|
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.13
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.26
|
| Rate for Payer: Aetna Commercial |
$16.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.82
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.78
|
| Rate for Payer: Cofinity Commercial |
$13.39
|
| Rate for Payer: Cofinity Commercial |
$13.81
|
| Rate for Payer: Cofinity Commercial |
$16.97
|
| Rate for Payer: Cofinity Commercial |
$16.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.78
|
| Rate for Payer: Healthscope Commercial |
$17.22
|
| Rate for Payer: Healthscope Commercial |
$17.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.77
|
| Rate for Payer: PHP Commercial |
$16.26
|
| Rate for Payer: PHP Commercial |
$16.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.43
|
| Rate for Payer: Priority Health SBD |
$12.43
|
| Rate for Payer: Priority Health SBD |
$12.05
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
IP
|
$71.15
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.82 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: Aetna Commercial |
$56.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.25
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$49.80
|
| Rate for Payer: Cofinity Commercial |
$46.59
|
| Rate for Payer: Cofinity Commercial |
$57.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$64.03
|
| Rate for Payer: Healthscope Commercial |
$59.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.48
|
| Rate for Payer: PHP Commercial |
$60.48
|
| Rate for Payer: PHP Commercial |
$56.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.25
|
| Rate for Payer: Priority Health SBD |
$41.93
|
| Rate for Payer: Priority Health SBD |
$44.82
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
OP
|
$71.15
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.46 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: Aetna Commercial |
$56.58
|
| Rate for Payer: Aetna Medicare |
$33.28
|
| Rate for Payer: Aetna Medicare |
$35.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.26
|
| Rate for Payer: BCBS Complete |
$28.46
|
| Rate for Payer: BCBS Complete |
$26.62
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cash Price |
$53.25
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Commercial |
$46.59
|
| Rate for Payer: Cofinity Commercial |
$57.24
|
| Rate for Payer: Cofinity Commercial |
$49.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$64.03
|
| Rate for Payer: Healthscope Commercial |
$59.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.58
|
| Rate for Payer: PHP Commercial |
$60.48
|
| Rate for Payer: PHP Commercial |
$56.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.25
|
| Rate for Payer: Priority Health SBD |
$41.93
|
| Rate for Payer: Priority Health SBD |
$44.82
|
|
|
DOPAMINE 400 MG/5 ML (80 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$22.65
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
118602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$20.39 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.72
|
| Rate for Payer: Cash Price |
$18.12
|
| Rate for Payer: Cofinity Commercial |
$15.86
|
| Rate for Payer: Cofinity Commercial |
$19.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.12
|
| Rate for Payer: Healthscope Commercial |
$20.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.25
|
| Rate for Payer: PHP Commercial |
$19.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.72
|
| Rate for Payer: Priority Health SBD |
$14.27
|
|
|
DOPAMINE 400 MG/5 ML (80 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$22.65
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
118602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$20.39 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Aetna Medicare |
$11.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.72
|
| Rate for Payer: BCBS Complete |
$9.06
|
| Rate for Payer: Cash Price |
$18.12
|
| Rate for Payer: Cofinity Commercial |
$15.86
|
| Rate for Payer: Cofinity Commercial |
$19.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.12
|
| Rate for Payer: Healthscope Commercial |
$20.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.25
|
| Rate for Payer: PHP Commercial |
$19.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.72
|
| Rate for Payer: Priority Health SBD |
$14.27
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION
|
Facility
|
IP
|
$460.32
|
|
|
Service Code
|
HCPCS J7639
|
| Hospital Charge Code |
12211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$290.00 |
| Max. Negotiated Rate |
$414.29 |
| Rate for Payer: Aetna Commercial |
$391.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$299.21
|
| Rate for Payer: Cash Price |
$368.26
|
| Rate for Payer: Cofinity Commercial |
$322.22
|
| Rate for Payer: Cofinity Commercial |
$395.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$322.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$368.26
|
| Rate for Payer: Healthscope Commercial |
$414.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$391.27
|
| Rate for Payer: PHP Commercial |
$391.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.21
|
| Rate for Payer: Priority Health SBD |
$290.00
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION
|
Facility
|
OP
|
$460.32
|
|
|
Service Code
|
HCPCS J7639
|
| Hospital Charge Code |
12211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$184.13 |
| Max. Negotiated Rate |
$414.29 |
| Rate for Payer: Aetna Commercial |
$391.27
|
| Rate for Payer: Aetna Medicare |
$230.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$299.21
|
| Rate for Payer: BCBS Complete |
$184.13
|
| Rate for Payer: Cash Price |
$368.26
|
| Rate for Payer: Cofinity Commercial |
$322.22
|
| Rate for Payer: Cofinity Commercial |
$395.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$322.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$368.26
|
| Rate for Payer: Healthscope Commercial |
$414.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$391.27
|
| Rate for Payer: PHP Commercial |
$391.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.21
|
| Rate for Payer: Priority Health SBD |
$290.00
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS
|
Facility
|
OP
|
$162.75
|
|
|
Service Code
|
NDC 50383023310
|
| Hospital Charge Code |
22982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.10 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Aetna Commercial |
$138.34
|
| Rate for Payer: Aetna Medicare |
$81.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.79
|
| Rate for Payer: BCBS Complete |
$65.10
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cofinity Commercial |
$113.92
|
| Rate for Payer: Cofinity Commercial |
$139.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.20
|
| Rate for Payer: Healthscope Commercial |
$146.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.34
|
| Rate for Payer: PHP Commercial |
$138.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.79
|
| Rate for Payer: Priority Health SBD |
$102.53
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS
|
Facility
|
IP
|
$65.10
|
|
|
Service Code
|
NDC 61314003002
|
| Hospital Charge Code |
22982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.01 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$55.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.31
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cofinity Commercial |
$45.57
|
| Rate for Payer: Cofinity Commercial |
$55.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$45.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Healthscope Commercial |
$58.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.34
|
| Rate for Payer: PHP Commercial |
$55.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.31
|
| Rate for Payer: Priority Health SBD |
$41.01
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS
|
Facility
|
OP
|
$65.10
|
|
|
Service Code
|
NDC 61314003002
|
| Hospital Charge Code |
22982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$58.59 |
| Rate for Payer: Aetna Commercial |
$55.34
|
| Rate for Payer: Aetna Medicare |
$32.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.31
|
| Rate for Payer: BCBS Complete |
$26.04
|
| Rate for Payer: Cash Price |
$52.08
|
| Rate for Payer: Cofinity Commercial |
$45.57
|
| Rate for Payer: Cofinity Commercial |
$55.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$45.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.08
|
| Rate for Payer: Healthscope Commercial |
$58.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.34
|
| Rate for Payer: PHP Commercial |
$55.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.31
|
| Rate for Payer: Priority Health SBD |
$41.01
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS
|
Facility
|
IP
|
$30.10
|
|
|
Service Code
|
NDC 24208048610
|
| Hospital Charge Code |
22982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.96 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: Aetna Commercial |
$25.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.57
|
| Rate for Payer: Cash Price |
$24.08
|
| Rate for Payer: Cofinity Commercial |
$21.07
|
| Rate for Payer: Cofinity Commercial |
$25.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.08
|
| Rate for Payer: Healthscope Commercial |
$27.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.59
|
| Rate for Payer: PHP Commercial |
$25.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.57
|
| Rate for Payer: Priority Health SBD |
$18.96
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS
|
Facility
|
IP
|
$162.75
|
|
|
Service Code
|
NDC 50383023310
|
| Hospital Charge Code |
22982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.53 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Aetna Commercial |
$138.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.79
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cofinity Commercial |
$113.92
|
| Rate for Payer: Cofinity Commercial |
$139.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.20
|
| Rate for Payer: Healthscope Commercial |
$146.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.34
|
| Rate for Payer: PHP Commercial |
$138.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.79
|
| Rate for Payer: Priority Health SBD |
$102.53
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS
|
Facility
|
OP
|
$30.10
|
|
|
Service Code
|
NDC 24208048610
|
| Hospital Charge Code |
22982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.04 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: Aetna Commercial |
$25.59
|
| Rate for Payer: Aetna Medicare |
$15.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.57
|
| Rate for Payer: BCBS Complete |
$12.04
|
| Rate for Payer: Cash Price |
$24.08
|
| Rate for Payer: Cofinity Commercial |
$21.07
|
| Rate for Payer: Cofinity Commercial |
$25.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.08
|
| Rate for Payer: Healthscope Commercial |
$27.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.59
|
| Rate for Payer: PHP Commercial |
$25.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.57
|
| Rate for Payer: Priority Health SBD |
$18.96
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$36.63
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.08 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.81
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cofinity Commercial |
$25.64
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.30
|
| Rate for Payer: Healthscope Commercial |
$32.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.14
|
| Rate for Payer: PHP Commercial |
$31.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.81
|
| Rate for Payer: Priority Health SBD |
$23.08
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$116.96
|
|
|
Service Code
|
NDC 24208048510
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.78 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna Commercial |
$99.42
|
| Rate for Payer: Aetna Medicare |
$58.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.02
|
| Rate for Payer: BCBS Complete |
$46.78
|
| Rate for Payer: Cash Price |
$93.57
|
| Rate for Payer: Cofinity Commercial |
$100.59
|
| Rate for Payer: Cofinity Commercial |
$81.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$105.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.42
|
| Rate for Payer: PHP Commercial |
$99.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.02
|
| Rate for Payer: Priority Health SBD |
$73.68
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$37.52
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.01 |
| Max. Negotiated Rate |
$33.77 |
| Rate for Payer: Aetna Commercial |
$31.89
|
| Rate for Payer: Aetna Medicare |
$18.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.39
|
| Rate for Payer: BCBS Complete |
$15.01
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cofinity Commercial |
$26.26
|
| Rate for Payer: Cofinity Commercial |
$32.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.02
|
| Rate for Payer: Healthscope Commercial |
$33.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.89
|
| Rate for Payer: PHP Commercial |
$31.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.39
|
| Rate for Payer: Priority Health SBD |
$23.64
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$116.96
|
|
|
Service Code
|
NDC 24208048510
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.68 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna Commercial |
$99.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.02
|
| Rate for Payer: Cash Price |
$93.57
|
| Rate for Payer: Cofinity Commercial |
$100.59
|
| Rate for Payer: Cofinity Commercial |
$81.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$105.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.42
|
| Rate for Payer: PHP Commercial |
$99.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.02
|
| Rate for Payer: Priority Health SBD |
$73.68
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$36.63
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna Medicare |
$18.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.81
|
| Rate for Payer: BCBS Complete |
$14.65
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cofinity Commercial |
$25.64
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.30
|
| Rate for Payer: Healthscope Commercial |
$32.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.14
|
| Rate for Payer: PHP Commercial |
$31.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.81
|
| Rate for Payer: Priority Health SBD |
$23.08
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$37.52
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.64 |
| Max. Negotiated Rate |
$33.77 |
| Rate for Payer: Aetna Commercial |
$31.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.39
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cofinity Commercial |
$26.26
|
| Rate for Payer: Cofinity Commercial |
$32.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.02
|
| Rate for Payer: Healthscope Commercial |
$33.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.89
|
| Rate for Payer: PHP Commercial |
$31.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.39
|
| Rate for Payer: Priority Health SBD |
$23.64
|
|
|
DOXEPIN 100 MG CAPSULE
|
Facility
|
IP
|
$735.36
|
|
|
Service Code
|
NDC 00904705561
|
| Hospital Charge Code |
2609
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$463.28 |
| Max. Negotiated Rate |
$661.82 |
| Rate for Payer: Aetna Commercial |
$625.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$477.98
|
| Rate for Payer: Cash Price |
$588.29
|
| Rate for Payer: Cofinity Commercial |
$514.75
|
| Rate for Payer: Cofinity Commercial |
$632.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$514.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$588.29
|
| Rate for Payer: Healthscope Commercial |
$661.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$625.06
|
| Rate for Payer: PHP Commercial |
$625.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$477.98
|
| Rate for Payer: Priority Health SBD |
$463.28
|
|
|
DOXEPIN 100 MG CAPSULE
|
Facility
|
OP
|
$735.36
|
|
|
Service Code
|
NDC 00904705561
|
| Hospital Charge Code |
2609
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.14 |
| Max. Negotiated Rate |
$661.82 |
| Rate for Payer: Aetna Commercial |
$625.06
|
| Rate for Payer: Aetna Medicare |
$367.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$477.98
|
| Rate for Payer: BCBS Complete |
$294.14
|
| Rate for Payer: Cash Price |
$588.29
|
| Rate for Payer: Cofinity Commercial |
$514.75
|
| Rate for Payer: Cofinity Commercial |
$632.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$514.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$588.29
|
| Rate for Payer: Healthscope Commercial |
$661.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$625.06
|
| Rate for Payer: PHP Commercial |
$625.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$477.98
|
| Rate for Payer: Priority Health SBD |
$463.28
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
OP
|
$2.62
|
|
|
Service Code
|
NDC 51079043601
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna Medicare |
$1.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: BCBS Complete |
$1.05
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 51079043601
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$261.12
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.51 |
| Max. Negotiated Rate |
$235.01 |
| Rate for Payer: Aetna Commercial |
$221.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.73
|
| Rate for Payer: Cash Price |
$208.90
|
| Rate for Payer: Cofinity Commercial |
$182.78
|
| Rate for Payer: Cofinity Commercial |
$224.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.90
|
| Rate for Payer: Healthscope Commercial |
$235.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.95
|
| Rate for Payer: PHP Commercial |
$221.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.73
|
| Rate for Payer: Priority Health SBD |
$164.51
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
OP
|
$261.12
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.45 |
| Max. Negotiated Rate |
$235.01 |
| Rate for Payer: Aetna Commercial |
$221.95
|
| Rate for Payer: Aetna Medicare |
$130.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.73
|
| Rate for Payer: BCBS Complete |
$104.45
|
| Rate for Payer: Cash Price |
$208.90
|
| Rate for Payer: Cofinity Commercial |
$182.78
|
| Rate for Payer: Cofinity Commercial |
$224.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.90
|
| Rate for Payer: Healthscope Commercial |
$235.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.95
|
| Rate for Payer: PHP Commercial |
$221.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.73
|
| Rate for Payer: Priority Health SBD |
$164.51
|
|
