|
CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET
|
Facility
|
OP
|
$177.43
|
|
|
Service Code
|
NDC 50268085315
|
| Hospital Charge Code |
2010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.97 |
| Max. Negotiated Rate |
$159.69 |
| Rate for Payer: Aetna Commercial |
$150.82
|
| Rate for Payer: Aetna Medicare |
$88.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$115.33
|
| Rate for Payer: BCBS Complete |
$70.97
|
| 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
|
|
|
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 |
$21.38
|
| 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
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$99.37
|
|
|
Service Code
|
NDC 00065039602
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.60 |
| Max. Negotiated Rate |
$89.43 |
| Rate for Payer: Aetna Commercial |
$84.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.59
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cofinity Commercial |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$85.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.50
|
| Rate for Payer: Healthscope Commercial |
$89.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.46
|
| Rate for Payer: PHP Commercial |
$84.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.59
|
| Rate for Payer: Priority Health SBD |
$62.60
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
OP
|
$99.37
|
|
|
Service Code
|
NDC 00065039602
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.75 |
| Max. Negotiated Rate |
$89.43 |
| Rate for Payer: Aetna Commercial |
$84.46
|
| Rate for Payer: Aetna Medicare |
$49.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.59
|
| Rate for Payer: BCBS Complete |
$39.75
|
| Rate for Payer: Cash Price |
$79.50
|
| Rate for Payer: Cofinity Commercial |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$85.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.50
|
| Rate for Payer: Healthscope Commercial |
$89.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$84.46
|
| Rate for Payer: PHP Commercial |
$84.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.59
|
| Rate for Payer: Priority Health SBD |
$62.60
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
OP
|
$18.86
|
|
|
Service Code
|
NDC 17478010002
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.54 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Aetna Commercial |
$16.03
|
| Rate for Payer: Aetna Medicare |
$9.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.26
|
| Rate for Payer: BCBS Complete |
$7.54
|
| Rate for Payer: Cash Price |
$15.09
|
| Rate for Payer: Cofinity Commercial |
$13.20
|
| Rate for Payer: Cofinity Commercial |
$16.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.20
|
| 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: PHP Commercial |
$16.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.26
|
| Rate for Payer: Priority Health SBD |
$11.88
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$40.25
|
|
|
Service Code
|
NDC 24208073501
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.36 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna Commercial |
$34.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.16
|
| Rate for Payer: Cash Price |
$32.20
|
| Rate for Payer: Cofinity Commercial |
$28.18
|
| Rate for Payer: Cofinity Commercial |
$34.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$28.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.20
|
| Rate for Payer: Healthscope Commercial |
$36.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.21
|
| Rate for Payer: PHP Commercial |
$34.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.16
|
| Rate for Payer: Priority Health SBD |
$25.36
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$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 Commercial |
$13.20
|
| Rate for Payer: Cofinity Commercial |
$16.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.20
|
| 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: PHP Commercial |
$16.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.26
|
| Rate for Payer: Priority Health SBD |
$11.88
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
OP
|
$40.25
|
|
|
Service Code
|
NDC 24208073501
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna Commercial |
$34.21
|
| Rate for Payer: Aetna Medicare |
$20.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.16
|
| Rate for Payer: BCBS Complete |
$16.10
|
| Rate for Payer: Cash Price |
$32.20
|
| Rate for Payer: Cofinity Commercial |
$28.18
|
| Rate for Payer: Cofinity Commercial |
$34.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$28.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.20
|
| Rate for Payer: Healthscope Commercial |
$36.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.21
|
| Rate for Payer: PHP Commercial |
$34.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.16
|
| Rate for Payer: Priority Health SBD |
$25.36
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,384.25
|
|
|
Service Code
|
HCPCS J9071
|
| Hospital Charge Code |
194691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1,245.82 |
| Rate for Payer: Aetna Commercial |
$1,176.61
|
| Rate for Payer: Aetna Commercial |
$2,489.97
|
| Rate for Payer: Aetna Medicare |
$0.73
|
| Rate for Payer: Aetna Medicare |
$0.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,904.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$899.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.88
|
| Rate for Payer: BCBS Complete |
$0.39
|
| Rate for Payer: BCBS Complete |
$0.39
|
| Rate for Payer: BCBS MAPPO |
$0.70
|
| Rate for Payer: BCBS MAPPO |
$0.70
|
| Rate for Payer: BCBS Trust/PPO |
$3.27
|
| Rate for Payer: BCBS Trust/PPO |
$3.27
|
| Rate for Payer: BCN Commercial |
$3.27
|
| Rate for Payer: BCN Commercial |
$3.27
|
| Rate for Payer: BCN Medicare Advantage |
$0.70
|
| Rate for Payer: BCN Medicare Advantage |
$0.70
|
| Rate for Payer: Cash Price |
$1,107.40
|
| Rate for Payer: Cash Price |
$2,343.50
|
| Rate for Payer: Cash Price |
$1,107.40
|
| Rate for Payer: Cash Price |
$2,343.50
|
| Rate for Payer: Cofinity Commercial |
$2,050.57
|
| Rate for Payer: Cofinity Commercial |
$968.98
|
| Rate for Payer: Cofinity Commercial |
$1,190.46
|
| Rate for Payer: Cofinity Commercial |
$2,519.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,050.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$968.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,107.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,343.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.70
|
| Rate for Payer: Healthscope Commercial |
$2,636.44
|
| Rate for Payer: Healthscope Commercial |
$1,245.82
|
| Rate for Payer: Mclaren Medicaid |
$0.38
|
| Rate for Payer: Mclaren Medicaid |
$0.38
|
| Rate for Payer: Mclaren Medicare |
$0.70
|
| Rate for Payer: Mclaren Medicare |
$0.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.74
|
| Rate for Payer: Meridian Medicaid |
$0.39
|
| Rate for Payer: Meridian Medicaid |
$0.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,176.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,489.97
|
| Rate for Payer: Nomi Health Commercial |
$2.10
|
| Rate for Payer: Nomi Health Commercial |
$2.10
|
| Rate for Payer: PACE Medicare |
$0.67
|
| Rate for Payer: PACE Medicare |
$0.67
|
| Rate for Payer: PACE SWMI |
$0.70
|
| Rate for Payer: PACE SWMI |
$0.70
|
| Rate for Payer: PHP Commercial |
$1,176.61
|
| Rate for Payer: PHP Commercial |
$2,489.97
|
| Rate for Payer: PHP Medicare Advantage |
$0.70
|
| Rate for Payer: PHP Medicare Advantage |
$0.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$899.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,904.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.34
|
| Rate for Payer: Priority Health Medicare |
$0.70
|
| Rate for Payer: Priority Health Medicare |
$0.70
|
| Rate for Payer: Priority Health Narrow Network |
$2.67
|
| Rate for Payer: Priority Health Narrow Network |
$2.67
|
| Rate for Payer: Priority Health SBD |
$1,845.51
|
| Rate for Payer: Priority Health SBD |
$872.08
|
| Rate for Payer: Railroad Medicare Medicare |
$0.70
|
| Rate for Payer: Railroad Medicare Medicare |
$0.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.97
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.70
|
| Rate for Payer: UHC Medicare Advantage |
$0.70
|
| Rate for Payer: UHC Medicare Advantage |
$0.70
|
| Rate for Payer: UHCCP Medicaid |
$0.39
|
| Rate for Payer: UHCCP Medicaid |
$0.39
|
| Rate for Payer: VA VA |
$0.70
|
| Rate for Payer: VA VA |
$0.70
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,136.88
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
194691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1,023.19 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Aetna Medicare |
$0.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$738.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.10
|
| Rate for Payer: BCBS Complete |
$0.50
|
| Rate for Payer: BCBS MAPPO |
$0.88
|
| Rate for Payer: BCBS Trust/PPO |
$2.83
|
| Rate for Payer: BCN Commercial |
$2.83
|
| Rate for Payer: BCN Medicare Advantage |
$0.88
|
| Rate for Payer: Cash Price |
$909.50
|
| Rate for Payer: Cash Price |
$909.50
|
| Rate for Payer: Cofinity Commercial |
$977.72
|
| Rate for Payer: Cofinity Commercial |
$795.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$795.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$909.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.88
|
| Rate for Payer: Healthscope Commercial |
$1,023.19
|
| Rate for Payer: Mclaren Medicaid |
$0.47
|
| Rate for Payer: Mclaren Medicare |
$0.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.92
|
| Rate for Payer: Meridian Medicaid |
$0.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$966.35
|
| Rate for Payer: Nomi Health Commercial |
$2.64
|
| Rate for Payer: PACE Medicare |
$0.84
|
| Rate for Payer: PACE SWMI |
$0.88
|
| Rate for Payer: PHP Commercial |
$966.35
|
| Rate for Payer: PHP Medicare Advantage |
$0.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$738.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.90
|
| Rate for Payer: Priority Health Medicare |
$0.88
|
| Rate for Payer: Priority Health Narrow Network |
$2.32
|
| Rate for Payer: Priority Health SBD |
$716.23
|
| Rate for Payer: Railroad Medicare Medicare |
$0.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.88
|
| Rate for Payer: UHC Medicare Advantage |
$0.88
|
| Rate for Payer: UHCCP Medicaid |
$0.50
|
| Rate for Payer: VA VA |
$0.88
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,149.02
|
|
|
Service Code
|
HCPCS J9073
|
| Hospital Charge Code |
194691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1,934.12 |
| Rate for Payer: Aetna Commercial |
$1,826.67
|
| Rate for Payer: Aetna Medicare |
$2.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,396.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.74
|
| Rate for Payer: BCBS Complete |
$1.23
|
| Rate for Payer: BCBS MAPPO |
$2.19
|
| Rate for Payer: BCBS Trust/PPO |
$2.99
|
| Rate for Payer: BCN Commercial |
$2.99
|
| Rate for Payer: BCN Medicare Advantage |
$2.19
|
| Rate for Payer: Cash Price |
$1,719.22
|
| Rate for Payer: Cash Price |
$1,719.22
|
| Rate for Payer: Cofinity Commercial |
$1,848.16
|
| Rate for Payer: Cofinity Commercial |
$1,504.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,504.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,719.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$1,934.12
|
| Rate for Payer: Mclaren Medicaid |
$1.17
|
| Rate for Payer: Mclaren Medicare |
$2.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.30
|
| Rate for Payer: Meridian Medicaid |
$1.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,826.67
|
| Rate for Payer: Nomi Health Commercial |
$6.57
|
| Rate for Payer: PACE Medicare |
$2.08
|
| Rate for Payer: PACE SWMI |
$2.19
|
| Rate for Payer: PHP Commercial |
$1,826.67
|
| Rate for Payer: PHP Medicare Advantage |
$2.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,396.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.67
|
| Rate for Payer: Priority Health Medicare |
$2.19
|
| Rate for Payer: Priority Health Narrow Network |
$2.14
|
| Rate for Payer: Priority Health SBD |
$1,353.88
|
| Rate for Payer: Railroad Medicare Medicare |
$2.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$2.19
|
| Rate for Payer: UHC Medicare Advantage |
$2.19
|
| Rate for Payer: UHCCP Medicaid |
$1.23
|
| Rate for Payer: VA VA |
$2.19
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,136.88
|
|
|
Service Code
|
HCPCS J9075
|
| Hospital Charge Code |
194691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$716.23 |
| Max. Negotiated Rate |
$1,023.19 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$738.97
|
| Rate for Payer: Cash Price |
$909.50
|
| Rate for Payer: Cofinity Commercial |
$795.82
|
| Rate for Payer: Cofinity Commercial |
$977.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$795.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$909.50
|
| Rate for Payer: Healthscope Commercial |
$1,023.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$966.35
|
| Rate for Payer: PHP Commercial |
$966.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$738.97
|
| Rate for Payer: Priority Health SBD |
$716.23
|
|
|
CYCLOSPORINE 25 MG CAPSULE
|
Facility
|
OP
|
$453.99
|
|
|
Service Code
|
HCPCS J7515
|
| Hospital Charge Code |
9707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$408.59 |
| Rate for Payer: Aetna Commercial |
$385.89
|
| Rate for Payer: Aetna Medicare |
$227.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$295.09
|
| Rate for Payer: BCBS Complete |
$181.60
|
| Rate for Payer: BCBS Trust/PPO |
$2.38
|
| Rate for Payer: BCN Commercial |
$2.38
|
| Rate for Payer: Cash Price |
$363.19
|
| Rate for Payer: Cash Price |
$363.19
|
| Rate for Payer: Cofinity Commercial |
$317.79
|
| Rate for Payer: Cofinity Commercial |
$390.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$317.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$363.19
|
| Rate for Payer: Healthscope Commercial |
$408.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$385.89
|
| Rate for Payer: PHP Commercial |
$385.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$295.09
|
| Rate for Payer: Priority Health SBD |
$286.01
|
|
|
CYCLOSPORINE 25 MG CAPSULE
|
Facility
|
IP
|
$453.99
|
|
|
Service Code
|
HCPCS J7515
|
| Hospital Charge Code |
9707
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$286.01 |
| Max. Negotiated Rate |
$408.59 |
| Rate for Payer: Aetna Commercial |
$385.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$295.09
|
| Rate for Payer: Cash Price |
$363.19
|
| Rate for Payer: Cofinity Commercial |
$317.79
|
| Rate for Payer: Cofinity Commercial |
$390.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$317.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$363.19
|
| Rate for Payer: Healthscope Commercial |
$408.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$385.89
|
| Rate for Payer: PHP Commercial |
$385.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$295.09
|
| Rate for Payer: Priority Health SBD |
$286.01
|
|
|
CYCLOSPORINE MODIFIED 100 MG CAPSULE
|
Facility
|
IP
|
$1,104.57
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
28843
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$695.88 |
| Max. Negotiated Rate |
$994.11 |
| Rate for Payer: Aetna Commercial |
$938.88
|
| Rate for Payer: Aetna Commercial |
$31.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$717.97
|
| Rate for Payer: Cash Price |
$883.66
|
| Rate for Payer: Cash Price |
$29.46
|
| Rate for Payer: Cofinity Commercial |
$773.20
|
| Rate for Payer: Cofinity Commercial |
$949.93
|
| Rate for Payer: Cofinity Commercial |
$25.77
|
| Rate for Payer: Cofinity Commercial |
$31.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$773.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$883.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.46
|
| Rate for Payer: Healthscope Commercial |
$994.11
|
| Rate for Payer: Healthscope Commercial |
$33.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$938.88
|
| Rate for Payer: PHP Commercial |
$938.88
|
| Rate for Payer: PHP Commercial |
$31.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$717.97
|
| Rate for Payer: Priority Health SBD |
$695.88
|
| Rate for Payer: Priority Health SBD |
$23.20
|
|
|
CYCLOSPORINE MODIFIED 100 MG CAPSULE
|
Facility
|
OP
|
$1,104.57
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
28843
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.74 |
| Max. Negotiated Rate |
$994.11 |
| Rate for Payer: Aetna Commercial |
$938.88
|
| Rate for Payer: Aetna Commercial |
$31.30
|
| Rate for Payer: Aetna Medicare |
$18.41
|
| Rate for Payer: Aetna Medicare |
$552.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$717.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.93
|
| Rate for Payer: BCBS Complete |
$14.73
|
| Rate for Payer: BCBS Complete |
$441.83
|
| Rate for Payer: BCBS Trust/PPO |
$6.74
|
| Rate for Payer: BCBS Trust/PPO |
$6.74
|
| Rate for Payer: BCN Commercial |
$6.74
|
| Rate for Payer: BCN Commercial |
$6.74
|
| Rate for Payer: Cash Price |
$29.46
|
| Rate for Payer: Cash Price |
$883.66
|
| Rate for Payer: Cash Price |
$883.66
|
| Rate for Payer: Cash Price |
$29.46
|
| Rate for Payer: Cofinity Commercial |
$949.93
|
| Rate for Payer: Cofinity Commercial |
$773.20
|
| Rate for Payer: Cofinity Commercial |
$25.77
|
| Rate for Payer: Cofinity Commercial |
$31.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$773.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$883.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.46
|
| Rate for Payer: Healthscope Commercial |
$33.14
|
| Rate for Payer: Healthscope Commercial |
$994.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$938.88
|
| Rate for Payer: PHP Commercial |
$31.30
|
| Rate for Payer: PHP Commercial |
$938.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$717.97
|
| Rate for Payer: Priority Health SBD |
$23.20
|
| Rate for Payer: Priority Health SBD |
$695.88
|
|
|
CYCLOSPORINE MODIFIED 25 MG CAPSULE
|
Facility
|
OP
|
$276.39
|
|
|
Service Code
|
HCPCS J7515
|
| Hospital Charge Code |
28842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$248.75 |
| Rate for Payer: Aetna Commercial |
$234.93
|
| Rate for Payer: Aetna Medicare |
$138.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.65
|
| Rate for Payer: BCBS Complete |
$110.56
|
| Rate for Payer: BCBS Trust/PPO |
$2.38
|
| Rate for Payer: BCN Commercial |
$2.38
|
| Rate for Payer: Cash Price |
$221.11
|
| Rate for Payer: Cash Price |
$221.11
|
| Rate for Payer: Cofinity Commercial |
$237.70
|
| Rate for Payer: Cofinity Commercial |
$193.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$193.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.11
|
| Rate for Payer: Healthscope Commercial |
$248.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.93
|
| Rate for Payer: PHP Commercial |
$234.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.65
|
| Rate for Payer: Priority Health SBD |
$174.13
|
|
|
CYCLOSPORINE MODIFIED 25 MG CAPSULE
|
Facility
|
IP
|
$276.39
|
|
|
Service Code
|
HCPCS J7515
|
| Hospital Charge Code |
28842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.13 |
| Max. Negotiated Rate |
$248.75 |
| Rate for Payer: Aetna Commercial |
$234.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.65
|
| Rate for Payer: Cash Price |
$221.11
|
| Rate for Payer: Cofinity Commercial |
$193.47
|
| Rate for Payer: Cofinity Commercial |
$237.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$193.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$221.11
|
| Rate for Payer: Healthscope Commercial |
$248.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.93
|
| Rate for Payer: PHP Commercial |
$234.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.65
|
| Rate for Payer: Priority Health SBD |
$174.13
|
|
|
CYPROHEPTADINE 4 MG TABLET
|
Facility
|
OP
|
$2.68
|
|
|
Service Code
|
NDC 50268018911
|
| Hospital Charge Code |
2033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: Aetna Medicare |
$1.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.74
|
| Rate for Payer: BCBS Complete |
$1.07
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Cofinity Commercial |
$2.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.14
|
| Rate for Payer: Healthscope Commercial |
$2.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.28
|
| Rate for Payer: PHP Commercial |
$2.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: Priority Health SBD |
$1.69
|
|
|
CYPROHEPTADINE 4 MG TABLET
|
Facility
|
IP
|
$229.90
|
|
|
Service Code
|
NDC 52817021010
|
| Hospital Charge Code |
2033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.84 |
| Max. Negotiated Rate |
$206.91 |
| Rate for Payer: Aetna Commercial |
$195.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.44
|
| Rate for Payer: Cash Price |
$183.92
|
| Rate for Payer: Cofinity Commercial |
$160.93
|
| Rate for Payer: Cofinity Commercial |
$197.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$160.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.92
|
| Rate for Payer: Healthscope Commercial |
$206.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.42
|
| Rate for Payer: PHP Commercial |
$195.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.44
|
| Rate for Payer: Priority Health SBD |
$144.84
|
|
|
CYPROHEPTADINE 4 MG TABLET
|
Facility
|
OP
|
$133.68
|
|
|
Service Code
|
NDC 50268018915
|
| Hospital Charge Code |
2033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.47 |
| Max. Negotiated Rate |
$120.31 |
| Rate for Payer: Aetna Commercial |
$113.63
|
| Rate for Payer: Aetna Medicare |
$66.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.89
|
| Rate for Payer: BCBS Complete |
$53.47
|
| Rate for Payer: Cash Price |
$106.94
|
| Rate for Payer: Cofinity Commercial |
$114.96
|
| Rate for Payer: Cofinity Commercial |
$93.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.94
|
| Rate for Payer: Healthscope Commercial |
$120.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.63
|
| Rate for Payer: PHP Commercial |
$113.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.89
|
| Rate for Payer: Priority Health SBD |
$84.22
|
|
|
CYPROHEPTADINE 4 MG TABLET
|
Facility
|
OP
|
$229.90
|
|
|
Service Code
|
NDC 52817021010
|
| Hospital Charge Code |
2033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.96 |
| Max. Negotiated Rate |
$206.91 |
| Rate for Payer: Aetna Commercial |
$195.42
|
| Rate for Payer: Aetna Medicare |
$114.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.44
|
| Rate for Payer: BCBS Complete |
$91.96
|
| Rate for Payer: Cash Price |
$183.92
|
| Rate for Payer: Cofinity Commercial |
$160.93
|
| Rate for Payer: Cofinity Commercial |
$197.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$160.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$183.92
|
| Rate for Payer: Healthscope Commercial |
$206.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.42
|
| Rate for Payer: PHP Commercial |
$195.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.44
|
| Rate for Payer: Priority Health SBD |
$144.84
|
|
|
CYPROHEPTADINE 4 MG TABLET
|
Facility
|
IP
|
$2.68
|
|
|
Service Code
|
NDC 50268018911
|
| Hospital Charge Code |
2033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Aetna Commercial |
$2.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.74
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Cofinity Commercial |
$2.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.14
|
| Rate for Payer: Healthscope Commercial |
$2.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.28
|
| Rate for Payer: PHP Commercial |
$2.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.74
|
| Rate for Payer: Priority Health SBD |
$1.69
|
|
|
CYPROHEPTADINE 4 MG TABLET
|
Facility
|
IP
|
$133.68
|
|
|
Service Code
|
NDC 50268018915
|
| Hospital Charge Code |
2033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.22 |
| Max. Negotiated Rate |
$120.31 |
| Rate for Payer: Aetna Commercial |
$113.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.89
|
| Rate for Payer: Cash Price |
$106.94
|
| Rate for Payer: Cofinity Commercial |
$114.96
|
| Rate for Payer: Cofinity Commercial |
$93.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.94
|
| Rate for Payer: Healthscope Commercial |
$120.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.63
|
| Rate for Payer: PHP Commercial |
$113.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.89
|
| Rate for Payer: Priority Health SBD |
$84.22
|
|
|
CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION
|
Facility
|
OP
|
$15,654.68
|
|
|
Service Code
|
CPT 51050
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$500.08 |
| Max. Negotiated Rate |
$15,654.68 |
| Rate for Payer: Aetna Medicare |
$5,180.06
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,226.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,226.04
|
| Rate for Payer: BCBS Complete |
$2,803.21
|
| Rate for Payer: BCBS MAPPO |
$4,980.83
|
| Rate for Payer: BCBS Trust/PPO |
$1,555.60
|
| Rate for Payer: BCN Commercial |
$1,555.60
|
| Rate for Payer: BCN Medicare Advantage |
$4,980.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4,980.83
|
| Rate for Payer: Mclaren Medicaid |
$2,669.72
|
| Rate for Payer: Mclaren Medicare |
$4,980.83
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5,229.87
|
| Rate for Payer: Meridian Medicaid |
$2,803.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,727.95
|
| Rate for Payer: Nomi Health Commercial |
$10,459.74
|
| Rate for Payer: PACE Medicare |
$4,731.79
|
| Rate for Payer: PACE SWMI |
$4,980.83
|
| Rate for Payer: PHP Medicare Advantage |
$4,980.83
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,669.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15,654.68
|
| Rate for Payer: Priority Health Medicare |
$4,980.83
|
| Rate for Payer: Priority Health Narrow Network |
$12,523.74
|
| Rate for Payer: Railroad Medicare Medicare |
$4,980.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$500.08
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$4,980.83
|
| Rate for Payer: UHC Exchange |
$4,450.00
|
| Rate for Payer: UHC Medicare Advantage |
$4,980.83
|
| Rate for Payer: UHCCP Medicaid |
$2,804.21
|
| Rate for Payer: VA VA |
$4,980.83
|
|
