|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$532.66
|
|
|
Service Code
|
NDC 00904752308
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$234.37 |
| Max. Negotiated Rate |
$479.39 |
| Rate for Payer: Aetna American Axle |
$346.23
|
| Rate for Payer: Aetna Commercial |
$452.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$346.23
|
| Rate for Payer: Cash Price |
$426.13
|
| Rate for Payer: Cofinity Advantage |
$372.86
|
| Rate for Payer: Cofinity Commercial |
$458.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$426.13
|
| Rate for Payer: Healthscope Commercial |
$479.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$372.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$399.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$452.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$399.50
|
| Rate for Payer: PHP Commercial |
$452.76
|
| Rate for Payer: Priority Health SBD |
$335.58
|
| Rate for Payer: UMR Bronson Commercial |
$234.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$399.50
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
OP
|
$532.66
|
|
|
Service Code
|
NDC 00904752308
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.08 |
| Max. Negotiated Rate |
$479.39 |
| Rate for Payer: Aetna American Axle |
$346.23
|
| Rate for Payer: Aetna Commercial |
$452.76
|
| Rate for Payer: Aetna Medicare |
$266.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$346.23
|
| Rate for Payer: BCBS Complete |
$213.06
|
| Rate for Payer: Cash Price |
$426.13
|
| Rate for Payer: Cofinity Advantage |
$372.86
|
| Rate for Payer: Cofinity Commercial |
$458.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$426.13
|
| Rate for Payer: Healthscope Commercial |
$479.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$372.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$399.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$426.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$452.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$399.50
|
| Rate for Payer: PHP Commercial |
$452.76
|
| Rate for Payer: Priority Health SBD |
$335.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$346.23
|
| Rate for Payer: UHC Core |
$277.52
|
| Rate for Payer: UHC Exchange |
$209.34
|
| Rate for Payer: UMR Bronson Commercial |
$197.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$399.50
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 00069581043
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna American Axle |
$0.61
|
| Rate for Payer: Aetna Commercial |
$0.80
|
| Rate for Payer: Aetna Medicare |
$0.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.61
|
| Rate for Payer: BCBS Complete |
$0.38
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$0.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$0.71
|
| Rate for Payer: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health SBD |
$0.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.61
|
| Rate for Payer: UHC Core |
$0.49
|
| Rate for Payer: UHC Exchange |
$0.37
|
| Rate for Payer: UMR Bronson Commercial |
$0.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.71
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
OP
|
$357.12
|
|
|
Service Code
|
NDC 59651011960
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.13 |
| Max. Negotiated Rate |
$321.41 |
| Rate for Payer: Aetna American Axle |
$232.13
|
| Rate for Payer: Aetna Commercial |
$303.55
|
| Rate for Payer: Aetna Medicare |
$178.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$232.13
|
| Rate for Payer: BCBS Complete |
$142.85
|
| Rate for Payer: Cash Price |
$285.70
|
| Rate for Payer: Cofinity Advantage |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$307.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.70
|
| Rate for Payer: Healthscope Commercial |
$321.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$249.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.84
|
| Rate for Payer: MI Amish Medical Board Commercial |
$285.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$303.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.84
|
| Rate for Payer: PHP Commercial |
$303.55
|
| Rate for Payer: Priority Health SBD |
$224.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$232.13
|
| Rate for Payer: UHC Core |
$186.06
|
| Rate for Payer: UHC Exchange |
$140.35
|
| Rate for Payer: UMR Bronson Commercial |
$132.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.84
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
OP
|
$151.62
|
|
|
Service Code
|
NDC 72205004060
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$136.46 |
| Rate for Payer: Aetna American Axle |
$98.55
|
| Rate for Payer: Aetna Commercial |
$128.88
|
| Rate for Payer: Aetna Medicare |
$75.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.55
|
| Rate for Payer: BCBS Complete |
$60.65
|
| Rate for Payer: Cash Price |
$121.30
|
| Rate for Payer: Cofinity Advantage |
$106.13
|
| Rate for Payer: Cofinity Commercial |
$130.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.30
|
| Rate for Payer: Healthscope Commercial |
$136.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$106.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$113.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$121.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$128.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$113.72
|
| Rate for Payer: PHP Commercial |
$128.88
|
| Rate for Payer: Priority Health SBD |
$95.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.55
|
| Rate for Payer: UHC Core |
$78.99
|
| Rate for Payer: UHC Exchange |
$59.59
|
| Rate for Payer: UMR Bronson Commercial |
$56.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$113.72
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 00069581043
|
| 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 Advantage |
$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 Commercial |
$0.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$0.71
|
| Rate for Payer: PHP Commercial |
$0.80
|
| 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
|
OP
|
$864.92
|
|
|
Service Code
|
NDC 59762003802
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$320.02 |
| Max. Negotiated Rate |
$778.43 |
| Rate for Payer: Aetna American Axle |
$562.20
|
| Rate for Payer: Aetna Commercial |
$735.18
|
| Rate for Payer: Aetna Medicare |
$432.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$562.20
|
| Rate for Payer: BCBS Complete |
$345.97
|
| Rate for Payer: Cash Price |
$691.94
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$691.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$735.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$648.69
|
| Rate for Payer: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health SBD |
$544.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$562.20
|
| Rate for Payer: UHC Core |
$450.62
|
| Rate for Payer: UHC Exchange |
$339.91
|
| Rate for Payer: UMR Bronson Commercial |
$320.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$648.69
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$428.55
|
|
|
Service Code
|
NDC 47335006286
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.56 |
| Max. Negotiated Rate |
$385.69 |
| 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 Advantage |
$299.99
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.84
|
| Rate for Payer: Healthscope Commercial |
$385.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$321.41
|
| Rate for Payer: PHP Commercial |
$364.27
|
| 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 59762003802
|
| 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 Advantage |
$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 Commercial |
$735.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$648.69
|
| Rate for Payer: PHP Commercial |
$735.18
|
| 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
|
$151.62
|
|
|
Service Code
|
NDC 72205004060
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.71 |
| Max. Negotiated Rate |
$136.46 |
| Rate for Payer: Aetna American Axle |
$98.55
|
| Rate for Payer: Aetna Commercial |
$128.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.55
|
| Rate for Payer: Cash Price |
$121.30
|
| Rate for Payer: Cofinity Advantage |
$106.13
|
| Rate for Payer: Cofinity Commercial |
$130.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.30
|
| Rate for Payer: Healthscope Commercial |
$136.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$106.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$113.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$128.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$113.72
|
| Rate for Payer: PHP Commercial |
$128.88
|
| Rate for Payer: Priority Health SBD |
$95.52
|
| Rate for Payer: UMR Bronson Commercial |
$66.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$113.72
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
OP
|
$428.55
|
|
|
Service Code
|
NDC 47335006286
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.56 |
| Max. Negotiated Rate |
$385.69 |
| Rate for Payer: Aetna American Axle |
$278.56
|
| Rate for Payer: Aetna Commercial |
$364.27
|
| Rate for Payer: Aetna Medicare |
$214.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$278.56
|
| Rate for Payer: BCBS Complete |
$171.42
|
| Rate for Payer: Cash Price |
$342.84
|
| Rate for Payer: Cofinity Advantage |
$299.99
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$342.84
|
| Rate for Payer: Healthscope Commercial |
$385.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$299.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$321.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$342.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$321.41
|
| Rate for Payer: PHP Commercial |
$364.27
|
| Rate for Payer: Priority Health SBD |
$269.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$278.56
|
| Rate for Payer: UHC Core |
$223.27
|
| Rate for Payer: UHC Exchange |
$168.42
|
| Rate for Payer: UMR Bronson Commercial |
$158.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.41
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$1,443.23
|
|
|
Service Code
|
NDC 51862002560
|
| 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 Advantage |
$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 Commercial |
$1,226.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,082.42
|
| Rate for Payer: PHP Commercial |
$1,226.75
|
| 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
|
OP
|
$1,443.23
|
|
|
Service Code
|
NDC 51862000560
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$534.00 |
| 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 Medicare |
$721.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$938.10
|
| Rate for Payer: BCBS Complete |
$577.29
|
| Rate for Payer: Cash Price |
$1,154.58
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$1,154.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,226.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,082.42
|
| Rate for Payer: PHP Commercial |
$1,226.75
|
| Rate for Payer: Priority Health SBD |
$909.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$938.10
|
| Rate for Payer: UHC Core |
$751.92
|
| Rate for Payer: UHC Exchange |
$567.19
|
| Rate for Payer: UMR Bronson Commercial |
$534.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,082.42
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
IP
|
$649.58
|
|
|
Service Code
|
NDC 00904668308
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.82 |
| Max. Negotiated Rate |
$584.62 |
| Rate for Payer: Aetna American Axle |
$422.23
|
| Rate for Payer: Aetna Commercial |
$552.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$422.23
|
| Rate for Payer: Cash Price |
$519.66
|
| Rate for Payer: Cofinity Advantage |
$454.71
|
| Rate for Payer: Cofinity Commercial |
$558.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$519.66
|
| Rate for Payer: Healthscope Commercial |
$584.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$454.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$487.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$552.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$487.19
|
| Rate for Payer: PHP Commercial |
$552.14
|
| Rate for Payer: Priority Health SBD |
$409.24
|
| Rate for Payer: UMR Bronson Commercial |
$285.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$487.19
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
IP
|
$1,443.23
|
|
|
Service Code
|
NDC 51862000560
|
| 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 Advantage |
$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 Commercial |
$1,226.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,082.42
|
| Rate for Payer: PHP Commercial |
$1,226.75
|
| 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
|
$0.94
|
|
|
Service Code
|
NDC 00069582043
|
| 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 Advantage |
$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 Commercial |
$0.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$0.71
|
| Rate for Payer: PHP Commercial |
$0.80
|
| 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 500 MCG CAPSULE
|
Facility
|
OP
|
$864.92
|
|
|
Service Code
|
NDC 59762003902
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$320.02 |
| Max. Negotiated Rate |
$778.43 |
| Rate for Payer: Aetna American Axle |
$562.20
|
| Rate for Payer: Aetna Commercial |
$735.18
|
| Rate for Payer: Aetna Medicare |
$432.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$562.20
|
| Rate for Payer: BCBS Complete |
$345.97
|
| Rate for Payer: Cash Price |
$691.94
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$691.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$735.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$648.69
|
| Rate for Payer: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health SBD |
$544.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$562.20
|
| Rate for Payer: UHC Core |
$450.62
|
| Rate for Payer: UHC Exchange |
$339.91
|
| Rate for Payer: UMR Bronson Commercial |
$320.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$648.69
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
OP
|
$161.31
|
|
|
Service Code
|
NDC 72205004160
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.68 |
| Max. Negotiated Rate |
$145.18 |
| Rate for Payer: Aetna American Axle |
$104.85
|
| Rate for Payer: Aetna Commercial |
$137.11
|
| Rate for Payer: Aetna Medicare |
$80.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$104.85
|
| Rate for Payer: BCBS Complete |
$64.52
|
| Rate for Payer: Cash Price |
$129.05
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$129.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$120.98
|
| Rate for Payer: PHP Commercial |
$137.11
|
| Rate for Payer: Priority Health SBD |
$101.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.85
|
| Rate for Payer: UHC Core |
$84.04
|
| Rate for Payer: UHC Exchange |
$63.39
|
| Rate for Payer: UMR Bronson Commercial |
$59.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$120.98
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 00069582043
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna American Axle |
$0.61
|
| Rate for Payer: Aetna Commercial |
$0.80
|
| Rate for Payer: Aetna Medicare |
$0.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.61
|
| Rate for Payer: BCBS Complete |
$0.38
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$0.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$0.71
|
| Rate for Payer: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health SBD |
$0.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.61
|
| Rate for Payer: UHC Core |
$0.49
|
| Rate for Payer: UHC Exchange |
$0.37
|
| Rate for Payer: UMR Bronson Commercial |
$0.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.71
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
OP
|
$649.58
|
|
|
Service Code
|
NDC 00904668308
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.34 |
| Max. Negotiated Rate |
$584.62 |
| Rate for Payer: Aetna American Axle |
$422.23
|
| Rate for Payer: Aetna Commercial |
$552.14
|
| Rate for Payer: Aetna Medicare |
$324.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$422.23
|
| Rate for Payer: BCBS Complete |
$259.83
|
| Rate for Payer: Cash Price |
$519.66
|
| Rate for Payer: Cofinity Advantage |
$454.71
|
| Rate for Payer: Cofinity Commercial |
$558.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$519.66
|
| Rate for Payer: Healthscope Commercial |
$584.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$454.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$487.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$519.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$552.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$487.19
|
| Rate for Payer: PHP Commercial |
$552.14
|
| Rate for Payer: Priority Health SBD |
$409.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$422.23
|
| Rate for Payer: UHC Core |
$338.43
|
| Rate for Payer: UHC Exchange |
$255.28
|
| Rate for Payer: UMR Bronson Commercial |
$240.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$487.19
|
|
|
DOFETILIDE 500 MCG CAPSULE
|
Facility
|
IP
|
$864.92
|
|
|
Service Code
|
NDC 59762003902
|
| 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 Advantage |
$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 Commercial |
$735.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$648.69
|
| Rate for Payer: PHP Commercial |
$735.18
|
| 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
|
$161.31
|
|
|
Service Code
|
NDC 72205004160
|
| Hospital Charge Code |
26967
|
|
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 Advantage |
$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 Commercial |
$137.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$120.98
|
| Rate for Payer: PHP Commercial |
$137.11
|
| 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
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET
|
Facility
|
IP
|
$13,572.53
|
|
|
Service Code
|
NDC 49702024213
|
| Hospital Charge Code |
185211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,971.91 |
| Max. Negotiated Rate |
$12,215.28 |
| Rate for Payer: Aetna American Axle |
$8,822.14
|
| Rate for Payer: Aetna Commercial |
$11,536.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8,822.14
|
| Rate for Payer: Cash Price |
$10,858.02
|
| Rate for Payer: Cofinity Advantage |
$9,500.77
|
| Rate for Payer: Cofinity Commercial |
$11,672.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10,858.02
|
| Rate for Payer: Healthscope Commercial |
$12,215.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9,500.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,179.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11,536.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10,179.40
|
| Rate for Payer: PHP Commercial |
$11,536.65
|
| Rate for Payer: Priority Health SBD |
$8,550.69
|
| Rate for Payer: UMR Bronson Commercial |
$5,971.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,179.40
|
|
|
DOLUTEGRAVIR 50 MG-RILPIVIRINE 25 MG TABLET
|
Facility
|
OP
|
$13,572.53
|
|
|
Service Code
|
NDC 49702024213
|
| Hospital Charge Code |
185211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,021.84 |
| Max. Negotiated Rate |
$12,215.28 |
| Rate for Payer: Aetna American Axle |
$8,822.14
|
| Rate for Payer: Aetna Commercial |
$11,536.65
|
| Rate for Payer: Aetna Medicare |
$6,786.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8,822.14
|
| Rate for Payer: BCBS Complete |
$5,429.01
|
| Rate for Payer: Cash Price |
$10,858.02
|
| Rate for Payer: Cofinity Advantage |
$9,500.77
|
| Rate for Payer: Cofinity Commercial |
$11,672.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10,858.02
|
| Rate for Payer: Healthscope Commercial |
$12,215.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9,500.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10,179.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10,858.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11,536.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10,179.40
|
| Rate for Payer: PHP Commercial |
$11,536.65
|
| Rate for Payer: Priority Health SBD |
$8,550.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,822.14
|
| Rate for Payer: UHC Core |
$7,071.29
|
| Rate for Payer: UHC Exchange |
$5,334.00
|
| Rate for Payer: UMR Bronson Commercial |
$5,021.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10,179.40
|
|
|
DOLUTEGRAVIR 50 MG TABLET
|
Facility
|
IP
|
$8,639.69
|
|
|
Service Code
|
NDC 49702022813
|
| Hospital Charge Code |
167672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,801.46 |
| Max. Negotiated Rate |
$7,775.72 |
| Rate for Payer: Aetna American Axle |
$5,615.80
|
| Rate for Payer: Aetna Commercial |
$7,343.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,615.80
|
| Rate for Payer: Cash Price |
$6,911.75
|
| Rate for Payer: Cofinity Advantage |
$6,047.78
|
| Rate for Payer: Cofinity Commercial |
$7,430.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,911.75
|
| Rate for Payer: Healthscope Commercial |
$7,775.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,047.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,479.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,343.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,479.77
|
| Rate for Payer: PHP Commercial |
$7,343.74
|
| Rate for Payer: Priority Health SBD |
$5,443.00
|
| Rate for Payer: UMR Bronson Commercial |
$3,801.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,479.77
|
|
