|
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
|
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
|
|
|
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
|
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
|
$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
|
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
|
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
|
$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 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
|
$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
|
|
|
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 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
|
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
|
|
|
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
|
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
|
|
|
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 |
$1.93 |
| 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 |
$9.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.82
|
| Rate for Payer: BCBS Complete |
$7.89
|
| Rate for Payer: BCBS Trust/PPO |
$1.93
|
| Rate for Payer: BCN Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$15.78
|
| 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
|
OP
|
$28.71
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
118601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.93 |
| 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: BCBS Trust/PPO |
$1.93
|
| Rate for Payer: BCN Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$22.97
|
| 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/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/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 |
$1.93 |
| Max. Negotiated Rate |
$64.04 |
| 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: BCBS Trust/PPO |
$1.93
|
| Rate for Payer: BCN Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$56.92
|
| 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 |
$64.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS 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
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
IP
|
$71.15
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.31 |
| Max. Negotiated Rate |
$64.04 |
| Rate for Payer: Aetna American Axle |
$46.25
|
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.25
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$49.80
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$64.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS 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
|
|
|
DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY)
|
Facility
|
OP
|
$85.98
|
|
|
Service Code
|
CPT 93325
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$21.08 |
| Max. Negotiated Rate |
$85.98 |
| Rate for Payer: BCBS Trust/PPO |
$85.98
|
| Rate for Payer: BCN Commercial |
$85.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.19
|
| Rate for Payer: UHC Exchange |
$21.08
|
|
