
$24.78
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Healthscope Commercial |
$24.41
|
| Rate for Payer: Healthscope Commercial |
$25.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.40
|
| Rate for Payer: PHP Commercial |
$23.40
|
| Rate for Payer: PHP Commercial |
$23.05
|
| Rate for Payer: PHP Commercial |
$24.00
|
| Rate for Payer: PHP Commercial |
$19.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.85
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: Priority Health SBD |
$17.78
|
| Rate for Payer: Priority Health SBD |
$17.09
|
| Rate for Payer: Priority Health SBD |
$14.39
|
| Rate for Payer: UMR Bronson Commercial |
$10.19
|
| Rate for Payer: UMR Bronson Commercial |
$10.03
|
| Rate for Payer: UMR Bronson Commercial |
$10.45
|
| Rate for Payer: UMR Bronson Commercial |
$8.45
|
| 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
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.34
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$27.53
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
7876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$24.78 |
| Rate for Payer: Aetna American Axle |
$17.89
|
| Rate for Payer: Aetna American Axle |
$17.63
|
| Rate for Payer: Aetna American Axle |
$14.85
|
| Rate for Payer: Aetna American Axle |
$18.35
|
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Commercial |
$24.00
|
| Rate for Payer: Aetna Commercial |
$23.05
|
| Rate for Payer: Aetna Commercial |
$19.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.89
|
| Rate for Payer: Cash Price |
$21.70
|
| Rate for Payer: Cash Price |
$22.02
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cash Price |
$22.58
|
| Rate for Payer: Cofinity Commercial |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$24.28
|
| Rate for Payer: Cofinity Commercial |
$19.76
|
| Rate for Payer: Cofinity Commercial |
$19.27
|
| 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 |
$19.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| 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: Healthscope Commercial |
$24.78
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Healthscope Commercial |
$24.41
|
| 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 |
$19.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.40
|
| Rate for Payer: PHP Commercial |
$23.40
|
| Rate for Payer: PHP Commercial |
$24.00
|
| Rate for Payer: PHP Commercial |
$19.41
|
| Rate for Payer: PHP Commercial |
$23.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.85
|
| Rate for Payer: Priority Health SBD |
$17.78
|
| Rate for Payer: Priority Health SBD |
$14.39
|
| Rate for Payer: Priority Health SBD |
$17.09
|
| Rate for Payer: Priority Health SBD |
$17.34
|
| Rate for Payer: UMR Bronson Commercial |
$12.11
|
| Rate for Payer: UMR Bronson Commercial |
$12.42
|
| Rate for Payer: UMR Bronson Commercial |
$11.93
|
| Rate for Payer: UMR Bronson Commercial |
$10.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.65
|
|
|
THIAMINE HCL (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 79854020010
|
| Hospital Charge Code |
7877
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.17 |
| 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 |
$74.03
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| 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 HCL (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$105.75
|
|
|
Service Code
|
NDC 79854020010
|
| Hospital Charge Code |
7877
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$95.17 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna Medicare |
$52.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: BCBS Complete |
$42.30
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.03
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$39.13
|
| 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 77333093425
|
| 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: Cofinity Medicare Advantage |
$2.72
|
| 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 Commercial |
$3.30
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| 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
|
$94.00
|
|
|
Service Code
|
NDC 96295013892
|
| 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: Cofinity Medicare Advantage |
$65.80
|
| 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 Commercial |
$79.90
|
| Rate for Payer: PHP Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.10
|
| 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 68094011661
|
| 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: Cofinity Medicare Advantage |
$287.88
|
| 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 Commercial |
$349.56
|
| Rate for Payer: PHP Commercial |
$349.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$267.31
|
| 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
|
OP
|
$411.25
|
|
|
Service Code
|
NDC 68094011661
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.16 |
| Max. Negotiated Rate |
$370.12 |
| Rate for Payer: Aetna American Axle |
$267.31
|
| Rate for Payer: Aetna Commercial |
$349.56
|
| Rate for Payer: Aetna Medicare |
$205.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$267.31
|
| Rate for Payer: BCBS Complete |
$164.50
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$287.88
|
| Rate for Payer: Cofinity Commercial |
$353.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$287.88
|
| 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 Commercial |
$349.56
|
| Rate for Payer: PHP Commercial |
$349.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$267.31
|
| Rate for Payer: Priority Health SBD |
$259.09
|
| Rate for Payer: UMR Bronson Commercial |
$152.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$308.44
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$4.12
|
|
|
Service Code
|
NDC 68094011659
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna American Axle |
$2.68
|
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Aetna Medicare |
$2.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.68
|
| Rate for Payer: BCBS Complete |
$1.65
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Commercial |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.88
|
| 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 Commercial |
$3.50
|
| Rate for Payer: PHP Commercial |
$3.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.68
|
| Rate for Payer: Priority Health SBD |
$2.60
|
| Rate for Payer: UMR Bronson Commercial |
$1.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.09
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
NDC 96295013892
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.78 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna American Axle |
$61.10
|
| Rate for Payer: Aetna Commercial |
$79.90
|
| Rate for Payer: Aetna Medicare |
$47.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.10
|
| Rate for Payer: BCBS Complete |
$37.60
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$80.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.80
|
| 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 Commercial |
$79.90
|
| Rate for Payer: PHP Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.10
|
| Rate for Payer: Priority Health SBD |
$59.22
|
| Rate for Payer: UMR Bronson Commercial |
$34.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.50
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
OP
|
$3.88
|
|
|
Service Code
|
NDC 77333093425
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Aetna Medicare |
$1.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: BCBS Complete |
$1.55
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$3.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.72
|
| 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 Commercial |
$3.30
|
| Rate for Payer: PHP Commercial |
$3.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.91
|
|
|
THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET
|
Facility
|
IP
|
$387.75
|
|
|
Service Code
|
NDC 77333093410
|
| Hospital Charge Code |
119871
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$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 |
$271.43
|
| Rate for Payer: Cofinity Commercial |
$333.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$271.43
|
| 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 |
$271.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$329.59
|
| Rate for Payer: PHP Commercial |
$329.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.04
|
| 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
|
|
