|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$3.42
|
|
|
Service Code
|
NDC 50268028811
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Aetna Medicare |
$1.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.22
|
| Rate for Payer: BCBS Complete |
$1.37
|
| Rate for Payer: Cash Price |
$2.74
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.74
|
| Rate for Payer: Healthscope Commercial |
$3.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.91
|
| Rate for Payer: PHP Commercial |
$2.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.22
|
| Rate for Payer: Priority Health SBD |
$2.15
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$114.92
|
|
|
Service Code
|
NDC 57237001930
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.40 |
| Max. Negotiated Rate |
$103.43 |
| Rate for Payer: Aetna Commercial |
$97.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.70
|
| Rate for Payer: Cash Price |
$91.94
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Cofinity Commercial |
$98.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.94
|
| Rate for Payer: Healthscope Commercial |
$103.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.68
|
| Rate for Payer: PHP Commercial |
$97.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.70
|
| Rate for Payer: Priority Health SBD |
$72.40
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$714.24
|
|
|
Service Code
|
NDC 68084069201
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$285.70 |
| Max. Negotiated Rate |
$642.82 |
| Rate for Payer: Aetna Commercial |
$607.10
|
| Rate for Payer: Aetna Medicare |
$357.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$464.26
|
| Rate for Payer: BCBS Complete |
$285.70
|
| Rate for Payer: Cash Price |
$571.39
|
| Rate for Payer: Cofinity Commercial |
$499.97
|
| Rate for Payer: Cofinity Commercial |
$614.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$499.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$571.39
|
| Rate for Payer: Healthscope Commercial |
$642.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$607.10
|
| Rate for Payer: PHP Commercial |
$607.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$464.26
|
| Rate for Payer: Priority Health SBD |
$449.97
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
OP
|
$114.92
|
|
|
Service Code
|
NDC 57237001930
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.97 |
| Max. Negotiated Rate |
$103.43 |
| Rate for Payer: Aetna Commercial |
$97.68
|
| Rate for Payer: Aetna Medicare |
$57.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.70
|
| Rate for Payer: BCBS Complete |
$45.97
|
| Rate for Payer: Cash Price |
$91.94
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Cofinity Commercial |
$98.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$80.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.94
|
| Rate for Payer: Healthscope Commercial |
$103.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$97.68
|
| Rate for Payer: PHP Commercial |
$97.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.70
|
| Rate for Payer: Priority Health SBD |
$72.40
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$3.42
|
|
|
Service Code
|
NDC 50268028811
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$3.08 |
| Rate for Payer: Aetna Commercial |
$2.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.22
|
| Rate for Payer: Cash Price |
$2.74
|
| Rate for Payer: Cofinity Commercial |
$2.39
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.74
|
| Rate for Payer: Healthscope Commercial |
$3.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.91
|
| Rate for Payer: PHP Commercial |
$2.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.22
|
| Rate for Payer: Priority Health SBD |
$2.15
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$102.53
|
|
|
Service Code
|
NDC 50268028813
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.59 |
| Max. Negotiated Rate |
$92.28 |
| Rate for Payer: Aetna Commercial |
$87.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.64
|
| Rate for Payer: Cash Price |
$82.02
|
| Rate for Payer: Cofinity Commercial |
$71.77
|
| Rate for Payer: Cofinity Commercial |
$88.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$71.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.02
|
| Rate for Payer: Healthscope Commercial |
$92.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.15
|
| Rate for Payer: PHP Commercial |
$87.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.64
|
| Rate for Payer: Priority Health SBD |
$64.59
|
|
|
DULOXETINE 60 MG CAPSULE,DELAYED RELEASE
|
Facility
|
IP
|
$7.15
|
|
|
Service Code
|
NDC 68084069211
|
| Hospital Charge Code |
39277
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Aetna Commercial |
$6.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.65
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: Cofinity Commercial |
$5.00
|
| Rate for Payer: Cofinity Commercial |
$6.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.72
|
| Rate for Payer: Healthscope Commercial |
$6.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.08
|
| Rate for Payer: PHP Commercial |
$6.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.65
|
| Rate for Payer: Priority Health SBD |
$4.50
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$18,904.93
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
183305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11,910.11 |
| Max. Negotiated Rate |
$17,014.44 |
| Rate for Payer: Aetna Commercial |
$16,069.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,288.20
|
| Rate for Payer: Cash Price |
$15,123.94
|
| Rate for Payer: Cofinity Commercial |
$13,233.45
|
| Rate for Payer: Cofinity Commercial |
$16,258.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,233.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,123.94
|
| Rate for Payer: Healthscope Commercial |
$17,014.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,069.19
|
| Rate for Payer: PHP Commercial |
$16,069.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,288.20
|
| Rate for Payer: Priority Health SBD |
$11,910.11
|
|
|
DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18,904.93
|
|
|
Service Code
|
HCPCS J9173
|
| Hospital Charge Code |
183305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.62 |
| Max. Negotiated Rate |
$17,014.44 |
| Rate for Payer: Aetna Commercial |
$16,069.19
|
| Rate for Payer: Aetna Commercial |
$3,856.62
|
| Rate for Payer: Aetna Medicare |
$88.52
|
| Rate for Payer: Aetna Medicare |
$88.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,288.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,949.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$106.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$106.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$106.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$106.40
|
| Rate for Payer: BCBS Complete |
$47.91
|
| Rate for Payer: BCBS Complete |
$47.91
|
| Rate for Payer: BCBS MAPPO |
$85.12
|
| Rate for Payer: BCBS MAPPO |
$85.12
|
| Rate for Payer: BCN Medicare Advantage |
$85.12
|
| Rate for Payer: BCN Medicare Advantage |
$85.12
|
| Rate for Payer: Cash Price |
$3,629.76
|
| Rate for Payer: Cash Price |
$3,629.76
|
| Rate for Payer: Cash Price |
$15,123.94
|
| Rate for Payer: Cash Price |
$15,123.94
|
| Rate for Payer: Cofinity Commercial |
$3,176.04
|
| Rate for Payer: Cofinity Commercial |
$3,901.99
|
| Rate for Payer: Cofinity Commercial |
$16,258.24
|
| Rate for Payer: Cofinity Commercial |
$13,233.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,233.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,176.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,629.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,123.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$85.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$85.12
|
| Rate for Payer: Healthscope Commercial |
$17,014.44
|
| Rate for Payer: Healthscope Commercial |
$4,083.48
|
| Rate for Payer: Mclaren Medicaid |
$45.62
|
| Rate for Payer: Mclaren Medicaid |
$45.62
|
| Rate for Payer: Mclaren Medicare |
$85.12
|
| Rate for Payer: Mclaren Medicare |
$85.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$89.38
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$89.38
|
| Rate for Payer: Meridian Medicaid |
$47.91
|
| Rate for Payer: Meridian Medicaid |
$47.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$97.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$97.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,069.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,856.62
|
| Rate for Payer: PACE Medicare |
$80.86
|
| Rate for Payer: PACE Medicare |
$80.86
|
| Rate for Payer: PACE SWMI |
$85.12
|
| Rate for Payer: PACE SWMI |
$85.12
|
| Rate for Payer: PHP Commercial |
$3,856.62
|
| Rate for Payer: PHP Commercial |
$16,069.19
|
| Rate for Payer: PHP Medicare Advantage |
$85.12
|
| Rate for Payer: PHP Medicare Advantage |
$85.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$45.62
|
| Rate for Payer: Priority Health Choice Medicaid |
$45.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,949.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,288.20
|
| Rate for Payer: Priority Health Medicare |
$85.12
|
| Rate for Payer: Priority Health Medicare |
$85.12
|
| Rate for Payer: Priority Health SBD |
$2,858.44
|
| Rate for Payer: Priority Health SBD |
$11,910.11
|
| Rate for Payer: Railroad Medicare Medicare |
$85.12
|
| Rate for Payer: Railroad Medicare Medicare |
$85.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$239.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$239.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$85.12
|
| Rate for Payer: UHC Dual Complete DSNP |
$85.12
|
| Rate for Payer: UHC Medicare Advantage |
$85.12
|
| Rate for Payer: UHC Medicare Advantage |
$85.12
|
| Rate for Payer: UHCCP Medicaid |
$47.92
|
| Rate for Payer: UHCCP Medicaid |
$47.92
|
| Rate for Payer: VA VA |
$85.12
|
| Rate for Payer: VA VA |
$85.12
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16,959.78
|
|
|
Service Code
|
HCPCS J1300
|
| Hospital Charge Code |
81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,684.66 |
| Max. Negotiated Rate |
$15,263.80 |
| Rate for Payer: Aetna Commercial |
$14,415.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,023.86
|
| Rate for Payer: Cash Price |
$13,567.82
|
| Rate for Payer: Cofinity Commercial |
$11,871.85
|
| Rate for Payer: Cofinity Commercial |
$14,585.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$11,871.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,567.82
|
| Rate for Payer: Healthscope Commercial |
$15,263.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,415.81
|
| Rate for Payer: PHP Commercial |
$14,415.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,023.86
|
| Rate for Payer: Priority Health SBD |
$10,684.66
|
|
|
ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16,959.78
|
|
|
Service Code
|
HCPCS J1300
|
| Hospital Charge Code |
81696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,783.91 |
| Max. Negotiated Rate |
$15,263.80 |
| Rate for Payer: Aetna Commercial |
$14,415.81
|
| Rate for Payer: Aetna Medicare |
$8,479.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11,023.86
|
| Rate for Payer: BCBS Complete |
$6,783.91
|
| Rate for Payer: Cash Price |
$13,567.82
|
| Rate for Payer: Cofinity Commercial |
$11,871.85
|
| Rate for Payer: Cofinity Commercial |
$14,585.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$11,871.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,567.82
|
| Rate for Payer: Healthscope Commercial |
$15,263.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14,415.81
|
| Rate for Payer: PHP Commercial |
$14,415.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11,023.86
|
| Rate for Payer: Priority Health SBD |
$10,684.66
|
|
|
EFGARTIGIMOD ALFA-FCAB 20 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16,094.99
|
|
|
Service Code
|
HCPCS J9332
|
| Hospital Charge Code |
198972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.23 |
| Max. Negotiated Rate |
$14,485.49 |
| Rate for Payer: Aetna Commercial |
$13,680.74
|
| Rate for Payer: Aetna Medicare |
$33.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,461.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$40.19
|
| Rate for Payer: Amish Plain Church Group Commercial |
$40.19
|
| Rate for Payer: BCBS Complete |
$18.09
|
| Rate for Payer: BCBS MAPPO |
$32.15
|
| Rate for Payer: BCN Medicare Advantage |
$32.15
|
| Rate for Payer: Cash Price |
$12,875.99
|
| Rate for Payer: Cash Price |
$12,875.99
|
| Rate for Payer: Cofinity Commercial |
$13,841.69
|
| Rate for Payer: Cofinity Commercial |
$11,266.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$11,266.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,875.99
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$32.15
|
| Rate for Payer: Healthscope Commercial |
$14,485.49
|
| Rate for Payer: Mclaren Medicaid |
$17.23
|
| Rate for Payer: Mclaren Medicare |
$32.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$33.76
|
| Rate for Payer: Meridian Medicaid |
$18.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$36.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,680.74
|
| Rate for Payer: PACE Medicare |
$30.54
|
| Rate for Payer: PACE SWMI |
$32.15
|
| Rate for Payer: PHP Commercial |
$13,680.74
|
| Rate for Payer: PHP Medicare Advantage |
$32.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$17.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,461.74
|
| Rate for Payer: Priority Health Medicare |
$32.15
|
| Rate for Payer: Priority Health SBD |
$10,139.84
|
| Rate for Payer: Railroad Medicare Medicare |
$32.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.50
|
| Rate for Payer: UHC Dual Complete DSNP |
$32.15
|
| Rate for Payer: UHC Medicare Advantage |
$32.15
|
| Rate for Payer: UHCCP Medicaid |
$18.10
|
| Rate for Payer: VA VA |
$32.15
|
|
|
EFGARTIGIMOD ALFA-FCAB 20 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16,094.99
|
|
|
Service Code
|
HCPCS J9332
|
| Hospital Charge Code |
198972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,139.84 |
| Max. Negotiated Rate |
$14,485.49 |
| Rate for Payer: Aetna Commercial |
$13,680.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10,461.74
|
| Rate for Payer: Cash Price |
$12,875.99
|
| Rate for Payer: Cofinity Commercial |
$11,266.49
|
| Rate for Payer: Cofinity Commercial |
$13,841.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$11,266.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,875.99
|
| Rate for Payer: Healthscope Commercial |
$14,485.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,680.74
|
| Rate for Payer: PHP Commercial |
$13,680.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,461.74
|
| Rate for Payer: Priority Health SBD |
$10,139.84
|
|
|
ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,916.72
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
176616
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$5,325.05 |
| Rate for Payer: Aetna Commercial |
$5,029.21
|
| Rate for Payer: Aetna Medicare |
$8.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,845.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.86
|
| Rate for Payer: BCBS Complete |
$4.44
|
| Rate for Payer: BCBS MAPPO |
$7.89
|
| Rate for Payer: BCN Medicare Advantage |
$7.89
|
| Rate for Payer: Cash Price |
$4,733.38
|
| Rate for Payer: Cash Price |
$4,733.38
|
| Rate for Payer: Cofinity Commercial |
$4,141.70
|
| Rate for Payer: Cofinity Commercial |
$5,088.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,141.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,733.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.89
|
| Rate for Payer: Healthscope Commercial |
$5,325.05
|
| Rate for Payer: Mclaren Medicaid |
$4.23
|
| Rate for Payer: Mclaren Medicare |
$7.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.28
|
| Rate for Payer: Meridian Medicaid |
$4.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,029.21
|
| Rate for Payer: PACE Medicare |
$7.50
|
| Rate for Payer: PACE SWMI |
$7.89
|
| Rate for Payer: PHP Commercial |
$5,029.21
|
| Rate for Payer: PHP Medicare Advantage |
$7.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,845.87
|
| Rate for Payer: Priority Health Medicare |
$7.89
|
| Rate for Payer: Priority Health SBD |
$3,727.53
|
| Rate for Payer: Railroad Medicare Medicare |
$7.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.89
|
| Rate for Payer: UHC Medicare Advantage |
$7.89
|
| Rate for Payer: UHCCP Medicaid |
$4.44
|
| Rate for Payer: VA VA |
$7.89
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$7,888.87
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
176617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,969.99 |
| Max. Negotiated Rate |
$7,099.98 |
| Rate for Payer: Aetna Commercial |
$6,705.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,127.77
|
| Rate for Payer: Cash Price |
$6,311.10
|
| Rate for Payer: Cofinity Commercial |
$5,522.21
|
| Rate for Payer: Cofinity Commercial |
$6,784.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,522.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,311.10
|
| Rate for Payer: Healthscope Commercial |
$7,099.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,705.54
|
| Rate for Payer: PHP Commercial |
$6,705.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,127.77
|
| Rate for Payer: Priority Health SBD |
$4,969.99
|
|
|
ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$7,888.87
|
|
|
Service Code
|
HCPCS J9176
|
| Hospital Charge Code |
176617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$7,099.98 |
| Rate for Payer: Aetna Commercial |
$6,705.54
|
| Rate for Payer: Aetna Medicare |
$8.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,127.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.86
|
| Rate for Payer: BCBS Complete |
$4.44
|
| Rate for Payer: BCBS MAPPO |
$7.89
|
| Rate for Payer: BCN Medicare Advantage |
$7.89
|
| Rate for Payer: Cash Price |
$6,311.10
|
| Rate for Payer: Cash Price |
$6,311.10
|
| Rate for Payer: Cofinity Commercial |
$6,784.43
|
| Rate for Payer: Cofinity Commercial |
$5,522.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$5,522.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,311.10
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.89
|
| Rate for Payer: Healthscope Commercial |
$7,099.98
|
| Rate for Payer: Mclaren Medicaid |
$4.23
|
| Rate for Payer: Mclaren Medicare |
$7.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$8.28
|
| Rate for Payer: Meridian Medicaid |
$4.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,705.54
|
| Rate for Payer: PACE Medicare |
$7.50
|
| Rate for Payer: PACE SWMI |
$7.89
|
| Rate for Payer: PHP Commercial |
$6,705.54
|
| Rate for Payer: PHP Medicare Advantage |
$7.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,127.77
|
| Rate for Payer: Priority Health Medicare |
$7.89
|
| Rate for Payer: Priority Health SBD |
$4,969.99
|
| Rate for Payer: Railroad Medicare Medicare |
$7.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.89
|
| Rate for Payer: UHC Medicare Advantage |
$7.89
|
| Rate for Payer: UHCCP Medicaid |
$4.44
|
| Rate for Payer: VA VA |
$7.89
|
|
|
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET
|
Facility
|
IP
|
$15,209.56
|
|
|
Service Code
|
NDC 61958190101
|
| Hospital Charge Code |
176485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9,582.02 |
| Max. Negotiated Rate |
$13,688.60 |
| Rate for Payer: Aetna Commercial |
$12,928.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,886.21
|
| Rate for Payer: Cash Price |
$12,167.65
|
| Rate for Payer: Cofinity Commercial |
$10,646.69
|
| Rate for Payer: Cofinity Commercial |
$13,080.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$10,646.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,167.65
|
| Rate for Payer: Healthscope Commercial |
$13,688.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,928.13
|
| Rate for Payer: PHP Commercial |
$12,928.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,886.21
|
| Rate for Payer: Priority Health SBD |
$9,582.02
|
|
|
ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET
|
Facility
|
OP
|
$15,209.56
|
|
|
Service Code
|
NDC 61958190101
|
| Hospital Charge Code |
176485
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6,083.82 |
| Max. Negotiated Rate |
$13,688.60 |
| Rate for Payer: Aetna Commercial |
$12,928.13
|
| Rate for Payer: Aetna Medicare |
$7,604.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9,886.21
|
| Rate for Payer: BCBS Complete |
$6,083.82
|
| Rate for Payer: Cash Price |
$12,167.65
|
| Rate for Payer: Cofinity Commercial |
$10,646.69
|
| Rate for Payer: Cofinity Commercial |
$13,080.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$10,646.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12,167.65
|
| Rate for Payer: Healthscope Commercial |
$13,688.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12,928.13
|
| Rate for Payer: PHP Commercial |
$12,928.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9,886.21
|
| Rate for Payer: Priority Health SBD |
$9,582.02
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$900.56 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$571.78 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$714.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$900.56 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015237
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$571.78 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$714.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$571.78 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna Medicare |
$714.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: BCBS Complete |
$571.78
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$900.56 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015337
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$900.56 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna Commercial |
$1,215.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$929.15
|
| Rate for Payer: Cash Price |
$1,143.57
|
| Rate for Payer: Cofinity Commercial |
$1,000.62
|
| Rate for Payer: Cofinity Commercial |
$1,229.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,000.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,143.57
|
| Rate for Payer: Healthscope Commercial |
$1,286.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,215.04
|
| Rate for Payer: PHP Commercial |
$1,215.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$929.15
|
| Rate for Payer: Priority Health SBD |
$900.56
|
|
