|
DOLUTEGRAVIR 50 MG TABLET
|
Facility
|
IP
|
$8,143.63
|
|
|
Service Code
|
NDC 49702-228-13
|
| Hospital Charge Code |
167672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,583.20 |
| Max. Negotiated Rate |
$7,329.27 |
| Rate for Payer: Aetna American Axle |
$5,293.36
|
| Rate for Payer: Aetna Commercial |
$6,922.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,293.36
|
| Rate for Payer: Cash Price |
$6,514.90
|
| Rate for Payer: Cofinity Commercial |
$5,700.54
|
| Rate for Payer: Cofinity Commercial |
$7,003.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,514.90
|
| Rate for Payer: Healthscope Commercial |
$7,329.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,700.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,107.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6,922.09
|
| Rate for Payer: PHP Commercial |
$6,922.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,700.54
|
| Rate for Payer: Priority Health SBD |
$5,130.49
|
| Rate for Payer: UMR Bronson Commercial |
$3,583.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,107.72
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$29.61
|
|
|
Service Code
|
NDC 43547-276-03
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna American Axle |
$19.25
|
| Rate for Payer: Aetna Commercial |
$25.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.25
|
| Rate for Payer: Cash Price |
$23.69
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Cofinity Commercial |
$25.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.69
|
| Rate for Payer: Healthscope Commercial |
$26.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.17
|
| Rate for Payer: PHP Commercial |
$25.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.73
|
| Rate for Payer: Priority Health SBD |
$18.65
|
| Rate for Payer: UMR Bronson Commercial |
$13.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.21
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$2.97
|
|
|
Service Code
|
NDC 60687-303-11
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna American Axle |
$1.93
|
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.93
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$2.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.38
|
| Rate for Payer: Healthscope Commercial |
$2.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.52
|
| Rate for Payer: PHP Commercial |
$2.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.08
|
| Rate for Payer: Priority Health SBD |
$1.87
|
| Rate for Payer: UMR Bronson Commercial |
$1.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.23
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$296.10
|
|
|
Service Code
|
NDC 60687-303-01
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.28 |
| Max. Negotiated Rate |
$266.49 |
| Rate for Payer: Aetna American Axle |
$192.46
|
| Rate for Payer: Aetna Commercial |
$251.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$192.46
|
| Rate for Payer: Cash Price |
$236.88
|
| Rate for Payer: Cofinity Commercial |
$207.27
|
| Rate for Payer: Cofinity Commercial |
$254.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$236.88
|
| Rate for Payer: Healthscope Commercial |
$266.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$207.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$222.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$251.68
|
| Rate for Payer: PHP Commercial |
$251.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.27
|
| Rate for Payer: Priority Health SBD |
$186.54
|
| Rate for Payer: UMR Bronson Commercial |
$130.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$222.08
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$67.68
|
|
|
Service Code
|
NDC 43547-276-09
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.78 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna American Axle |
$43.99
|
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.99
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$47.38
|
| Rate for Payer: Cofinity Commercial |
$58.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.14
|
| Rate for Payer: Healthscope Commercial |
$60.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.53
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: Priority Health SBD |
$42.64
|
| Rate for Payer: UMR Bronson Commercial |
$29.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.76
|
|
|
DONEPEZIL 23 MG TABLET
|
Facility
|
IP
|
$1,556.67
|
|
|
Service Code
|
NDC 62856-247-30
|
| Hospital Charge Code |
105906
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$684.93 |
| Max. Negotiated Rate |
$1,401.00 |
| Rate for Payer: Aetna American Axle |
$1,011.84
|
| Rate for Payer: Aetna Commercial |
$1,323.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,011.84
|
| Rate for Payer: Cash Price |
$1,245.34
|
| Rate for Payer: Cofinity Commercial |
$1,089.67
|
| Rate for Payer: Cofinity Commercial |
$1,338.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,245.34
|
| Rate for Payer: Healthscope Commercial |
$1,401.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,089.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,167.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,323.17
|
| Rate for Payer: PHP Commercial |
$1,323.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,089.67
|
| Rate for Payer: Priority Health SBD |
$980.70
|
| Rate for Payer: UMR Bronson Commercial |
$684.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,167.50
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$256.15
|
|
|
Service Code
|
NDC 0904-6477-61
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.71 |
| Max. Negotiated Rate |
$230.54 |
| Rate for Payer: Aetna American Axle |
$166.50
|
| Rate for Payer: Aetna Commercial |
$217.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.50
|
| Rate for Payer: Cash Price |
$204.92
|
| Rate for Payer: Cofinity Commercial |
$179.30
|
| Rate for Payer: Cofinity Commercial |
$220.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.92
|
| Rate for Payer: Healthscope Commercial |
$230.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.73
|
| Rate for Payer: PHP Commercial |
$217.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.30
|
| Rate for Payer: Priority Health SBD |
$161.37
|
| Rate for Payer: UMR Bronson Commercial |
$112.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.11
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
NDC 31722-737-30
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna American Axle |
$63.70
|
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.70
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cofinity Commercial |
$68.60
|
| Rate for Payer: Cofinity Commercial |
$84.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.40
|
| Rate for Payer: Healthscope Commercial |
$88.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.30
|
| Rate for Payer: PHP Commercial |
$83.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.60
|
| Rate for Payer: Priority Health SBD |
$61.74
|
| Rate for Payer: UMR Bronson Commercial |
$43.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.50
|
|
|
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18.80
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.27 |
| Max. Negotiated Rate |
$16.92 |
| Rate for Payer: Aetna American Axle |
$12.22
|
| Rate for Payer: Aetna Commercial |
$15.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.22
|
| Rate for Payer: Cash Price |
$15.04
|
| Rate for Payer: Cofinity Commercial |
$13.16
|
| Rate for Payer: Cofinity Commercial |
$16.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.04
|
| Rate for Payer: Healthscope Commercial |
$16.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.98
|
| Rate for Payer: PHP Commercial |
$15.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health SBD |
$11.84
|
| Rate for Payer: UMR Bronson Commercial |
$8.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.10
|
|
|
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$27.41
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
118601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$24.67 |
| Rate for Payer: Aetna American Axle |
$17.82
|
| Rate for Payer: Aetna Commercial |
$23.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.82
|
| Rate for Payer: Cash Price |
$21.93
|
| Rate for Payer: Cofinity Commercial |
$19.19
|
| Rate for Payer: Cofinity Commercial |
$23.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.93
|
| Rate for Payer: Healthscope Commercial |
$24.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.30
|
| Rate for Payer: PHP Commercial |
$23.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.19
|
| Rate for Payer: Priority Health SBD |
$17.27
|
| Rate for Payer: UMR Bronson Commercial |
$12.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.56
|
|
|
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 |
$31.31 |
| Max. Negotiated Rate |
$64.04 |
| Rate for Payer: Aetna American Axle |
$46.25
|
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.25
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$49.80
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$64.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.48
|
| Rate for Payer: PHP Commercial |
$60.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.80
|
| Rate for Payer: Priority Health SBD |
$44.82
|
| Rate for Payer: UMR Bronson Commercial |
$31.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.36
|
|
|
DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY)
|
Facility
|
OP
|
$102.22
|
|
|
Service Code
|
CPT 93325
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$22.92 |
| Max. Negotiated Rate |
$102.22 |
| Rate for Payer: BCBS Trust/PPO |
$102.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.21
|
| Rate for Payer: UHC Exchange |
$22.92
|
|
|
DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE
|
Facility
|
OP
|
$165.88
|
|
|
Service Code
|
CPT 93320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$49.77 |
| Max. Negotiated Rate |
$165.88 |
| Rate for Payer: BCBS Trust/PPO |
$165.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$54.75
|
| Rate for Payer: UHC Exchange |
$49.77
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION
|
Facility
|
IP
|
$446.92
|
|
|
Service Code
|
HCPCS J7639
|
| Hospital Charge Code |
12211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$196.64 |
| Max. Negotiated Rate |
$402.23 |
| Rate for Payer: Aetna American Axle |
$290.50
|
| Rate for Payer: Aetna Commercial |
$379.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$290.50
|
| Rate for Payer: Cash Price |
$357.54
|
| Rate for Payer: Cofinity Commercial |
$312.84
|
| Rate for Payer: Cofinity Commercial |
$384.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.54
|
| Rate for Payer: Healthscope Commercial |
$402.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$312.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$335.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$379.88
|
| Rate for Payer: PHP Commercial |
$379.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$312.84
|
| Rate for Payer: Priority Health SBD |
$281.56
|
| Rate for Payer: UMR Bronson Commercial |
$196.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$335.19
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$36.63
|
|
|
Service Code
|
NDC 50383-232-10
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.12 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna American Axle |
$23.81
|
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.81
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cofinity Commercial |
$25.64
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.30
|
| Rate for Payer: Healthscope Commercial |
$32.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.14
|
| Rate for Payer: PHP Commercial |
$31.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.64
|
| Rate for Payer: Priority Health SBD |
$23.08
|
| Rate for Payer: UMR Bronson Commercial |
$16.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.47
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$262.33
|
|
|
Service Code
|
NDC 0006-3519-36
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.43 |
| Max. Negotiated Rate |
$236.10 |
| Rate for Payer: Aetna American Axle |
$170.51
|
| Rate for Payer: Aetna Commercial |
$222.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.51
|
| Rate for Payer: Cash Price |
$209.86
|
| Rate for Payer: Cofinity Commercial |
$183.63
|
| Rate for Payer: Cofinity Commercial |
$225.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.86
|
| Rate for Payer: Healthscope Commercial |
$236.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$222.98
|
| Rate for Payer: PHP Commercial |
$222.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.63
|
| Rate for Payer: Priority Health SBD |
$165.27
|
| Rate for Payer: UMR Bronson Commercial |
$115.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.75
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$116.96
|
|
|
Service Code
|
NDC 69315-304-10
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.46 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna American Axle |
$76.02
|
| 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: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$105.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.42
|
| Rate for Payer: PHP Commercial |
$99.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.87
|
| Rate for Payer: Priority Health SBD |
$73.68
|
| Rate for Payer: UMR Bronson Commercial |
$51.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.72
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$37.04
|
|
|
Service Code
|
NDC 61314-019-10
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$33.34 |
| Rate for Payer: Aetna American Axle |
$24.08
|
| Rate for Payer: Aetna Commercial |
$31.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.08
|
| Rate for Payer: Cash Price |
$29.63
|
| Rate for Payer: Cofinity Commercial |
$25.93
|
| Rate for Payer: Cofinity Commercial |
$31.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.63
|
| Rate for Payer: Healthscope Commercial |
$33.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.48
|
| Rate for Payer: PHP Commercial |
$31.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.93
|
| Rate for Payer: Priority Health SBD |
$23.34
|
| Rate for Payer: UMR Bronson Commercial |
$16.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.78
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$116.96
|
|
|
Service Code
|
NDC 24208-485-10
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.46 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna American Axle |
$76.02
|
| 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: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$105.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.42
|
| Rate for Payer: PHP Commercial |
$99.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.87
|
| Rate for Payer: Priority Health SBD |
$73.68
|
| Rate for Payer: UMR Bronson Commercial |
$51.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.72
|
|
|
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$50,900.40
|
|
|
Service Code
|
HCPCS J9272
|
| Hospital Charge Code |
197057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.59 |
| Max. Negotiated Rate |
$45,810.36 |
| Rate for Payer: Aetna American Axle |
$33,085.26
|
| Rate for Payer: Aetna Commercial |
$43,265.34
|
| Rate for Payer: Aetna Medicare |
$242.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33,085.26
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$291.57
|
| Rate for Payer: Amish Plain Church Group Commercial |
$291.57
|
| Rate for Payer: BCBS Complete |
$133.98
|
| Rate for Payer: BCBS MAPPO |
$233.26
|
| Rate for Payer: BCBS Trust/PPO |
$753.75
|
| Rate for Payer: BCN Medicare Advantage |
$233.26
|
| Rate for Payer: Cash Price |
$40,720.32
|
| Rate for Payer: Cash Price |
$40,720.32
|
| Rate for Payer: Cofinity Commercial |
$35,630.28
|
| Rate for Payer: Cofinity Commercial |
$43,774.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40,720.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$233.26
|
| Rate for Payer: Healthscope Commercial |
$45,810.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35,630.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38,175.30
|
| Rate for Payer: Mclaren Medicaid |
$127.59
|
| Rate for Payer: Mclaren Medicare |
$233.26
|
| Rate for Payer: Meridian Medicaid |
$133.98
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$244.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$268.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43,265.34
|
| Rate for Payer: PACE Medicare |
$221.60
|
| Rate for Payer: PACE SWMI |
$233.26
|
| Rate for Payer: PHP Commercial |
$43,265.34
|
| Rate for Payer: PHP Medicare Advantage |
$233.26
|
| Rate for Payer: Priority Health Choice Medicaid |
$127.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35,630.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$677.89
|
| Rate for Payer: Priority Health Medicare |
$233.26
|
| Rate for Payer: Priority Health Narrow Network |
$542.31
|
| Rate for Payer: Priority Health SBD |
$32,067.25
|
| Rate for Payer: Railroad Medicare Medicare |
$233.26
|
| Rate for Payer: UHC Dual Complete DSNP |
$233.26
|
| Rate for Payer: UHC Medicare Advantage |
$240.26
|
| Rate for Payer: UMR Bronson Commercial |
$18,833.15
|
| Rate for Payer: VA VA |
$233.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38,175.30
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$241.92
|
|
|
Service Code
|
NDC 51079-436-20
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.44 |
| Max. Negotiated Rate |
$217.73 |
| Rate for Payer: Aetna American Axle |
$157.25
|
| Rate for Payer: Aetna Commercial |
$205.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.25
|
| Rate for Payer: Cash Price |
$193.54
|
| Rate for Payer: Cofinity Commercial |
$169.34
|
| Rate for Payer: Cofinity Commercial |
$208.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.54
|
| Rate for Payer: Healthscope Commercial |
$217.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$169.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$205.63
|
| Rate for Payer: PHP Commercial |
$205.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.34
|
| Rate for Payer: Priority Health SBD |
$152.41
|
| Rate for Payer: UMR Bronson Commercial |
$106.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.44
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$372.40
|
|
|
Service Code
|
NDC 0904-6970-61
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.86 |
| Max. Negotiated Rate |
$335.16 |
| Rate for Payer: Aetna American Axle |
$242.06
|
| Rate for Payer: Aetna Commercial |
$316.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.06
|
| Rate for Payer: Cash Price |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$320.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.92
|
| Rate for Payer: Healthscope Commercial |
$335.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$316.54
|
| Rate for Payer: PHP Commercial |
$316.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.68
|
| Rate for Payer: Priority Health SBD |
$234.61
|
| Rate for Payer: UMR Bronson Commercial |
$163.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.30
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$414.20
|
|
|
Service Code
|
NDC 0378-1049-01
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.25 |
| Max. Negotiated Rate |
$372.78 |
| Rate for Payer: Aetna American Axle |
$269.23
|
| Rate for Payer: Aetna Commercial |
$352.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$269.23
|
| Rate for Payer: Cash Price |
$331.36
|
| Rate for Payer: Cofinity Commercial |
$289.94
|
| Rate for Payer: Cofinity Commercial |
$356.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$331.36
|
| Rate for Payer: Healthscope Commercial |
$372.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$289.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$310.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$352.07
|
| Rate for Payer: PHP Commercial |
$352.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$289.94
|
| Rate for Payer: Priority Health SBD |
$260.95
|
| Rate for Payer: UMR Bronson Commercial |
$182.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$310.65
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$456.95
|
|
|
Service Code
|
NDC 0904-7052-61
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$201.06 |
| Max. Negotiated Rate |
$411.26 |
| Rate for Payer: Aetna American Axle |
$297.02
|
| Rate for Payer: Aetna Commercial |
$388.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.02
|
| Rate for Payer: Cash Price |
$365.56
|
| Rate for Payer: Cofinity Commercial |
$319.86
|
| Rate for Payer: Cofinity Commercial |
$392.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$365.56
|
| Rate for Payer: Healthscope Commercial |
$411.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$319.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$342.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$388.41
|
| Rate for Payer: PHP Commercial |
$388.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$319.86
|
| Rate for Payer: Priority Health SBD |
$287.88
|
| Rate for Payer: UMR Bronson Commercial |
$201.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$342.71
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$2.42
|
|
|
Service Code
|
NDC 51079-436-01
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna American Axle |
$1.57
|
| Rate for Payer: Aetna Commercial |
$2.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.57
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.94
|
| Rate for Payer: Healthscope Commercial |
$2.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.06
|
| Rate for Payer: PHP Commercial |
$2.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health SBD |
$1.52
|
| Rate for Payer: UMR Bronson Commercial |
$1.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.82
|
|
