|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.30 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna Commercial |
$239.70
|
| Rate for Payer: BCBS Trust/PPO |
$230.20
|
| Rate for Payer: BCN Commercial |
$217.93
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.60
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.70
|
| Rate for Payer: Nomi Health Commercial |
$231.24
|
| Rate for Payer: PHP Commercial |
$239.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.30
|
| Rate for Payer: Priority Health HMO/PPO |
$245.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$188.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$248.16
|
| Rate for Payer: UHC Core |
$235.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.50
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$69.80
|
|
|
Service Code
|
NDC 43547027609
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.58 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Aetna Medicare |
$18.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.81
|
| Rate for Payer: BCBS Complete |
$27.92
|
| Rate for Payer: BCBS MAPPO |
$17.45
|
| Rate for Payer: BCBS Trust/PPO |
$57.38
|
| Rate for Payer: BCN Commercial |
$54.27
|
| Rate for Payer: BCN Medicare Advantage |
$17.45
|
| Rate for Payer: Cash Price |
$55.84
|
| Rate for Payer: Cofinity Commercial |
$60.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.45
|
| Rate for Payer: Healthscope Commercial |
$62.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.35
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.33
|
| Rate for Payer: Nomi Health Commercial |
$57.24
|
| Rate for Payer: PACE Senior Care Partners |
$16.58
|
| Rate for Payer: PACE SWMI |
$17.45
|
| Rate for Payer: PHP Commercial |
$59.33
|
| Rate for Payer: PHP Medicare Advantage |
$17.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: Priority Health HMO/PPO |
$60.73
|
| Rate for Payer: Priority Health Medicare |
$17.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$46.77
|
| Rate for Payer: Railroad Medicare Medicare |
$17.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.42
|
| Rate for Payer: UHC Core |
$58.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.45
|
| Rate for Payer: UHC Exchange |
$17.45
|
| Rate for Payer: UHC Medicare Advantage |
$17.45
|
| Rate for Payer: VA VA |
$17.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.35
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
OP
|
$43.01
|
|
|
Service Code
|
NDC 43547027503
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$38.71 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: Aetna Medicare |
$11.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$13.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$13.44
|
| Rate for Payer: BCBS Complete |
$17.20
|
| Rate for Payer: BCBS MAPPO |
$10.75
|
| Rate for Payer: BCBS Trust/PPO |
$35.36
|
| Rate for Payer: BCN Commercial |
$33.44
|
| Rate for Payer: BCN Medicare Advantage |
$10.75
|
| Rate for Payer: Cash Price |
$34.41
|
| Rate for Payer: Cofinity Commercial |
$36.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.75
|
| Rate for Payer: Healthscope Commercial |
$38.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.56
|
| Rate for Payer: Nomi Health Commercial |
$35.27
|
| Rate for Payer: PACE Senior Care Partners |
$10.21
|
| Rate for Payer: PACE SWMI |
$10.75
|
| Rate for Payer: PHP Commercial |
$36.56
|
| Rate for Payer: PHP Medicare Advantage |
$10.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.96
|
| Rate for Payer: Priority Health HMO/PPO |
$37.42
|
| Rate for Payer: Priority Health Medicare |
$10.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$28.82
|
| Rate for Payer: Railroad Medicare Medicare |
$10.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.85
|
| Rate for Payer: UHC Core |
$35.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$10.75
|
| Rate for Payer: UHC Exchange |
$10.75
|
| Rate for Payer: UHC Medicare Advantage |
$10.75
|
| Rate for Payer: VA VA |
$10.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.26
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$80.37
|
|
|
Service Code
|
NDC 43547027509
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.24 |
| Max. Negotiated Rate |
$72.33 |
| Rate for Payer: Aetna Commercial |
$68.31
|
| Rate for Payer: BCBS Trust/PPO |
$65.61
|
| Rate for Payer: BCN Commercial |
$62.11
|
| Rate for Payer: Cash Price |
$64.30
|
| Rate for Payer: Cofinity Commercial |
$69.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.30
|
| Rate for Payer: Healthscope Commercial |
$72.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.31
|
| Rate for Payer: Nomi Health Commercial |
$65.90
|
| Rate for Payer: PHP Commercial |
$68.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.24
|
| Rate for Payer: Priority Health HMO/PPO |
$69.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.73
|
| Rate for Payer: UHC Core |
$67.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.28
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$43.01
|
|
|
Service Code
|
NDC 43547027503
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$38.71 |
| Rate for Payer: Aetna Commercial |
$36.56
|
| Rate for Payer: BCBS Trust/PPO |
$35.11
|
| Rate for Payer: BCN Commercial |
$33.24
|
| Rate for Payer: Cash Price |
$34.41
|
| Rate for Payer: Cofinity Commercial |
$36.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.41
|
| Rate for Payer: Healthscope Commercial |
$38.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.56
|
| Rate for Payer: Nomi Health Commercial |
$35.27
|
| Rate for Payer: PHP Commercial |
$36.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.96
|
| Rate for Payer: Priority Health HMO/PPO |
$37.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$28.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.85
|
| Rate for Payer: UHC Core |
$35.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.26
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
OP
|
$80.37
|
|
|
Service Code
|
NDC 43547027509
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.09 |
| Max. Negotiated Rate |
$72.33 |
| Rate for Payer: Aetna Commercial |
$68.31
|
| Rate for Payer: Aetna Medicare |
$20.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$25.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$25.12
|
| Rate for Payer: BCBS Complete |
$32.15
|
| Rate for Payer: BCBS MAPPO |
$20.09
|
| Rate for Payer: BCBS Trust/PPO |
$66.07
|
| Rate for Payer: BCN Commercial |
$62.49
|
| Rate for Payer: BCN Medicare Advantage |
$20.09
|
| Rate for Payer: Cash Price |
$64.30
|
| Rate for Payer: Cofinity Commercial |
$69.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$20.09
|
| Rate for Payer: Healthscope Commercial |
$72.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$21.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.31
|
| Rate for Payer: Nomi Health Commercial |
$65.90
|
| Rate for Payer: PACE Senior Care Partners |
$19.09
|
| Rate for Payer: PACE SWMI |
$20.09
|
| Rate for Payer: PHP Commercial |
$68.31
|
| Rate for Payer: PHP Medicare Advantage |
$20.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.24
|
| Rate for Payer: Priority Health HMO/PPO |
$69.92
|
| Rate for Payer: Priority Health Medicare |
$20.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.85
|
| Rate for Payer: Railroad Medicare Medicare |
$20.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.73
|
| Rate for Payer: UHC Core |
$67.11
|
| Rate for Payer: UHC Dual Complete DSNP |
$20.09
|
| Rate for Payer: UHC Exchange |
$20.09
|
| Rate for Payer: UHC Medicare Advantage |
$20.09
|
| Rate for Payer: VA VA |
$20.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.28
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$263.20
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.08 |
| Max. Negotiated Rate |
$236.88 |
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: BCBS Trust/PPO |
$214.85
|
| Rate for Payer: BCN Commercial |
$203.40
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$226.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Healthscope Commercial |
$236.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$197.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.72
|
| Rate for Payer: Nomi Health Commercial |
$215.82
|
| Rate for Payer: PHP Commercial |
$223.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.08
|
| Rate for Payer: Priority Health HMO/PPO |
$228.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$176.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$231.62
|
| Rate for Payer: UHC Core |
$219.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$197.40
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
OP
|
$263.20
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.51 |
| Max. Negotiated Rate |
$236.88 |
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Aetna Medicare |
$68.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$82.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$82.25
|
| Rate for Payer: BCBS Complete |
$105.28
|
| Rate for Payer: BCBS MAPPO |
$65.80
|
| Rate for Payer: BCBS Trust/PPO |
$216.38
|
| Rate for Payer: BCN Commercial |
$204.64
|
| Rate for Payer: BCN Medicare Advantage |
$65.80
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$226.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$236.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$197.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$69.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$75.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.72
|
| Rate for Payer: Nomi Health Commercial |
$215.82
|
| Rate for Payer: PACE Senior Care Partners |
$62.51
|
| Rate for Payer: PACE SWMI |
$65.80
|
| Rate for Payer: PHP Commercial |
$223.72
|
| Rate for Payer: PHP Medicare Advantage |
$65.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.08
|
| Rate for Payer: Priority Health HMO/PPO |
$228.98
|
| Rate for Payer: Priority Health Medicare |
$66.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$176.34
|
| Rate for Payer: Railroad Medicare Medicare |
$65.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$231.62
|
| Rate for Payer: UHC Core |
$219.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$65.80
|
| Rate for Payer: UHC Exchange |
$65.80
|
| Rate for Payer: UHC Medicare Advantage |
$65.80
|
| Rate for Payer: VA VA |
$65.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$197.40
|
|
|
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 |
$16.90 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: Aetna Medicare |
$18.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$22.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$22.23
|
| Rate for Payer: BCBS Complete |
$28.46
|
| Rate for Payer: BCBS MAPPO |
$17.79
|
| Rate for Payer: BCBS Trust/PPO |
$58.49
|
| Rate for Payer: BCN Commercial |
$55.32
|
| Rate for Payer: BCN Medicare Advantage |
$17.79
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.79
|
| Rate for Payer: Healthscope Commercial |
$64.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$18.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.48
|
| Rate for Payer: Nomi Health Commercial |
$58.34
|
| Rate for Payer: PACE Senior Care Partners |
$16.90
|
| Rate for Payer: PACE SWMI |
$17.79
|
| Rate for Payer: PHP Commercial |
$60.48
|
| Rate for Payer: PHP Medicare Advantage |
$17.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.25
|
| Rate for Payer: Priority Health HMO/PPO |
$61.90
|
| Rate for Payer: Priority Health Medicare |
$17.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.67
|
| Rate for Payer: Railroad Medicare Medicare |
$17.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.61
|
| Rate for Payer: UHC Core |
$59.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.79
|
| Rate for Payer: UHC Exchange |
$17.79
|
| Rate for Payer: UHC Medicare Advantage |
$17.79
|
| Rate for Payer: VA VA |
$17.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.36
|
|
|
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 |
$46.25 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: BCBS Trust/PPO |
$58.08
|
| Rate for Payer: BCN Commercial |
$54.98
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$64.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.48
|
| Rate for Payer: Nomi Health Commercial |
$58.34
|
| Rate for Payer: PHP Commercial |
$60.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.25
|
| Rate for Payer: Priority Health HMO/PPO |
$61.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.61
|
| Rate for Payer: UHC Core |
$59.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.36
|
|
|
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 |
$19.57 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: Aetna Commercial |
$25.59
|
| Rate for Payer: BCBS Trust/PPO |
$24.57
|
| Rate for Payer: BCN Commercial |
$23.26
|
| Rate for Payer: Cash Price |
$24.08
|
| Rate for Payer: Cofinity Commercial |
$25.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.08
|
| Rate for Payer: Healthscope Commercial |
$27.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.59
|
| Rate for Payer: Nomi Health Commercial |
$24.68
|
| Rate for Payer: PHP Commercial |
$25.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.57
|
| Rate for Payer: Priority Health HMO/PPO |
$26.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.49
|
| Rate for Payer: UHC Core |
$25.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.57
|
|
|
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 |
$7.15 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: Aetna Commercial |
$25.59
|
| Rate for Payer: Aetna Medicare |
$7.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.41
|
| Rate for Payer: BCBS Complete |
$12.04
|
| Rate for Payer: BCBS MAPPO |
$7.53
|
| Rate for Payer: BCBS Trust/PPO |
$24.75
|
| Rate for Payer: BCN Commercial |
$23.40
|
| Rate for Payer: BCN Medicare Advantage |
$7.53
|
| Rate for Payer: Cash Price |
$24.08
|
| Rate for Payer: Cofinity Commercial |
$25.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.53
|
| Rate for Payer: Healthscope Commercial |
$27.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.59
|
| Rate for Payer: Nomi Health Commercial |
$24.68
|
| Rate for Payer: PACE Senior Care Partners |
$7.15
|
| Rate for Payer: PACE SWMI |
$7.53
|
| Rate for Payer: PHP Commercial |
$25.59
|
| Rate for Payer: PHP Medicare Advantage |
$7.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.57
|
| Rate for Payer: Priority Health HMO/PPO |
$26.19
|
| Rate for Payer: Priority Health Medicare |
$7.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.17
|
| Rate for Payer: Railroad Medicare Medicare |
$7.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.49
|
| Rate for Payer: UHC Core |
$25.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.53
|
| Rate for Payer: UHC Exchange |
$7.53
|
| Rate for Payer: UHC Medicare Advantage |
$7.53
|
| Rate for Payer: VA VA |
$7.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.57
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$37.52
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.39 |
| Max. Negotiated Rate |
$33.77 |
| Rate for Payer: Aetna Commercial |
$31.89
|
| Rate for Payer: BCBS Trust/PPO |
$30.63
|
| Rate for Payer: BCN Commercial |
$29.00
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cofinity Commercial |
$32.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.02
|
| Rate for Payer: Healthscope Commercial |
$33.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.89
|
| Rate for Payer: Nomi Health Commercial |
$30.77
|
| Rate for Payer: PHP Commercial |
$31.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.39
|
| Rate for Payer: Priority Health HMO/PPO |
$32.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.02
|
| Rate for Payer: UHC Core |
$31.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.14
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$36.63
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna Medicare |
$9.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.45
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.45
|
| Rate for Payer: BCBS Complete |
$14.65
|
| Rate for Payer: BCBS MAPPO |
$9.16
|
| Rate for Payer: BCBS Trust/PPO |
$30.11
|
| Rate for Payer: BCN Commercial |
$28.48
|
| Rate for Payer: BCN Medicare Advantage |
$9.16
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.16
|
| Rate for Payer: Healthscope Commercial |
$32.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.14
|
| Rate for Payer: Nomi Health Commercial |
$30.04
|
| Rate for Payer: PACE Senior Care Partners |
$8.70
|
| Rate for Payer: PACE SWMI |
$9.16
|
| Rate for Payer: PHP Commercial |
$31.14
|
| Rate for Payer: PHP Medicare Advantage |
$9.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.81
|
| Rate for Payer: Priority Health HMO/PPO |
$31.87
|
| Rate for Payer: Priority Health Medicare |
$9.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$24.54
|
| Rate for Payer: Railroad Medicare Medicare |
$9.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.23
|
| Rate for Payer: UHC Core |
$30.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.16
|
| Rate for Payer: UHC Exchange |
$9.16
|
| Rate for Payer: UHC Medicare Advantage |
$9.16
|
| Rate for Payer: VA VA |
$9.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.47
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$36.63
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.81 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: BCBS Trust/PPO |
$29.90
|
| Rate for Payer: BCN Commercial |
$28.31
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.30
|
| Rate for Payer: Healthscope Commercial |
$32.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.14
|
| Rate for Payer: Nomi Health Commercial |
$30.04
|
| Rate for Payer: PHP Commercial |
$31.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.81
|
| Rate for Payer: Priority Health HMO/PPO |
$31.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$24.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.23
|
| Rate for Payer: UHC Core |
$30.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.47
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$51.62
|
|
|
Service Code
|
NDC 72266019701
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.55 |
| Max. Negotiated Rate |
$46.46 |
| Rate for Payer: Aetna Commercial |
$43.88
|
| Rate for Payer: BCBS Trust/PPO |
$42.14
|
| Rate for Payer: BCN Commercial |
$39.89
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cofinity Commercial |
$44.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.30
|
| Rate for Payer: Healthscope Commercial |
$46.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.88
|
| Rate for Payer: Nomi Health Commercial |
$42.33
|
| Rate for Payer: PHP Commercial |
$43.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.55
|
| Rate for Payer: Priority Health HMO/PPO |
$44.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.43
|
| Rate for Payer: UHC Core |
$43.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.72
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$51.62
|
|
|
Service Code
|
NDC 72266019701
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.26 |
| Max. Negotiated Rate |
$46.46 |
| Rate for Payer: Aetna Commercial |
$43.88
|
| Rate for Payer: Aetna Medicare |
$13.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.13
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.13
|
| Rate for Payer: BCBS Complete |
$20.65
|
| Rate for Payer: BCBS MAPPO |
$12.90
|
| Rate for Payer: BCBS Trust/PPO |
$42.44
|
| Rate for Payer: BCN Commercial |
$40.13
|
| Rate for Payer: BCN Medicare Advantage |
$12.90
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: Cofinity Commercial |
$44.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.90
|
| Rate for Payer: Healthscope Commercial |
$46.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.72
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.88
|
| Rate for Payer: Nomi Health Commercial |
$42.33
|
| Rate for Payer: PACE Senior Care Partners |
$12.26
|
| Rate for Payer: PACE SWMI |
$12.90
|
| Rate for Payer: PHP Commercial |
$43.88
|
| Rate for Payer: PHP Medicare Advantage |
$12.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.55
|
| Rate for Payer: Priority Health HMO/PPO |
$44.91
|
| Rate for Payer: Priority Health Medicare |
$13.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.59
|
| Rate for Payer: Railroad Medicare Medicare |
$12.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.43
|
| Rate for Payer: UHC Core |
$43.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$12.90
|
| Rate for Payer: UHC Exchange |
$12.90
|
| Rate for Payer: UHC Medicare Advantage |
$12.90
|
| Rate for Payer: VA VA |
$12.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.72
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$37.52
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$33.77 |
| Rate for Payer: Aetna Commercial |
$31.89
|
| Rate for Payer: Aetna Medicare |
$9.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.72
|
| Rate for Payer: BCBS Complete |
$15.01
|
| Rate for Payer: BCBS MAPPO |
$9.38
|
| Rate for Payer: BCBS Trust/PPO |
$30.85
|
| Rate for Payer: BCN Commercial |
$29.17
|
| Rate for Payer: BCN Medicare Advantage |
$9.38
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cofinity Commercial |
$32.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.38
|
| Rate for Payer: Healthscope Commercial |
$33.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.89
|
| Rate for Payer: Nomi Health Commercial |
$30.77
|
| Rate for Payer: PACE Senior Care Partners |
$8.91
|
| Rate for Payer: PACE SWMI |
$9.38
|
| Rate for Payer: PHP Commercial |
$31.89
|
| Rate for Payer: PHP Medicare Advantage |
$9.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.39
|
| Rate for Payer: Priority Health HMO/PPO |
$32.64
|
| Rate for Payer: Priority Health Medicare |
$9.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.14
|
| Rate for Payer: Railroad Medicare Medicare |
$9.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.02
|
| Rate for Payer: UHC Core |
$31.33
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.38
|
| Rate for Payer: UHC Exchange |
$9.38
|
| Rate for Payer: UHC Medicare Advantage |
$9.38
|
| Rate for Payer: VA VA |
$9.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.14
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
OP
|
$423.00
|
|
|
Service Code
|
NDC 69238117009
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.46 |
| Max. Negotiated Rate |
$380.70 |
| Rate for Payer: Aetna Commercial |
$359.55
|
| Rate for Payer: Aetna Medicare |
$109.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$132.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$132.19
|
| Rate for Payer: BCBS Complete |
$169.20
|
| Rate for Payer: BCBS MAPPO |
$105.75
|
| Rate for Payer: BCBS Trust/PPO |
$347.75
|
| Rate for Payer: BCN Commercial |
$328.88
|
| Rate for Payer: BCN Medicare Advantage |
$105.75
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$363.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$105.75
|
| Rate for Payer: Healthscope Commercial |
$380.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.25
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$111.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$121.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.55
|
| Rate for Payer: Nomi Health Commercial |
$346.86
|
| Rate for Payer: PACE Senior Care Partners |
$100.46
|
| Rate for Payer: PACE SWMI |
$105.75
|
| Rate for Payer: PHP Commercial |
$359.55
|
| Rate for Payer: PHP Medicare Advantage |
$105.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.95
|
| Rate for Payer: Priority Health HMO/PPO |
$368.01
|
| Rate for Payer: Priority Health Medicare |
$106.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$283.41
|
| Rate for Payer: Railroad Medicare Medicare |
$105.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$372.24
|
| Rate for Payer: UHC Core |
$353.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$105.75
|
| Rate for Payer: UHC Exchange |
$105.75
|
| Rate for Payer: UHC Medicare Advantage |
$105.75
|
| Rate for Payer: VA VA |
$105.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.25
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$339.84
|
|
|
Service Code
|
NDC 51079043720
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.90 |
| Max. Negotiated Rate |
$305.86 |
| Rate for Payer: Aetna Commercial |
$288.86
|
| Rate for Payer: BCBS Trust/PPO |
$277.41
|
| Rate for Payer: BCN Commercial |
$262.63
|
| Rate for Payer: Cash Price |
$271.87
|
| Rate for Payer: Cofinity Commercial |
$292.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.87
|
| Rate for Payer: Healthscope Commercial |
$305.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$254.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.86
|
| Rate for Payer: Nomi Health Commercial |
$278.67
|
| Rate for Payer: PHP Commercial |
$288.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.90
|
| Rate for Payer: Priority Health HMO/PPO |
$295.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$227.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$299.06
|
| Rate for Payer: UHC Core |
$283.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$254.88
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
OP
|
$339.84
|
|
|
Service Code
|
NDC 51079043720
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.71 |
| Max. Negotiated Rate |
$305.86 |
| Rate for Payer: Aetna Commercial |
$288.86
|
| Rate for Payer: Aetna Medicare |
$88.36
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$106.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$106.20
|
| Rate for Payer: BCBS Complete |
$135.94
|
| Rate for Payer: BCBS MAPPO |
$84.96
|
| Rate for Payer: BCBS Trust/PPO |
$279.38
|
| Rate for Payer: BCN Commercial |
$264.23
|
| Rate for Payer: BCN Medicare Advantage |
$84.96
|
| Rate for Payer: Cash Price |
$271.87
|
| Rate for Payer: Cofinity Commercial |
$292.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.87
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$84.96
|
| Rate for Payer: Healthscope Commercial |
$305.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$254.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$89.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$97.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.86
|
| Rate for Payer: Nomi Health Commercial |
$278.67
|
| Rate for Payer: PACE Senior Care Partners |
$80.71
|
| Rate for Payer: PACE SWMI |
$84.96
|
| Rate for Payer: PHP Commercial |
$288.86
|
| Rate for Payer: PHP Medicare Advantage |
$84.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.90
|
| Rate for Payer: Priority Health HMO/PPO |
$295.66
|
| Rate for Payer: Priority Health Medicare |
$85.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$227.69
|
| Rate for Payer: Railroad Medicare Medicare |
$84.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$299.06
|
| Rate for Payer: UHC Core |
$283.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$84.96
|
| Rate for Payer: UHC Exchange |
$84.96
|
| Rate for Payer: UHC Medicare Advantage |
$84.96
|
| Rate for Payer: VA VA |
$84.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$254.88
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 51079043701
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna Commercial |
$2.89
|
| Rate for Payer: BCBS Trust/PPO |
$2.78
|
| Rate for Payer: BCN Commercial |
$2.63
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: Nomi Health Commercial |
$2.79
|
| Rate for Payer: PHP Commercial |
$2.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health HMO/PPO |
$2.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.99
|
| Rate for Payer: UHC Core |
$2.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.55
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
NDC 69238117009
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$274.95 |
| Max. Negotiated Rate |
$380.70 |
| Rate for Payer: Aetna Commercial |
$359.55
|
| Rate for Payer: BCBS Trust/PPO |
$345.29
|
| Rate for Payer: BCN Commercial |
$326.89
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$363.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$380.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.55
|
| Rate for Payer: Nomi Health Commercial |
$346.86
|
| Rate for Payer: PHP Commercial |
$359.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.95
|
| Rate for Payer: Priority Health HMO/PPO |
$368.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$283.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$372.24
|
| Rate for Payer: UHC Core |
$353.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.25
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 51079043701
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna Commercial |
$2.89
|
| Rate for Payer: Aetna Medicare |
$0.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.06
|
| Rate for Payer: BCBS Complete |
$1.36
|
| Rate for Payer: BCBS MAPPO |
$0.85
|
| Rate for Payer: BCBS Trust/PPO |
$2.80
|
| Rate for Payer: BCN Commercial |
$2.64
|
| Rate for Payer: BCN Medicare Advantage |
$0.85
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.85
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: Nomi Health Commercial |
$2.79
|
| Rate for Payer: PACE Senior Care Partners |
$0.81
|
| Rate for Payer: PACE SWMI |
$0.85
|
| Rate for Payer: PHP Commercial |
$2.89
|
| Rate for Payer: PHP Medicare Advantage |
$0.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health HMO/PPO |
$2.96
|
| Rate for Payer: Priority Health Medicare |
$0.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.28
|
| Rate for Payer: Railroad Medicare Medicare |
$0.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.99
|
| Rate for Payer: UHC Core |
$2.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.85
|
| Rate for Payer: UHC Exchange |
$0.85
|
| Rate for Payer: UHC Medicare Advantage |
$0.85
|
| Rate for Payer: VA VA |
$0.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.55
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$68.25
|
|
|
Service Code
|
NDC 63323013013
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.21 |
| Max. Negotiated Rate |
$61.42 |
| Rate for Payer: Aetna Commercial |
$58.01
|
| Rate for Payer: Aetna Medicare |
$17.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.33
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.33
|
| Rate for Payer: BCBS Complete |
$27.30
|
| Rate for Payer: BCBS MAPPO |
$17.06
|
| Rate for Payer: BCBS Trust/PPO |
$56.11
|
| Rate for Payer: BCN Commercial |
$53.06
|
| Rate for Payer: BCN Medicare Advantage |
$17.06
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cofinity Commercial |
$58.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.06
|
| Rate for Payer: Healthscope Commercial |
$61.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$58.01
|
| Rate for Payer: Nomi Health Commercial |
$55.97
|
| Rate for Payer: PACE Senior Care Partners |
$16.21
|
| Rate for Payer: PACE SWMI |
$17.06
|
| Rate for Payer: PHP Commercial |
$58.01
|
| Rate for Payer: PHP Medicare Advantage |
$17.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.36
|
| Rate for Payer: Priority Health HMO/PPO |
$59.38
|
| Rate for Payer: Priority Health Medicare |
$17.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.73
|
| Rate for Payer: Railroad Medicare Medicare |
$17.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.06
|
| Rate for Payer: UHC Core |
$56.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.06
|
| Rate for Payer: UHC Exchange |
$17.06
|
| Rate for Payer: UHC Medicare Advantage |
$17.06
|
| Rate for Payer: VA VA |
$17.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.19
|
|
