Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

EMPAGLIFLOZIN 25 MG TABLET

Facility

$1,429.46

Service Code	NDC 00597015330
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

EMPTY CONTAINER BOTTLE

Facility

$50.99

Service Code	NDC 00264975706
Hospital Charge Code	113131
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
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 Commercial	$35.69
Rate for Payer: Cofinity Commercial	$43.85
Rate for Payer: Cofinity Medicare Advantage	$35.69
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: PHP Commercial	$43.34
Rate for Payer: Priority Health Cigna Priority Health	$33.14
Rate for Payer: Priority Health SBD	$32.12

EMPTY CONTAINER BOTTLE

Facility

$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 Commercial	$35.69
Rate for Payer: Cofinity Commercial	$43.85
Rate for Payer: Cofinity Medicare Advantage	$35.69
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: PHP Commercial	$43.34
Rate for Payer: Priority Health Cigna Priority Health	$33.14
Rate for Payer: Priority Health SBD	$32.12

EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET

Facility

$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 Commercial	$5,561.38
Rate for Payer: Cofinity Commercial	$6,832.55
Rate for Payer: Cofinity Medicare Advantage	$5,561.38
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: PHP Commercial	$6,753.11
Rate for Payer: Priority Health Cigna Priority Health	$5,164.14
Rate for Payer: Priority Health SBD	$5,005.24

EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET

Facility

$7,944.83

Service Code	NDC 61958200201
Hospital Charge Code	178497
Hospital Revenue Code	637
Min. Negotiated Rate	$3,177.93
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 Commercial	$5,561.38
Rate for Payer: Cofinity Commercial	$6,832.55
Rate for Payer: Cofinity Medicare Advantage	$5,561.38
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: PHP Commercial	$6,753.11
Rate for Payer: Priority Health Cigna Priority Health	$5,164.14
Rate for Payer: Priority Health SBD	$5,005.24

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET

Facility

$6,646.02

Service Code	NDC 61958070101
Hospital Charge Code	39255
Hospital Revenue Code	637
Min. Negotiated Rate	$4,186.99
Max. Negotiated Rate	$5,981.42
Rate for Payer: Aetna Commercial	$5,649.12
Rate for Payer: Aetna New Business (MI Preferred)	$4,319.91
Rate for Payer: Cash Price	$5,316.82
Rate for Payer: Cofinity Commercial	$4,652.21
Rate for Payer: Cofinity Commercial	$5,715.58
Rate for Payer: Cofinity Medicare Advantage	$4,652.21
Rate for Payer: Encore Health Key Benefits Commercial	$5,316.82
Rate for Payer: Healthscope Commercial	$5,981.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,649.12
Rate for Payer: PHP Commercial	$5,649.12
Rate for Payer: Priority Health Cigna Priority Health	$4,319.91
Rate for Payer: Priority Health SBD	$4,186.99

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET

Facility

$87.84

Service Code	NDC 42385095330
Hospital Charge Code	39255
Hospital Revenue Code	637
Min. Negotiated Rate	$55.34
Max. Negotiated Rate	$79.06
Rate for Payer: Aetna Commercial	$74.66
Rate for Payer: Aetna New Business (MI Preferred)	$57.10
Rate for Payer: Cash Price	$70.27
Rate for Payer: Cofinity Commercial	$61.49
Rate for Payer: Cofinity Commercial	$75.54
Rate for Payer: Cofinity Medicare Advantage	$61.49
Rate for Payer: Encore Health Key Benefits Commercial	$70.27
Rate for Payer: Healthscope Commercial	$79.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$74.66
Rate for Payer: PHP Commercial	$74.66
Rate for Payer: Priority Health Cigna Priority Health	$57.10
Rate for Payer: Priority Health SBD	$55.34

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET

Facility

$87.84

Service Code	NDC 42385095330
Hospital Charge Code	39255
Hospital Revenue Code	637
Min. Negotiated Rate	$35.14
Max. Negotiated Rate	$79.06
Rate for Payer: Aetna Commercial	$74.66
Rate for Payer: Aetna Medicare	$43.92
Rate for Payer: Aetna New Business (MI Preferred)	$57.10
Rate for Payer: BCBS Complete	$35.14
Rate for Payer: Cash Price	$70.27
Rate for Payer: Cofinity Commercial	$61.49
Rate for Payer: Cofinity Commercial	$75.54
Rate for Payer: Cofinity Medicare Advantage	$61.49
Rate for Payer: Encore Health Key Benefits Commercial	$70.27
Rate for Payer: Healthscope Commercial	$79.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$74.66
Rate for Payer: PHP Commercial	$74.66
Rate for Payer: Priority Health Cigna Priority Health	$57.10
Rate for Payer: Priority Health SBD	$55.34

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET

Facility

$6,646.02

Service Code	NDC 61958070101
Hospital Charge Code	39255
Hospital Revenue Code	637
Min. Negotiated Rate	$2,658.41
Max. Negotiated Rate	$5,981.42
Rate for Payer: Aetna Commercial	$5,649.12
Rate for Payer: Aetna Medicare	$3,323.01
Rate for Payer: Aetna New Business (MI Preferred)	$4,319.91
Rate for Payer: BCBS Complete	$2,658.41
Rate for Payer: Cash Price	$5,316.82
Rate for Payer: Cofinity Commercial	$4,652.21
Rate for Payer: Cofinity Commercial	$5,715.58
Rate for Payer: Cofinity Medicare Advantage	$4,652.21
Rate for Payer: Encore Health Key Benefits Commercial	$5,316.82
Rate for Payer: Healthscope Commercial	$5,981.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,649.12
Rate for Payer: PHP Commercial	$5,649.12
Rate for Payer: Priority Health Cigna Priority Health	$4,319.91
Rate for Payer: Priority Health SBD	$4,186.99

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION

Facility

$57.56

Service Code	NDC 00143978610
Hospital Charge Code	9929
Hospital Revenue Code	250
Min. Negotiated Rate	$23.02
Max. Negotiated Rate	$51.80
Rate for Payer: Aetna Commercial	$48.93
Rate for Payer: Aetna Medicare	$28.78
Rate for Payer: Aetna New Business (MI Preferred)	$37.41
Rate for Payer: BCBS Complete	$23.02
Rate for Payer: Cash Price	$46.05
Rate for Payer: Cofinity Commercial	$40.29
Rate for Payer: Cofinity Commercial	$49.50
Rate for Payer: Cofinity Medicare Advantage	$40.29
Rate for Payer: Encore Health Key Benefits Commercial	$46.05
Rate for Payer: Healthscope Commercial	$51.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$48.93
Rate for Payer: PHP Commercial	$48.93
Rate for Payer: Priority Health Cigna Priority Health	$37.41
Rate for Payer: Priority Health SBD	$36.26

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION

Facility

$57.56

Service Code	NDC 00143978601
Hospital Charge Code	9929
Hospital Revenue Code	250
Min. Negotiated Rate	$23.02
Max. Negotiated Rate	$51.80
Rate for Payer: Aetna Commercial	$48.93
Rate for Payer: Aetna Medicare	$28.78
Rate for Payer: Aetna New Business (MI Preferred)	$37.41
Rate for Payer: BCBS Complete	$23.02
Rate for Payer: Cash Price	$46.05
Rate for Payer: Cofinity Commercial	$40.29
Rate for Payer: Cofinity Commercial	$49.50
Rate for Payer: Cofinity Medicare Advantage	$40.29
Rate for Payer: Encore Health Key Benefits Commercial	$46.05
Rate for Payer: Healthscope Commercial	$51.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$48.93
Rate for Payer: PHP Commercial	$48.93
Rate for Payer: Priority Health Cigna Priority Health	$37.41
Rate for Payer: Priority Health SBD	$36.26

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION

Facility

$57.56

Service Code	NDC 00143978601
Hospital Charge Code	9929
Hospital Revenue Code	250
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$51.80
Rate for Payer: Aetna Commercial	$48.93
Rate for Payer: Aetna New Business (MI Preferred)	$37.41
Rate for Payer: Cash Price	$46.05
Rate for Payer: Cofinity Commercial	$40.29
Rate for Payer: Cofinity Commercial	$49.50
Rate for Payer: Cofinity Medicare Advantage	$40.29
Rate for Payer: Encore Health Key Benefits Commercial	$46.05
Rate for Payer: Healthscope Commercial	$51.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$48.93
Rate for Payer: PHP Commercial	$48.93
Rate for Payer: Priority Health Cigna Priority Health	$37.41
Rate for Payer: Priority Health SBD	$36.26

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION

Facility

$57.56

Service Code	NDC 00143978610
Hospital Charge Code	9929
Hospital Revenue Code	250
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$51.80
Rate for Payer: Aetna Commercial	$48.93
Rate for Payer: Aetna New Business (MI Preferred)	$37.41
Rate for Payer: Cash Price	$46.05
Rate for Payer: Cofinity Commercial	$40.29
Rate for Payer: Cofinity Commercial	$49.50
Rate for Payer: Cofinity Medicare Advantage	$40.29
Rate for Payer: Encore Health Key Benefits Commercial	$46.05
Rate for Payer: Healthscope Commercial	$51.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$48.93
Rate for Payer: PHP Commercial	$48.93
Rate for Payer: Priority Health Cigna Priority Health	$37.41
Rate for Payer: Priority Health SBD	$36.26

ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND CURETTAGE)

Facility

$2,390.47

Service Code	CPT 57505
Hospital Revenue Code	360
Min. Negotiated Rate	$455.18
Max. Negotiated Rate	$2,390.47
Rate for Payer: Aetna Medicare	$883.19
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,061.53
Rate for Payer: Amish Plain Church Group Commercial	$1,061.53
Rate for Payer: BCBS Complete	$477.94
Rate for Payer: BCBS MAPPO	$849.22
Rate for Payer: BCN Medicare Advantage	$849.22
Rate for Payer: Health Alliance Plan Medicare Advantage	$849.22
Rate for Payer: Mclaren Medicaid	$455.18
Rate for Payer: Mclaren Medicare	$849.22
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$891.68
Rate for Payer: Meridian Medicaid	$477.94
Rate for Payer: MI Amish Medical Board Commercial	$976.60
Rate for Payer: PACE Medicare	$806.76
Rate for Payer: PACE SWMI	$849.22
Rate for Payer: PHP Medicare Advantage	$849.22
Rate for Payer: Priority Health Choice Medicaid	$455.18
Rate for Payer: Priority Health Medicare	$849.22
Rate for Payer: Railroad Medicare Medicare	$849.22
Rate for Payer: UHC All Payor (Choice/PPO)	$2,390.47
Rate for Payer: UHC Dual Complete DSNP	$849.22
Rate for Payer: UHC Medicare Advantage	$849.22
Rate for Payer: UHCCP Medicaid	$478.11
Rate for Payer: VA VA	$849.22

ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE

Facility

$13,552.11

Service Code	CPT 58353
Hospital Revenue Code	360
Min. Negotiated Rate	$2,580.53
Max. Negotiated Rate	$13,552.11
Rate for Payer: Aetna Medicare	$5,007.00
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,018.02
Rate for Payer: Amish Plain Church Group Commercial	$6,018.02
Rate for Payer: BCBS Complete	$2,709.56
Rate for Payer: BCBS MAPPO	$4,814.42
Rate for Payer: BCN Medicare Advantage	$4,814.42
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,814.42
Rate for Payer: Mclaren Medicaid	$2,580.53
Rate for Payer: Mclaren Medicare	$4,814.42
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5,055.14
Rate for Payer: Meridian Medicaid	$2,709.56
Rate for Payer: MI Amish Medical Board Commercial	$5,536.58
Rate for Payer: PACE Medicare	$4,573.70
Rate for Payer: PACE SWMI	$4,814.42
Rate for Payer: PHP Medicare Advantage	$4,814.42
Rate for Payer: Priority Health Choice Medicaid	$2,580.53
Rate for Payer: Priority Health Medicare	$4,814.42
Rate for Payer: Railroad Medicare Medicare	$4,814.42
Rate for Payer: UHC All Payor (Choice/PPO)	$13,552.11
Rate for Payer: UHC Dual Complete DSNP	$4,814.42
Rate for Payer: UHC Medicare Advantage	$4,814.42
Rate for Payer: UHCCP Medicaid	$2,710.52
Rate for Payer: VA VA	$4,814.42

ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)

Facility

$552.28

Service Code	CPT 58100
Hospital Revenue Code	360
Min. Negotiated Rate	$105.16
Max. Negotiated Rate	$552.28
Rate for Payer: Aetna Medicare	$204.05
Rate for Payer: Allen County Amish Medical Aid Commercial	$245.25
Rate for Payer: Amish Plain Church Group Commercial	$245.25
Rate for Payer: BCBS Complete	$110.42
Rate for Payer: BCBS MAPPO	$196.20
Rate for Payer: BCN Medicare Advantage	$196.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$196.20
Rate for Payer: Mclaren Medicaid	$105.16
Rate for Payer: Mclaren Medicare	$196.20
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$206.01
Rate for Payer: Meridian Medicaid	$110.42
Rate for Payer: MI Amish Medical Board Commercial	$225.63
Rate for Payer: PACE Medicare	$186.39
Rate for Payer: PACE SWMI	$196.20
Rate for Payer: PHP Medicare Advantage	$196.20
Rate for Payer: Priority Health Choice Medicaid	$105.16
Rate for Payer: Priority Health Medicare	$196.20
Rate for Payer: Railroad Medicare Medicare	$196.20
Rate for Payer: UHC All Payor (Choice/PPO)	$552.28
Rate for Payer: UHC Dual Complete DSNP	$196.20
Rate for Payer: UHC Medicare Advantage	$196.20
Rate for Payer: UHCCP Medicaid	$110.46
Rate for Payer: VA VA	$196.20

ENDOSCOPIC EVALUATION OF SMALL INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$2,502.92

Service Code	CPT 44385
Hospital Revenue Code	360
Min. Negotiated Rate	$476.60
Max. Negotiated Rate	$2,502.92
Rate for Payer: Aetna Medicare	$924.74
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,111.46
Rate for Payer: Amish Plain Church Group Commercial	$1,111.46
Rate for Payer: BCBS Complete	$500.42
Rate for Payer: BCBS MAPPO	$889.17
Rate for Payer: BCN Medicare Advantage	$889.17
Rate for Payer: Health Alliance Plan Medicare Advantage	$889.17
Rate for Payer: Mclaren Medicaid	$476.60
Rate for Payer: Mclaren Medicare	$889.17
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$933.63
Rate for Payer: Meridian Medicaid	$500.42
Rate for Payer: MI Amish Medical Board Commercial	$1,022.55
Rate for Payer: PACE Medicare	$844.71
Rate for Payer: PACE SWMI	$889.17
Rate for Payer: PHP Medicare Advantage	$889.17
Rate for Payer: Priority Health Choice Medicaid	$476.60
Rate for Payer: Priority Health Medicare	$889.17
Rate for Payer: Railroad Medicare Medicare	$889.17
Rate for Payer: UHC All Payor (Choice/PPO)	$2,502.92
Rate for Payer: UHC Dual Complete DSNP	$889.17
Rate for Payer: UHC Medicare Advantage	$889.17
Rate for Payer: UHCCP Medicaid	$500.60
Rate for Payer: VA VA	$889.17

ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK

Facility

$9,468.51

Service Code	CPT 51715
Hospital Revenue Code	360
Min. Negotiated Rate	$1,802.95
Max. Negotiated Rate	$9,468.51
Rate for Payer: Aetna Medicare	$3,498.26
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,204.64
Rate for Payer: Amish Plain Church Group Commercial	$4,204.64
Rate for Payer: BCBS Complete	$1,893.10
Rate for Payer: BCBS MAPPO	$3,363.71
Rate for Payer: BCN Medicare Advantage	$3,363.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,363.71
Rate for Payer: Mclaren Medicaid	$1,802.95
Rate for Payer: Mclaren Medicare	$3,363.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,531.90
Rate for Payer: Meridian Medicaid	$1,893.10
Rate for Payer: MI Amish Medical Board Commercial	$3,868.27
Rate for Payer: PACE Medicare	$3,195.52
Rate for Payer: PACE SWMI	$3,363.71
Rate for Payer: PHP Medicare Advantage	$3,363.71
Rate for Payer: Priority Health Choice Medicaid	$1,802.95
Rate for Payer: Priority Health Medicare	$3,363.71
Rate for Payer: Railroad Medicare Medicare	$3,363.71
Rate for Payer: UHC All Payor (Choice/PPO)	$9,468.51
Rate for Payer: UHC Dual Complete DSNP	$3,363.71
Rate for Payer: UHC Medicare Advantage	$3,363.71
Rate for Payer: UHCCP Medicaid	$1,893.77
Rate for Payer: VA VA	$3,363.71

ENDOSCOPIC MARKER

Facility

$77.70

Service Code	NDC 09900000099
Hospital Charge Code	2138700
Hospital Revenue Code	250
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$69.93
Rate for Payer: Aetna Commercial	$66.05
Rate for Payer: Aetna New Business (MI Preferred)	$50.51
Rate for Payer: Cash Price	$62.16
Rate for Payer: Cofinity Commercial	$54.39
Rate for Payer: Cofinity Commercial	$66.82
Rate for Payer: Cofinity Medicare Advantage	$54.39
Rate for Payer: Encore Health Key Benefits Commercial	$62.16
Rate for Payer: Healthscope Commercial	$69.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$66.05
Rate for Payer: PHP Commercial	$66.05
Rate for Payer: Priority Health Cigna Priority Health	$50.51
Rate for Payer: Priority Health SBD	$48.95

ENDOSCOPIC MARKER

Facility

$77.70

Service Code	NDC 09900000099
Hospital Charge Code	2138700
Hospital Revenue Code	250
Min. Negotiated Rate	$31.08
Max. Negotiated Rate	$69.93
Rate for Payer: Aetna Commercial	$66.05
Rate for Payer: Aetna Medicare	$38.85
Rate for Payer: Aetna New Business (MI Preferred)	$50.51
Rate for Payer: BCBS Complete	$31.08
Rate for Payer: Cash Price	$62.16
Rate for Payer: Cofinity Commercial	$54.39
Rate for Payer: Cofinity Commercial	$66.82
Rate for Payer: Cofinity Medicare Advantage	$54.39
Rate for Payer: Encore Health Key Benefits Commercial	$62.16
Rate for Payer: Healthscope Commercial	$69.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$66.05
Rate for Payer: PHP Commercial	$66.05
Rate for Payer: Priority Health Cigna Priority Health	$50.51
Rate for Payer: Priority Health SBD	$48.95

ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED

Facility

$8,640.87

Service Code	CPT 36475
Hospital Revenue Code	360
Min. Negotiated Rate	$1,645.35
Max. Negotiated Rate	$8,640.87
Rate for Payer: Aetna Medicare	$3,192.48
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,837.11
Rate for Payer: Amish Plain Church Group Commercial	$3,837.11
Rate for Payer: BCBS Complete	$1,727.62
Rate for Payer: BCBS MAPPO	$3,069.69
Rate for Payer: BCN Medicare Advantage	$3,069.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,069.69
Rate for Payer: Mclaren Medicaid	$1,645.35
Rate for Payer: Mclaren Medicare	$3,069.69
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,223.17
Rate for Payer: Meridian Medicaid	$1,727.62
Rate for Payer: MI Amish Medical Board Commercial	$3,530.14
Rate for Payer: PACE Medicare	$2,916.21
Rate for Payer: PACE SWMI	$3,069.69
Rate for Payer: PHP Medicare Advantage	$3,069.69
Rate for Payer: Priority Health Choice Medicaid	$1,645.35
Rate for Payer: Priority Health Medicare	$3,069.69
Rate for Payer: Railroad Medicare Medicare	$3,069.69
Rate for Payer: UHC All Payor (Choice/PPO)	$8,640.87
Rate for Payer: UHC Dual Complete DSNP	$3,069.69
Rate for Payer: UHC Medicare Advantage	$3,069.69
Rate for Payer: UHCCP Medicaid	$1,728.24
Rate for Payer: VA VA	$3,069.69

ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION

Facility

$12,612.41

Service Code	HCPCS J9177
Hospital Charge Code	192400
Hospital Revenue Code	636
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$11,351.17
Rate for Payer: Aetna Commercial	$10,720.55
Rate for Payer: Aetna Medicare	$38.21
Rate for Payer: Aetna New Business (MI Preferred)	$8,198.07
Rate for Payer: Allen County Amish Medical Aid Commercial	$45.92
Rate for Payer: Amish Plain Church Group Commercial	$45.92
Rate for Payer: BCBS Complete	$20.68
Rate for Payer: BCBS MAPPO	$36.74
Rate for Payer: BCN Medicare Advantage	$36.74
Rate for Payer: Cash Price	$10,089.93
Rate for Payer: Cash Price	$10,089.93
Rate for Payer: Cofinity Commercial	$8,828.69
Rate for Payer: Cofinity Commercial	$10,846.67
Rate for Payer: Cofinity Medicare Advantage	$8,828.69
Rate for Payer: Encore Health Key Benefits Commercial	$10,089.93
Rate for Payer: Health Alliance Plan Medicare Advantage	$36.74
Rate for Payer: Healthscope Commercial	$11,351.17
Rate for Payer: Mclaren Medicaid	$19.69
Rate for Payer: Mclaren Medicare	$36.74
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$38.58
Rate for Payer: Meridian Medicaid	$20.68
Rate for Payer: MI Amish Medical Board Commercial	$42.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10,720.55
Rate for Payer: PACE Medicare	$34.90
Rate for Payer: PACE SWMI	$36.74
Rate for Payer: PHP Commercial	$10,720.55
Rate for Payer: PHP Medicare Advantage	$36.74
Rate for Payer: Priority Health Choice Medicaid	$19.69
Rate for Payer: Priority Health Cigna Priority Health	$8,198.07
Rate for Payer: Priority Health Medicare	$36.74
Rate for Payer: Priority Health SBD	$7,945.82
Rate for Payer: Railroad Medicare Medicare	$36.74
Rate for Payer: UHC All Payor (Choice/PPO)	$103.42
Rate for Payer: UHC Dual Complete DSNP	$36.74
Rate for Payer: UHC Medicare Advantage	$36.74
Rate for Payer: UHCCP Medicaid	$20.68
Rate for Payer: VA VA	$36.74

ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION

Facility

$12,612.41

Service Code	HCPCS J9177
Hospital Charge Code	192400
Hospital Revenue Code	636
Min. Negotiated Rate	$7,945.82
Max. Negotiated Rate	$11,351.17
Rate for Payer: Aetna Commercial	$10,720.55
Rate for Payer: Aetna New Business (MI Preferred)	$8,198.07
Rate for Payer: Cash Price	$10,089.93
Rate for Payer: Cofinity Commercial	$10,846.67
Rate for Payer: Cofinity Commercial	$8,828.69
Rate for Payer: Cofinity Medicare Advantage	$8,828.69
Rate for Payer: Encore Health Key Benefits Commercial	$10,089.93
Rate for Payer: Healthscope Commercial	$11,351.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10,720.55
Rate for Payer: PHP Commercial	$10,720.55
Rate for Payer: Priority Health Cigna Priority Health	$8,198.07
Rate for Payer: Priority Health SBD	$7,945.82

ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION

Facility

$18,918.62

Service Code	HCPCS J9177
Hospital Charge Code	192401
Hospital Revenue Code	636
Min. Negotiated Rate	$11,918.73
Max. Negotiated Rate	$17,026.76
Rate for Payer: Aetna Commercial	$16,080.83
Rate for Payer: Aetna New Business (MI Preferred)	$12,297.10
Rate for Payer: Cash Price	$15,134.90
Rate for Payer: Cofinity Commercial	$13,243.03
Rate for Payer: Cofinity Commercial	$16,270.01
Rate for Payer: Cofinity Medicare Advantage	$13,243.03
Rate for Payer: Encore Health Key Benefits Commercial	$15,134.90
Rate for Payer: Healthscope Commercial	$17,026.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16,080.83
Rate for Payer: PHP Commercial	$16,080.83
Rate for Payer: Priority Health Cigna Priority Health	$12,297.10
Rate for Payer: Priority Health SBD	$11,918.73

ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION

Facility

$18,918.62

Service Code	HCPCS J9177
Hospital Charge Code	192401
Hospital Revenue Code	636
Min. Negotiated Rate	$19.69
Max. Negotiated Rate	$17,026.76
Rate for Payer: Aetna Commercial	$16,080.83
Rate for Payer: Aetna Medicare	$38.21
Rate for Payer: Aetna New Business (MI Preferred)	$12,297.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$45.92
Rate for Payer: Amish Plain Church Group Commercial	$45.92
Rate for Payer: BCBS Complete	$20.68
Rate for Payer: BCBS MAPPO	$36.74
Rate for Payer: BCN Medicare Advantage	$36.74
Rate for Payer: Cash Price	$15,134.90
Rate for Payer: Cash Price	$15,134.90
Rate for Payer: Cofinity Commercial	$16,270.01
Rate for Payer: Cofinity Commercial	$13,243.03
Rate for Payer: Cofinity Medicare Advantage	$13,243.03
Rate for Payer: Encore Health Key Benefits Commercial	$15,134.90
Rate for Payer: Health Alliance Plan Medicare Advantage	$36.74
Rate for Payer: Healthscope Commercial	$17,026.76
Rate for Payer: Mclaren Medicaid	$19.69
Rate for Payer: Mclaren Medicare	$36.74
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$38.58
Rate for Payer: Meridian Medicaid	$20.68
Rate for Payer: MI Amish Medical Board Commercial	$42.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16,080.83
Rate for Payer: PACE Medicare	$34.90
Rate for Payer: PACE SWMI	$36.74
Rate for Payer: PHP Commercial	$16,080.83
Rate for Payer: PHP Medicare Advantage	$36.74
Rate for Payer: Priority Health Choice Medicaid	$19.69
Rate for Payer: Priority Health Cigna Priority Health	$12,297.10
Rate for Payer: Priority Health Medicare	$36.74
Rate for Payer: Priority Health SBD	$11,918.73
Rate for Payer: Railroad Medicare Medicare	$36.74
Rate for Payer: UHC All Payor (Choice/PPO)	$103.42
Rate for Payer: UHC Dual Complete DSNP	$36.74
Rate for Payer: UHC Medicare Advantage	$36.74
Rate for Payer: UHCCP Medicaid	$20.68
Rate for Payer: VA VA	$36.74

Know your out-of-pocket cost for care.

All Charges