|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$15,097.28
|
|
|
Service Code
|
APR-DRG 3243
|
| Min. Negotiated Rate |
$14,378.36 |
| Max. Negotiated Rate |
$15,097.28 |
| Rate for Payer: BCBS Complete |
$15,097.28
|
| Rate for Payer: Mclaren Medicaid |
$14,378.36
|
| Rate for Payer: Meridian Medicaid |
$15,097.28
|
| Rate for Payer: Priority Health Choice Medicaid |
$14,378.36
|
| Rate for Payer: UHC Medicaid |
$14,378.36
|
| Rate for Payer: UHCCP Medicaid |
$14,378.36
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$10,575.67
|
|
|
Service Code
|
APR-DRG 3242
|
| Min. Negotiated Rate |
$10,072.06 |
| Max. Negotiated Rate |
$10,575.67 |
| Rate for Payer: BCBS Complete |
$10,575.67
|
| Rate for Payer: Mclaren Medicaid |
$10,072.06
|
| Rate for Payer: Meridian Medicaid |
$10,575.67
|
| Rate for Payer: Priority Health Choice Medicaid |
$10,072.06
|
| Rate for Payer: UHC Medicaid |
$10,072.06
|
| Rate for Payer: UHCCP Medicaid |
$10,072.06
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$23,089.08
|
|
|
Service Code
|
APR-DRG 3244
|
| Min. Negotiated Rate |
$21,989.60 |
| Max. Negotiated Rate |
$23,089.08 |
| Rate for Payer: BCBS Complete |
$23,089.08
|
| Rate for Payer: Mclaren Medicaid |
$21,989.60
|
| Rate for Payer: Meridian Medicaid |
$23,089.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$21,989.60
|
| Rate for Payer: UHC Medicaid |
$21,989.60
|
| Rate for Payer: UHCCP Medicaid |
$21,989.60
|
|
|
ELECTIVE HIP JOINT REPLACEMENT
|
Facility
|
IP
|
$8,592.62
|
|
|
Service Code
|
APR-DRG 3241
|
| Min. Negotiated Rate |
$8,183.45 |
| Max. Negotiated Rate |
$8,592.62 |
| Rate for Payer: BCBS Complete |
$8,592.62
|
| Rate for Payer: Mclaren Medicaid |
$8,183.45
|
| Rate for Payer: Meridian Medicaid |
$8,592.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,183.45
|
| Rate for Payer: UHC Medicaid |
$8,183.45
|
| Rate for Payer: UHCCP Medicaid |
$8,183.45
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$21,167.38
|
|
|
Service Code
|
APR-DRG 3264
|
| Min. Negotiated Rate |
$20,159.41 |
| Max. Negotiated Rate |
$21,167.38 |
| Rate for Payer: BCBS Complete |
$21,167.38
|
| Rate for Payer: Mclaren Medicaid |
$20,159.41
|
| Rate for Payer: Meridian Medicaid |
$21,167.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$20,159.41
|
| Rate for Payer: UHC Medicaid |
$20,159.41
|
| Rate for Payer: UHCCP Medicaid |
$20,159.41
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$12,773.70
|
|
|
Service Code
|
APR-DRG 3263
|
| Min. Negotiated Rate |
$12,165.43 |
| Max. Negotiated Rate |
$12,773.70 |
| Rate for Payer: BCBS Complete |
$12,773.70
|
| Rate for Payer: Mclaren Medicaid |
$12,165.43
|
| Rate for Payer: Meridian Medicaid |
$12,773.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$12,165.43
|
| Rate for Payer: UHC Medicaid |
$12,165.43
|
| Rate for Payer: UHCCP Medicaid |
$12,165.43
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$8,432.10
|
|
|
Service Code
|
APR-DRG 3261
|
| Min. Negotiated Rate |
$8,030.57 |
| Max. Negotiated Rate |
$8,432.10 |
| Rate for Payer: BCBS Complete |
$8,432.10
|
| Rate for Payer: Mclaren Medicaid |
$8,030.57
|
| Rate for Payer: Meridian Medicaid |
$8,432.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$8,030.57
|
| Rate for Payer: UHC Medicaid |
$8,030.57
|
| Rate for Payer: UHCCP Medicaid |
$8,030.57
|
|
|
ELECTIVE KNEE JOINT REPLACEMENT
|
Facility
|
IP
|
$9,684.76
|
|
|
Service Code
|
APR-DRG 3262
|
| Min. Negotiated Rate |
$9,223.58 |
| Max. Negotiated Rate |
$9,684.76 |
| Rate for Payer: BCBS Complete |
$9,684.76
|
| Rate for Payer: Mclaren Medicaid |
$9,223.58
|
| Rate for Payer: Meridian Medicaid |
$9,684.76
|
| Rate for Payer: Priority Health Choice Medicaid |
$9,223.58
|
| Rate for Payer: UHC Medicaid |
$9,223.58
|
| Rate for Payer: UHCCP Medicaid |
$9,223.58
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$6,155.74
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
176616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$5,540.17 |
| Rate for Payer: Aetna Commercial |
$5,232.38
|
| Rate for Payer: Aetna Medicare |
$8.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,001.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.05
|
| Rate for Payer: BCBS Complete |
$4.42
|
| Rate for Payer: BCBS MAPPO |
$8.04
|
| Rate for Payer: BCBS Trust/PPO |
$20.14
|
| Rate for Payer: BCN Commercial |
$20.14
|
| Rate for Payer: BCN Medicare Advantage |
$8.04
|
| Rate for Payer: Cash Price |
$4,924.59
|
| Rate for Payer: Cash Price |
$4,924.59
|
| Rate for Payer: Cofinity Advantage |
$4,309.02
|
| Rate for Payer: Cofinity Commercial |
$5,293.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,924.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.04
|
| Rate for Payer: Healthscope Commercial |
$5,540.17
|
| Rate for Payer: Mclaren Medicaid |
$4.20
|
| Rate for Payer: Mclaren Medicare |
$8.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.44
|
| Rate for Payer: Meridian Medicaid |
$8.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.25
|
| Rate for Payer: Molina Medicare/Medicaid |
$8.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,232.38
|
| Rate for Payer: Nomi Health Commercial |
$24.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,616.81
|
| Rate for Payer: PACE Medicare |
$7.64
|
| Rate for Payer: PACE SWMI |
$8.04
|
| Rate for Payer: PHP Commercial |
$5,232.38
|
| Rate for Payer: PHP Medicare Advantage |
$8.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$24.88
|
| Rate for Payer: Priority Health Medicare |
$8.04
|
| Rate for Payer: Priority Health SBD |
$3,878.12
|
| Rate for Payer: Priority Health Tiered Network |
$19.90
|
| Rate for Payer: Railroad Medicare Medicare |
$8.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.27
|
| Rate for Payer: UHC Core |
$13.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8.04
|
| Rate for Payer: UHC Exchange |
$13.27
|
| Rate for Payer: UHC Medicaid |
$4.20
|
| Rate for Payer: UHCCP Medicaid |
$4.20
|
| Rate for Payer: VA VA |
$8.04
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$8,207.58
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
176617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.20 |
| Max. Negotiated Rate |
$7,386.82 |
| Rate for Payer: Aetna Commercial |
$6,976.44
|
| Rate for Payer: Aetna Medicare |
$8.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,334.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$10.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$10.05
|
| Rate for Payer: BCBS Complete |
$4.42
|
| Rate for Payer: BCBS MAPPO |
$8.04
|
| Rate for Payer: BCBS Trust/PPO |
$20.14
|
| Rate for Payer: BCN Commercial |
$20.14
|
| Rate for Payer: BCN Medicare Advantage |
$8.04
|
| Rate for Payer: Cash Price |
$6,566.06
|
| Rate for Payer: Cash Price |
$6,566.06
|
| Rate for Payer: Cofinity Advantage |
$5,745.31
|
| Rate for Payer: Cofinity Commercial |
$7,058.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,566.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$8.04
|
| Rate for Payer: Healthscope Commercial |
$7,386.82
|
| Rate for Payer: Mclaren Medicaid |
$4.20
|
| Rate for Payer: Mclaren Medicare |
$8.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.44
|
| Rate for Payer: Meridian Medicaid |
$8.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.25
|
| Rate for Payer: Molina Medicare/Medicaid |
$8.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,976.44
|
| Rate for Payer: Nomi Health Commercial |
$24.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,155.69
|
| Rate for Payer: PACE Medicare |
$7.64
|
| Rate for Payer: PACE SWMI |
$8.04
|
| Rate for Payer: PHP Commercial |
$6,976.44
|
| Rate for Payer: PHP Medicare Advantage |
$8.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$24.88
|
| Rate for Payer: Priority Health Medicare |
$8.04
|
| Rate for Payer: Priority Health SBD |
$5,170.78
|
| Rate for Payer: Priority Health Tiered Network |
$19.90
|
| Rate for Payer: Railroad Medicare Medicare |
$8.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.27
|
| Rate for Payer: UHC Core |
$13.27
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$8.04
|
| Rate for Payer: UHC Exchange |
$13.27
|
| Rate for Payer: UHC Medicaid |
$4.20
|
| Rate for Payer: UHCCP Medicaid |
$4.20
|
| Rate for Payer: VA VA |
$8.04
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$8,207.58
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
176617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,170.78 |
| Max. Negotiated Rate |
$7,386.82 |
| Rate for Payer: Aetna Commercial |
$6,976.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,334.93
|
| Rate for Payer: Cash Price |
$6,566.06
|
| Rate for Payer: Cofinity Advantage |
$5,745.31
|
| Rate for Payer: Cofinity Commercial |
$7,058.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,566.06
|
| Rate for Payer: Healthscope Commercial |
$7,386.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,976.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6,155.69
|
| Rate for Payer: PHP Commercial |
$6,976.44
|
| Rate for Payer: Priority Health SBD |
$5,170.78
|
|
|
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET
|
Facility
|
OP
|
$15,954.81
|
|
|
Service Code
|
NDC 61958190101
|
| Hospital Charge Code |
176485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,270.24 |
| Max. Negotiated Rate |
$14,359.33 |
| Rate for Payer: Aetna Commercial |
$13,561.59
|
| Rate for Payer: Aetna Medicare |
$7,977.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,370.63
|
| Rate for Payer: BCBS Complete |
$6,381.92
|
| Rate for Payer: Cash Price |
$12,763.85
|
| Rate for Payer: Cofinity Advantage |
$11,168.37
|
| Rate for Payer: Cofinity Commercial |
$13,721.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,763.85
|
| Rate for Payer: Healthscope Commercial |
$14,359.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12,763.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,561.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11,966.11
|
| Rate for Payer: PHP Commercial |
$13,561.59
|
| Rate for Payer: Priority Health SBD |
$10,051.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,370.63
|
| Rate for Payer: UHC Core |
$8,312.46
|
| Rate for Payer: UHC Exchange |
$6,270.24
|
|
|
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET
|
Facility
|
IP
|
$15,954.81
|
|
|
Service Code
|
NDC 61958190101
|
| Hospital Charge Code |
176485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10,051.53 |
| Max. Negotiated Rate |
$14,359.33 |
| Rate for Payer: Aetna Commercial |
$13,561.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,370.63
|
| Rate for Payer: Cash Price |
$12,763.85
|
| Rate for Payer: Cofinity Advantage |
$11,168.37
|
| Rate for Payer: Cofinity Commercial |
$13,721.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,763.85
|
| Rate for Payer: Healthscope Commercial |
$14,359.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,561.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11,966.11
|
| Rate for Payer: PHP Commercial |
$13,561.59
|
| Rate for Payer: Priority Health SBD |
$10,051.53
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,083.92
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$682.87 |
| Max. Negotiated Rate |
$975.53 |
| Rate for Payer: Aetna Commercial |
$921.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.55
|
| Rate for Payer: Cash Price |
$867.14
|
| Rate for Payer: Cofinity Advantage |
$758.74
|
| Rate for Payer: Cofinity Commercial |
$932.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$867.14
|
| Rate for Payer: Healthscope Commercial |
$975.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$921.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.94
|
| Rate for Payer: PHP Commercial |
$921.33
|
| Rate for Payer: Priority Health SBD |
$682.87
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,083.92
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$682.87 |
| Max. Negotiated Rate |
$975.53 |
| Rate for Payer: Aetna Commercial |
$921.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.55
|
| Rate for Payer: Cash Price |
$867.14
|
| Rate for Payer: Cofinity Advantage |
$758.74
|
| Rate for Payer: Cofinity Commercial |
$932.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$867.14
|
| Rate for Payer: Healthscope Commercial |
$975.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$921.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.94
|
| Rate for Payer: PHP Commercial |
$921.33
|
| Rate for Payer: Priority Health SBD |
$682.87
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$1,083.92
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$425.98 |
| Max. Negotiated Rate |
$975.53 |
| Rate for Payer: Aetna Commercial |
$921.33
|
| Rate for Payer: Aetna Medicare |
$541.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.55
|
| Rate for Payer: BCBS Complete |
$433.57
|
| Rate for Payer: Cash Price |
$867.14
|
| Rate for Payer: Cofinity Advantage |
$758.74
|
| Rate for Payer: Cofinity Commercial |
$932.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$867.14
|
| Rate for Payer: Healthscope Commercial |
$975.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$867.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$921.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.94
|
| Rate for Payer: PHP Commercial |
$921.33
|
| Rate for Payer: Priority Health SBD |
$682.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$704.55
|
| Rate for Payer: UHC Core |
$564.72
|
| Rate for Payer: UHC Exchange |
$425.98
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$1,083.92
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$425.98 |
| Max. Negotiated Rate |
$975.53 |
| Rate for Payer: Aetna Commercial |
$921.33
|
| Rate for Payer: Aetna Medicare |
$541.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.55
|
| Rate for Payer: BCBS Complete |
$433.57
|
| Rate for Payer: Cash Price |
$867.14
|
| Rate for Payer: Cofinity Advantage |
$758.74
|
| Rate for Payer: Cofinity Commercial |
$932.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$867.14
|
| Rate for Payer: Healthscope Commercial |
$975.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$867.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$921.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.94
|
| Rate for Payer: PHP Commercial |
$921.33
|
| Rate for Payer: Priority Health SBD |
$682.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$704.55
|
| Rate for Payer: UHC Core |
$564.72
|
| Rate for Payer: UHC Exchange |
$425.98
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,083.92
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$682.87 |
| Max. Negotiated Rate |
$975.53 |
| Rate for Payer: Aetna Commercial |
$921.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.55
|
| Rate for Payer: Cash Price |
$867.14
|
| Rate for Payer: Cofinity Advantage |
$758.74
|
| Rate for Payer: Cofinity Commercial |
$932.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$867.14
|
| Rate for Payer: Healthscope Commercial |
$975.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$921.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.94
|
| Rate for Payer: PHP Commercial |
$921.33
|
| Rate for Payer: Priority Health SBD |
$682.87
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,083.92
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$682.87 |
| Max. Negotiated Rate |
$975.53 |
| Rate for Payer: Aetna Commercial |
$921.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.55
|
| Rate for Payer: Cash Price |
$867.14
|
| Rate for Payer: Cofinity Advantage |
$758.74
|
| Rate for Payer: Cofinity Commercial |
$932.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$867.14
|
| Rate for Payer: Healthscope Commercial |
$975.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$921.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.94
|
| Rate for Payer: PHP Commercial |
$921.33
|
| Rate for Payer: Priority Health SBD |
$682.87
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
OP
|
$1,083.92
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$425.98 |
| Max. Negotiated Rate |
$975.53 |
| Rate for Payer: Aetna Commercial |
$921.33
|
| Rate for Payer: Aetna Medicare |
$541.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.55
|
| Rate for Payer: BCBS Complete |
$433.57
|
| Rate for Payer: Cash Price |
$867.14
|
| Rate for Payer: Cofinity Advantage |
$758.74
|
| Rate for Payer: Cofinity Commercial |
$932.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$867.14
|
| Rate for Payer: Healthscope Commercial |
$975.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$867.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$921.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.94
|
| Rate for Payer: PHP Commercial |
$921.33
|
| Rate for Payer: Priority Health SBD |
$682.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$704.55
|
| Rate for Payer: UHC Core |
$564.72
|
| Rate for Payer: UHC Exchange |
$425.98
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
OP
|
$1,083.92
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$425.98 |
| Max. Negotiated Rate |
$975.53 |
| Rate for Payer: Aetna Commercial |
$921.33
|
| Rate for Payer: Aetna Medicare |
$541.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$704.55
|
| Rate for Payer: BCBS Complete |
$433.57
|
| Rate for Payer: Cash Price |
$867.14
|
| Rate for Payer: Cofinity Advantage |
$758.74
|
| Rate for Payer: Cofinity Commercial |
$932.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$867.14
|
| Rate for Payer: Healthscope Commercial |
$975.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$867.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$921.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$812.94
|
| Rate for Payer: PHP Commercial |
$921.33
|
| Rate for Payer: Priority Health SBD |
$682.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$704.55
|
| Rate for Payer: UHC Core |
$564.72
|
| Rate for Payer: UHC Exchange |
$425.98
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
OP
|
$50.99
|
|
|
Service Code
|
NDC 00264975706
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.04 |
| Max. Negotiated Rate |
$45.89 |
| Rate for Payer: Aetna Commercial |
$43.34
|
| Rate for Payer: Aetna Medicare |
$25.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.14
|
| Rate for Payer: BCBS Complete |
$20.40
|
| Rate for Payer: Cash Price |
$40.79
|
| Rate for Payer: Cofinity Advantage |
$35.69
|
| Rate for Payer: Cofinity Commercial |
$43.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.79
|
| Rate for Payer: Healthscope Commercial |
$45.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$40.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.24
|
| Rate for Payer: PHP Commercial |
$43.34
|
| Rate for Payer: Priority Health SBD |
$32.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.14
|
| Rate for Payer: UHC Core |
$26.57
|
| Rate for Payer: UHC Exchange |
$20.04
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
IP
|
$50.99
|
|
|
Service Code
|
NDC 00264975706
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.12 |
| Max. Negotiated Rate |
$45.89 |
| Rate for Payer: Aetna Commercial |
$43.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.14
|
| Rate for Payer: Cash Price |
$40.79
|
| Rate for Payer: Cofinity Advantage |
$35.69
|
| Rate for Payer: Cofinity Commercial |
$43.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.79
|
| Rate for Payer: Healthscope Commercial |
$45.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.24
|
| Rate for Payer: PHP Commercial |
$43.34
|
| Rate for Payer: Priority Health SBD |
$32.12
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET
|
Facility
|
OP
|
$7,944.83
|
|
|
Service Code
|
NDC 61958200201
|
| Hospital Charge Code |
178497
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,122.32 |
| Max. Negotiated Rate |
$7,150.35 |
| Rate for Payer: Aetna Commercial |
$6,753.11
|
| Rate for Payer: Aetna Medicare |
$3,972.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,164.14
|
| Rate for Payer: BCBS Complete |
$3,177.93
|
| Rate for Payer: Cash Price |
$6,355.86
|
| Rate for Payer: Cofinity Advantage |
$5,561.38
|
| Rate for Payer: Cofinity Commercial |
$6,832.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,355.86
|
| Rate for Payer: Healthscope Commercial |
$7,150.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,355.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,753.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,958.62
|
| Rate for Payer: PHP Commercial |
$6,753.11
|
| Rate for Payer: Priority Health SBD |
$5,005.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,164.14
|
| Rate for Payer: UHC Core |
$4,139.26
|
| Rate for Payer: UHC Exchange |
$3,122.32
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET
|
Facility
|
IP
|
$7,944.83
|
|
|
Service Code
|
NDC 61958200201
|
| Hospital Charge Code |
178497
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,005.24 |
| Max. Negotiated Rate |
$7,150.35 |
| Rate for Payer: Aetna Commercial |
$6,753.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,164.14
|
| Rate for Payer: Cash Price |
$6,355.86
|
| Rate for Payer: Cofinity Advantage |
$5,561.38
|
| Rate for Payer: Cofinity Commercial |
$6,832.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,355.86
|
| Rate for Payer: Healthscope Commercial |
$7,150.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,753.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,958.62
|
| Rate for Payer: PHP Commercial |
$6,753.11
|
| Rate for Payer: Priority Health SBD |
$5,005.24
|
|
