|
DOLUTEGRAVIR 50 MG TABLET
|
Facility
|
OP
|
$8,639.69
|
|
|
Service Code
|
NDC 49702022813
|
| Hospital Charge Code |
167672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,196.69 |
| 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 Medicare |
$4,319.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,615.80
|
| Rate for Payer: BCBS Complete |
$3,455.88
|
| 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: MI Amish Medical Board Commercial |
$6,911.75
|
| 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: UHC All Payor (Choice/PPO) |
$5,615.80
|
| Rate for Payer: UHC Core |
$4,501.28
|
| Rate for Payer: UHC Exchange |
$3,395.40
|
| Rate for Payer: UMR Bronson Commercial |
$3,196.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,479.77
|
|
|
DONANEMAB-AZBT 17.5 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$2,275.33
|
|
|
Service Code
|
HCPCS J0175
|
| Hospital Charge Code |
207892
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$2,047.80 |
| Rate for Payer: Aetna American Axle |
$1,478.96
|
| Rate for Payer: Aetna Commercial |
$1,934.03
|
| Rate for Payer: Aetna Medicare |
$4.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,478.96
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.17
|
| Rate for Payer: BCBS Complete |
$2.27
|
| Rate for Payer: BCBS MAPPO |
$4.14
|
| Rate for Payer: BCN Medicare Advantage |
$4.14
|
| Rate for Payer: Cash Price |
$1,820.26
|
| Rate for Payer: Cash Price |
$1,820.26
|
| Rate for Payer: Cofinity Advantage |
$1,592.73
|
| Rate for Payer: Cofinity Commercial |
$1,956.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,820.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.14
|
| Rate for Payer: Healthscope Commercial |
$2,047.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,592.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,706.50
|
| Rate for Payer: Mclaren Medicaid |
$4.14
|
| Rate for Payer: Mclaren Medicare |
$4.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.35
|
| Rate for Payer: Meridian Medicaid |
$4.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.76
|
| Rate for Payer: Molina Medicare/Medicaid |
$4.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,934.03
|
| Rate for Payer: Nomi Health Commercial |
$12.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,706.50
|
| Rate for Payer: PACE Medicare |
$3.93
|
| Rate for Payer: PACE SWMI |
$4.14
|
| Rate for Payer: PHP Commercial |
$1,934.03
|
| Rate for Payer: PHP Medicare Advantage |
$4.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$2.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$13.03
|
| Rate for Payer: Priority Health Medicare |
$4.14
|
| Rate for Payer: Priority Health SBD |
$1,433.46
|
| Rate for Payer: Priority Health Tiered Network |
$10.42
|
| Rate for Payer: Railroad Medicare Medicare |
$4.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.88
|
| Rate for Payer: UHC Core |
$6.88
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$4.14
|
| Rate for Payer: UHC Exchange |
$6.88
|
| Rate for Payer: UHC Medicaid |
$2.17
|
| Rate for Payer: UHCCP Medicaid |
$2.17
|
| Rate for Payer: UMR Bronson Commercial |
$841.87
|
| Rate for Payer: VA VA |
$4.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,706.50
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$71.91
|
|
|
Service Code
|
NDC 43547027609
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.61 |
| Max. Negotiated Rate |
$64.72 |
| Rate for Payer: Aetna American Axle |
$46.74
|
| Rate for Payer: Aetna Commercial |
$61.12
|
| Rate for Payer: Aetna Medicare |
$35.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.74
|
| Rate for Payer: BCBS Complete |
$28.76
|
| Rate for Payer: Cash Price |
$57.53
|
| Rate for Payer: Cofinity Advantage |
$50.34
|
| Rate for Payer: Cofinity Commercial |
$61.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.53
|
| Rate for Payer: Healthscope Commercial |
$64.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.93
|
| Rate for Payer: PHP Commercial |
$61.12
|
| Rate for Payer: Priority Health SBD |
$45.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.74
|
| Rate for Payer: UHC Core |
$37.47
|
| Rate for Payer: UHC Exchange |
$28.26
|
| Rate for Payer: UMR Bronson Commercial |
$26.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.93
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$2.92
|
|
|
Service Code
|
NDC 60687030311
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Aetna American Axle |
$1.90
|
| Rate for Payer: Aetna Commercial |
$2.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.90
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cofinity Advantage |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$2.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.34
|
| Rate for Payer: Healthscope Commercial |
$2.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.19
|
| Rate for Payer: PHP Commercial |
$2.48
|
| Rate for Payer: Priority Health SBD |
$1.84
|
| Rate for Payer: UMR Bronson Commercial |
$1.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.19
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$35.96
|
|
|
Service Code
|
NDC 43547027603
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.82 |
| Max. Negotiated Rate |
$32.36 |
| Rate for Payer: Aetna American Axle |
$23.37
|
| Rate for Payer: Aetna Commercial |
$30.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.37
|
| Rate for Payer: Cash Price |
$28.77
|
| Rate for Payer: Cofinity Advantage |
$25.17
|
| Rate for Payer: Cofinity Commercial |
$30.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.77
|
| Rate for Payer: Healthscope Commercial |
$32.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.97
|
| Rate for Payer: PHP Commercial |
$30.57
|
| Rate for Payer: Priority Health SBD |
$22.65
|
| Rate for Payer: UMR Bronson Commercial |
$15.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.97
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$35.96
|
|
|
Service Code
|
NDC 43547027603
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.31 |
| Max. Negotiated Rate |
$32.36 |
| Rate for Payer: Aetna American Axle |
$23.37
|
| Rate for Payer: Aetna Commercial |
$30.57
|
| Rate for Payer: Aetna Medicare |
$17.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.37
|
| Rate for Payer: BCBS Complete |
$14.38
|
| Rate for Payer: Cash Price |
$28.77
|
| Rate for Payer: Cofinity Advantage |
$25.17
|
| Rate for Payer: Cofinity Commercial |
$30.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.77
|
| Rate for Payer: Healthscope Commercial |
$32.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.97
|
| Rate for Payer: PHP Commercial |
$30.57
|
| Rate for Payer: Priority Health SBD |
$22.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.37
|
| Rate for Payer: UHC Core |
$18.74
|
| Rate for Payer: UHC Exchange |
$14.13
|
| Rate for Payer: UMR Bronson Commercial |
$13.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.97
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$2.92
|
|
|
Service Code
|
NDC 60687030311
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$2.63 |
| Rate for Payer: Aetna American Axle |
$1.90
|
| Rate for Payer: Aetna Commercial |
$2.48
|
| Rate for Payer: Aetna Medicare |
$1.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.90
|
| Rate for Payer: BCBS Complete |
$1.17
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cofinity Advantage |
$2.04
|
| Rate for Payer: Cofinity Commercial |
$2.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.34
|
| Rate for Payer: Healthscope Commercial |
$2.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.19
|
| Rate for Payer: PHP Commercial |
$2.48
|
| Rate for Payer: Priority Health SBD |
$1.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.90
|
| Rate for Payer: UHC Core |
$1.52
|
| Rate for Payer: UHC Exchange |
$1.15
|
| Rate for Payer: UMR Bronson Commercial |
$1.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.19
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$71.91
|
|
|
Service Code
|
NDC 43547027609
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.64 |
| Max. Negotiated Rate |
$64.72 |
| Rate for Payer: Aetna American Axle |
$46.74
|
| Rate for Payer: Aetna Commercial |
$61.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.74
|
| Rate for Payer: Cash Price |
$57.53
|
| Rate for Payer: Cofinity Advantage |
$50.34
|
| Rate for Payer: Cofinity Commercial |
$61.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.53
|
| Rate for Payer: Healthscope Commercial |
$64.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.93
|
| Rate for Payer: PHP Commercial |
$61.12
|
| Rate for Payer: Priority Health SBD |
$45.30
|
| Rate for Payer: UMR Bronson Commercial |
$31.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.93
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.82 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna American Axle |
$189.41
|
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna Medicare |
$145.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Advantage |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$233.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$218.55
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health SBD |
$183.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$189.41
|
| Rate for Payer: UHC Core |
$151.82
|
| Rate for Payer: UHC Exchange |
$114.52
|
| Rate for Payer: UMR Bronson Commercial |
$107.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.22 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna American Axle |
$189.41
|
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Advantage |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$218.55
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health SBD |
$183.58
|
| Rate for Payer: UMR Bronson Commercial |
$128.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
DONEPEZIL 23 MG TABLET
|
Facility
|
OP
|
$1,556.67
|
|
|
Service Code
|
NDC 62856024730
|
| Hospital Charge Code |
105906
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$575.97 |
| 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 Medicare |
$778.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,011.84
|
| Rate for Payer: BCBS Complete |
$622.67
|
| Rate for Payer: Cash Price |
$1,245.34
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$1,245.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,323.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,167.50
|
| Rate for Payer: PHP Commercial |
$1,323.17
|
| Rate for Payer: Priority Health SBD |
$980.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,011.84
|
| Rate for Payer: UHC Core |
$811.03
|
| Rate for Payer: UHC Exchange |
$611.77
|
| Rate for Payer: UMR Bronson Commercial |
$575.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,167.50
|
|
|
DONEPEZIL 23 MG TABLET
|
Facility
|
IP
|
$1,556.67
|
|
|
Service Code
|
NDC 62856024730
|
| 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 Advantage |
$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 Commercial |
$1,323.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,167.50
|
| Rate for Payer: PHP Commercial |
$1,323.17
|
| 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
|
OP
|
$95.88
|
|
|
Service Code
|
NDC 31722073730
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$86.29 |
| Rate for Payer: Aetna American Axle |
$62.32
|
| Rate for Payer: Aetna Commercial |
$81.50
|
| Rate for Payer: Aetna Medicare |
$47.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.32
|
| Rate for Payer: BCBS Complete |
$38.35
|
| Rate for Payer: Cash Price |
$76.70
|
| Rate for Payer: Cofinity Advantage |
$67.12
|
| Rate for Payer: Cofinity Commercial |
$82.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.70
|
| Rate for Payer: Healthscope Commercial |
$86.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.91
|
| Rate for Payer: PHP Commercial |
$81.50
|
| Rate for Payer: Priority Health SBD |
$60.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.32
|
| Rate for Payer: UHC Core |
$49.95
|
| Rate for Payer: UHC Exchange |
$37.68
|
| Rate for Payer: UMR Bronson Commercial |
$35.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.91
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
OP
|
$260.85
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.51 |
| Max. Negotiated Rate |
$234.76 |
| Rate for Payer: Aetna American Axle |
$169.55
|
| Rate for Payer: Aetna Commercial |
$221.72
|
| Rate for Payer: Aetna Medicare |
$130.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.55
|
| Rate for Payer: BCBS Complete |
$104.34
|
| Rate for Payer: Cash Price |
$208.68
|
| Rate for Payer: Cofinity Advantage |
$182.59
|
| Rate for Payer: Cofinity Commercial |
$224.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.68
|
| Rate for Payer: Healthscope Commercial |
$234.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.64
|
| Rate for Payer: PHP Commercial |
$221.72
|
| Rate for Payer: Priority Health SBD |
$164.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.55
|
| Rate for Payer: UHC Core |
$135.90
|
| Rate for Payer: UHC Exchange |
$102.51
|
| Rate for Payer: UMR Bronson Commercial |
$96.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.64
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$95.88
|
|
|
Service Code
|
NDC 31722073730
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.19 |
| Max. Negotiated Rate |
$86.29 |
| Rate for Payer: Aetna American Axle |
$62.32
|
| Rate for Payer: Aetna Commercial |
$81.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.32
|
| Rate for Payer: Cash Price |
$76.70
|
| Rate for Payer: Cofinity Advantage |
$67.12
|
| Rate for Payer: Cofinity Commercial |
$82.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.70
|
| Rate for Payer: Healthscope Commercial |
$86.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.91
|
| Rate for Payer: PHP Commercial |
$81.50
|
| Rate for Payer: Priority Health SBD |
$60.40
|
| Rate for Payer: UMR Bronson Commercial |
$42.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.91
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$260.85
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.77 |
| Max. Negotiated Rate |
$234.76 |
| Rate for Payer: Aetna American Axle |
$169.55
|
| Rate for Payer: Aetna Commercial |
$221.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.55
|
| Rate for Payer: Cash Price |
$208.68
|
| Rate for Payer: Cofinity Advantage |
$182.59
|
| Rate for Payer: Cofinity Commercial |
$224.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.68
|
| Rate for Payer: Healthscope Commercial |
$234.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.64
|
| Rate for Payer: PHP Commercial |
$221.72
|
| Rate for Payer: Priority Health SBD |
$164.34
|
| Rate for Payer: UMR Bronson Commercial |
$114.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.64
|
|
|
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.02
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$18.02 |
| Rate for Payer: Aetna American Axle |
$13.01
|
| Rate for Payer: Aetna Commercial |
$17.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.01
|
| Rate for Payer: Cash Price |
$16.02
|
| Rate for Payer: Cofinity Advantage |
$14.01
|
| Rate for Payer: Cofinity Commercial |
$17.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.02
|
| Rate for Payer: Healthscope Commercial |
$18.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.02
|
| Rate for Payer: PHP Commercial |
$17.02
|
| Rate for Payer: Priority Health SBD |
$12.61
|
| Rate for Payer: UMR Bronson Commercial |
$8.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.02
|
|
|
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$20.02
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$18.02 |
| Rate for Payer: Aetna American Axle |
$13.01
|
| Rate for Payer: Aetna Commercial |
$17.02
|
| Rate for Payer: Aetna Medicare |
$10.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.01
|
| Rate for Payer: BCBS Complete |
$8.01
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$16.02
|
| Rate for Payer: Cash Price |
$16.02
|
| Rate for Payer: Cofinity Advantage |
$14.01
|
| Rate for Payer: Cofinity Commercial |
$17.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.02
|
| Rate for Payer: Healthscope Commercial |
$18.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.02
|
| Rate for Payer: PHP Commercial |
$17.02
|
| Rate for Payer: Priority Health SBD |
$12.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.32
|
| Rate for Payer: UHC Core |
$1.32
|
| Rate for Payer: UHC Exchange |
$1.32
|
| Rate for Payer: UMR Bronson Commercial |
$7.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.02
|
|
|
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$14.88
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
118601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$13.39 |
| Rate for Payer: Aetna American Axle |
$9.67
|
| Rate for Payer: Aetna Commercial |
$12.65
|
| Rate for Payer: Aetna Medicare |
$7.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.67
|
| Rate for Payer: BCBS Complete |
$5.95
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$11.90
|
| Rate for Payer: Cash Price |
$11.90
|
| Rate for Payer: Cofinity Advantage |
$10.42
|
| Rate for Payer: Cofinity Commercial |
$12.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.90
|
| Rate for Payer: Healthscope Commercial |
$13.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.16
|
| Rate for Payer: PHP Commercial |
$12.65
|
| Rate for Payer: Priority Health SBD |
$9.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.32
|
| Rate for Payer: UHC Core |
$1.32
|
| Rate for Payer: UHC Exchange |
$1.32
|
| Rate for Payer: UMR Bronson Commercial |
$5.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.16
|
|
|
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$14.88
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
118601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.55 |
| Max. Negotiated Rate |
$13.39 |
| Rate for Payer: Aetna American Axle |
$9.67
|
| Rate for Payer: Aetna Commercial |
$12.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.67
|
| Rate for Payer: Cash Price |
$11.90
|
| Rate for Payer: Cofinity Advantage |
$10.42
|
| Rate for Payer: Cofinity Commercial |
$12.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.90
|
| Rate for Payer: Healthscope Commercial |
$13.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.16
|
| Rate for Payer: PHP Commercial |
$12.65
|
| Rate for Payer: Priority Health SBD |
$9.37
|
| Rate for Payer: UMR Bronson Commercial |
$6.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.16
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
IP
|
$73.44
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.31 |
| Max. Negotiated Rate |
$66.10 |
| Rate for Payer: Aetna American Axle |
$47.74
|
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.74
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cofinity Advantage |
$51.41
|
| Rate for Payer: Cofinity Commercial |
$63.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.75
|
| Rate for Payer: Healthscope Commercial |
$66.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.08
|
| Rate for Payer: PHP Commercial |
$62.42
|
| Rate for Payer: Priority Health SBD |
$46.27
|
| Rate for Payer: UMR Bronson Commercial |
$32.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.08
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
OP
|
$73.44
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$66.10 |
| Rate for Payer: Aetna American Axle |
$47.74
|
| Rate for Payer: Aetna Commercial |
$62.42
|
| Rate for Payer: Aetna Medicare |
$36.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.74
|
| Rate for Payer: BCBS Complete |
$29.38
|
| Rate for Payer: BCBS Trust/PPO |
$2.58
|
| Rate for Payer: BCN Commercial |
$2.58
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cash Price |
$58.75
|
| Rate for Payer: Cofinity Advantage |
$51.41
|
| Rate for Payer: Cofinity Commercial |
$63.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.75
|
| Rate for Payer: Healthscope Commercial |
$66.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$58.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.08
|
| Rate for Payer: PHP Commercial |
$62.42
|
| Rate for Payer: Priority Health SBD |
$46.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.32
|
| Rate for Payer: UHC Core |
$1.32
|
| Rate for Payer: UHC Exchange |
$1.32
|
| Rate for Payer: UMR Bronson Commercial |
$27.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.08
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION
|
Facility
|
OP
|
$474.13
|
|
|
Service Code
|
HCPCS J7639
|
| Hospital Charge Code |
12211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.13 |
| Max. Negotiated Rate |
$426.72 |
| Rate for Payer: Aetna American Axle |
$308.18
|
| Rate for Payer: Aetna Commercial |
$403.01
|
| Rate for Payer: Aetna Medicare |
$237.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.18
|
| Rate for Payer: BCBS Complete |
$189.65
|
| Rate for Payer: Cash Price |
$379.30
|
| Rate for Payer: Cash Price |
$379.30
|
| Rate for Payer: Cofinity Advantage |
$331.89
|
| Rate for Payer: Cofinity Commercial |
$407.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$379.30
|
| Rate for Payer: Healthscope Commercial |
$426.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$331.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$355.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$379.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$355.60
|
| Rate for Payer: PHP Commercial |
$403.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$55.16
|
| Rate for Payer: Priority Health SBD |
$298.70
|
| Rate for Payer: Priority Health Tiered Network |
$44.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$308.18
|
| Rate for Payer: UHC Core |
$247.02
|
| Rate for Payer: UHC Exchange |
$186.33
|
| Rate for Payer: UMR Bronson Commercial |
$175.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$355.60
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION
|
Facility
|
IP
|
$474.13
|
|
|
Service Code
|
HCPCS J7639
|
| Hospital Charge Code |
12211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$208.62 |
| Max. Negotiated Rate |
$426.72 |
| Rate for Payer: Aetna American Axle |
$308.18
|
| Rate for Payer: Aetna Commercial |
$403.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.18
|
| Rate for Payer: Cash Price |
$379.30
|
| Rate for Payer: Cofinity Advantage |
$331.89
|
| Rate for Payer: Cofinity Commercial |
$407.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$379.30
|
| Rate for Payer: Healthscope Commercial |
$426.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$331.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$355.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$355.60
|
| Rate for Payer: PHP Commercial |
$403.01
|
| Rate for Payer: Priority Health SBD |
$298.70
|
| Rate for Payer: UMR Bronson Commercial |
$208.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$355.60
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$34,666.36
|
|
|
Service Code
|
APR-DRG 3044
|
| Min. Negotiated Rate |
$33,015.58 |
| Max. Negotiated Rate |
$34,666.36 |
| Rate for Payer: BCBS Complete |
$34,666.36
|
| Rate for Payer: Mclaren Medicaid |
$33,015.58
|
| Rate for Payer: Meridian Medicaid |
$34,666.36
|
| Rate for Payer: Priority Health Choice Medicaid |
$33,015.58
|
| Rate for Payer: UHC Medicaid |
$33,015.58
|
| Rate for Payer: UHCCP Medicaid |
$33,015.58
|
|
