Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$4.05

Service Code	NDC 77333093825
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$3.65
Rate for Payer: Aetna Commercial	$3.44
Rate for Payer: Aetna New Business (MI Preferred)	$2.63
Rate for Payer: Cash Price	$3.24
Rate for Payer: Cofinity Advantage	$2.83
Rate for Payer: Cofinity Commercial	$3.48
Rate for Payer: Encore Health Key Benefits Commercial	$3.24
Rate for Payer: Healthscope Commercial	$3.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.44
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.04
Rate for Payer: PHP Commercial	$3.44
Rate for Payer: Priority Health SBD	$2.55

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$171.55

Service Code	NDC 20555000600
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$108.08
Max. Negotiated Rate	$154.40
Rate for Payer: Aetna Commercial	$145.82
Rate for Payer: Aetna New Business (MI Preferred)	$111.51
Rate for Payer: Cash Price	$137.24
Rate for Payer: Cofinity Advantage	$120.08
Rate for Payer: Cofinity Commercial	$147.53
Rate for Payer: Encore Health Key Benefits Commercial	$137.24
Rate for Payer: Healthscope Commercial	$154.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$145.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$128.66
Rate for Payer: PHP Commercial	$145.82
Rate for Payer: Priority Health SBD	$108.08

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$4.05

Service Code	NDC 77333093825
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$3.65
Rate for Payer: Aetna Commercial	$3.44
Rate for Payer: Aetna Medicare	$2.02
Rate for Payer: Aetna New Business (MI Preferred)	$2.63
Rate for Payer: BCBS Complete	$1.62
Rate for Payer: Cash Price	$3.24
Rate for Payer: Cofinity Advantage	$2.83
Rate for Payer: Cofinity Commercial	$3.48
Rate for Payer: Encore Health Key Benefits Commercial	$3.24
Rate for Payer: Healthscope Commercial	$3.65
Rate for Payer: MI Amish Medical Board Commercial	$3.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.44
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.04
Rate for Payer: PHP Commercial	$3.44
Rate for Payer: Priority Health SBD	$2.55
Rate for Payer: UHC All Payor (Choice/PPO)	$2.63
Rate for Payer: UHC Core	$2.11
Rate for Payer: UHC Exchange	$1.59

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$189.18

Service Code	NDC 50268085515
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$74.35
Max. Negotiated Rate	$170.26
Rate for Payer: Aetna Commercial	$160.80
Rate for Payer: Aetna Medicare	$94.59
Rate for Payer: Aetna New Business (MI Preferred)	$122.97
Rate for Payer: BCBS Complete	$75.67
Rate for Payer: Cash Price	$151.34
Rate for Payer: Cofinity Advantage	$132.43
Rate for Payer: Cofinity Commercial	$162.69
Rate for Payer: Encore Health Key Benefits Commercial	$151.34
Rate for Payer: Healthscope Commercial	$170.26
Rate for Payer: MI Amish Medical Board Commercial	$151.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$160.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$141.88
Rate for Payer: PHP Commercial	$160.80
Rate for Payer: Priority Health SBD	$119.18
Rate for Payer: UHC All Payor (Choice/PPO)	$122.97
Rate for Payer: UHC Core	$98.56
Rate for Payer: UHC Exchange	$74.35

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$404.20

Service Code	NDC 77333093810
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$158.85
Max. Negotiated Rate	$363.78
Rate for Payer: Aetna Commercial	$343.57
Rate for Payer: Aetna Medicare	$202.10
Rate for Payer: Aetna New Business (MI Preferred)	$262.73
Rate for Payer: BCBS Complete	$161.68
Rate for Payer: Cash Price	$323.36
Rate for Payer: Cofinity Advantage	$282.94
Rate for Payer: Cofinity Commercial	$347.61
Rate for Payer: Encore Health Key Benefits Commercial	$323.36
Rate for Payer: Healthscope Commercial	$363.78
Rate for Payer: MI Amish Medical Board Commercial	$323.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$343.57
Rate for Payer: Opus (Opus Packaging Group) HMA	$303.15
Rate for Payer: PHP Commercial	$343.57
Rate for Payer: Priority Health SBD	$254.65
Rate for Payer: UHC All Payor (Choice/PPO)	$262.73
Rate for Payer: UHC Core	$210.59
Rate for Payer: UHC Exchange	$158.85

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$189.18

Service Code	NDC 50268085515
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$119.18
Max. Negotiated Rate	$170.26
Rate for Payer: Aetna Commercial	$160.80
Rate for Payer: Aetna New Business (MI Preferred)	$122.97
Rate for Payer: Cash Price	$151.34
Rate for Payer: Cofinity Advantage	$132.43
Rate for Payer: Cofinity Commercial	$162.69
Rate for Payer: Encore Health Key Benefits Commercial	$151.34
Rate for Payer: Healthscope Commercial	$170.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$160.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$141.88
Rate for Payer: PHP Commercial	$160.80
Rate for Payer: Priority Health SBD	$119.18

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$404.20

Service Code	NDC 77333093810
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$254.65
Max. Negotiated Rate	$363.78
Rate for Payer: Aetna Commercial	$343.57
Rate for Payer: Aetna New Business (MI Preferred)	$262.73
Rate for Payer: Cash Price	$323.36
Rate for Payer: Cofinity Advantage	$282.94
Rate for Payer: Cofinity Commercial	$347.61
Rate for Payer: Encore Health Key Benefits Commercial	$323.36
Rate for Payer: Healthscope Commercial	$363.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$343.57
Rate for Payer: Opus (Opus Packaging Group) HMA	$303.15
Rate for Payer: PHP Commercial	$343.57
Rate for Payer: Priority Health SBD	$254.65

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$3.79

Service Code	NDC 50268085511
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$3.41
Rate for Payer: Aetna Commercial	$3.22
Rate for Payer: Aetna New Business (MI Preferred)	$2.46
Rate for Payer: Cash Price	$3.03
Rate for Payer: Cofinity Advantage	$2.65
Rate for Payer: Cofinity Commercial	$3.26
Rate for Payer: Encore Health Key Benefits Commercial	$3.03
Rate for Payer: Healthscope Commercial	$3.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.22
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.84
Rate for Payer: PHP Commercial	$3.22
Rate for Payer: Priority Health SBD	$2.39

CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET

Facility

$171.55

Service Code	NDC 20555000600
Hospital Charge Code	2009
Hospital Revenue Code	637
Min. Negotiated Rate	$67.42
Max. Negotiated Rate	$154.40
Rate for Payer: Aetna Commercial	$145.82
Rate for Payer: Aetna Medicare	$85.78
Rate for Payer: Aetna New Business (MI Preferred)	$111.51
Rate for Payer: BCBS Complete	$68.62
Rate for Payer: Cash Price	$137.24
Rate for Payer: Cofinity Advantage	$120.08
Rate for Payer: Cofinity Commercial	$147.53
Rate for Payer: Encore Health Key Benefits Commercial	$137.24
Rate for Payer: Healthscope Commercial	$154.40
Rate for Payer: MI Amish Medical Board Commercial	$137.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$145.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$128.66
Rate for Payer: PHP Commercial	$145.82
Rate for Payer: Priority Health SBD	$108.08
Rate for Payer: UHC All Payor (Choice/PPO)	$111.51
Rate for Payer: UHC Core	$89.38
Rate for Payer: UHC Exchange	$67.42

CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET

Facility

$88.00

Service Code	NDC 50268085215
Hospital Charge Code	2008
Hospital Revenue Code	637
Min. Negotiated Rate	$34.58
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna Commercial	$74.80
Rate for Payer: Aetna Medicare	$44.00
Rate for Payer: Aetna New Business (MI Preferred)	$57.20
Rate for Payer: BCBS Complete	$35.20
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cofinity Advantage	$61.60
Rate for Payer: Cofinity Commercial	$75.68
Rate for Payer: Encore Health Key Benefits Commercial	$70.40
Rate for Payer: Healthscope Commercial	$79.20
Rate for Payer: MI Amish Medical Board Commercial	$70.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$74.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.00
Rate for Payer: PHP Commercial	$74.80
Rate for Payer: Priority Health SBD	$55.44
Rate for Payer: UHC All Payor (Choice/PPO)	$57.20
Rate for Payer: UHC Core	$45.85
Rate for Payer: UHC Exchange	$34.58

CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET

Facility

$1.76

Service Code	NDC 50268085211
Hospital Charge Code	2008
Hospital Revenue Code	637
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna Commercial	$1.50
Rate for Payer: Aetna New Business (MI Preferred)	$1.14
Rate for Payer: Cash Price	$1.41
Rate for Payer: Cofinity Advantage	$1.23
Rate for Payer: Cofinity Commercial	$1.51
Rate for Payer: Encore Health Key Benefits Commercial	$1.41
Rate for Payer: Healthscope Commercial	$1.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.32
Rate for Payer: PHP Commercial	$1.50
Rate for Payer: Priority Health SBD	$1.11

CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET

Facility

$1.76

Service Code	NDC 50268085211
Hospital Charge Code	2008
Hospital Revenue Code	637
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna Commercial	$1.50
Rate for Payer: Aetna Medicare	$0.88
Rate for Payer: Aetna New Business (MI Preferred)	$1.14
Rate for Payer: BCBS Complete	$0.70
Rate for Payer: Cash Price	$1.41
Rate for Payer: Cofinity Advantage	$1.23
Rate for Payer: Cofinity Commercial	$1.51
Rate for Payer: Encore Health Key Benefits Commercial	$1.41
Rate for Payer: Healthscope Commercial	$1.58
Rate for Payer: MI Amish Medical Board Commercial	$1.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.32
Rate for Payer: PHP Commercial	$1.50
Rate for Payer: Priority Health SBD	$1.11
Rate for Payer: UHC All Payor (Choice/PPO)	$1.14
Rate for Payer: UHC Core	$0.92
Rate for Payer: UHC Exchange	$0.69

CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET

Facility

$88.00

Service Code	NDC 50268085215
Hospital Charge Code	2008
Hospital Revenue Code	637
Min. Negotiated Rate	$55.44
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna Commercial	$74.80
Rate for Payer: Aetna New Business (MI Preferred)	$57.20
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cofinity Advantage	$61.60
Rate for Payer: Cofinity Commercial	$75.68
Rate for Payer: Encore Health Key Benefits Commercial	$70.40
Rate for Payer: Healthscope Commercial	$79.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$74.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.00
Rate for Payer: PHP Commercial	$74.80
Rate for Payer: Priority Health SBD	$55.44

CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET

Facility

$3.81

Service Code	NDC 50268085311
Hospital Charge Code	2010
Hospital Revenue Code	637
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.43
Rate for Payer: Aetna Commercial	$3.24
Rate for Payer: Aetna New Business (MI Preferred)	$2.48
Rate for Payer: Cash Price	$3.05
Rate for Payer: Cofinity Advantage	$2.67
Rate for Payer: Cofinity Commercial	$3.28
Rate for Payer: Encore Health Key Benefits Commercial	$3.05
Rate for Payer: Healthscope Commercial	$3.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.86
Rate for Payer: PHP Commercial	$3.24
Rate for Payer: Priority Health SBD	$2.40

CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET

Facility

$190.35

Service Code	NDC 50268085315
Hospital Charge Code	2010
Hospital Revenue Code	637
Min. Negotiated Rate	$74.81
Max. Negotiated Rate	$171.31
Rate for Payer: Aetna Commercial	$161.80
Rate for Payer: Aetna Medicare	$95.17
Rate for Payer: Aetna New Business (MI Preferred)	$123.73
Rate for Payer: BCBS Complete	$76.14
Rate for Payer: Cash Price	$152.28
Rate for Payer: Cofinity Advantage	$133.25
Rate for Payer: Cofinity Commercial	$163.70
Rate for Payer: Encore Health Key Benefits Commercial	$152.28
Rate for Payer: Healthscope Commercial	$171.31
Rate for Payer: MI Amish Medical Board Commercial	$152.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$142.76
Rate for Payer: PHP Commercial	$161.80
Rate for Payer: Priority Health SBD	$119.92
Rate for Payer: UHC All Payor (Choice/PPO)	$123.73
Rate for Payer: UHC Core	$99.17
Rate for Payer: UHC Exchange	$74.81

CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET

Facility

$42.77

Service Code	NDC 80681016500
Hospital Charge Code	2010
Hospital Revenue Code	637
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$38.49
Rate for Payer: Aetna Commercial	$36.35
Rate for Payer: Aetna New Business (MI Preferred)	$27.80
Rate for Payer: Cash Price	$34.22
Rate for Payer: Cofinity Advantage	$29.94
Rate for Payer: Cofinity Commercial	$36.78
Rate for Payer: Encore Health Key Benefits Commercial	$34.22
Rate for Payer: Healthscope Commercial	$38.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.35
Rate for Payer: Opus (Opus Packaging Group) HMA	$32.08
Rate for Payer: PHP Commercial	$36.35
Rate for Payer: Priority Health SBD	$26.95

CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET

Facility

$42.77

Service Code	NDC 80681016500
Hospital Charge Code	2010
Hospital Revenue Code	637
Min. Negotiated Rate	$16.81
Max. Negotiated Rate	$38.49
Rate for Payer: Aetna Commercial	$36.35
Rate for Payer: Aetna Medicare	$21.39
Rate for Payer: Aetna New Business (MI Preferred)	$27.80
Rate for Payer: BCBS Complete	$17.11
Rate for Payer: Cash Price	$34.22
Rate for Payer: Cofinity Advantage	$29.94
Rate for Payer: Cofinity Commercial	$36.78
Rate for Payer: Encore Health Key Benefits Commercial	$34.22
Rate for Payer: Healthscope Commercial	$38.49
Rate for Payer: MI Amish Medical Board Commercial	$34.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.35
Rate for Payer: Opus (Opus Packaging Group) HMA	$32.08
Rate for Payer: PHP Commercial	$36.35
Rate for Payer: Priority Health SBD	$26.95
Rate for Payer: UHC All Payor (Choice/PPO)	$27.80
Rate for Payer: UHC Core	$22.28
Rate for Payer: UHC Exchange	$16.81

CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET

Facility

$190.35

Service Code	NDC 50268085315
Hospital Charge Code	2010
Hospital Revenue Code	637
Min. Negotiated Rate	$119.92
Max. Negotiated Rate	$171.31
Rate for Payer: Aetna Commercial	$161.80
Rate for Payer: Aetna New Business (MI Preferred)	$123.73
Rate for Payer: Cash Price	$152.28
Rate for Payer: Cofinity Advantage	$133.25
Rate for Payer: Cofinity Commercial	$163.70
Rate for Payer: Encore Health Key Benefits Commercial	$152.28
Rate for Payer: Healthscope Commercial	$171.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$142.76
Rate for Payer: PHP Commercial	$161.80
Rate for Payer: Priority Health SBD	$119.92

CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET

Facility

$3.81

Service Code	NDC 50268085311
Hospital Charge Code	2010
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$3.43
Rate for Payer: Aetna Commercial	$3.24
Rate for Payer: Aetna Medicare	$1.91
Rate for Payer: Aetna New Business (MI Preferred)	$2.48
Rate for Payer: BCBS Complete	$1.52
Rate for Payer: Cash Price	$3.05
Rate for Payer: Cofinity Advantage	$2.67
Rate for Payer: Cofinity Commercial	$3.28
Rate for Payer: Encore Health Key Benefits Commercial	$3.05
Rate for Payer: Healthscope Commercial	$3.43
Rate for Payer: MI Amish Medical Board Commercial	$3.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.86
Rate for Payer: PHP Commercial	$3.24
Rate for Payer: Priority Health SBD	$2.40
Rate for Payer: UHC All Payor (Choice/PPO)	$2.48
Rate for Payer: UHC Core	$1.99
Rate for Payer: UHC Exchange	$1.50

CYCLOBENZAPRINE 10 MG TABLET

Facility

$51.70

Service Code	NDC 69097084607
Hospital Charge Code	2017
Hospital Revenue Code	637
Min. Negotiated Rate	$32.57
Max. Negotiated Rate	$46.53
Rate for Payer: Aetna Commercial	$43.95
Rate for Payer: Aetna New Business (MI Preferred)	$33.60
Rate for Payer: Cash Price	$41.36
Rate for Payer: Cofinity Advantage	$36.19
Rate for Payer: Cofinity Commercial	$44.46
Rate for Payer: Encore Health Key Benefits Commercial	$41.36
Rate for Payer: Healthscope Commercial	$46.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$38.77
Rate for Payer: PHP Commercial	$43.95
Rate for Payer: Priority Health SBD	$32.57

CYCLOBENZAPRINE 10 MG TABLET

Facility

$51.70

Service Code	NDC 69097084607
Hospital Charge Code	2017
Hospital Revenue Code	637
Min. Negotiated Rate	$20.32
Max. Negotiated Rate	$46.53
Rate for Payer: Aetna Commercial	$43.95
Rate for Payer: Aetna Medicare	$25.85
Rate for Payer: Aetna New Business (MI Preferred)	$33.60
Rate for Payer: BCBS Complete	$20.68
Rate for Payer: Cash Price	$41.36
Rate for Payer: Cofinity Advantage	$36.19
Rate for Payer: Cofinity Commercial	$44.46
Rate for Payer: Encore Health Key Benefits Commercial	$41.36
Rate for Payer: Healthscope Commercial	$46.53
Rate for Payer: MI Amish Medical Board Commercial	$41.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$38.77
Rate for Payer: PHP Commercial	$43.95
Rate for Payer: Priority Health SBD	$32.57
Rate for Payer: UHC All Payor (Choice/PPO)	$33.60
Rate for Payer: UHC Core	$26.94
Rate for Payer: UHC Exchange	$20.32

CYCLOPENTOLATE 1 % EYE DROPS

Facility

$16.97

Service Code	NDC 61314039601
Hospital Charge Code	2025
Hospital Revenue Code	637
Min. Negotiated Rate	$6.67
Max. Negotiated Rate	$15.27
Rate for Payer: Aetna Commercial	$14.42
Rate for Payer: Aetna Medicare	$8.48
Rate for Payer: Aetna New Business (MI Preferred)	$11.03
Rate for Payer: BCBS Complete	$6.79
Rate for Payer: Cash Price	$13.58
Rate for Payer: Cofinity Advantage	$11.88
Rate for Payer: Cofinity Commercial	$14.59
Rate for Payer: Encore Health Key Benefits Commercial	$13.58
Rate for Payer: Healthscope Commercial	$15.27
Rate for Payer: MI Amish Medical Board Commercial	$13.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$14.42
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.73
Rate for Payer: PHP Commercial	$14.42
Rate for Payer: Priority Health SBD	$10.69
Rate for Payer: UHC All Payor (Choice/PPO)	$11.03
Rate for Payer: UHC Core	$8.84
Rate for Payer: UHC Exchange	$6.67

CYCLOPENTOLATE 1 % EYE DROPS

Facility

$110.01

Service Code	NDC 00065039602
Hospital Charge Code	2025
Hospital Revenue Code	637
Min. Negotiated Rate	$43.23
Max. Negotiated Rate	$99.01
Rate for Payer: Aetna Commercial	$93.51
Rate for Payer: Aetna Medicare	$55.01
Rate for Payer: Aetna New Business (MI Preferred)	$71.51
Rate for Payer: BCBS Complete	$44.00
Rate for Payer: Cash Price	$88.01
Rate for Payer: Cofinity Advantage	$77.01
Rate for Payer: Cofinity Commercial	$94.61
Rate for Payer: Encore Health Key Benefits Commercial	$88.01
Rate for Payer: Healthscope Commercial	$99.01
Rate for Payer: MI Amish Medical Board Commercial	$88.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$82.51
Rate for Payer: PHP Commercial	$93.51
Rate for Payer: Priority Health SBD	$69.31
Rate for Payer: UHC All Payor (Choice/PPO)	$71.51
Rate for Payer: UHC Core	$57.32
Rate for Payer: UHC Exchange	$43.23

CYCLOPENTOLATE 1 % EYE DROPS

Facility

$16.97

Service Code	NDC 61314039601
Hospital Charge Code	2025
Hospital Revenue Code	637
Min. Negotiated Rate	$10.69
Max. Negotiated Rate	$15.27
Rate for Payer: Aetna Commercial	$14.42
Rate for Payer: Aetna New Business (MI Preferred)	$11.03
Rate for Payer: Cash Price	$13.58
Rate for Payer: Cofinity Advantage	$11.88
Rate for Payer: Cofinity Commercial	$14.59
Rate for Payer: Encore Health Key Benefits Commercial	$13.58
Rate for Payer: Healthscope Commercial	$15.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$14.42
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.73
Rate for Payer: PHP Commercial	$14.42
Rate for Payer: Priority Health SBD	$10.69

CYCLOPENTOLATE 1 % EYE DROPS

Facility

$18.86

Service Code	NDC 17478010002
Hospital Charge Code	2025
Hospital Revenue Code	637
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$16.97
Rate for Payer: Aetna Commercial	$16.03
Rate for Payer: Aetna New Business (MI Preferred)	$12.26
Rate for Payer: Cash Price	$15.09
Rate for Payer: Cofinity Advantage	$13.20
Rate for Payer: Cofinity Commercial	$16.22
Rate for Payer: Encore Health Key Benefits Commercial	$15.09
Rate for Payer: Healthscope Commercial	$16.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$14.14
Rate for Payer: PHP Commercial	$16.03
Rate for Payer: Priority Health SBD	$11.88

Know your out-of-pocket cost for care.

All Charges