|
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 Commercial |
$299.99
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.99
|
| 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: PHP Commercial |
$364.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.56
|
| Rate for Payer: Priority Health SBD |
$269.99
|
| Rate for Payer: UMR Bronson Commercial |
$158.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$321.41
|
|
|
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 Commercial |
$605.44
|
| Rate for Payer: Cofinity Commercial |
$743.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$605.44
|
| 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: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$562.20
|
| Rate for Payer: Priority Health SBD |
$544.90
|
| 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
|
$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 Commercial |
$0.66
|
| Rate for Payer: Cofinity Commercial |
$0.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.66
|
| 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: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.61
|
| Rate for Payer: Priority Health SBD |
$0.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.71
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$1,443.23
|
|
|
Service Code
|
NDC 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 Commercial |
$1,010.26
|
| Rate for Payer: Cofinity Commercial |
$1,241.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,010.26
|
| 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: PHP Commercial |
$1,226.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$938.10
|
| Rate for Payer: Priority Health SBD |
$909.23
|
| Rate for Payer: UMR Bronson Commercial |
$635.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,082.42
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
OP
|
$1,443.23
|
|
|
Service Code
|
NDC 51862002560
|
| Hospital Charge Code |
26966
|
|
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 Commercial |
$1,010.26
|
| Rate for Payer: Cofinity Commercial |
$1,241.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,010.26
|
| 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: PHP Commercial |
$1,226.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$938.10
|
| Rate for Payer: Priority Health SBD |
$909.23
|
| Rate for Payer: UMR Bronson Commercial |
$534.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,082.42
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
OP
|
$176.70
|
|
|
Service Code
|
NDC 72205004060
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.38 |
| Max. Negotiated Rate |
$159.03 |
| Rate for Payer: Aetna American Axle |
$114.86
|
| Rate for Payer: Aetna Commercial |
$150.19
|
| Rate for Payer: Aetna Medicare |
$88.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.86
|
| Rate for Payer: BCBS Complete |
$70.68
|
| Rate for Payer: Cash Price |
$141.36
|
| Rate for Payer: Cofinity Commercial |
$123.69
|
| Rate for Payer: Cofinity Commercial |
$151.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.36
|
| Rate for Payer: Healthscope Commercial |
$159.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.19
|
| Rate for Payer: PHP Commercial |
$150.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.86
|
| Rate for Payer: Priority Health SBD |
$111.32
|
| Rate for Payer: UMR Bronson Commercial |
$65.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.53
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$428.55
|
|
|
Service Code
|
NDC 59651011960
|
| 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 Commercial |
$299.99
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.99
|
| 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: PHP Commercial |
$364.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.56
|
| 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
|
OP
|
$428.55
|
|
|
Service Code
|
NDC 59651011960
|
| 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 Commercial |
$299.99
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.99
|
| 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: PHP Commercial |
$364.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.56
|
| Rate for Payer: Priority Health SBD |
$269.99
|
| 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
|
$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 Commercial |
$299.99
|
| Rate for Payer: Cofinity Commercial |
$368.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$299.99
|
| 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: PHP Commercial |
$364.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.56
|
| 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
|
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 Commercial |
$0.66
|
| Rate for Payer: Cofinity Commercial |
$0.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.66
|
| 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: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.61
|
| Rate for Payer: Priority Health SBD |
$0.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.71
|
|
|
DOFETILIDE 250 MCG CAPSULE
|
Facility
|
IP
|
$176.70
|
|
|
Service Code
|
NDC 72205004060
|
| Hospital Charge Code |
26966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.75 |
| Max. Negotiated Rate |
$159.03 |
| Rate for Payer: Aetna American Axle |
$114.86
|
| Rate for Payer: Aetna Commercial |
$150.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.86
|
| Rate for Payer: Cash Price |
$141.36
|
| Rate for Payer: Cofinity Commercial |
$123.69
|
| Rate for Payer: Cofinity Commercial |
$151.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$141.36
|
| Rate for Payer: Healthscope Commercial |
$159.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$150.19
|
| Rate for Payer: PHP Commercial |
$150.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.86
|
| Rate for Payer: Priority Health SBD |
$111.32
|
| Rate for Payer: UMR Bronson Commercial |
$77.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.53
|
|
|
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 Commercial |
$605.44
|
| Rate for Payer: Cofinity Commercial |
$743.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$605.44
|
| 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: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$562.20
|
| 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
|
$629.30
|
|
|
Service Code
|
NDC 00904668308
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$276.89 |
| Max. Negotiated Rate |
$566.37 |
| Rate for Payer: Aetna American Axle |
$409.05
|
| Rate for Payer: Aetna Commercial |
$534.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.05
|
| Rate for Payer: Cash Price |
$503.44
|
| Rate for Payer: Cofinity Commercial |
$440.51
|
| Rate for Payer: Cofinity Commercial |
$541.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$440.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$503.44
|
| Rate for Payer: Healthscope Commercial |
$566.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$440.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$471.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$534.90
|
| Rate for Payer: PHP Commercial |
$534.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$409.05
|
| Rate for Payer: Priority Health SBD |
$396.46
|
| Rate for Payer: UMR Bronson Commercial |
$276.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$471.98
|
|
|
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 Commercial |
$605.44
|
| Rate for Payer: Cofinity Commercial |
$743.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$605.44
|
| 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: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$562.20
|
| 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
|
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 Commercial |
$1,010.26
|
| Rate for Payer: Cofinity Commercial |
$1,241.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,010.26
|
| 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: PHP Commercial |
$1,226.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$938.10
|
| Rate for Payer: Priority Health SBD |
$909.23
|
| 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
|
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 Commercial |
$605.44
|
| Rate for Payer: Cofinity Commercial |
$743.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$605.44
|
| 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: PHP Commercial |
$735.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$562.20
|
| Rate for Payer: Priority Health SBD |
$544.90
|
| Rate for Payer: UMR Bronson Commercial |
$320.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$648.69
|
|
|
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 Commercial |
$1,010.26
|
| Rate for Payer: Cofinity Commercial |
$1,241.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,010.26
|
| 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: PHP Commercial |
$1,226.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$938.10
|
| 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 Commercial |
$0.66
|
| Rate for Payer: Cofinity Commercial |
$0.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.66
|
| 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: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.61
|
| 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
|
$629.30
|
|
|
Service Code
|
NDC 00904668308
|
| Hospital Charge Code |
26967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.84 |
| Max. Negotiated Rate |
$566.37 |
| Rate for Payer: Aetna American Axle |
$409.05
|
| Rate for Payer: Aetna Commercial |
$534.90
|
| Rate for Payer: Aetna Medicare |
$314.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$409.05
|
| Rate for Payer: BCBS Complete |
$251.72
|
| Rate for Payer: Cash Price |
$503.44
|
| Rate for Payer: Cofinity Commercial |
$440.51
|
| Rate for Payer: Cofinity Commercial |
$541.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$440.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$503.44
|
| Rate for Payer: Healthscope Commercial |
$566.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$440.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$471.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$534.90
|
| Rate for Payer: PHP Commercial |
$534.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$409.05
|
| Rate for Payer: Priority Health SBD |
$396.46
|
| Rate for Payer: UMR Bronson Commercial |
$232.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$471.98
|
|
|
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 Commercial |
$0.66
|
| Rate for Payer: Cofinity Commercial |
$0.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.66
|
| 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: PHP Commercial |
$0.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.61
|
| Rate for Payer: Priority Health SBD |
$0.59
|
| Rate for Payer: UMR Bronson Commercial |
$0.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.71
|
|
|
DOLUTEGRAVIR 50 MG TABLET
|
Facility
|
IP
|
$8,388.05
|
|
|
Service Code
|
NDC 49702022813
|
| Hospital Charge Code |
167672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,690.74 |
| Max. Negotiated Rate |
$7,549.24 |
| Rate for Payer: Aetna American Axle |
$5,452.23
|
| Rate for Payer: Aetna Commercial |
$7,129.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,452.23
|
| Rate for Payer: Cash Price |
$6,710.44
|
| Rate for Payer: Cofinity Commercial |
$5,871.64
|
| Rate for Payer: Cofinity Commercial |
$7,213.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,871.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,710.44
|
| Rate for Payer: Healthscope Commercial |
$7,549.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,871.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,291.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,129.84
|
| Rate for Payer: PHP Commercial |
$7,129.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,452.23
|
| Rate for Payer: Priority Health SBD |
$5,284.47
|
| Rate for Payer: UMR Bronson Commercial |
$3,690.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,291.04
|
|
|
DOLUTEGRAVIR 50 MG TABLET
|
Facility
|
OP
|
$8,388.05
|
|
|
Service Code
|
NDC 49702022813
|
| Hospital Charge Code |
167672
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,103.58 |
| Max. Negotiated Rate |
$7,549.24 |
| Rate for Payer: Aetna American Axle |
$5,452.23
|
| Rate for Payer: Aetna Commercial |
$7,129.84
|
| Rate for Payer: Aetna Medicare |
$4,194.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,452.23
|
| Rate for Payer: BCBS Complete |
$3,355.22
|
| Rate for Payer: Cash Price |
$6,710.44
|
| Rate for Payer: Cofinity Commercial |
$5,871.64
|
| Rate for Payer: Cofinity Commercial |
$7,213.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,871.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,710.44
|
| Rate for Payer: Healthscope Commercial |
$7,549.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,871.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,291.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7,129.84
|
| Rate for Payer: PHP Commercial |
$7,129.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,452.23
|
| Rate for Payer: Priority Health SBD |
$5,284.47
|
| Rate for Payer: UMR Bronson Commercial |
$3,103.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,291.04
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.08 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna American Axle |
$183.30
|
| Rate for Payer: Aetna Commercial |
$239.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.30
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cofinity Commercial |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$197.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.60
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.70
|
| Rate for Payer: PHP Commercial |
$239.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.30
|
| Rate for Payer: Priority Health SBD |
$177.66
|
| Rate for Payer: UMR Bronson Commercial |
$124.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.50
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$69.80
|
|
|
Service Code
|
NDC 43547027609
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.83 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Aetna American Axle |
$45.37
|
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Aetna Medicare |
$34.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.37
|
| Rate for Payer: BCBS Complete |
$27.92
|
| Rate for Payer: Cash Price |
$55.84
|
| Rate for Payer: Cofinity Commercial |
$48.86
|
| Rate for Payer: Cofinity Commercial |
$60.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$48.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.84
|
| Rate for Payer: Healthscope Commercial |
$62.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.33
|
| Rate for Payer: PHP Commercial |
$59.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.37
|
| Rate for Payer: Priority Health SBD |
$43.97
|
| Rate for Payer: UMR Bronson Commercial |
$25.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.35
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$282.00
|
|
|
Service Code
|
NDC 60687030301
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.34 |
| Max. Negotiated Rate |
$253.80 |
| Rate for Payer: Aetna American Axle |
$183.30
|
| Rate for Payer: Aetna Commercial |
$239.70
|
| Rate for Payer: Aetna Medicare |
$141.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.30
|
| Rate for Payer: BCBS Complete |
$112.80
|
| Rate for Payer: Cash Price |
$225.60
|
| Rate for Payer: Cofinity Commercial |
$197.40
|
| Rate for Payer: Cofinity Commercial |
$242.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$197.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.60
|
| Rate for Payer: Healthscope Commercial |
$253.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$239.70
|
| Rate for Payer: PHP Commercial |
$239.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.30
|
| Rate for Payer: Priority Health SBD |
$177.66
|
| Rate for Payer: UMR Bronson Commercial |
$104.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.50
|
|
