|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$119.85
|
|
|
Service Code
|
NDC 43547040010
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.73 |
| Max. Negotiated Rate |
$107.86 |
| Rate for Payer: Aetna American Axle |
$77.90
|
| Rate for Payer: Aetna Commercial |
$101.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.90
|
| Rate for Payer: Cash Price |
$95.88
|
| Rate for Payer: Cofinity Commercial |
$103.07
|
| Rate for Payer: Cofinity Commercial |
$83.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.88
|
| Rate for Payer: Healthscope Commercial |
$107.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.87
|
| Rate for Payer: PHP Commercial |
$101.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.90
|
| Rate for Payer: Priority Health SBD |
$75.51
|
| Rate for Payer: UMR Bronson Commercial |
$52.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.89
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 51079064401
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna American Axle |
$1.64
|
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: Aetna Medicare |
$1.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: BCBS Complete |
$1.01
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.14
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.64
|
| Rate for Payer: Priority Health SBD |
$1.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.89
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$361.90
|
|
|
Service Code
|
NDC 59746021106
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.24 |
| Max. Negotiated Rate |
$325.71 |
| Rate for Payer: Aetna American Axle |
$235.24
|
| Rate for Payer: Aetna Commercial |
$307.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.24
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$253.33
|
| Rate for Payer: Cofinity Commercial |
$311.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$253.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.52
|
| Rate for Payer: Healthscope Commercial |
$325.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$253.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.62
|
| Rate for Payer: PHP Commercial |
$307.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.24
|
| Rate for Payer: Priority Health SBD |
$228.00
|
| Rate for Payer: UMR Bronson Commercial |
$159.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.42
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 72888001201
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.69 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna Medicare |
$38.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: BCBS Complete |
$31.02
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$28.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 72888001201
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$34.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
OP
|
$361.90
|
|
|
Service Code
|
NDC 59746021106
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.90 |
| Max. Negotiated Rate |
$325.71 |
| Rate for Payer: Aetna American Axle |
$235.24
|
| Rate for Payer: Aetna Commercial |
$307.62
|
| Rate for Payer: Aetna Medicare |
$180.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$235.24
|
| Rate for Payer: BCBS Complete |
$144.76
|
| Rate for Payer: Cash Price |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$253.33
|
| Rate for Payer: Cofinity Commercial |
$311.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$253.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.52
|
| Rate for Payer: Healthscope Commercial |
$325.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$253.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.62
|
| Rate for Payer: PHP Commercial |
$307.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$235.24
|
| Rate for Payer: Priority Health SBD |
$228.00
|
| Rate for Payer: UMR Bronson Commercial |
$133.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.42
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$84.60
|
|
|
Service Code
|
NDC 69097084507
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.22 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna American Axle |
$54.99
|
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Commercial |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$59.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.91
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.99
|
| Rate for Payer: Priority Health SBD |
$53.30
|
| Rate for Payer: UMR Bronson Commercial |
$37.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.45
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
OP
|
$84.60
|
|
|
Service Code
|
NDC 69097084507
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.30 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna American Axle |
$54.99
|
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: Aetna Medicare |
$42.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
| Rate for Payer: BCBS Complete |
$33.84
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Commercial |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$59.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$59.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$63.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.91
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.99
|
| Rate for Payer: Priority Health SBD |
$53.30
|
| Rate for Payer: UMR Bronson Commercial |
$31.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$63.45
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
OP
|
$103.40
|
|
|
Service Code
|
NDC 10702000601
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.26 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna American Axle |
$67.21
|
| Rate for Payer: Aetna Commercial |
$87.89
|
| Rate for Payer: Aetna Medicare |
$51.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.21
|
| Rate for Payer: BCBS Complete |
$41.36
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Commercial |
$72.38
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.89
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.21
|
| Rate for Payer: Priority Health SBD |
$65.14
|
| Rate for Payer: UMR Bronson Commercial |
$38.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$103.40
|
|
|
Service Code
|
NDC 10702000601
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna American Axle |
$67.21
|
| 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: Cofinity Medicare Advantage |
$72.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.89
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.21
|
| Rate for Payer: Priority Health SBD |
$65.14
|
| Rate for Payer: UMR Bronson Commercial |
$45.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$18.86
|
|
|
Service Code
|
NDC 17478010002
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.30 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Aetna American Axle |
$12.26
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$13.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.14
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$8.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.14
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
OP
|
$178.78
|
|
|
Service Code
|
NDC 00065039605
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.15 |
| Max. Negotiated Rate |
$160.90 |
| Rate for Payer: Aetna American Axle |
$116.21
|
| Rate for Payer: Aetna Commercial |
$151.96
|
| Rate for Payer: Aetna Medicare |
$89.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.21
|
| Rate for Payer: BCBS Complete |
$71.51
|
| Rate for Payer: Cash Price |
$143.02
|
| Rate for Payer: Cofinity Commercial |
$125.15
|
| Rate for Payer: Cofinity Commercial |
$153.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$143.02
|
| Rate for Payer: Healthscope Commercial |
$160.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$134.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.96
|
| Rate for Payer: PHP Commercial |
$151.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.21
|
| Rate for Payer: Priority Health SBD |
$112.63
|
| Rate for Payer: UMR Bronson Commercial |
$66.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$134.08
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$15.21
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.69 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna American Axle |
$9.89
|
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.89
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Cofinity Commercial |
$10.65
|
| Rate for Payer: Cofinity Commercial |
$13.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.17
|
| Rate for Payer: Healthscope Commercial |
$13.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.93
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.89
|
| Rate for Payer: Priority Health SBD |
$9.58
|
| Rate for Payer: UMR Bronson Commercial |
$6.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.41
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$178.78
|
|
|
Service Code
|
NDC 00065039605
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.66 |
| Max. Negotiated Rate |
$160.90 |
| Rate for Payer: Aetna American Axle |
$116.21
|
| Rate for Payer: Aetna Commercial |
$151.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.21
|
| Rate for Payer: Cash Price |
$143.02
|
| Rate for Payer: Cofinity Commercial |
$125.15
|
| Rate for Payer: Cofinity Commercial |
$153.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$143.02
|
| Rate for Payer: Healthscope Commercial |
$160.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$134.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$151.96
|
| Rate for Payer: PHP Commercial |
$151.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.21
|
| Rate for Payer: Priority Health SBD |
$112.63
|
| Rate for Payer: UMR Bronson Commercial |
$78.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$134.08
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
OP
|
$40.25
|
|
|
Service Code
|
NDC 24208073501
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.89 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna American Axle |
$26.16
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$28.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.19
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$14.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.19
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
OP
|
$15.21
|
|
|
Service Code
|
NDC 61314039601
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.63 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna American Axle |
$9.89
|
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Aetna Medicare |
$7.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.89
|
| Rate for Payer: BCBS Complete |
$6.08
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Cofinity Commercial |
$10.65
|
| Rate for Payer: Cofinity Commercial |
$13.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.17
|
| Rate for Payer: Healthscope Commercial |
$13.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.93
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.89
|
| Rate for Payer: Priority Health SBD |
$9.58
|
| Rate for Payer: UMR Bronson Commercial |
$5.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.41
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$40.25
|
|
|
Service Code
|
NDC 24208073501
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.71 |
| Max. Negotiated Rate |
$36.22 |
| Rate for Payer: Aetna American Axle |
$26.16
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$28.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.19
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$17.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.19
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
OP
|
$18.86
|
|
|
Service Code
|
NDC 17478010002
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Aetna American Axle |
$12.26
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$13.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.14
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$6.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.14
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS
|
Facility
|
IP
|
$182.53
|
|
|
Service Code
|
NDC 00065035905
|
| Hospital Charge Code |
9701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.31 |
| Max. Negotiated Rate |
$164.28 |
| Rate for Payer: Aetna American Axle |
$118.64
|
| Rate for Payer: Aetna Commercial |
$155.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.64
|
| Rate for Payer: Cash Price |
$146.02
|
| Rate for Payer: Cofinity Commercial |
$127.77
|
| Rate for Payer: Cofinity Commercial |
$156.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.02
|
| Rate for Payer: Healthscope Commercial |
$164.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.15
|
| Rate for Payer: PHP Commercial |
$155.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.64
|
| Rate for Payer: Priority Health SBD |
$114.99
|
| Rate for Payer: UMR Bronson Commercial |
$80.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.90
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS
|
Facility
|
OP
|
$182.53
|
|
|
Service Code
|
NDC 00065035905
|
| Hospital Charge Code |
9701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.54 |
| Max. Negotiated Rate |
$164.28 |
| Rate for Payer: Aetna American Axle |
$118.64
|
| Rate for Payer: Aetna Commercial |
$155.15
|
| Rate for Payer: Aetna Medicare |
$91.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.64
|
| Rate for Payer: BCBS Complete |
$73.01
|
| Rate for Payer: Cash Price |
$146.02
|
| Rate for Payer: Cofinity Commercial |
$127.77
|
| Rate for Payer: Cofinity Commercial |
$156.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.02
|
| Rate for Payer: Healthscope Commercial |
$164.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.15
|
| Rate for Payer: PHP Commercial |
$155.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.64
|
| Rate for Payer: Priority Health SBD |
$114.99
|
| Rate for Payer: UMR Bronson Commercial |
$67.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.90
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS
|
Facility
|
IP
|
$103.92
|
|
|
Service Code
|
NDC 00065035902
|
| Hospital Charge Code |
9701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.72 |
| Max. Negotiated Rate |
$93.53 |
| Rate for Payer: Aetna American Axle |
$67.55
|
| Rate for Payer: Aetna Commercial |
$88.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.55
|
| Rate for Payer: Cash Price |
$83.14
|
| Rate for Payer: Cofinity Commercial |
$72.74
|
| Rate for Payer: Cofinity Commercial |
$89.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.14
|
| Rate for Payer: Healthscope Commercial |
$93.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.33
|
| Rate for Payer: PHP Commercial |
$88.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.55
|
| Rate for Payer: Priority Health SBD |
$65.47
|
| Rate for Payer: UMR Bronson Commercial |
$45.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.94
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS
|
Facility
|
OP
|
$103.92
|
|
|
Service Code
|
NDC 00065035902
|
| Hospital Charge Code |
9701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.45 |
| Max. Negotiated Rate |
$93.53 |
| Rate for Payer: Aetna American Axle |
$67.55
|
| Rate for Payer: Aetna Commercial |
$88.33
|
| Rate for Payer: Aetna Medicare |
$51.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.55
|
| Rate for Payer: BCBS Complete |
$41.57
|
| Rate for Payer: Cash Price |
$83.14
|
| Rate for Payer: Cofinity Commercial |
$72.74
|
| Rate for Payer: Cofinity Commercial |
$89.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.14
|
| Rate for Payer: Healthscope Commercial |
$93.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.33
|
| Rate for Payer: PHP Commercial |
$88.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.55
|
| Rate for Payer: Priority Health SBD |
$65.47
|
| Rate for Payer: UMR Bronson Commercial |
$38.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.94
|
|
|
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 |
$500.23 |
| Max. Negotiated Rate |
$1,023.19 |
| Rate for Payer: Aetna American Axle |
$738.97
|
| Rate for Payer: Aetna American Axle |
$1,390.94
|
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Aetna Commercial |
$1,818.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$738.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,390.94
|
| Rate for Payer: Cash Price |
$909.50
|
| Rate for Payer: Cash Price |
$1,711.92
|
| Rate for Payer: Cofinity Commercial |
$1,840.31
|
| Rate for Payer: Cofinity Commercial |
$1,497.93
|
| 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: Cofinity Medicare Advantage |
$1,497.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$909.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,711.92
|
| Rate for Payer: Healthscope Commercial |
$1,023.19
|
| Rate for Payer: Healthscope Commercial |
$1,925.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$795.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,497.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$852.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,604.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,818.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$966.35
|
| Rate for Payer: PHP Commercial |
$1,818.92
|
| Rate for Payer: PHP Commercial |
$966.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$738.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,390.94
|
| Rate for Payer: Priority Health SBD |
$716.23
|
| Rate for Payer: Priority Health SBD |
$1,348.14
|
| Rate for Payer: UMR Bronson Commercial |
$500.23
|
| Rate for Payer: UMR Bronson Commercial |
$941.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$852.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,604.92
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,149.02
|
|
|
Service Code
|
HCPCS J9073
|
| Hospital Charge Code |
194691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$945.57 |
| Max. Negotiated Rate |
$1,934.12 |
| Rate for Payer: Aetna American Axle |
$1,396.86
|
| Rate for Payer: Aetna Commercial |
$1,826.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,396.86
|
| Rate for Payer: Cash Price |
$1,719.22
|
| Rate for Payer: Cofinity Commercial |
$1,504.31
|
| Rate for Payer: Cofinity Commercial |
$1,848.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,504.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,719.22
|
| Rate for Payer: Healthscope Commercial |
$1,934.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,504.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,611.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,826.67
|
| Rate for Payer: PHP Commercial |
$1,826.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,396.86
|
| Rate for Payer: Priority Health SBD |
$1,353.88
|
| Rate for Payer: UMR Bronson Commercial |
$945.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,611.76
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,384.25
|
|
|
Service Code
|
HCPCS J9071
|
| Hospital Charge Code |
194691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$609.07 |
| Max. Negotiated Rate |
$1,245.82 |
| Rate for Payer: Aetna American Axle |
$899.76
|
| Rate for Payer: Aetna American Axle |
$1,581.71
|
| Rate for Payer: Aetna Commercial |
$1,176.61
|
| Rate for Payer: Aetna Commercial |
$2,068.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$899.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,581.71
|
| Rate for Payer: Cash Price |
$1,107.40
|
| Rate for Payer: Cash Price |
$1,946.72
|
| Rate for Payer: Cofinity Commercial |
$2,092.72
|
| Rate for Payer: Cofinity Commercial |
$1,703.38
|
| Rate for Payer: Cofinity Commercial |
$1,190.46
|
| Rate for Payer: Cofinity Commercial |
$968.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$968.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,703.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,107.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,946.72
|
| Rate for Payer: Healthscope Commercial |
$1,245.82
|
| Rate for Payer: Healthscope Commercial |
$2,190.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$968.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,703.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,038.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,825.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,068.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,176.61
|
| Rate for Payer: PHP Commercial |
$2,068.39
|
| Rate for Payer: PHP Commercial |
$1,176.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$899.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,581.71
|
| Rate for Payer: Priority Health SBD |
$872.08
|
| Rate for Payer: Priority Health SBD |
$1,533.04
|
| Rate for Payer: UMR Bronson Commercial |
$609.07
|
| Rate for Payer: UMR Bronson Commercial |
$1,070.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,038.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,825.05
|
|
