|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$29.61
|
|
|
Service Code
|
NDC 43547027603
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna American Axle |
$19.25
|
| Rate for Payer: Aetna Commercial |
$25.17
|
| Rate for Payer: Aetna Medicare |
$14.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.25
|
| Rate for Payer: BCBS Complete |
$11.84
|
| Rate for Payer: Cash Price |
$23.69
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Cofinity Commercial |
$25.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.69
|
| Rate for Payer: Healthscope Commercial |
$26.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.17
|
| Rate for Payer: PHP Commercial |
$25.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.25
|
| Rate for Payer: Priority Health SBD |
$18.65
|
| Rate for Payer: UMR Bronson Commercial |
$10.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.21
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
OP
|
$2.82
|
|
|
Service Code
|
NDC 60687030311
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna Medicare |
$1.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: BCBS Complete |
$1.13
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 60687030311
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$69.80
|
|
|
Service Code
|
NDC 43547027609
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.71 |
| Max. Negotiated Rate |
$62.82 |
| Rate for Payer: Aetna American Axle |
$45.37
|
| Rate for Payer: Aetna Commercial |
$59.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.37
|
| 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 |
$30.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.35
|
|
|
DONEPEZIL 10 MG TABLET
|
Facility
|
IP
|
$29.61
|
|
|
Service Code
|
NDC 43547027603
|
| Hospital Charge Code |
18787
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna American Axle |
$19.25
|
| Rate for Payer: Aetna Commercial |
$25.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.25
|
| Rate for Payer: Cash Price |
$23.69
|
| Rate for Payer: Cofinity Commercial |
$20.73
|
| Rate for Payer: Cofinity Commercial |
$25.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.69
|
| Rate for Payer: Healthscope Commercial |
$26.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.17
|
| Rate for Payer: PHP Commercial |
$25.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.25
|
| Rate for Payer: Priority Health SBD |
$18.65
|
| Rate for Payer: UMR Bronson Commercial |
$13.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.21
|
|
|
DONEPEZIL 23 MG TABLET
|
Facility
|
OP
|
$1,559.78
|
|
|
Service Code
|
NDC 62856024730
|
| Hospital Charge Code |
105906
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$577.12 |
| Max. Negotiated Rate |
$1,403.80 |
| Rate for Payer: Aetna American Axle |
$1,013.86
|
| Rate for Payer: Aetna Commercial |
$1,325.81
|
| Rate for Payer: Aetna Medicare |
$779.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,013.86
|
| Rate for Payer: BCBS Complete |
$623.91
|
| Rate for Payer: Cash Price |
$1,247.82
|
| Rate for Payer: Cofinity Commercial |
$1,091.85
|
| Rate for Payer: Cofinity Commercial |
$1,341.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,091.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,247.82
|
| Rate for Payer: Healthscope Commercial |
$1,403.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,091.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,169.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,325.81
|
| Rate for Payer: PHP Commercial |
$1,325.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,013.86
|
| Rate for Payer: Priority Health SBD |
$982.66
|
| Rate for Payer: UMR Bronson Commercial |
$577.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,169.84
|
|
|
DONEPEZIL 23 MG TABLET
|
Facility
|
IP
|
$1,559.78
|
|
|
Service Code
|
NDC 62856024730
|
| Hospital Charge Code |
105906
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$686.30 |
| Max. Negotiated Rate |
$1,403.80 |
| Rate for Payer: Aetna American Axle |
$1,013.86
|
| Rate for Payer: Aetna Commercial |
$1,325.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,013.86
|
| Rate for Payer: Cash Price |
$1,247.82
|
| Rate for Payer: Cofinity Commercial |
$1,091.85
|
| Rate for Payer: Cofinity Commercial |
$1,341.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,091.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,247.82
|
| Rate for Payer: Healthscope Commercial |
$1,403.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,091.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,169.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,325.81
|
| Rate for Payer: PHP Commercial |
$1,325.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,013.86
|
| Rate for Payer: Priority Health SBD |
$982.66
|
| Rate for Payer: UMR Bronson Commercial |
$686.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,169.84
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
OP
|
$263.20
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.38 |
| Max. Negotiated Rate |
$236.88 |
| Rate for Payer: Aetna American Axle |
$171.08
|
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Aetna Medicare |
$131.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.08
|
| Rate for Payer: BCBS Complete |
$105.28
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$226.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$184.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Healthscope Commercial |
$236.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$197.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.72
|
| Rate for Payer: PHP Commercial |
$223.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.08
|
| Rate for Payer: Priority Health SBD |
$165.82
|
| Rate for Payer: UMR Bronson Commercial |
$97.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$197.40
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$263.20
|
|
|
Service Code
|
NDC 00904647761
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.81 |
| Max. Negotiated Rate |
$236.88 |
| Rate for Payer: Aetna American Axle |
$171.08
|
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.08
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$226.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$184.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Healthscope Commercial |
$236.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$197.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.72
|
| Rate for Payer: PHP Commercial |
$223.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.08
|
| Rate for Payer: Priority Health SBD |
$165.82
|
| Rate for Payer: UMR Bronson Commercial |
$115.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$197.40
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
NDC 31722073730
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.26 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna American Axle |
$63.70
|
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna Medicare |
$49.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.70
|
| Rate for Payer: BCBS Complete |
$39.20
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cofinity Commercial |
$68.60
|
| Rate for Payer: Cofinity Commercial |
$84.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.40
|
| Rate for Payer: Healthscope Commercial |
$88.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.30
|
| Rate for Payer: PHP Commercial |
$83.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.70
|
| Rate for Payer: Priority Health SBD |
$61.74
|
| Rate for Payer: UMR Bronson Commercial |
$36.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.50
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
NDC 31722073730
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.12 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna American Axle |
$63.70
|
| Rate for Payer: Aetna Commercial |
$83.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.70
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: Cofinity Commercial |
$68.60
|
| Rate for Payer: Cofinity Commercial |
$84.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.40
|
| Rate for Payer: Healthscope Commercial |
$88.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.30
|
| Rate for Payer: PHP Commercial |
$83.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.70
|
| Rate for Payer: Priority Health SBD |
$61.74
|
| Rate for Payer: UMR Bronson Commercial |
$43.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.50
|
|
|
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.73
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.30 |
| Max. Negotiated Rate |
$17.76 |
| Rate for Payer: Aetna American Axle |
$12.82
|
| Rate for Payer: Aetna Commercial |
$16.77
|
| Rate for Payer: Aetna Medicare |
$9.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.82
|
| Rate for Payer: BCBS Complete |
$7.89
|
| Rate for Payer: Cash Price |
$15.78
|
| Rate for Payer: Cofinity Commercial |
$13.81
|
| Rate for Payer: Cofinity Commercial |
$16.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.78
|
| Rate for Payer: Healthscope Commercial |
$17.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.77
|
| Rate for Payer: PHP Commercial |
$16.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.82
|
| Rate for Payer: Priority Health SBD |
$12.43
|
| Rate for Payer: UMR Bronson Commercial |
$7.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.80
|
|
|
DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$19.73
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$17.76 |
| Rate for Payer: Aetna American Axle |
$12.82
|
| Rate for Payer: Aetna Commercial |
$16.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.82
|
| Rate for Payer: Cash Price |
$15.78
|
| Rate for Payer: Cofinity Commercial |
$13.81
|
| Rate for Payer: Cofinity Commercial |
$16.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.78
|
| Rate for Payer: Healthscope Commercial |
$17.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.77
|
| Rate for Payer: PHP Commercial |
$16.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.82
|
| Rate for Payer: Priority Health SBD |
$12.43
|
| Rate for Payer: UMR Bronson Commercial |
$8.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.80
|
|
|
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$28.71
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
118601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.63 |
| Max. Negotiated Rate |
$25.84 |
| Rate for Payer: Aetna American Axle |
$18.66
|
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.66
|
| Rate for Payer: Cash Price |
$22.97
|
| Rate for Payer: Cofinity Commercial |
$20.10
|
| Rate for Payer: Cofinity Commercial |
$24.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.97
|
| Rate for Payer: Healthscope Commercial |
$25.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: PHP Commercial |
$24.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health SBD |
$18.09
|
| Rate for Payer: UMR Bronson Commercial |
$12.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.53
|
|
|
DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$28.71
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
118601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.62 |
| Max. Negotiated Rate |
$25.84 |
| Rate for Payer: Aetna American Axle |
$18.66
|
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: Aetna Medicare |
$14.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.66
|
| Rate for Payer: BCBS Complete |
$11.48
|
| Rate for Payer: Cash Price |
$22.97
|
| Rate for Payer: Cofinity Commercial |
$20.10
|
| Rate for Payer: Cofinity Commercial |
$24.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.97
|
| Rate for Payer: Healthscope Commercial |
$25.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: PHP Commercial |
$24.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health SBD |
$18.09
|
| Rate for Payer: UMR Bronson Commercial |
$10.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.53
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
IP
|
$71.15
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.31 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna American Axle |
$46.25
|
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.25
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$49.80
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$64.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.48
|
| Rate for Payer: PHP Commercial |
$60.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.25
|
| Rate for Payer: Priority Health SBD |
$44.82
|
| Rate for Payer: UMR Bronson Commercial |
$31.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.36
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
OP
|
$71.15
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.33 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna American Axle |
$46.25
|
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: Aetna Medicare |
$35.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.25
|
| Rate for Payer: BCBS Complete |
$28.46
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$49.80
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$64.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.48
|
| Rate for Payer: PHP Commercial |
$60.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.25
|
| Rate for Payer: Priority Health SBD |
$44.82
|
| Rate for Payer: UMR Bronson Commercial |
$26.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.36
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION
|
Facility
|
OP
|
$460.32
|
|
|
Service Code
|
HCPCS J7639
|
| Hospital Charge Code |
12211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.32 |
| Max. Negotiated Rate |
$414.29 |
| Rate for Payer: Aetna American Axle |
$299.21
|
| Rate for Payer: Aetna Commercial |
$391.27
|
| Rate for Payer: Aetna Medicare |
$230.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$299.21
|
| Rate for Payer: BCBS Complete |
$184.13
|
| Rate for Payer: Cash Price |
$368.26
|
| Rate for Payer: Cofinity Commercial |
$322.22
|
| Rate for Payer: Cofinity Commercial |
$395.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$322.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$368.26
|
| Rate for Payer: Healthscope Commercial |
$414.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$322.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$345.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$391.27
|
| Rate for Payer: PHP Commercial |
$391.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.21
|
| Rate for Payer: Priority Health SBD |
$290.00
|
| Rate for Payer: UMR Bronson Commercial |
$170.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$345.24
|
|
|
DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION
|
Facility
|
IP
|
$460.32
|
|
|
Service Code
|
HCPCS J7639
|
| Hospital Charge Code |
12211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$202.54 |
| Max. Negotiated Rate |
$414.29 |
| Rate for Payer: Aetna American Axle |
$299.21
|
| Rate for Payer: Aetna Commercial |
$391.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$299.21
|
| Rate for Payer: Cash Price |
$368.26
|
| Rate for Payer: Cofinity Commercial |
$322.22
|
| Rate for Payer: Cofinity Commercial |
$395.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$322.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$368.26
|
| Rate for Payer: Healthscope Commercial |
$414.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$322.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$345.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$391.27
|
| Rate for Payer: PHP Commercial |
$391.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$299.21
|
| Rate for Payer: Priority Health SBD |
$290.00
|
| Rate for Payer: UMR Bronson Commercial |
$202.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$345.24
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$116.96
|
|
|
Service Code
|
NDC 69315030410
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.46 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna American Axle |
$76.02
|
| Rate for Payer: Aetna Commercial |
$99.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.02
|
| Rate for Payer: Cash Price |
$93.57
|
| Rate for Payer: Cofinity Commercial |
$100.59
|
| Rate for Payer: Cofinity Commercial |
$81.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$105.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.42
|
| Rate for Payer: PHP Commercial |
$99.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.02
|
| Rate for Payer: Priority Health SBD |
$73.68
|
| Rate for Payer: UMR Bronson Commercial |
$51.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.72
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$37.52
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$33.77 |
| Rate for Payer: Aetna American Axle |
$24.39
|
| Rate for Payer: Aetna Commercial |
$31.89
|
| Rate for Payer: Aetna Medicare |
$18.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.39
|
| Rate for Payer: BCBS Complete |
$15.01
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cofinity Commercial |
$26.26
|
| Rate for Payer: Cofinity Commercial |
$32.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.02
|
| Rate for Payer: Healthscope Commercial |
$33.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.89
|
| Rate for Payer: PHP Commercial |
$31.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.39
|
| Rate for Payer: Priority Health SBD |
$23.64
|
| Rate for Payer: UMR Bronson Commercial |
$13.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.14
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$37.52
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$33.77 |
| Rate for Payer: Aetna American Axle |
$24.39
|
| Rate for Payer: Aetna Commercial |
$31.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.39
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cofinity Commercial |
$26.26
|
| Rate for Payer: Cofinity Commercial |
$32.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.02
|
| Rate for Payer: Healthscope Commercial |
$33.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.89
|
| Rate for Payer: PHP Commercial |
$31.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.39
|
| Rate for Payer: Priority Health SBD |
$23.64
|
| Rate for Payer: UMR Bronson Commercial |
$16.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.14
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$36.63
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.55 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna American Axle |
$23.81
|
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna Medicare |
$18.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.81
|
| Rate for Payer: BCBS Complete |
$14.65
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cofinity Commercial |
$25.64
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.30
|
| Rate for Payer: Healthscope Commercial |
$32.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.14
|
| Rate for Payer: PHP Commercial |
$31.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.81
|
| Rate for Payer: Priority Health SBD |
$23.08
|
| Rate for Payer: UMR Bronson Commercial |
$13.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.47
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$116.96
|
|
|
Service Code
|
NDC 69315030410
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.28 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna American Axle |
$76.02
|
| Rate for Payer: Aetna Commercial |
$99.42
|
| Rate for Payer: Aetna Medicare |
$58.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.02
|
| Rate for Payer: BCBS Complete |
$46.78
|
| Rate for Payer: Cash Price |
$93.57
|
| Rate for Payer: Cofinity Commercial |
$100.59
|
| Rate for Payer: Cofinity Commercial |
$81.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$105.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.42
|
| Rate for Payer: PHP Commercial |
$99.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.02
|
| Rate for Payer: Priority Health SBD |
$73.68
|
| Rate for Payer: UMR Bronson Commercial |
$43.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.72
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$116.96
|
|
|
Service Code
|
NDC 24208048510
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.28 |
| Max. Negotiated Rate |
$105.26 |
| Rate for Payer: Aetna American Axle |
$76.02
|
| Rate for Payer: Aetna Commercial |
$99.42
|
| Rate for Payer: Aetna Medicare |
$58.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$76.02
|
| Rate for Payer: BCBS Complete |
$46.78
|
| Rate for Payer: Cash Price |
$93.57
|
| Rate for Payer: Cofinity Commercial |
$100.59
|
| Rate for Payer: Cofinity Commercial |
$81.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$105.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.42
|
| Rate for Payer: PHP Commercial |
$99.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.02
|
| Rate for Payer: Priority Health SBD |
$73.68
|
| Rate for Payer: UMR Bronson Commercial |
$43.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.72
|
|
