|
TESTOSTERONE 1 % (50 MG/5 GRAM) TRANSDERMAL GEL PACKET
|
Facility
|
OP
|
$65.89
|
|
|
Service Code
|
NDC 00051845030
|
| Hospital Charge Code |
36093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.38 |
| Max. Negotiated Rate |
$59.30 |
| Rate for Payer: Aetna American Axle |
$42.83
|
| Rate for Payer: Aetna Commercial |
$56.01
|
| Rate for Payer: Aetna Medicare |
$32.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.83
|
| Rate for Payer: BCBS Complete |
$26.36
|
| Rate for Payer: Cash Price |
$52.71
|
| Rate for Payer: Cofinity Commercial |
$46.12
|
| Rate for Payer: Cofinity Commercial |
$56.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.71
|
| Rate for Payer: Healthscope Commercial |
$59.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.01
|
| Rate for Payer: PHP Commercial |
$56.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.83
|
| Rate for Payer: Priority Health SBD |
$41.51
|
| Rate for Payer: UMR Bronson Commercial |
$24.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.42
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
IP
|
$110.40
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.58 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna American Axle |
$71.76
|
| Rate for Payer: Aetna American Axle |
$40.66
|
| Rate for Payer: Aetna Commercial |
$93.84
|
| Rate for Payer: Aetna Commercial |
$53.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.66
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cash Price |
$50.04
|
| Rate for Payer: Cofinity Commercial |
$53.79
|
| Rate for Payer: Cofinity Commercial |
$43.78
|
| Rate for Payer: Cofinity Commercial |
$77.28
|
| Rate for Payer: Cofinity Commercial |
$94.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.04
|
| Rate for Payer: Healthscope Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$56.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$43.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.84
|
| Rate for Payer: PHP Commercial |
$53.17
|
| Rate for Payer: PHP Commercial |
$93.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.66
|
| Rate for Payer: Priority Health SBD |
$69.55
|
| Rate for Payer: Priority Health SBD |
$39.41
|
| Rate for Payer: UMR Bronson Commercial |
$48.58
|
| Rate for Payer: UMR Bronson Commercial |
$27.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.91
|
|
|
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL
|
Facility
|
OP
|
$110.40
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
7784
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna American Axle |
$71.76
|
| Rate for Payer: Aetna American Axle |
$263.58
|
| Rate for Payer: Aetna American Axle |
$57.23
|
| Rate for Payer: Aetna American Axle |
$63.47
|
| Rate for Payer: Aetna American Axle |
$369.66
|
| Rate for Payer: Aetna American Axle |
$42.32
|
| Rate for Payer: Aetna American Axle |
$40.66
|
| Rate for Payer: Aetna Commercial |
$53.17
|
| Rate for Payer: Aetna Commercial |
$83.00
|
| Rate for Payer: Aetna Commercial |
$55.34
|
| Rate for Payer: Aetna Commercial |
$74.84
|
| Rate for Payer: Aetna Commercial |
$483.40
|
| Rate for Payer: Aetna Commercial |
$93.84
|
| Rate for Payer: Aetna Commercial |
$344.68
|
| Rate for Payer: Aetna Medicare |
$31.28
|
| Rate for Payer: Aetna Medicare |
$32.55
|
| Rate for Payer: Aetna Medicare |
$202.75
|
| Rate for Payer: Aetna Medicare |
$44.02
|
| Rate for Payer: Aetna Medicare |
$284.35
|
| Rate for Payer: Aetna Medicare |
$55.20
|
| Rate for Payer: Aetna Medicare |
$48.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$369.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.23
|
| Rate for Payer: BCBS Complete |
$26.04
|
| Rate for Payer: BCBS Complete |
$162.20
|
| Rate for Payer: BCBS Complete |
$227.48
|
| Rate for Payer: BCBS Complete |
$44.16
|
| Rate for Payer: BCBS Complete |
$39.06
|
| Rate for Payer: BCBS Complete |
$35.22
|
| Rate for Payer: BCBS Complete |
$25.02
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCBS Trust/PPO |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: BCN Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cash Price |
$324.40
|
| Rate for Payer: Cash Price |
$454.96
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cash Price |
$324.40
|
| Rate for Payer: Cash Price |
$88.32
|
| Rate for Payer: Cash Price |
$454.96
|
| Rate for Payer: Cash Price |
$50.04
|
| Rate for Payer: Cash Price |
$50.04
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cash Price |
$70.44
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cofinity Commercial |
$283.85
|
| Rate for Payer: Cofinity Commercial |
$83.98
|
| Rate for Payer: Cofinity Commercial |
$45.57
|
| Rate for Payer: Cofinity Commercial |
$94.94
|
| Rate for Payer: Cofinity Commercial |
$489.08
|
| Rate for Payer: Cofinity Commercial |
$68.36
|
| Rate for Payer: Cofinity Commercial |
$77.28
|
| Rate for Payer: Cofinity Commercial |
$55.99
|
| Rate for Payer: Cofinity Commercial |
$398.09
|
| Rate for Payer: Cofinity Commercial |
$75.72
|
| Rate for Payer: Cofinity Commercial |
$61.64
|
| Rate for Payer: Cofinity Commercial |
$348.73
|
| Rate for Payer: Cofinity Commercial |
$43.78
|
| Rate for Payer: Cofinity Commercial |
$53.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$45.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$398.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$283.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$324.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$454.96
|
| Rate for Payer: Healthscope Commercial |
$56.30
|
| Rate for Payer: Healthscope Commercial |
$87.88
|
| Rate for Payer: Healthscope Commercial |
$58.59
|
| Rate for Payer: Healthscope Commercial |
$99.36
|
| Rate for Payer: Healthscope Commercial |
$364.95
|
| Rate for Payer: Healthscope Commercial |
$511.83
|
| Rate for Payer: Healthscope Commercial |
$79.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$43.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$283.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$398.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$426.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$483.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$344.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: PHP Commercial |
$344.68
|
| Rate for Payer: PHP Commercial |
$53.17
|
| Rate for Payer: PHP Commercial |
$83.00
|
| Rate for Payer: PHP Commercial |
$483.40
|
| Rate for Payer: PHP Commercial |
$93.84
|
| Rate for Payer: PHP Commercial |
$55.34
|
| Rate for Payer: PHP Commercial |
$74.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$369.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.47
|
| Rate for Payer: Priority Health SBD |
$39.41
|
| Rate for Payer: Priority Health SBD |
$41.01
|
| Rate for Payer: Priority Health SBD |
$61.52
|
| Rate for Payer: Priority Health SBD |
$55.47
|
| Rate for Payer: Priority Health SBD |
$255.46
|
| Rate for Payer: Priority Health SBD |
$358.28
|
| Rate for Payer: Priority Health SBD |
$69.55
|
| Rate for Payer: UMR Bronson Commercial |
$24.09
|
| Rate for Payer: UMR Bronson Commercial |
$210.42
|
| Rate for Payer: UMR Bronson Commercial |
$40.85
|
| Rate for Payer: UMR Bronson Commercial |
$150.04
|
| Rate for Payer: UMR Bronson Commercial |
$23.14
|
| Rate for Payer: UMR Bronson Commercial |
$32.58
|
| Rate for Payer: UMR Bronson Commercial |
$36.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$426.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.04
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
IP
|
$1,678.15
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$738.39 |
| Max. Negotiated Rate |
$1,510.34 |
| Rate for Payer: Aetna American Axle |
$1,090.80
|
| Rate for Payer: Aetna Commercial |
$1,426.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,090.80
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cofinity Commercial |
$1,174.70
|
| Rate for Payer: Cofinity Commercial |
$1,443.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,174.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,342.52
|
| Rate for Payer: Healthscope Commercial |
$1,510.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,174.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,258.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,426.43
|
| Rate for Payer: PHP Commercial |
$1,426.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,090.80
|
| Rate for Payer: Priority Health SBD |
$1,057.23
|
| Rate for Payer: UMR Bronson Commercial |
$738.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,258.61
|
|
|
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE
|
Facility
|
OP
|
$1,678.15
|
|
|
Service Code
|
HCPCS J1670
|
| Hospital Charge Code |
118208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$306.63 |
| Max. Negotiated Rate |
$1,716.21 |
| Rate for Payer: Aetna American Axle |
$1,090.80
|
| Rate for Payer: Aetna Commercial |
$1,426.43
|
| Rate for Payer: Aetna Medicare |
$594.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,090.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$715.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$715.09
|
| Rate for Payer: BCBS Complete |
$321.96
|
| Rate for Payer: BCBS MAPPO |
$572.07
|
| Rate for Payer: BCBS Trust/PPO |
$1,568.65
|
| Rate for Payer: BCN Commercial |
$1,568.65
|
| Rate for Payer: BCN Medicare Advantage |
$572.07
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cash Price |
$1,342.52
|
| Rate for Payer: Cofinity Commercial |
$1,443.21
|
| Rate for Payer: Cofinity Commercial |
$1,174.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,174.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,342.52
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$572.07
|
| Rate for Payer: Healthscope Commercial |
$1,510.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,174.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,258.61
|
| Rate for Payer: Mclaren Medicaid |
$306.63
|
| Rate for Payer: Mclaren Medicare |
$572.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$600.67
|
| Rate for Payer: Meridian Medicaid |
$321.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$657.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,426.43
|
| Rate for Payer: Nomi Health Commercial |
$1,716.21
|
| Rate for Payer: PACE Medicare |
$543.47
|
| Rate for Payer: PACE SWMI |
$572.07
|
| Rate for Payer: PHP Commercial |
$1,426.43
|
| Rate for Payer: PHP Medicare Advantage |
$572.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$306.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,090.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,674.36
|
| Rate for Payer: Priority Health Medicare |
$572.07
|
| Rate for Payer: Priority Health Narrow Network |
$1,339.49
|
| Rate for Payer: Priority Health SBD |
$1,057.23
|
| Rate for Payer: Railroad Medicare Medicare |
$572.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,610.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$572.07
|
| Rate for Payer: UHC Exchange |
$1,093.28
|
| Rate for Payer: UHC Medicare Advantage |
$572.07
|
| Rate for Payer: UHCCP Medicaid |
$306.63
|
| Rate for Payer: UMR Bronson Commercial |
$620.92
|
| Rate for Payer: VA VA |
$572.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,258.61
|
|
|
TETRACAINE 0.5 % EYE DROPS
|
Facility
|
IP
|
$88.03
|
|
|
Service Code
|
NDC 68682092005
|
| Hospital Charge Code |
7795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$79.23 |
| Rate for Payer: Aetna American Axle |
$57.22
|
| Rate for Payer: Aetna Commercial |
$74.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.22
|
| Rate for Payer: Cash Price |
$70.42
|
| Rate for Payer: Cofinity Commercial |
$61.62
|
| Rate for Payer: Cofinity Commercial |
$75.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.42
|
| Rate for Payer: Healthscope Commercial |
$79.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.83
|
| Rate for Payer: PHP Commercial |
$74.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.22
|
| Rate for Payer: Priority Health SBD |
$55.46
|
| Rate for Payer: UMR Bronson Commercial |
$38.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.02
|
|
|
TETRACAINE 0.5 % EYE DROPS
|
Facility
|
OP
|
$88.03
|
|
|
Service Code
|
NDC 68682092005
|
| Hospital Charge Code |
7795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$79.23 |
| Rate for Payer: Aetna American Axle |
$57.22
|
| Rate for Payer: Aetna Commercial |
$74.83
|
| Rate for Payer: Aetna Medicare |
$44.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.22
|
| Rate for Payer: BCBS Complete |
$35.21
|
| Rate for Payer: Cash Price |
$70.42
|
| Rate for Payer: Cofinity Commercial |
$61.62
|
| Rate for Payer: Cofinity Commercial |
$75.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.42
|
| Rate for Payer: Healthscope Commercial |
$79.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.83
|
| Rate for Payer: PHP Commercial |
$74.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.22
|
| Rate for Payer: Priority Health SBD |
$55.46
|
| Rate for Payer: UMR Bronson Commercial |
$32.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.02
|
|
|
TETRACAINE HCL (BULK) POWDER
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 51552026909
|
| Hospital Charge Code |
13583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Aetna American Axle |
$18.20
|
| Rate for Payer: Aetna Commercial |
$23.80
|
| Rate for Payer: Aetna Medicare |
$14.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.20
|
| Rate for Payer: BCBS Complete |
$11.20
|
| Rate for Payer: Cash Price |
$22.40
|
| Rate for Payer: Cofinity Commercial |
$19.60
|
| Rate for Payer: Cofinity Commercial |
$24.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.40
|
| Rate for Payer: Healthscope Commercial |
$25.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.80
|
| Rate for Payer: PHP Commercial |
$23.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.20
|
| Rate for Payer: Priority Health SBD |
$17.64
|
| Rate for Payer: UMR Bronson Commercial |
$10.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.00
|
|
|
TETRACAINE HCL (BULK) POWDER
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 51552026909
|
| Hospital Charge Code |
13583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$25.20 |
| Rate for Payer: Aetna American Axle |
$18.20
|
| Rate for Payer: Aetna Commercial |
$23.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.20
|
| Rate for Payer: Cash Price |
$22.40
|
| Rate for Payer: Cofinity Commercial |
$19.60
|
| Rate for Payer: Cofinity Commercial |
$24.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.40
|
| Rate for Payer: Healthscope Commercial |
$25.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.80
|
| Rate for Payer: PHP Commercial |
$23.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.20
|
| Rate for Payer: Priority Health SBD |
$17.64
|
| Rate for Payer: UMR Bronson Commercial |
$12.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.00
|
|
|
TETRACAINE HCL (BULK) POWDER
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
NDC 62991206702
|
| Hospital Charge Code |
13583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.52 |
| Max. Negotiated Rate |
$356.40 |
| Rate for Payer: Aetna American Axle |
$257.40
|
| Rate for Payer: Aetna Commercial |
$336.60
|
| Rate for Payer: Aetna Medicare |
$198.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.40
|
| Rate for Payer: BCBS Complete |
$158.40
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Cofinity Commercial |
$277.20
|
| Rate for Payer: Cofinity Commercial |
$340.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.80
|
| Rate for Payer: Healthscope Commercial |
$356.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.60
|
| Rate for Payer: PHP Commercial |
$336.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.40
|
| Rate for Payer: Priority Health SBD |
$249.48
|
| Rate for Payer: UMR Bronson Commercial |
$146.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.00
|
|
|
TETRACAINE HCL (BULK) POWDER
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
NDC 62991206702
|
| Hospital Charge Code |
13583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.24 |
| Max. Negotiated Rate |
$356.40 |
| Rate for Payer: Aetna American Axle |
$257.40
|
| Rate for Payer: Aetna Commercial |
$336.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.40
|
| Rate for Payer: Cash Price |
$316.80
|
| Rate for Payer: Cofinity Commercial |
$277.20
|
| Rate for Payer: Cofinity Commercial |
$340.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.80
|
| Rate for Payer: Healthscope Commercial |
$356.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.60
|
| Rate for Payer: PHP Commercial |
$336.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.40
|
| Rate for Payer: Priority Health SBD |
$249.48
|
| Rate for Payer: UMR Bronson Commercial |
$174.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.00
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
IP
|
$38.25
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$34.42 |
| Rate for Payer: Aetna American Axle |
$24.86
|
| Rate for Payer: Aetna Commercial |
$32.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.86
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cofinity Commercial |
$26.78
|
| Rate for Payer: Cofinity Commercial |
$32.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.60
|
| Rate for Payer: Healthscope Commercial |
$34.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.51
|
| Rate for Payer: PHP Commercial |
$32.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.86
|
| Rate for Payer: Priority Health SBD |
$24.10
|
| Rate for Payer: UMR Bronson Commercial |
$16.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.69
|
|
|
TETRACAINE HCL (PF) 0.5 % EYE DROPS
|
Facility
|
OP
|
$38.25
|
|
|
Service Code
|
NDC 00065074114
|
| Hospital Charge Code |
151946
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.15 |
| Max. Negotiated Rate |
$34.42 |
| Rate for Payer: Aetna American Axle |
$24.86
|
| Rate for Payer: Aetna Commercial |
$32.51
|
| Rate for Payer: Aetna Medicare |
$19.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.86
|
| Rate for Payer: BCBS Complete |
$15.30
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cofinity Commercial |
$26.78
|
| Rate for Payer: Cofinity Commercial |
$32.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.60
|
| Rate for Payer: Healthscope Commercial |
$34.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.51
|
| Rate for Payer: PHP Commercial |
$32.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.86
|
| Rate for Payer: Priority Health SBD |
$24.10
|
| Rate for Payer: UMR Bronson Commercial |
$14.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.69
|
|
|
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
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$155.20
|
|
|
Service Code
|
NDC 54288012701
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Aetna American Axle |
$100.88
|
| Rate for Payer: Aetna Commercial |
$131.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.88
|
| Rate for Payer: Cash Price |
$124.16
|
| Rate for Payer: Cofinity Commercial |
$108.64
|
| Rate for Payer: Cofinity Commercial |
$133.47
|
| Rate for Payer: 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 |
$68.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.40
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
IP
|
$155.20
|
|
|
Service Code
|
NDC 54288012710
|
| Hospital Charge Code |
11517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Aetna American Axle |
$100.88
|
| Rate for Payer: Aetna Commercial |
$131.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.88
|
| Rate for Payer: Cash Price |
$124.16
|
| Rate for Payer: Cofinity Commercial |
$108.64
|
| Rate for Payer: Cofinity Commercial |
$133.47
|
| Rate for Payer: 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 |
$68.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.40
|
|
|
TETRACAINE HCL (PF) 1 % (10 MG/ML) INJECTION SOLUTION
|
Facility
|
OP
|
$155.20
|
|
|
Service Code
|
NDC 54288012701
|
| 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
|
|
|
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 Commercial |
$175.51
|
| Rate for Payer: Cofinity Commercial |
$215.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.51
|
| 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: PHP Commercial |
$213.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.97
|
| 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 Commercial |
$175.51
|
| Rate for Payer: Cofinity Commercial |
$215.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$175.51
|
| 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: PHP Commercial |
$213.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.97
|
| Rate for Payer: Priority Health SBD |
$157.96
|
| Rate for Payer: UMR Bronson Commercial |
$92.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.05
|
|
|
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
|
|
|
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
|
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
|
$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
|
|
|
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
|
|
|
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 |
$9.73 |
| Max. Negotiated Rate |
$10,222.34 |
| Rate for Payer: Aetna Commercial |
$9,654.44
|
| Rate for Payer: Aetna Medicare |
$18.89
|
| Rate for Payer: Aetna American Axle |
$7,382.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,382.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.70
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.70
|
| Rate for Payer: BCBS Complete |
$10.22
|
| Rate for Payer: BCBS MAPPO |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$48.83
|
| Rate for Payer: BCN Commercial |
$48.83
|
| Rate for Payer: BCN Medicare Advantage |
$18.16
|
| 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 |
$18.16
|
| 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 |
$9.73
|
| Rate for Payer: Mclaren Medicare |
$18.16
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.07
|
| Rate for Payer: Meridian Medicaid |
$10.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,654.44
|
| Rate for Payer: Nomi Health Commercial |
$54.48
|
| Rate for Payer: PACE Medicare |
$17.25
|
| Rate for Payer: PACE SWMI |
$18.16
|
| Rate for Payer: PHP Commercial |
$9,654.44
|
| Rate for Payer: PHP Medicare Advantage |
$18.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$9.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,382.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$52.12
|
| Rate for Payer: Priority Health Medicare |
$18.16
|
| Rate for Payer: Priority Health Narrow Network |
$41.70
|
| Rate for Payer: Priority Health SBD |
$7,155.64
|
| Rate for Payer: Railroad Medicare Medicare |
$18.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.16
|
| Rate for Payer: UHC Exchange |
$34.71
|
| Rate for Payer: UHC Medicare Advantage |
$18.16
|
| Rate for Payer: UHCCP Medicaid |
$9.73
|
| Rate for Payer: UMR Bronson Commercial |
$4,202.52
|
| Rate for Payer: VA VA |
$18.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,518.62
|
|
