|
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET
|
Facility
|
IP
|
$1.61
|
|
|
Service Code
|
NDC 5026885411
|
| Hospital Charge Code |
2012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.45 |
| Rate for Payer: Aetna American Axle |
$1.05
|
| Rate for Payer: Aetna Commercial |
$1.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.05
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cofinity Commercial |
$1.13
|
| Rate for Payer: Cofinity Commercial |
$1.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.29
|
| Rate for Payer: Healthscope Commercial |
$1.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.37
|
| Rate for Payer: PHP Commercial |
$1.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.13
|
| Rate for Payer: Priority Health SBD |
$1.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.21
|
|
|
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
NDC 5164591301
|
| Hospital Charge Code |
2012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.96 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Aetna American Axle |
$119.60
|
| Rate for Payer: Aetna Commercial |
$156.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.60
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cofinity Commercial |
$128.80
|
| Rate for Payer: Cofinity Commercial |
$158.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.20
|
| Rate for Payer: Healthscope Commercial |
$165.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$156.40
|
| Rate for Payer: PHP Commercial |
$156.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.80
|
| Rate for Payer: Priority Health SBD |
$115.92
|
| Rate for Payer: UMR Bronson Commercial |
$80.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.00
|
|
|
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET
|
Facility
|
IP
|
$80.30
|
|
|
Service Code
|
NDC 5026885415
|
| Hospital Charge Code |
2012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.33 |
| Max. Negotiated Rate |
$72.27 |
| Rate for Payer: Aetna American Axle |
$52.20
|
| Rate for Payer: Aetna Commercial |
$68.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.20
|
| Rate for Payer: Cash Price |
$64.24
|
| Rate for Payer: Cofinity Commercial |
$56.21
|
| Rate for Payer: Cofinity Commercial |
$69.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.24
|
| Rate for Payer: Healthscope Commercial |
$72.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.26
|
| Rate for Payer: PHP Commercial |
$68.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.21
|
| Rate for Payer: Priority Health SBD |
$50.59
|
| Rate for Payer: UMR Bronson Commercial |
$35.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.22
|
|
|
CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET
|
Facility
|
IP
|
$74.25
|
|
|
Service Code
|
NDC 2055503200
|
| Hospital Charge Code |
2012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.67 |
| Max. Negotiated Rate |
$66.82 |
| Rate for Payer: Aetna American Axle |
$48.26
|
| Rate for Payer: Aetna Commercial |
$63.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.26
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cofinity Commercial |
$51.98
|
| Rate for Payer: Cofinity Commercial |
$63.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.40
|
| Rate for Payer: Healthscope Commercial |
$66.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.11
|
| Rate for Payer: PHP Commercial |
$63.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.98
|
| Rate for Payer: Priority Health SBD |
$46.78
|
| Rate for Payer: UMR Bronson Commercial |
$32.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.69
|
|
|
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 |
$110.64 |
| Max. Negotiated Rate |
$226.30 |
| Rate for Payer: Aetna American Axle |
$163.44
|
| 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: Encore Health Key Benefits Commercial |
$201.16
|
| Rate for Payer: Healthscope Commercial |
$226.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.59
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$110.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.59
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$51.70
|
|
|
Service Code
|
NDC 72888-014-01
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$46.53 |
| Rate for Payer: Aetna American Axle |
$33.60
|
| 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: Encore Health Key Benefits Commercial |
$41.36
|
| Rate for Payer: Healthscope Commercial |
$46.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.78
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$22.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.78
|
|
|
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 |
$22.75 |
| Max. Negotiated Rate |
$46.53 |
| Rate for Payer: Aetna American Axle |
$33.60
|
| 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: Encore Health Key Benefits Commercial |
$41.36
|
| Rate for Payer: Healthscope Commercial |
$46.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.78
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$22.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.78
|
|
|
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 |
$68.24 |
| Max. Negotiated Rate |
$139.59 |
| Rate for Payer: Aetna American Axle |
$100.82
|
| 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: Encore Health Key Benefits Commercial |
$124.08
|
| Rate for Payer: Healthscope Commercial |
$139.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.32
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$68.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.32
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$155.10
|
|
|
Service Code
|
NDC 50268-191-15
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.24 |
| Max. Negotiated Rate |
$139.59 |
| Rate for Payer: Aetna American Axle |
$100.82
|
| 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: Encore Health Key Benefits Commercial |
$124.08
|
| Rate for Payer: Healthscope Commercial |
$139.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.32
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$68.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.32
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$119.85
|
|
|
Service Code
|
NDC 43547-400-10
|
| 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: 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 Multiplan/Beech St/PHCS |
$101.87
|
| Rate for Payer: PHP Commercial |
$101.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.90
|
| 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
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 51079-644-01
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna American Axle |
$1.64
|
| 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: 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 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
|
| Rate for Payer: UMR Bronson Commercial |
$1.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.89
|
|
|
CYCLOBENZAPRINE 10 MG TABLET
|
Facility
|
IP
|
$3.11
|
|
|
Service Code
|
NDC 50268-191-11
|
| Hospital Charge Code |
2017
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna American Axle |
$2.02
|
| Rate for Payer: Aetna Commercial |
$2.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.02
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cofinity Commercial |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.64
|
| Rate for Payer: PHP Commercial |
$2.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.18
|
| Rate for Payer: Priority Health SBD |
$1.96
|
| Rate for Payer: UMR Bronson Commercial |
$1.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.33
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$361.90
|
|
|
Service Code
|
NDC 59746-211-06
|
| 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: 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 Multiplan/Beech St/PHCS |
$307.62
|
| Rate for Payer: PHP Commercial |
$307.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.33
|
| 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
|
IP
|
$364.25
|
|
|
Service Code
|
NDC 0591-3256-01
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.27 |
| Max. Negotiated Rate |
$327.82 |
| Rate for Payer: Aetna American Axle |
$236.76
|
| Rate for Payer: Aetna Commercial |
$309.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$236.76
|
| Rate for Payer: Cash Price |
$291.40
|
| Rate for Payer: Cofinity Commercial |
$254.98
|
| Rate for Payer: Cofinity Commercial |
$313.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.40
|
| Rate for Payer: Healthscope Commercial |
$327.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$254.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$273.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$309.61
|
| Rate for Payer: PHP Commercial |
$309.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$254.98
|
| Rate for Payer: Priority Health SBD |
$229.48
|
| Rate for Payer: UMR Bronson Commercial |
$160.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$273.19
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 72888-012-01
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.85 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna American Axle |
$38.19
|
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.12
|
| Rate for Payer: Priority Health SBD |
$37.01
|
| Rate for Payer: UMR Bronson Commercial |
$25.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.06
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$103.40
|
|
|
Service Code
|
NDC 69097-845-07
|
| 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: 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 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
|
| Rate for Payer: UMR Bronson Commercial |
$45.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
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 |
$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: 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 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
|
| Rate for Payer: UMR Bronson Commercial |
$45.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
CYCLOBENZAPRINE 5 MG TABLET
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 0378-0771-01
|
| Hospital Charge Code |
35184
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.90
|
| Rate for Payer: PHP Commercial |
$83.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.09
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$43.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.02
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$40.25
|
|
|
Service Code
|
NDC 24208-735-01
|
| 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: 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 Multiplan/Beech St/PHCS |
$34.21
|
| Rate for Payer: PHP Commercial |
$34.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.18
|
| 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
|
IP
|
$170.24
|
|
|
Service Code
|
NDC 0065-0396-05
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.91 |
| Max. Negotiated Rate |
$153.22 |
| Rate for Payer: Aetna American Axle |
$110.66
|
| Rate for Payer: Aetna Commercial |
$144.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.66
|
| Rate for Payer: Cash Price |
$136.19
|
| Rate for Payer: Cofinity Commercial |
$119.17
|
| Rate for Payer: Cofinity Commercial |
$146.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.19
|
| Rate for Payer: Healthscope Commercial |
$153.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$144.70
|
| Rate for Payer: PHP Commercial |
$144.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$119.17
|
| Rate for Payer: Priority Health SBD |
$107.25
|
| Rate for Payer: UMR Bronson Commercial |
$74.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.68
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS
|
Facility
|
IP
|
$18.86
|
|
|
Service Code
|
NDC 17478-100-02
|
| 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: 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 Multiplan/Beech St/PHCS |
$16.03
|
| Rate for Payer: PHP Commercial |
$16.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.20
|
| 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
|
IP
|
$12.78
|
|
|
Service Code
|
NDC 61314-396-01
|
| Hospital Charge Code |
2025
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.62 |
| Max. Negotiated Rate |
$11.50 |
| Rate for Payer: Aetna American Axle |
$8.31
|
| Rate for Payer: Aetna Commercial |
$10.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.31
|
| Rate for Payer: Cash Price |
$10.22
|
| Rate for Payer: Cofinity Commercial |
$10.99
|
| Rate for Payer: Cofinity Commercial |
$8.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.22
|
| Rate for Payer: Healthscope Commercial |
$11.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.86
|
| Rate for Payer: PHP Commercial |
$10.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.95
|
| Rate for Payer: Priority Health SBD |
$8.05
|
| Rate for Payer: UMR Bronson Commercial |
$5.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.58
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS
|
Facility
|
IP
|
$173.85
|
|
|
Service Code
|
NDC 0065-0359-05
|
| Hospital Charge Code |
9701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.49 |
| Max. Negotiated Rate |
$156.46 |
| Rate for Payer: Aetna American Axle |
$113.00
|
| Rate for Payer: Aetna Commercial |
$147.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$113.00
|
| Rate for Payer: Cash Price |
$139.08
|
| Rate for Payer: Cofinity Commercial |
$121.70
|
| Rate for Payer: Cofinity Commercial |
$149.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$139.08
|
| Rate for Payer: Healthscope Commercial |
$156.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$121.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$130.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$147.77
|
| Rate for Payer: PHP Commercial |
$147.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.70
|
| Rate for Payer: Priority Health SBD |
$109.53
|
| Rate for Payer: UMR Bronson Commercial |
$76.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$130.39
|
|
|
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS
|
Facility
|
IP
|
$98.98
|
|
|
Service Code
|
NDC 0065-0359-02
|
| Hospital Charge Code |
9701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$89.08 |
| Rate for Payer: Aetna American Axle |
$64.34
|
| Rate for Payer: Aetna Commercial |
$84.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.34
|
| Rate for Payer: Cash Price |
$79.18
|
| Rate for Payer: Cofinity Commercial |
$69.29
|
| Rate for Payer: Cofinity Commercial |
$85.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.18
|
| Rate for Payer: Healthscope Commercial |
$89.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$84.13
|
| Rate for Payer: PHP Commercial |
$84.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.29
|
| Rate for Payer: Priority Health SBD |
$62.36
|
| Rate for Payer: UMR Bronson Commercial |
$43.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.24
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,433.40
|
|
|
Service Code
|
HCPCS J9071
|
| Hospital Charge Code |
194691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,070.70 |
| Max. Negotiated Rate |
$2,190.06 |
| Rate for Payer: Aetna American Axle |
$1,581.71
|
| Rate for Payer: Aetna Commercial |
$2,068.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,581.71
|
| Rate for Payer: Cash Price |
$1,946.72
|
| Rate for Payer: Cofinity Commercial |
$1,703.38
|
| Rate for Payer: Cofinity Commercial |
$2,092.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,946.72
|
| Rate for Payer: Healthscope Commercial |
$2,190.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,703.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,825.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,068.39
|
| Rate for Payer: PHP Commercial |
$2,068.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,703.38
|
| Rate for Payer: Priority Health SBD |
$1,533.04
|
| Rate for Payer: UMR Bronson Commercial |
$1,070.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,825.05
|
|
