|
DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE
|
Facility
|
OP
|
$140.95
|
|
|
Service Code
|
CPT 93320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$46.62 |
| Max. Negotiated Rate |
$140.95 |
| Rate for Payer: BCBS Trust/PPO |
$140.95
|
| Rate for Payer: BCN Commercial |
$140.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.28
|
| Rate for Payer: UHC Exchange |
$46.62
|
|
|
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
|
|
|
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 |
$42.87 |
| 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: Cash Price |
$368.26
|
| Rate for Payer: Cofinity Commercial |
$395.88
|
| Rate for Payer: Cofinity Commercial |
$322.22
|
| 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 HMO/PPO/Tiered Network |
$53.59
|
| Rate for Payer: Priority Health Narrow Network |
$42.87
|
| 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
|
|
|
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
|
$262.33
|
|
|
Service Code
|
NDC 00006351936
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.43 |
| Max. Negotiated Rate |
$236.10 |
| Rate for Payer: Aetna American Axle |
$170.51
|
| Rate for Payer: Aetna Commercial |
$222.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.51
|
| Rate for Payer: Cash Price |
$209.86
|
| Rate for Payer: Cofinity Commercial |
$183.63
|
| Rate for Payer: Cofinity Commercial |
$225.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.86
|
| Rate for Payer: Healthscope Commercial |
$236.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.98
|
| Rate for Payer: PHP Commercial |
$222.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.51
|
| Rate for Payer: Priority Health SBD |
$165.27
|
| Rate for Payer: UMR Bronson Commercial |
$115.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.75
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$36.63
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.12 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna American Axle |
$23.81
|
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.81
|
| 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 |
$16.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.47
|
|
|
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
|
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
|
$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
|
IP
|
$116.96
|
|
|
Service Code
|
NDC 24208048510
|
| 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
|
$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 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
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$262.33
|
|
|
Service Code
|
NDC 00006351936
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.06 |
| Max. Negotiated Rate |
$236.10 |
| Rate for Payer: Aetna American Axle |
$170.51
|
| Rate for Payer: Aetna Commercial |
$222.98
|
| Rate for Payer: Aetna Medicare |
$131.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.51
|
| Rate for Payer: BCBS Complete |
$104.93
|
| Rate for Payer: Cash Price |
$209.86
|
| Rate for Payer: Cofinity Commercial |
$183.63
|
| Rate for Payer: Cofinity Commercial |
$225.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.86
|
| Rate for Payer: Healthscope Commercial |
$236.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.98
|
| Rate for Payer: PHP Commercial |
$222.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.51
|
| Rate for Payer: Priority Health SBD |
$165.27
|
| Rate for Payer: UMR Bronson Commercial |
$97.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.75
|
|
|
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$52,956.77
|
|
|
Service Code
|
HCPCS J9272
|
| Hospital Charge Code |
197057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$128.67 |
| Max. Negotiated Rate |
$47,661.09 |
| Rate for Payer: Aetna American Axle |
$34,421.90
|
| Rate for Payer: Aetna Commercial |
$45,013.25
|
| Rate for Payer: Aetna Medicare |
$249.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34,421.90
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$300.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$300.08
|
| Rate for Payer: BCBS Complete |
$135.11
|
| Rate for Payer: BCBS MAPPO |
$240.06
|
| Rate for Payer: BCBS Trust/PPO |
$647.28
|
| Rate for Payer: BCN Commercial |
$647.28
|
| Rate for Payer: BCN Medicare Advantage |
$240.06
|
| Rate for Payer: Cash Price |
$42,365.42
|
| Rate for Payer: Cash Price |
$42,365.42
|
| Rate for Payer: Cofinity Commercial |
$45,542.82
|
| Rate for Payer: Cofinity Commercial |
$37,069.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$37,069.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42,365.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$240.06
|
| Rate for Payer: Healthscope Commercial |
$47,661.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37,069.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39,717.58
|
| Rate for Payer: Mclaren Medicaid |
$128.67
|
| Rate for Payer: Mclaren Medicare |
$240.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$252.06
|
| Rate for Payer: Meridian Medicaid |
$135.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$276.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45,013.25
|
| Rate for Payer: Nomi Health Commercial |
$720.18
|
| Rate for Payer: PACE Medicare |
$228.06
|
| Rate for Payer: PACE SWMI |
$240.06
|
| Rate for Payer: PHP Commercial |
$45,013.25
|
| Rate for Payer: PHP Medicare Advantage |
$240.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$128.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34,421.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$680.38
|
| Rate for Payer: Priority Health Medicare |
$240.06
|
| Rate for Payer: Priority Health Narrow Network |
$544.30
|
| Rate for Payer: Priority Health SBD |
$33,362.77
|
| Rate for Payer: Railroad Medicare Medicare |
$240.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$675.74
|
| Rate for Payer: UHC Dual Complete DSNP |
$240.06
|
| Rate for Payer: UHC Exchange |
$458.78
|
| Rate for Payer: UHC Medicare Advantage |
$240.06
|
| Rate for Payer: UHCCP Medicaid |
$128.67
|
| Rate for Payer: UMR Bronson Commercial |
$19,594.00
|
| Rate for Payer: VA VA |
$240.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39,717.58
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$261.12
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.89 |
| Max. Negotiated Rate |
$235.01 |
| Rate for Payer: Aetna American Axle |
$169.73
|
| Rate for Payer: Aetna Commercial |
$221.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.73
|
| Rate for Payer: Cash Price |
$208.90
|
| Rate for Payer: Cofinity Commercial |
$182.78
|
| Rate for Payer: Cofinity Commercial |
$224.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.90
|
| Rate for Payer: Healthscope Commercial |
$235.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.95
|
| Rate for Payer: PHP Commercial |
$221.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.73
|
| Rate for Payer: Priority Health SBD |
$164.51
|
| Rate for Payer: UMR Bronson Commercial |
$114.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.84
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
OP
|
$414.20
|
|
|
Service Code
|
NDC 00378104901
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.25 |
| Max. Negotiated Rate |
$372.78 |
| Rate for Payer: Aetna American Axle |
$269.23
|
| Rate for Payer: Aetna Commercial |
$352.07
|
| Rate for Payer: Aetna Medicare |
$207.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$269.23
|
| Rate for Payer: BCBS Complete |
$165.68
|
| Rate for Payer: Cash Price |
$331.36
|
| Rate for Payer: Cofinity Commercial |
$289.94
|
| Rate for Payer: Cofinity Commercial |
$356.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$289.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$331.36
|
| Rate for Payer: Healthscope Commercial |
$372.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$289.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$310.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$352.07
|
| Rate for Payer: PHP Commercial |
$352.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.23
|
| Rate for Payer: Priority Health SBD |
$260.95
|
| Rate for Payer: UMR Bronson Commercial |
$153.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$310.65
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 51079043601
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna American Axle |
$1.70
|
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$414.20
|
|
|
Service Code
|
NDC 00378104901
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.25 |
| Max. Negotiated Rate |
$372.78 |
| Rate for Payer: Aetna American Axle |
$269.23
|
| Rate for Payer: Aetna Commercial |
$352.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$269.23
|
| Rate for Payer: Cash Price |
$331.36
|
| Rate for Payer: Cofinity Commercial |
$289.94
|
| Rate for Payer: Cofinity Commercial |
$356.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$289.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$331.36
|
| Rate for Payer: Healthscope Commercial |
$372.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$289.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$310.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$352.07
|
| Rate for Payer: PHP Commercial |
$352.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.23
|
| Rate for Payer: Priority Health SBD |
$260.95
|
| Rate for Payer: UMR Bronson Commercial |
$182.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$310.65
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
IP
|
$470.25
|
|
|
Service Code
|
NDC 00904705261
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.91 |
| Max. Negotiated Rate |
$423.22 |
| Rate for Payer: Aetna American Axle |
$305.66
|
| Rate for Payer: Aetna Commercial |
$399.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.66
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$329.18
|
| Rate for Payer: Cofinity Commercial |
$404.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$329.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$423.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.71
|
| Rate for Payer: PHP Commercial |
$399.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.66
|
| Rate for Payer: Priority Health SBD |
$296.26
|
| Rate for Payer: UMR Bronson Commercial |
$206.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.69
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
OP
|
$261.12
|
|
|
Service Code
|
NDC 51079043620
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.61 |
| Max. Negotiated Rate |
$235.01 |
| Rate for Payer: Aetna American Axle |
$169.73
|
| Rate for Payer: Aetna Commercial |
$221.95
|
| Rate for Payer: Aetna Medicare |
$130.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.73
|
| Rate for Payer: BCBS Complete |
$104.45
|
| Rate for Payer: Cash Price |
$208.90
|
| Rate for Payer: Cofinity Commercial |
$182.78
|
| Rate for Payer: Cofinity Commercial |
$224.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.90
|
| Rate for Payer: Healthscope Commercial |
$235.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.95
|
| Rate for Payer: PHP Commercial |
$221.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.73
|
| Rate for Payer: Priority Health SBD |
$164.51
|
| Rate for Payer: UMR Bronson Commercial |
$96.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.84
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
OP
|
$2.62
|
|
|
Service Code
|
NDC 51079043601
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna American Axle |
$1.70
|
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna Medicare |
$1.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: BCBS Complete |
$1.05
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
| Rate for Payer: UMR Bronson Commercial |
$0.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
DOXEPIN 10 MG CAPSULE
|
Facility
|
OP
|
$470.25
|
|
|
Service Code
|
NDC 00904705261
|
| Hospital Charge Code |
2608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.99 |
| Max. Negotiated Rate |
$423.22 |
| Rate for Payer: Aetna American Axle |
$305.66
|
| Rate for Payer: Aetna Commercial |
$399.71
|
| Rate for Payer: Aetna Medicare |
$235.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.66
|
| Rate for Payer: BCBS Complete |
$188.10
|
| Rate for Payer: Cash Price |
$376.20
|
| Rate for Payer: Cofinity Commercial |
$329.18
|
| Rate for Payer: Cofinity Commercial |
$404.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$329.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.20
|
| Rate for Payer: Healthscope Commercial |
$423.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.71
|
| Rate for Payer: PHP Commercial |
$399.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.66
|
| Rate for Payer: Priority Health SBD |
$296.26
|
| Rate for Payer: UMR Bronson Commercial |
$173.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.69
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 51079043701
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna American Axle |
$2.21
|
| Rate for Payer: Aetna Commercial |
$2.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.21
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$2.38
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: PHP Commercial |
$2.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health SBD |
$2.14
|
| Rate for Payer: UMR Bronson Commercial |
$1.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.55
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
OP
|
$309.12
|
|
|
Service Code
|
NDC 00904705361
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.37 |
| Max. Negotiated Rate |
$278.21 |
| Rate for Payer: Aetna American Axle |
$200.93
|
| Rate for Payer: Aetna Commercial |
$262.75
|
| Rate for Payer: Aetna Medicare |
$154.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.93
|
| Rate for Payer: BCBS Complete |
$123.65
|
| Rate for Payer: Cash Price |
$247.30
|
| Rate for Payer: Cofinity Commercial |
$216.38
|
| Rate for Payer: Cofinity Commercial |
$265.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.30
|
| Rate for Payer: Healthscope Commercial |
$278.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$262.75
|
| Rate for Payer: PHP Commercial |
$262.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.93
|
| Rate for Payer: Priority Health SBD |
$194.75
|
| Rate for Payer: UMR Bronson Commercial |
$114.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.84
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$339.84
|
|
|
Service Code
|
NDC 51079043720
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.53 |
| Max. Negotiated Rate |
$305.86 |
| Rate for Payer: PHP Commercial |
$288.86
|
| Rate for Payer: Aetna American Axle |
$220.90
|
| Rate for Payer: Aetna Commercial |
$288.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$220.90
|
| Rate for Payer: Cash Price |
$271.87
|
| Rate for Payer: Cofinity Commercial |
$237.89
|
| Rate for Payer: Cofinity Commercial |
$292.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$237.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.87
|
| Rate for Payer: Healthscope Commercial |
$305.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$237.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$254.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.90
|
| Rate for Payer: Priority Health SBD |
$214.10
|
| Rate for Payer: UMR Bronson Commercial |
$149.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$254.88
|
|
