Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DONEPEZIL 10 MG TABLET

Facility

$225.60

Service Code	NDC 00904647861
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$90.24
Max. Negotiated Rate	$203.04
Rate for Payer: Aetna Commercial	$191.76
Rate for Payer: Aetna Medicare	$112.80
Rate for Payer: Aetna New Business (MI Preferred)	$146.64
Rate for Payer: BCBS Complete	$90.24
Rate for Payer: Cash Price	$180.48
Rate for Payer: Cofinity Commercial	$157.92
Rate for Payer: Cofinity Commercial	$194.02
Rate for Payer: Cofinity Medicare Advantage	$157.92
Rate for Payer: Encore Health Key Benefits Commercial	$180.48
Rate for Payer: Healthscope Commercial	$203.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$191.76
Rate for Payer: PHP Commercial	$191.76
Rate for Payer: Priority Health Cigna Priority Health	$146.64
Rate for Payer: Priority Health SBD	$142.13

DONEPEZIL 10 MG TABLET

Facility

$225.60

Service Code	NDC 00904647861
Hospital Charge Code	18787
Hospital Revenue Code	637
Min. Negotiated Rate	$142.13
Max. Negotiated Rate	$203.04
Rate for Payer: Aetna Commercial	$191.76
Rate for Payer: Aetna New Business (MI Preferred)	$146.64
Rate for Payer: Cash Price	$180.48
Rate for Payer: Cofinity Commercial	$157.92
Rate for Payer: Cofinity Commercial	$194.02
Rate for Payer: Cofinity Medicare Advantage	$157.92
Rate for Payer: Encore Health Key Benefits Commercial	$180.48
Rate for Payer: Healthscope Commercial	$203.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$191.76
Rate for Payer: PHP Commercial	$191.76
Rate for Payer: Priority Health Cigna Priority Health	$146.64
Rate for Payer: Priority Health SBD	$142.13

DONEPEZIL 5 MG TABLET

Facility

$263.20

Service Code	NDC 00904647761
Hospital Charge Code	18786
Hospital Revenue Code	637
Min. Negotiated Rate	$165.82
Max. Negotiated Rate	$236.88
Rate for Payer: Aetna Commercial	$223.72
Rate for Payer: Aetna New Business (MI Preferred)	$171.08
Rate for Payer: Cash Price	$210.56
Rate for Payer: Cofinity Commercial	$184.24
Rate for Payer: Cofinity Commercial	$226.35
Rate for Payer: Cofinity Medicare Advantage	$184.24
Rate for Payer: Encore Health Key Benefits Commercial	$210.56
Rate for Payer: Healthscope Commercial	$236.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$223.72
Rate for Payer: PHP Commercial	$223.72
Rate for Payer: Priority Health Cigna Priority Health	$171.08
Rate for Payer: Priority Health SBD	$165.82

DONEPEZIL 5 MG TABLET

Facility

$263.20

Service Code	NDC 00904647761
Hospital Charge Code	18786
Hospital Revenue Code	637
Min. Negotiated Rate	$105.28
Max. Negotiated Rate	$236.88
Rate for Payer: Aetna Commercial	$223.72
Rate for Payer: Aetna Medicare	$131.60
Rate for Payer: Aetna New Business (MI Preferred)	$171.08
Rate for Payer: BCBS Complete	$105.28
Rate for Payer: Cash Price	$210.56
Rate for Payer: Cofinity Commercial	$184.24
Rate for Payer: Cofinity Commercial	$226.35
Rate for Payer: Cofinity Medicare Advantage	$184.24
Rate for Payer: Encore Health Key Benefits Commercial	$210.56
Rate for Payer: Healthscope Commercial	$236.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$223.72
Rate for Payer: PHP Commercial	$223.72
Rate for Payer: Priority Health Cigna Priority Health	$171.08
Rate for Payer: Priority Health SBD	$165.82

DONEPEZIL 5 MG TABLET

Facility

$43.01

Service Code	NDC 43547027503
Hospital Charge Code	18786
Hospital Revenue Code	637
Min. Negotiated Rate	$27.10
Max. Negotiated Rate	$38.71
Rate for Payer: Aetna Commercial	$36.56
Rate for Payer: Aetna New Business (MI Preferred)	$27.96
Rate for Payer: Cash Price	$34.41
Rate for Payer: Cofinity Commercial	$30.11
Rate for Payer: Cofinity Commercial	$36.99
Rate for Payer: Cofinity Medicare Advantage	$30.11
Rate for Payer: Encore Health Key Benefits Commercial	$34.41
Rate for Payer: Healthscope Commercial	$38.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.56
Rate for Payer: PHP Commercial	$36.56
Rate for Payer: Priority Health Cigna Priority Health	$27.96
Rate for Payer: Priority Health SBD	$27.10

DONEPEZIL 5 MG TABLET

Facility

$43.01

Service Code	NDC 43547027503
Hospital Charge Code	18786
Hospital Revenue Code	637
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$38.71
Rate for Payer: Aetna Commercial	$36.56
Rate for Payer: Aetna Medicare	$21.50
Rate for Payer: Aetna New Business (MI Preferred)	$27.96
Rate for Payer: BCBS Complete	$17.20
Rate for Payer: Cash Price	$34.41
Rate for Payer: Cofinity Commercial	$30.11
Rate for Payer: Cofinity Commercial	$36.99
Rate for Payer: Cofinity Medicare Advantage	$30.11
Rate for Payer: Encore Health Key Benefits Commercial	$34.41
Rate for Payer: Healthscope Commercial	$38.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.56
Rate for Payer: PHP Commercial	$36.56
Rate for Payer: Priority Health Cigna Priority Health	$27.96
Rate for Payer: Priority Health SBD	$27.10

DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION

Facility

$19.13

Service Code	HCPCS J1265
Hospital Charge Code	2595
Hospital Revenue Code	636
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$17.22
Rate for Payer: Aetna Commercial	$16.26
Rate for Payer: Aetna Commercial	$16.77
Rate for Payer: Aetna Medicare	$9.86
Rate for Payer: Aetna Medicare	$9.56
Rate for Payer: Aetna New Business (MI Preferred)	$12.43
Rate for Payer: Aetna New Business (MI Preferred)	$12.82
Rate for Payer: BCBS Complete	$7.89
Rate for Payer: BCBS Complete	$7.65
Rate for Payer: BCBS Trust/PPO	$2.02
Rate for Payer: BCBS Trust/PPO	$2.02
Rate for Payer: BCN Commercial	$2.02
Rate for Payer: BCN Commercial	$2.02
Rate for Payer: Cash Price	$15.78
Rate for Payer: Cash Price	$15.78
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cofinity Commercial	$13.39
Rate for Payer: Cofinity Commercial	$16.97
Rate for Payer: Cofinity Commercial	$13.81
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	$16.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.26
Rate for Payer: PHP Commercial	$16.77
Rate for Payer: PHP Commercial	$16.26
Rate for Payer: Priority Health Cigna Priority Health	$12.43
Rate for Payer: Priority Health Cigna Priority Health	$12.82
Rate for Payer: Priority Health SBD	$12.43
Rate for Payer: Priority Health SBD	$12.05

DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION

Facility

$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

$71.15

Service Code	HCPCS J1265
Hospital Charge Code	14845
Hospital Revenue Code	636
Min. Negotiated Rate	$44.82
Max. Negotiated Rate	$64.04
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	$64.04
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

$66.56

Service Code	HCPCS J1265
Hospital Charge Code	14845
Hospital Revenue Code	636
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$59.90
Rate for Payer: Aetna Commercial	$56.58
Rate for Payer: Aetna Commercial	$60.48
Rate for Payer: Aetna Medicare	$35.58
Rate for Payer: Aetna Medicare	$33.28
Rate for Payer: Aetna New Business (MI Preferred)	$43.26
Rate for Payer: Aetna New Business (MI Preferred)	$46.25
Rate for Payer: BCBS Complete	$28.46
Rate for Payer: BCBS Complete	$26.62
Rate for Payer: BCBS Trust/PPO	$2.02
Rate for Payer: BCBS Trust/PPO	$2.02
Rate for Payer: BCN Commercial	$2.02
Rate for Payer: BCN Commercial	$2.02
Rate for Payer: Cash Price	$56.92
Rate for Payer: Cash Price	$53.25
Rate for Payer: Cash Price	$53.25
Rate for Payer: Cash Price	$56.92
Rate for Payer: Cofinity Commercial	$57.24
Rate for Payer: Cofinity Commercial	$46.59
Rate for Payer: Cofinity Commercial	$49.80
Rate for Payer: Cofinity Commercial	$61.19
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	$64.04
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	$46.25
Rate for Payer: Priority Health Cigna Priority Health	$43.26
Rate for Payer: Priority Health SBD	$44.82
Rate for Payer: Priority Health SBD	$41.93

DOPAMINE 400 MG/5 ML (80 MG/ML) INTRAVENOUS SOLUTION

Facility

$22.65

Service Code	HCPCS J1265
Hospital Charge Code	118602
Hospital Revenue Code	636
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$20.38
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	$20.38
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

$22.65

Service Code	HCPCS J1265
Hospital Charge Code	118602
Hospital Revenue Code	636
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$20.38
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: BCBS Trust/PPO	$2.02
Rate for Payer: BCN Commercial	$2.02
Rate for Payer: Cash Price	$18.12
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	$20.38
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

$460.32

Service Code	HCPCS J7639
Hospital Charge Code	12211
Hospital Revenue Code	250
Min. Negotiated Rate	$42.87
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: Cash Price	$368.26
Rate for Payer: Cofinity Commercial	$395.88
Rate for Payer: Cofinity Commercial	$322.22
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 HMO/PPO/Tiered Network	$53.59
Rate for Payer: Priority Health Narrow Network	$42.87
Rate for Payer: Priority Health SBD	$290.00

DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION

Facility

$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

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS

Facility

$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	$25.58
Rate for Payer: Aetna Medicare	$15.05
Rate for Payer: Aetna New Business (MI Preferred)	$19.56
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	$25.58
Rate for Payer: PHP Commercial	$25.58
Rate for Payer: Priority Health Cigna Priority Health	$19.56
Rate for Payer: Priority Health SBD	$18.96

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS

Facility

$162.75

Service Code	NDC 50383023310
Hospital Charge Code	22982
Hospital Revenue Code	637
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$146.48
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	$139.96
Rate for Payer: Cofinity Medicare Advantage	$113.92
Rate for Payer: Encore Health Key Benefits Commercial	$130.20
Rate for Payer: Healthscope Commercial	$146.48
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

$162.75

Service Code	NDC 50383023310
Hospital Charge Code	22982
Hospital Revenue Code	637
Min. Negotiated Rate	$102.53
Max. Negotiated Rate	$146.48
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	$139.96
Rate for Payer: Cofinity Medicare Advantage	$113.92
Rate for Payer: Encore Health Key Benefits Commercial	$130.20
Rate for Payer: Healthscope Commercial	$146.48
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

$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	$25.58
Rate for Payer: Aetna New Business (MI Preferred)	$19.56
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	$25.58
Rate for Payer: PHP Commercial	$25.58
Rate for Payer: Priority Health Cigna Priority Health	$19.56
Rate for Payer: Priority Health SBD	$18.96

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS

Facility

$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)	$42.32
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	$42.32
Rate for Payer: Priority Health SBD	$41.01

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS

Facility

$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)	$42.32
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	$42.32
Rate for Payer: Priority Health SBD	$41.01

DORZOLAMIDE 2 % EYE DROPS

Facility

$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

DORZOLAMIDE 2 % EYE DROPS

Facility

$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

$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

$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

$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

Know your out-of-pocket cost for care.

All Charges