|
CRYOSURGICAL ABLATION OF THE PROSTATE (INCLUDES ULTRASONIC GUIDANCE AND MONITORING)
|
Facility
|
OP
|
$10,246.31
|
|
|
Service Code
|
CPT 55873
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$747.88 |
| Max. Negotiated Rate |
$10,246.31 |
| Rate for Payer: Aetna Medicare |
$8,524.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10,246.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10,246.31
|
| Rate for Payer: BCBS Complete |
$4,708.39
|
| Rate for Payer: BCBS MAPPO |
$8,197.05
|
| Rate for Payer: BCBS Trust/PPO |
$6,229.80
|
| Rate for Payer: BCN Medicare Advantage |
$8,197.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8,197.05
|
| Rate for Payer: Mclaren Medicaid |
$4,483.79
|
| Rate for Payer: Mclaren Medicare |
$8,197.05
|
| Rate for Payer: Meridian Medicaid |
$4,708.39
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$8,606.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9,426.61
|
| Rate for Payer: PACE Medicare |
$7,787.20
|
| Rate for Payer: PACE SWMI |
$8,197.05
|
| Rate for Payer: PHP Medicare Advantage |
$8,197.05
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,483.79
|
| Rate for Payer: Priority Health Medicare |
$8,197.05
|
| Rate for Payer: Railroad Medicare Medicare |
$8,197.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$822.67
|
| Rate for Payer: UHC Core |
$8,819.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$8,197.05
|
| Rate for Payer: UHC Exchange |
$747.88
|
| Rate for Payer: UHC Medicare Advantage |
$8,442.96
|
| Rate for Payer: VA VA |
$8,197.05
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$176.27
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
108145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.51 |
| Max. Negotiated Rate |
$158.64 |
| Rate for Payer: Aetna Commercial |
$149.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.58
|
| Rate for Payer: BCBS Complete |
$70.51
|
| Rate for Payer: Cash Price |
$141.02
|
| Rate for Payer: Cofinity Commercial |
$123.39
|
| Rate for Payer: Cofinity Commercial |
$151.59
|
| Rate for Payer: Healthscope Commercial |
$158.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$149.83
|
| Rate for Payer: PHP Commercial |
$149.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.39
|
| Rate for Payer: Priority Health SBD |
$111.05
|
|
|
CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$176.27
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
108145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$111.05 |
| Max. Negotiated Rate |
$158.64 |
| Rate for Payer: Aetna Commercial |
$149.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.58
|
| Rate for Payer: Cash Price |
$141.02
|
| Rate for Payer: Cofinity Commercial |
$123.39
|
| Rate for Payer: Cofinity Commercial |
$151.59
|
| Rate for Payer: Healthscope Commercial |
$158.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$149.83
|
| Rate for Payer: PHP Commercial |
$149.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.39
|
| Rate for Payer: Priority Health SBD |
$111.05
|
|
|
CURETTAGE, POSTPARTUM
|
Facility
|
OP
|
$8,478.18
|
|
|
Service Code
|
CPT 59160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$187.30 |
| Max. Negotiated Rate |
$8,478.18 |
| Rate for Payer: Aetna Medicare |
$2,893.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,477.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,477.26
|
| Rate for Payer: BCBS Complete |
$1,597.87
|
| Rate for Payer: BCBS MAPPO |
$2,781.81
|
| Rate for Payer: BCBS Trust/PPO |
$1,610.55
|
| Rate for Payer: BCN Medicare Advantage |
$2,781.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,781.81
|
| Rate for Payer: Mclaren Medicaid |
$1,521.65
|
| Rate for Payer: Mclaren Medicare |
$2,781.81
|
| Rate for Payer: Meridian Medicaid |
$1,597.87
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$2,920.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,199.08
|
| Rate for Payer: PACE Medicare |
$2,642.72
|
| Rate for Payer: PACE SWMI |
$2,781.81
|
| Rate for Payer: PHP Medicare Advantage |
$2,781.81
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,521.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8,478.18
|
| Rate for Payer: Priority Health Medicare |
$2,781.81
|
| Rate for Payer: Priority Health Narrow Network |
$6,782.54
|
| Rate for Payer: Railroad Medicare Medicare |
$2,781.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$206.03
|
| Rate for Payer: UHC Core |
$4,155.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,781.81
|
| Rate for Payer: UHC Exchange |
$187.30
|
| Rate for Payer: UHC Medicare Advantage |
$2,865.26
|
| Rate for Payer: VA VA |
$2,781.81
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$17.54
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
2007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$15.79 |
| Rate for Payer: Aetna Commercial |
$14.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.40
|
| Rate for Payer: BCBS Complete |
$7.02
|
| Rate for Payer: BCBS Trust/PPO |
$4.27
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Cofinity Commercial |
$12.28
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Healthscope Commercial |
$15.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.91
|
| Rate for Payer: PHP Commercial |
$14.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.28
|
| Rate for Payer: Priority Health SBD |
$11.05
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$22.55
|
|
|
Service Code
|
HCPCS J3420
|
| Hospital Charge Code |
2007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.21 |
| Max. Negotiated Rate |
$20.30 |
| Rate for Payer: Aetna Commercial |
$19.17
|
| Rate for Payer: Aetna Commercial |
$14.91
|
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Aetna Commercial |
$22.89
|
| Rate for Payer: Aetna Commercial |
$18.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.88
|
| Rate for Payer: Cash Price |
$22.01
|
| Rate for Payer: Cash Price |
$14.03
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$18.04
|
| Rate for Payer: Cash Price |
$21.54
|
| Rate for Payer: Cofinity Commercial |
$23.66
|
| Rate for Payer: Cofinity Commercial |
$15.27
|
| Rate for Payer: Cofinity Commercial |
$19.26
|
| Rate for Payer: Cofinity Commercial |
$12.28
|
| Rate for Payer: Cofinity Commercial |
$15.08
|
| Rate for Payer: Cofinity Commercial |
$23.16
|
| Rate for Payer: Cofinity Commercial |
$18.85
|
| Rate for Payer: Cofinity Commercial |
$18.77
|
| Rate for Payer: Cofinity Commercial |
$15.78
|
| Rate for Payer: Cofinity Commercial |
$19.39
|
| Rate for Payer: Healthscope Commercial |
$24.76
|
| Rate for Payer: Healthscope Commercial |
$20.30
|
| Rate for Payer: Healthscope Commercial |
$19.64
|
| Rate for Payer: Healthscope Commercial |
$24.24
|
| Rate for Payer: Healthscope Commercial |
$15.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.91
|
| Rate for Payer: PHP Commercial |
$14.91
|
| Rate for Payer: PHP Commercial |
$18.55
|
| Rate for Payer: PHP Commercial |
$23.38
|
| Rate for Payer: PHP Commercial |
$22.89
|
| Rate for Payer: PHP Commercial |
$19.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.27
|
| Rate for Payer: Priority Health SBD |
$14.21
|
| Rate for Payer: Priority Health SBD |
$13.75
|
| Rate for Payer: Priority Health SBD |
$11.05
|
| Rate for Payer: Priority Health SBD |
$16.97
|
| Rate for Payer: Priority Health SBD |
$17.33
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$312.55
|
|
|
Service Code
|
NDC 7733393810
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$196.91 |
| Max. Negotiated Rate |
$281.30 |
| Rate for Payer: Aetna Commercial |
$265.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.16
|
| Rate for Payer: Cash Price |
$250.04
|
| Rate for Payer: Cofinity Commercial |
$218.78
|
| Rate for Payer: Cofinity Commercial |
$268.79
|
| Rate for Payer: Healthscope Commercial |
$281.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$265.67
|
| Rate for Payer: PHP Commercial |
$265.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.78
|
| Rate for Payer: Priority Health SBD |
$196.91
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 5026885515
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.52 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.02
|
| Rate for Payer: Priority Health SBD |
$112.52
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$164.50
|
|
|
Service Code
|
NDC 2055500600
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.64 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.92
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$115.15
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.82
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.15
|
| Rate for Payer: Priority Health SBD |
$103.64
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$3.13
|
|
|
Service Code
|
NDC 7733393825
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna Commercial |
$2.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.03
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.69
|
| Rate for Payer: Healthscope Commercial |
$2.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.66
|
| Rate for Payer: PHP Commercial |
$2.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.19
|
| Rate for Payer: Priority Health SBD |
$1.97
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET
|
Facility
|
IP
|
$3.58
|
|
|
Service Code
|
NDC 5026885511
|
| Hospital Charge Code |
2009
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna Commercial |
$3.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.33
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Commercial |
$2.51
|
| Rate for Payer: Cofinity Commercial |
$3.08
|
| Rate for Payer: Healthscope Commercial |
$3.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.04
|
| Rate for Payer: PHP Commercial |
$3.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.51
|
| Rate for Payer: Priority Health SBD |
$2.26
|
|
|
CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET
|
Facility
|
IP
|
$81.95
|
|
|
Service Code
|
NDC 5026885215
|
| Hospital Charge Code |
2008
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.63 |
| Max. Negotiated Rate |
$73.76 |
| Rate for Payer: Aetna Commercial |
$69.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.27
|
| Rate for Payer: Cash Price |
$65.56
|
| Rate for Payer: Cofinity Commercial |
$57.36
|
| Rate for Payer: Cofinity Commercial |
$70.48
|
| Rate for Payer: Healthscope Commercial |
$73.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.66
|
| Rate for Payer: PHP Commercial |
$69.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.36
|
| Rate for Payer: Priority Health SBD |
$51.63
|
|
|
CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 5026885211
|
| Hospital Charge Code |
2008
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Aetna Commercial |
$1.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.07
|
| Rate for Payer: Cash Price |
$1.31
|
| Rate for Payer: Cofinity Commercial |
$1.15
|
| Rate for Payer: Cofinity Commercial |
$1.41
|
| Rate for Payer: Healthscope Commercial |
$1.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.39
|
| Rate for Payer: PHP Commercial |
$1.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.15
|
| Rate for Payer: Priority Health SBD |
$1.03
|
|
|
CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET
|
Facility
|
IP
|
$3.48
|
|
|
Service Code
|
NDC 5026885311
|
| Hospital Charge Code |
2010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.26
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: Cofinity Commercial |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.96
|
| Rate for Payer: PHP Commercial |
$2.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.44
|
| Rate for Payer: Priority Health SBD |
$2.19
|
|
|
CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET
|
Facility
|
IP
|
$42.77
|
|
|
Service Code
|
NDC 8068116500
|
| 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 Commercial |
$29.94
|
| Rate for Payer: Cofinity Commercial |
$36.78
|
| Rate for Payer: Healthscope Commercial |
$38.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$36.35
|
| Rate for Payer: PHP Commercial |
$36.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.94
|
| Rate for Payer: Priority Health SBD |
$26.95
|
|
|
CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET
|
Facility
|
IP
|
$173.90
|
|
|
Service Code
|
NDC 5026885315
|
| Hospital Charge Code |
2010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.56 |
| Max. Negotiated Rate |
$156.51 |
| Rate for Payer: Aetna Commercial |
$147.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.04
|
| Rate for Payer: Cash Price |
$139.12
|
| Rate for Payer: Cofinity Commercial |
$121.73
|
| Rate for Payer: Cofinity Commercial |
$149.55
|
| Rate for Payer: Healthscope Commercial |
$156.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.82
|
| Rate for Payer: PHP Commercial |
$147.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.73
|
| Rate for Payer: Priority Health SBD |
$109.56
|
|
|
CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET
|
Facility
|
IP
|
$39.72
|
|
|
Service Code
|
NDC 904421813
|
| Hospital Charge Code |
2010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.02 |
| Max. Negotiated Rate |
$35.75 |
| Rate for Payer: Aetna Commercial |
$33.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.82
|
| Rate for Payer: Cash Price |
$31.78
|
| Rate for Payer: Cofinity Commercial |
$27.80
|
| Rate for Payer: Cofinity Commercial |
$34.16
|
| Rate for Payer: Healthscope Commercial |
$35.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.76
|
| Rate for Payer: PHP Commercial |
$33.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.80
|
| Rate for Payer: Priority Health SBD |
$25.02
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$155.10
|
|
|
Service Code
|
NDC 0591-5658-01
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.71 |
| Max. Negotiated Rate |
$139.59 |
| Rate for Payer: Aetna Commercial |
$131.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.82
|
| Rate for Payer: Cash Price |
$124.08
|
| Rate for Payer: Cofinity Commercial |
$108.57
|
| Rate for Payer: Cofinity Commercial |
$133.39
|
| Rate for Payer: Healthscope Commercial |
$139.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$131.84
|
| Rate for Payer: PHP Commercial |
$131.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.57
|
| Rate for Payer: Priority Health SBD |
$97.71
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 63739-531-10
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.62 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.02
|
| Rate for Payer: Priority Health SBD |
$66.62
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$51.70
|
|
|
Service Code
|
NDC 69097-846-07
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$46.53 |
| Rate for Payer: Aetna Commercial |
$43.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.60
|
| Rate for Payer: Cash Price |
$41.36
|
| Rate for Payer: Cofinity Commercial |
$36.19
|
| Rate for Payer: Cofinity Commercial |
$44.46
|
| Rate for Payer: Healthscope Commercial |
$46.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.94
|
| Rate for Payer: PHP Commercial |
$43.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.19
|
| Rate for Payer: Priority Health SBD |
$32.57
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 51079-644-01
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.14
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.76
|
| Rate for Payer: Priority Health SBD |
$1.59
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$390.10
|
|
|
Service Code
|
NDC 60687-558-01
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.76 |
| Max. Negotiated Rate |
$351.09 |
| Rate for Payer: Aetna Commercial |
$331.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.56
|
| Rate for Payer: Cash Price |
$312.08
|
| Rate for Payer: Cofinity Commercial |
$273.07
|
| Rate for Payer: Cofinity Commercial |
$335.49
|
| Rate for Payer: Healthscope Commercial |
$351.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$331.58
|
| Rate for Payer: PHP Commercial |
$331.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.07
|
| Rate for Payer: Priority Health SBD |
$245.76
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$3.91
|
|
|
Service Code
|
NDC 60687-558-11
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$3.52 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.54
|
| Rate for Payer: Cash Price |
$3.13
|
| Rate for Payer: Cofinity Commercial |
$2.74
|
| Rate for Payer: Cofinity Commercial |
$3.36
|
| Rate for Payer: Healthscope Commercial |
$3.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.32
|
| Rate for Payer: PHP Commercial |
$3.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.74
|
| Rate for Payer: Priority Health SBD |
$2.46
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$251.45
|
|
|
Service Code
|
NDC 51079-644-20
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.41 |
| Max. Negotiated Rate |
$226.30 |
| Rate for Payer: Aetna Commercial |
$213.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.44
|
| Rate for Payer: Cash Price |
$201.16
|
| Rate for Payer: Cofinity Commercial |
$176.02
|
| Rate for Payer: Cofinity Commercial |
$216.25
|
| Rate for Payer: Healthscope Commercial |
$226.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.73
|
| Rate for Payer: PHP Commercial |
$213.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.02
|
| Rate for Payer: Priority Health SBD |
$158.41
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$103.40
|
|
|
Service Code
|
NDC 10702-006-01
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna Commercial |
$87.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.21
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Commercial |
$72.38
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.89
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.38
|
| Rate for Payer: Priority Health SBD |
$65.14
|
|
