|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$49.01
|
|
|
Service Code
|
NDC 54838-116-80
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$44.11 |
| Rate for Payer: Aetna American Axle |
$31.86
|
| Rate for Payer: Aetna Commercial |
$41.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.86
|
| Rate for Payer: Cash Price |
$39.21
|
| Rate for Payer: Cofinity Commercial |
$34.31
|
| Rate for Payer: Cofinity Commercial |
$42.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.21
|
| Rate for Payer: Healthscope Commercial |
$44.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.66
|
| Rate for Payer: PHP Commercial |
$41.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.31
|
| Rate for Payer: Priority Health SBD |
$30.88
|
| Rate for Payer: UMR Bronson Commercial |
$21.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.76
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$7.89
|
|
|
Service Code
|
NDC 48433-220-40
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$7.10 |
| Rate for Payer: Aetna American Axle |
$5.13
|
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.13
|
| Rate for Payer: Cash Price |
$6.31
|
| Rate for Payer: Cofinity Commercial |
$5.52
|
| Rate for Payer: Cofinity Commercial |
$6.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.31
|
| Rate for Payer: Healthscope Commercial |
$7.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.71
|
| Rate for Payer: PHP Commercial |
$6.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.52
|
| Rate for Payer: Priority Health SBD |
$4.97
|
| Rate for Payer: UMR Bronson Commercial |
$3.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.92
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$3.61
|
|
|
Service Code
|
NDC 50383-771-10
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Aetna American Axle |
$2.35
|
| Rate for Payer: Aetna Commercial |
$3.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.35
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Cofinity Commercial |
$3.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.89
|
| Rate for Payer: Healthscope Commercial |
$3.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.07
|
| Rate for Payer: PHP Commercial |
$3.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.53
|
| Rate for Payer: Priority Health SBD |
$2.27
|
| Rate for Payer: UMR Bronson Commercial |
$1.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.71
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 50383-349-11
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna American Axle |
$2.16
|
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.16
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.66
|
| Rate for Payer: Healthscope Commercial |
$2.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.82
|
| Rate for Payer: PHP Commercial |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.32
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.49
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$7.89
|
|
|
Service Code
|
NDC 48433-220-10
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$7.10 |
| Rate for Payer: Aetna American Axle |
$5.13
|
| Rate for Payer: Aetna Commercial |
$6.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.13
|
| Rate for Payer: Cash Price |
$6.31
|
| Rate for Payer: Cofinity Commercial |
$5.52
|
| Rate for Payer: Cofinity Commercial |
$6.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.31
|
| Rate for Payer: Healthscope Commercial |
$7.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.71
|
| Rate for Payer: PHP Commercial |
$6.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.52
|
| Rate for Payer: Priority Health SBD |
$4.97
|
| Rate for Payer: UMR Bronson Commercial |
$3.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.92
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 0904-7279-72
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna American Axle |
$3.12
|
| Rate for Payer: Aetna Commercial |
$4.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.12
|
| Rate for Payer: Cash Price |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$3.36
|
| Rate for Payer: Cofinity Commercial |
$4.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.84
|
| Rate for Payer: Healthscope Commercial |
$4.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.08
|
| Rate for Payer: PHP Commercial |
$4.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.36
|
| Rate for Payer: Priority Health SBD |
$3.02
|
| Rate for Payer: UMR Bronson Commercial |
$2.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.60
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$31.51
|
|
|
Service Code
|
NDC 0536-1304-85
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$28.36 |
| Rate for Payer: Aetna American Axle |
$20.48
|
| Rate for Payer: Aetna Commercial |
$26.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.48
|
| Rate for Payer: Cash Price |
$25.21
|
| Rate for Payer: Cofinity Commercial |
$22.06
|
| Rate for Payer: Cofinity Commercial |
$27.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.21
|
| Rate for Payer: Healthscope Commercial |
$28.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.78
|
| Rate for Payer: PHP Commercial |
$26.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.06
|
| Rate for Payer: Priority Health SBD |
$19.85
|
| Rate for Payer: UMR Bronson Commercial |
$13.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.63
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$4.28
|
|
|
Service Code
|
NDC 9900-0003-06
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$3.85 |
| Rate for Payer: Aetna American Axle |
$2.78
|
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.78
|
| Rate for Payer: Cash Price |
$3.42
|
| Rate for Payer: Cofinity Commercial |
$3.00
|
| Rate for Payer: Cofinity Commercial |
$3.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.42
|
| Rate for Payer: Healthscope Commercial |
$3.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.64
|
| Rate for Payer: PHP Commercial |
$3.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.00
|
| Rate for Payer: Priority Health SBD |
$2.70
|
| Rate for Payer: UMR Bronson Commercial |
$1.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.21
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 50383-349-10
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Aetna American Axle |
$2.16
|
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.16
|
| Rate for Payer: Cash Price |
$2.66
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.66
|
| Rate for Payer: Healthscope Commercial |
$2.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.82
|
| Rate for Payer: PHP Commercial |
$2.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.32
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.49
|
|
|
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
NDC 0121-0544-10
|
| Hospital Charge Code |
36962
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Aetna American Axle |
$2.54
|
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.54
|
| Rate for Payer: Cash Price |
$3.12
|
| Rate for Payer: Cofinity Commercial |
$2.73
|
| Rate for Payer: Cofinity Commercial |
$3.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.12
|
| Rate for Payer: Healthscope Commercial |
$3.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.32
|
| Rate for Payer: PHP Commercial |
$3.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.73
|
| Rate for Payer: Priority Health SBD |
$2.46
|
| Rate for Payer: UMR Bronson Commercial |
$1.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.92
|
|
|
DOFETILIDE 125 MCG CAPSULE
|
Facility
|
IP
|
$1,443.23
|
|
|
Service Code
|
NDC 51862-125-60
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$635.02 |
| Max. Negotiated Rate |
$1,298.91 |
| Rate for Payer: Aetna American Axle |
$938.10
|
| Rate for Payer: Aetna Commercial |
$1,226.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$938.10
|
| Rate for Payer: Cash Price |
$1,154.58
|
| Rate for Payer: Cofinity Commercial |
$1,010.26
|
| Rate for Payer: Cofinity Commercial |
$1,241.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,154.58
|
| Rate for Payer: Healthscope Commercial |
$1,298.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,010.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,082.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,226.75
|
| Rate for Payer: PHP Commercial |
$1,226.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,010.26
|
| Rate for Payer: Priority Health SBD |
$909.23
|
| Rate for Payer: UMR Bronson Commercial |
$635.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,082.42
|
|
|
DOFETILIDE 125 MCG CAPSULE
|
Facility
|
IP
|
$428.55
|
|
|
Service Code
|
NDC 47335-061-86
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.56 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Aetna American Axle |
$278.56
|
| Rate for Payer: Aetna Commercial |
$364.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.56
|
| Rate for Payer: Cash Price |
$342.84
|
| Rate for Payer: Cofinity Commercial |
$299.98
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.84
|
| Rate for Payer: Healthscope Commercial |
$385.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.27
|
| Rate for Payer: PHP Commercial |
$364.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.98
|
| Rate for Payer: Priority Health SBD |
$269.99
|
| Rate for Payer: UMR Bronson Commercial |
$188.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.41
|
|
|
DOFETILIDE 125 MCG CAPSULE
|
Facility
|
IP
|
$161.31
|
|
|
Service Code
|
NDC 72205-039-60
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$145.18 |
| Rate for Payer: Aetna American Axle |
$104.85
|
| Rate for Payer: Aetna Commercial |
$137.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$104.85
|
| Rate for Payer: Cash Price |
$129.05
|
| Rate for Payer: Cofinity Commercial |
$112.92
|
| Rate for Payer: Cofinity Commercial |
$138.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.05
|
| Rate for Payer: Healthscope Commercial |
$145.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$112.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$120.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$137.11
|
| Rate for Payer: PHP Commercial |
$137.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$112.92
|
| Rate for Payer: Priority Health SBD |
$101.63
|
| Rate for Payer: UMR Bronson Commercial |
$70.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$120.98
|
|
|
DOFETILIDE 125 MCG CAPSULE
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 0069-5800-43
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna American Axle |
$0.61
|
| Rate for Payer: Aetna Commercial |
$0.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.61
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cofinity Commercial |
$0.66
|
| Rate for Payer: Cofinity Commercial |
$0.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.75
|
| Rate for Payer: Healthscope Commercial |
$0.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.80
|
| Rate for Payer: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.66
|
| Rate for Payer: Priority Health SBD |
$0.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.71
|
|
|
DOFETILIDE 125 MCG CAPSULE
|
Facility
|
IP
|
$864.92
|
|
|
Service Code
|
NDC 59762-0037-2
|
| Hospital Charge Code |
26965
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$380.56 |
| Max. Negotiated Rate |
$778.43 |
| Rate for Payer: Aetna American Axle |
$562.20
|
| Rate for Payer: Aetna Commercial |
$735.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$562.20
|
| Rate for Payer: Cash Price |
$691.94
|
| Rate for Payer: Cofinity Commercial |
$605.44
|
| Rate for Payer: Cofinity Commercial |
$743.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$691.94
|
| Rate for Payer: Healthscope Commercial |
$778.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$605.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$648.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$735.18
|
| Rate for Payer: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$605.44
|
| Rate for Payer: Priority Health SBD |
$544.90
|
| Rate for Payer: UMR Bronson Commercial |
$380.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$648.69
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$428.55
|
|
|
Service Code
|
NDC 59651-119-60
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.56 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Aetna American Axle |
$278.56
|
| Rate for Payer: Aetna Commercial |
$364.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.56
|
| Rate for Payer: Cash Price |
$342.84
|
| Rate for Payer: Cofinity Commercial |
$299.98
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.84
|
| Rate for Payer: Healthscope Commercial |
$385.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.27
|
| Rate for Payer: PHP Commercial |
$364.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.98
|
| Rate for Payer: Priority Health SBD |
$269.99
|
| Rate for Payer: UMR Bronson Commercial |
$188.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.41
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
NDC 72205-040-60
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.20 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna American Axle |
$117.00
|
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$117.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cofinity Commercial |
$126.00
|
| Rate for Payer: Cofinity Commercial |
$154.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$144.00
|
| Rate for Payer: Healthscope Commercial |
$162.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$126.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$135.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$153.00
|
| Rate for Payer: PHP Commercial |
$153.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.00
|
| Rate for Payer: Priority Health SBD |
$113.40
|
| Rate for Payer: UMR Bronson Commercial |
$79.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$135.00
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 0069-5810-43
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna American Axle |
$0.61
|
| Rate for Payer: Aetna Commercial |
$0.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.61
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cofinity Commercial |
$0.66
|
| Rate for Payer: Cofinity Commercial |
$0.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.75
|
| Rate for Payer: Healthscope Commercial |
$0.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.80
|
| Rate for Payer: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.66
|
| Rate for Payer: Priority Health SBD |
$0.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.71
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$1,443.23
|
|
|
Service Code
|
NDC 51862-025-60
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$635.02 |
| Max. Negotiated Rate |
$1,298.91 |
| Rate for Payer: Aetna American Axle |
$938.10
|
| Rate for Payer: Aetna Commercial |
$1,226.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$938.10
|
| Rate for Payer: Cash Price |
$1,154.58
|
| Rate for Payer: Cofinity Commercial |
$1,010.26
|
| Rate for Payer: Cofinity Commercial |
$1,241.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,154.58
|
| Rate for Payer: Healthscope Commercial |
$1,298.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,010.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,082.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,226.75
|
| Rate for Payer: PHP Commercial |
$1,226.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,010.26
|
| Rate for Payer: Priority Health SBD |
$909.23
|
| Rate for Payer: UMR Bronson Commercial |
$635.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,082.42
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$428.55
|
|
|
Service Code
|
NDC 47335-062-86
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.56 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Aetna American Axle |
$278.56
|
| Rate for Payer: Aetna Commercial |
$364.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.56
|
| Rate for Payer: Cash Price |
$342.84
|
| Rate for Payer: Cofinity Commercial |
$299.98
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.84
|
| Rate for Payer: Healthscope Commercial |
$385.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$364.27
|
| Rate for Payer: PHP Commercial |
$364.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.98
|
| Rate for Payer: Priority Health SBD |
$269.99
|
| Rate for Payer: UMR Bronson Commercial |
$188.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.41
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$864.92
|
|
|
Service Code
|
NDC 59762-0038-2
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$380.56 |
| Max. Negotiated Rate |
$778.43 |
| Rate for Payer: Aetna American Axle |
$562.20
|
| Rate for Payer: Aetna Commercial |
$735.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$562.20
|
| Rate for Payer: Cash Price |
$691.94
|
| Rate for Payer: Cofinity Commercial |
$605.44
|
| Rate for Payer: Cofinity Commercial |
$743.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$691.94
|
| Rate for Payer: Healthscope Commercial |
$778.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$605.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$648.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$735.18
|
| Rate for Payer: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$605.44
|
| Rate for Payer: Priority Health SBD |
$544.90
|
| Rate for Payer: UMR Bronson Commercial |
$380.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$648.69
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
IP
|
$1,443.23
|
|
|
Service Code
|
NDC 51862-005-60
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$635.02 |
| Max. Negotiated Rate |
$1,298.91 |
| Rate for Payer: Aetna American Axle |
$938.10
|
| Rate for Payer: Aetna Commercial |
$1,226.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$938.10
|
| Rate for Payer: Cash Price |
$1,154.58
|
| Rate for Payer: Cofinity Commercial |
$1,010.26
|
| Rate for Payer: Cofinity Commercial |
$1,241.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,154.58
|
| Rate for Payer: Healthscope Commercial |
$1,298.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,010.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,082.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,226.75
|
| Rate for Payer: PHP Commercial |
$1,226.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,010.26
|
| Rate for Payer: Priority Health SBD |
$909.23
|
| Rate for Payer: UMR Bronson Commercial |
$635.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,082.42
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
IP
|
$615.54
|
|
|
Service Code
|
NDC 0904-6683-08
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$270.84 |
| Max. Negotiated Rate |
$553.99 |
| Rate for Payer: Aetna American Axle |
$400.10
|
| Rate for Payer: Aetna Commercial |
$523.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$400.10
|
| Rate for Payer: Cash Price |
$492.43
|
| Rate for Payer: Cofinity Commercial |
$430.88
|
| Rate for Payer: Cofinity Commercial |
$529.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$492.43
|
| Rate for Payer: Healthscope Commercial |
$553.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$430.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$461.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$523.21
|
| Rate for Payer: PHP Commercial |
$523.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$430.88
|
| Rate for Payer: Priority Health SBD |
$387.79
|
| Rate for Payer: UMR Bronson Commercial |
$270.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$461.66
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
IP
|
$864.92
|
|
|
Service Code
|
NDC 59762-0039-2
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$380.56 |
| Max. Negotiated Rate |
$778.43 |
| Rate for Payer: Aetna American Axle |
$562.20
|
| Rate for Payer: Aetna Commercial |
$735.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$562.20
|
| Rate for Payer: Cash Price |
$691.94
|
| Rate for Payer: Cofinity Commercial |
$605.44
|
| Rate for Payer: Cofinity Commercial |
$743.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$691.94
|
| Rate for Payer: Healthscope Commercial |
$778.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$605.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$648.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$735.18
|
| Rate for Payer: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$605.44
|
| Rate for Payer: Priority Health SBD |
$544.90
|
| Rate for Payer: UMR Bronson Commercial |
$380.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$648.69
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 0069-5820-43
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna American Axle |
$0.61
|
| Rate for Payer: Aetna Commercial |
$0.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.61
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cofinity Commercial |
$0.66
|
| Rate for Payer: Cofinity Commercial |
$0.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.75
|
| Rate for Payer: Healthscope Commercial |
$0.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.80
|
| Rate for Payer: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.66
|
| Rate for Payer: Priority Health SBD |
$0.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.71
|
|
