|
CPT 0255T
|
Professional
|
Both
|
$455.00
|
|
|
Service Code
|
HCPCS 0255T
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$295.75 |
| Rate for Payer: Aetna Medicare |
$227.50
|
| Rate for Payer: BCBS Complete |
$182.00
|
| Rate for Payer: Cash Price |
$364.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$295.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$295.75
|
|
|
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT
|
Facility
|
OP
|
$14,840.35
|
|
|
Service Code
|
CPT 36825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,825.83 |
| Max. Negotiated Rate |
$14,840.35 |
| Rate for Payer: Aetna Medicare |
$5,482.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,590.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,590.09
|
| Rate for Payer: BCBS Complete |
$2,967.12
|
| Rate for Payer: BCBS MAPPO |
$5,272.07
|
| Rate for Payer: BCN Medicare Advantage |
$5,272.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,272.07
|
| Rate for Payer: Mclaren Medicaid |
$2,825.83
|
| Rate for Payer: Mclaren Medicare |
$5,272.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,535.67
|
| Rate for Payer: Meridian Medicaid |
$2,967.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,062.88
|
| Rate for Payer: PACE Medicare |
$5,008.47
|
| Rate for Payer: PACE SWMI |
$5,272.07
|
| Rate for Payer: PHP Medicare Advantage |
$5,272.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,825.83
|
| Rate for Payer: Priority Health Medicare |
$5,272.07
|
| Rate for Payer: Railroad Medicare Medicare |
$5,272.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,840.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,272.07
|
| Rate for Payer: UHC Medicare Advantage |
$5,272.07
|
| Rate for Payer: UHCCP Medicaid |
$2,968.18
|
| Rate for Payer: VA VA |
$5,272.07
|
|
|
CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)
|
Facility
|
OP
|
$14,840.35
|
|
|
Service Code
|
CPT 36830
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,825.83 |
| Max. Negotiated Rate |
$14,840.35 |
| Rate for Payer: Aetna Medicare |
$5,482.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,590.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,590.09
|
| Rate for Payer: BCBS Complete |
$2,967.12
|
| Rate for Payer: BCBS MAPPO |
$5,272.07
|
| Rate for Payer: BCN Medicare Advantage |
$5,272.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,272.07
|
| Rate for Payer: Mclaren Medicaid |
$2,825.83
|
| Rate for Payer: Mclaren Medicare |
$5,272.07
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,535.67
|
| Rate for Payer: Meridian Medicaid |
$2,967.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,062.88
|
| Rate for Payer: PACE Medicare |
$5,008.47
|
| Rate for Payer: PACE SWMI |
$5,272.07
|
| Rate for Payer: PHP Medicare Advantage |
$5,272.07
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,825.83
|
| Rate for Payer: Priority Health Medicare |
$5,272.07
|
| Rate for Payer: Railroad Medicare Medicare |
$5,272.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14,840.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,272.07
|
| Rate for Payer: UHC Medicare Advantage |
$5,272.07
|
| Rate for Payer: UHCCP Medicaid |
$2,968.18
|
| Rate for Payer: VA VA |
$5,272.07
|
|
|
CRYOSURGICAL ABLATION OF THE PROSTATE (INCLUDES ULTRASONIC GUIDANCE AND MONITORING)
|
Facility
|
OP
|
$25,386.34
|
|
|
Service Code
|
CPT 55873
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,833.95 |
| Max. Negotiated Rate |
$25,386.34 |
| Rate for Payer: Aetna Medicare |
$9,379.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11,273.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11,273.20
|
| Rate for Payer: BCBS Complete |
$5,075.65
|
| Rate for Payer: BCBS MAPPO |
$9,018.56
|
| Rate for Payer: BCN Medicare Advantage |
$9,018.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9,018.56
|
| Rate for Payer: Mclaren Medicaid |
$4,833.95
|
| Rate for Payer: Mclaren Medicare |
$9,018.56
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9,469.49
|
| Rate for Payer: Meridian Medicaid |
$5,075.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,371.34
|
| Rate for Payer: PACE Medicare |
$8,567.63
|
| Rate for Payer: PACE SWMI |
$9,018.56
|
| Rate for Payer: PHP Medicare Advantage |
$9,018.56
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,833.95
|
| Rate for Payer: Priority Health Medicare |
$9,018.56
|
| Rate for Payer: Railroad Medicare Medicare |
$9,018.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25,386.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$9,018.56
|
| Rate for Payer: UHC Medicare Advantage |
$9,018.56
|
| Rate for Payer: UHCCP Medicaid |
$5,077.45
|
| Rate for Payer: VA VA |
$9,018.56
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$177.53
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
108145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.84 |
| Max. Negotiated Rate |
$159.78 |
| Rate for Payer: Aetna Commercial |
$150.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.39
|
| Rate for Payer: Cash Price |
$142.02
|
| Rate for Payer: Cofinity Commercial |
$124.27
|
| Rate for Payer: Cofinity Commercial |
$152.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$124.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.02
|
| Rate for Payer: Healthscope Commercial |
$159.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.90
|
| Rate for Payer: PHP Commercial |
$150.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.39
|
| Rate for Payer: Priority Health SBD |
$111.84
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$177.53
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
108145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$71.01 |
| Max. Negotiated Rate |
$159.78 |
| Rate for Payer: Aetna Commercial |
$150.90
|
| Rate for Payer: Aetna Medicare |
$88.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.39
|
| Rate for Payer: BCBS Complete |
$71.01
|
| Rate for Payer: Cash Price |
$142.02
|
| Rate for Payer: Cofinity Commercial |
$124.27
|
| Rate for Payer: Cofinity Commercial |
$152.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$124.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.02
|
| Rate for Payer: Healthscope Commercial |
$159.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.90
|
| Rate for Payer: PHP Commercial |
$150.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.39
|
| Rate for Payer: Priority Health SBD |
$111.84
|
|
|
CURETTAGE, POSTPARTUM
|
Facility
|
OP
|
$8,728.81
|
|
|
Service Code
|
CPT 59160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,662.10 |
| Max. Negotiated Rate |
$8,728.81 |
| Rate for Payer: Aetna Medicare |
$3,224.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,876.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,876.16
|
| Rate for Payer: BCBS Complete |
$1,745.20
|
| Rate for Payer: BCBS MAPPO |
$3,100.93
|
| Rate for Payer: BCN Medicare Advantage |
$3,100.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,100.93
|
| Rate for Payer: Mclaren Medicaid |
$1,662.10
|
| Rate for Payer: Mclaren Medicare |
$3,100.93
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,255.98
|
| Rate for Payer: Meridian Medicaid |
$1,745.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,566.07
|
| Rate for Payer: PACE Medicare |
$2,945.88
|
| Rate for Payer: PACE SWMI |
$3,100.93
|
| Rate for Payer: PHP Medicare Advantage |
$3,100.93
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,662.10
|
| Rate for Payer: Priority Health Medicare |
$3,100.93
|
| Rate for Payer: Railroad Medicare Medicare |
$3,100.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,728.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,100.93
|
| Rate for Payer: UHC Medicare Advantage |
$3,100.93
|
| Rate for Payer: UHCCP Medicaid |
$1,745.82
|
| Rate for Payer: VA VA |
$3,100.93
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$21.82
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
2007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.73 |
| Max. Negotiated Rate |
$19.64 |
| Rate for Payer: Aetna Commercial |
$18.55
|
| Rate for Payer: Aetna Commercial |
$15.35
|
| Rate for Payer: Aetna Commercial |
$19.17
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Commercial |
$14.91
|
| Rate for Payer: Aetna Medicare |
$9.03
|
| Rate for Payer: Aetna Medicare |
$11.28
|
| Rate for Payer: Aetna Medicare |
$10.91
|
| Rate for Payer: Aetna Medicare |
$8.77
|
| Rate for Payer: Aetna Medicare |
$6.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.77
|
| Rate for Payer: BCBS Complete |
$7.02
|
| Rate for Payer: BCBS Complete |
$8.73
|
| Rate for Payer: BCBS Complete |
$7.22
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: BCBS Complete |
$9.02
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cash Price |
$18.04
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cofinity Commercial |
$18.77
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$9.44
|
| Rate for Payer: Cofinity Commercial |
$12.28
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Cofinity Commercial |
$12.64
|
| Rate for Payer: Cofinity Commercial |
$15.53
|
| Rate for Payer: Cofinity Commercial |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$15.79
|
| Rate for Payer: Cofinity Commercial |
$19.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.03
|
| Rate for Payer: Healthscope Commercial |
$15.79
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$19.64
|
| Rate for Payer: Healthscope Commercial |
$20.30
|
| Rate for Payer: Healthscope Commercial |
$16.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.17
|
| Rate for Payer: PHP Commercial |
$18.55
|
| Rate for Payer: PHP Commercial |
$15.35
|
| Rate for Payer: PHP Commercial |
$14.91
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$19.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.74
|
| Rate for Payer: Priority Health SBD |
$14.21
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| Rate for Payer: Priority Health SBD |
$11.05
|
| Rate for Payer: Priority Health SBD |
$13.75
|
| Rate for Payer: Priority Health SBD |
$11.38
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$13.49
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
2007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$12.14 |
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Commercial |
$14.91
|
| Rate for Payer: Aetna Commercial |
$15.35
|
| Rate for Payer: Aetna Commercial |
$18.55
|
| Rate for Payer: Aetna Commercial |
$19.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.40
|
| Rate for Payer: Cash Price |
$18.04
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$14.45
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Cofinity Commercial |
$12.28
|
| Rate for Payer: Cofinity Commercial |
$11.60
|
| Rate for Payer: Cofinity Commercial |
$9.44
|
| Rate for Payer: Cofinity Commercial |
$19.39
|
| Rate for Payer: Cofinity Commercial |
$15.79
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Cofinity Commercial |
$18.77
|
| Rate for Payer: Cofinity Commercial |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$12.64
|
| Rate for Payer: Cofinity Commercial |
$15.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.04
|
| Rate for Payer: Healthscope Commercial |
$16.25
|
| Rate for Payer: Healthscope Commercial |
$15.79
|
| Rate for Payer: Healthscope Commercial |
$12.14
|
| Rate for Payer: Healthscope Commercial |
$19.64
|
| Rate for Payer: Healthscope Commercial |
$20.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$18.55
|
| Rate for Payer: PHP Commercial |
$19.17
|
| Rate for Payer: PHP Commercial |
$15.35
|
| Rate for Payer: PHP Commercial |
$14.91
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.18
|
| Rate for Payer: Priority Health SBD |
$13.75
|
| Rate for Payer: Priority Health SBD |
$11.05
|
| Rate for Payer: Priority Health SBD |
$11.38
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| Rate for Payer: Priority Health SBD |
$14.21
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
OP
|
$3.27
|
|
|
Service Code
|
NDC 77333093825
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Aetna Commercial |
$2.78
|
| Rate for Payer: Aetna Medicare |
$1.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.13
|
| Rate for Payer: BCBS Complete |
$1.31
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.62
|
| Rate for Payer: Healthscope Commercial |
$2.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.78
|
| Rate for Payer: PHP Commercial |
$2.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.13
|
| Rate for Payer: Priority Health SBD |
$2.06
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$186.83
|
|
|
Service Code
|
NDC 50268085515
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.70 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Aetna Commercial |
$158.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.44
|
| Rate for Payer: Cash Price |
$149.46
|
| Rate for Payer: Cofinity Commercial |
$130.78
|
| Rate for Payer: Cofinity Commercial |
$160.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$130.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$149.46
|
| Rate for Payer: Healthscope Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$158.81
|
| Rate for Payer: PHP Commercial |
$158.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.44
|
| Rate for Payer: Priority Health SBD |
$117.70
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$169.20
|
|
|
Service Code
|
NDC 20555000600
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.60 |
| Max. Negotiated Rate |
$152.28 |
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.98
|
| Rate for Payer: Cash Price |
$135.36
|
| Rate for Payer: Cofinity Commercial |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$145.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.36
|
| Rate for Payer: Healthscope Commercial |
$152.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.82
|
| Rate for Payer: PHP Commercial |
$143.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.98
|
| Rate for Payer: Priority Health SBD |
$106.60
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
OP
|
$326.65
|
|
|
Service Code
|
NDC 77333093810
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.66 |
| Max. Negotiated Rate |
$293.99 |
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna Medicare |
$163.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: BCBS Complete |
$130.66
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$228.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.32
|
| Rate for Payer: Priority Health SBD |
$205.79
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$326.65
|
|
|
Service Code
|
NDC 77333093810
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.79 |
| Max. Negotiated Rate |
$293.99 |
| Rate for Payer: Aetna Commercial |
$277.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.32
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$228.66
|
| Rate for Payer: Cofinity Commercial |
$280.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$228.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$293.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$277.65
|
| Rate for Payer: PHP Commercial |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.32
|
| Rate for Payer: Priority Health SBD |
$205.79
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
OP
|
$3.74
|
|
|
Service Code
|
NDC 50268085511
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna Medicare |
$1.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: BCBS Complete |
$1.50
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 50268085511
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.43
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$3.27
|
|
|
Service Code
|
NDC 77333093825
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Aetna Commercial |
$2.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.13
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$2.29
|
| Rate for Payer: Cofinity Commercial |
$2.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.62
|
| Rate for Payer: Healthscope Commercial |
$2.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.78
|
| Rate for Payer: PHP Commercial |
$2.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.13
|
| Rate for Payer: Priority Health SBD |
$2.06
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
OP
|
$186.83
|
|
|
Service Code
|
NDC 50268085515
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.73 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Aetna Commercial |
$158.81
|
| Rate for Payer: Aetna Medicare |
$93.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.44
|
| Rate for Payer: BCBS Complete |
$74.73
|
| Rate for Payer: Cash Price |
$149.46
|
| Rate for Payer: Cofinity Commercial |
$130.78
|
| Rate for Payer: Cofinity Commercial |
$160.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$130.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$149.46
|
| Rate for Payer: Healthscope Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$158.81
|
| Rate for Payer: PHP Commercial |
$158.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.44
|
| Rate for Payer: Priority Health SBD |
$117.70
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
OP
|
$169.20
|
|
|
Service Code
|
NDC 20555000600
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.68 |
| Max. Negotiated Rate |
$152.28 |
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: Aetna Medicare |
$84.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$109.98
|
| Rate for Payer: BCBS Complete |
$67.68
|
| Rate for Payer: Cash Price |
$135.36
|
| Rate for Payer: Cofinity Commercial |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$145.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$118.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$135.36
|
| Rate for Payer: Healthscope Commercial |
$152.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$143.82
|
| Rate for Payer: PHP Commercial |
$143.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$109.98
|
| Rate for Payer: Priority Health SBD |
$106.60
|
|
|
CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET
|
Facility
|
IP
|
$1.68
|
|
|
Service Code
|
NDC 50268085211
|
| Hospital Charge Code |
2008
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna Commercial |
$1.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.09
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Cofinity Commercial |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.34
|
| Rate for Payer: Healthscope Commercial |
$1.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.43
|
| Rate for Payer: PHP Commercial |
$1.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.09
|
| Rate for Payer: Priority Health SBD |
$1.06
|
|
|
CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET
|
Facility
|
IP
|
$83.60
|
|
|
Service Code
|
NDC 50268085215
|
| Hospital Charge Code |
2008
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.67 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$71.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.34
|
| Rate for Payer: Cash Price |
$66.88
|
| Rate for Payer: Cofinity Commercial |
$58.52
|
| Rate for Payer: Cofinity Commercial |
$71.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$58.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.88
|
| Rate for Payer: Healthscope Commercial |
$75.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.06
|
| Rate for Payer: PHP Commercial |
$71.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.34
|
| Rate for Payer: Priority Health SBD |
$52.67
|
|
|
CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET
|
Facility
|
OP
|
$83.60
|
|
|
Service Code
|
NDC 50268085215
|
| Hospital Charge Code |
2008
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.44 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$71.06
|
| Rate for Payer: Aetna Medicare |
$41.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.34
|
| Rate for Payer: BCBS Complete |
$33.44
|
| Rate for Payer: Cash Price |
$66.88
|
| Rate for Payer: Cofinity Commercial |
$58.52
|
| Rate for Payer: Cofinity Commercial |
$71.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$58.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.88
|
| Rate for Payer: Healthscope Commercial |
$75.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.06
|
| Rate for Payer: PHP Commercial |
$71.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.34
|
| Rate for Payer: Priority Health SBD |
$52.67
|
|
|
CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET
|
Facility
|
OP
|
$1.68
|
|
|
Service Code
|
NDC 50268085211
|
| Hospital Charge Code |
2008
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$1.51 |
| Rate for Payer: Aetna Commercial |
$1.43
|
| Rate for Payer: Aetna Medicare |
$0.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.09
|
| Rate for Payer: BCBS Complete |
$0.67
|
| Rate for Payer: Cash Price |
$1.34
|
| Rate for Payer: Cofinity Commercial |
$1.18
|
| Rate for Payer: Cofinity Commercial |
$1.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.34
|
| Rate for Payer: Healthscope Commercial |
$1.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.43
|
| Rate for Payer: PHP Commercial |
$1.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.09
|
| Rate for Payer: Priority Health SBD |
$1.06
|
|
|
CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET
|
Facility
|
OP
|
$42.77
|
|
|
Service Code
|
NDC 80681016500
|
| Hospital Charge Code |
2010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.11 |
| 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 Commercial |
$29.94
|
| Rate for Payer: Cofinity Commercial |
$36.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$29.94
|
| 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: PHP Commercial |
$36.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.80
|
| Rate for Payer: Priority Health SBD |
$26.95
|
|
|
CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET
|
Facility
|
IP
|
$177.43
|
|
|
Service Code
|
NDC 50268085315
|
| Hospital Charge Code |
2010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.78 |
| Max. Negotiated Rate |
$159.69 |
| Rate for Payer: Aetna Commercial |
$150.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.33
|
| Rate for Payer: Cash Price |
$141.94
|
| Rate for Payer: Cofinity Commercial |
$124.20
|
| Rate for Payer: Cofinity Commercial |
$152.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$124.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.94
|
| Rate for Payer: Healthscope Commercial |
$159.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.82
|
| Rate for Payer: PHP Commercial |
$150.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.33
|
| Rate for Payer: Priority Health SBD |
$111.78
|
|
