Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$714.24

Service Code	NDC 68084-683-01
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$449.97
Max. Negotiated Rate	$642.82
Rate for Payer: Aetna Commercial	$607.10
Rate for Payer: Aetna New Business (MI Preferred)	$464.26
Rate for Payer: Cash Price	$571.39
Rate for Payer: Cofinity Commercial	$499.97
Rate for Payer: Cofinity Commercial	$614.25
Rate for Payer: Healthscope Commercial	$642.82
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$607.10
Rate for Payer: PHP Commercial	$607.10
Rate for Payer: Priority Health Cigna Priority Health	$499.97
Rate for Payer: Priority Health SBD	$449.97

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$7.15

Service Code	NDC 68084-683-11
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$6.44
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: Healthscope Commercial	$6.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.08
Rate for Payer: PHP Commercial	$6.08
Rate for Payer: Priority Health Cigna Priority Health	$5.00
Rate for Payer: Priority Health SBD	$4.50

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$102.53

Service Code	NDC 50268-288-13
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: Healthscope Commercial	$92.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$87.15
Rate for Payer: PHP Commercial	$87.15
Rate for Payer: Priority Health Cigna Priority Health	$71.77
Rate for Payer: Priority Health SBD	$64.59

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$714.24

Service Code	NDC 68084-692-01
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$449.97
Max. Negotiated Rate	$642.82
Rate for Payer: Aetna Commercial	$607.10
Rate for Payer: Aetna New Business (MI Preferred)	$464.26
Rate for Payer: Cash Price	$571.39
Rate for Payer: Cofinity Commercial	$499.97
Rate for Payer: Cofinity Commercial	$614.25
Rate for Payer: Healthscope Commercial	$642.82
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$607.10
Rate for Payer: PHP Commercial	$607.10
Rate for Payer: Priority Health Cigna Priority Health	$499.97
Rate for Payer: Priority Health SBD	$449.97

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$394.56

Service Code	NDC 0904-6454-61
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$248.57
Max. Negotiated Rate	$355.10
Rate for Payer: Aetna Commercial	$335.38
Rate for Payer: Aetna New Business (MI Preferred)	$256.46
Rate for Payer: Cash Price	$315.65
Rate for Payer: Cofinity Commercial	$276.19
Rate for Payer: Cofinity Commercial	$339.32
Rate for Payer: Healthscope Commercial	$355.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$335.38
Rate for Payer: PHP Commercial	$335.38
Rate for Payer: Priority Health Cigna Priority Health	$276.19
Rate for Payer: Priority Health SBD	$248.57

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$78.96

Service Code	NDC 57237-019-30
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$49.74
Max. Negotiated Rate	$71.06
Rate for Payer: Aetna Commercial	$67.12
Rate for Payer: Aetna New Business (MI Preferred)	$51.32
Rate for Payer: Cash Price	$63.17
Rate for Payer: Cofinity Commercial	$55.27
Rate for Payer: Cofinity Commercial	$67.91
Rate for Payer: Healthscope Commercial	$71.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$67.12
Rate for Payer: PHP Commercial	$67.12
Rate for Payer: Priority Health Cigna Priority Health	$55.27
Rate for Payer: Priority Health SBD	$49.74

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$3.42

Service Code	NDC 50268-288-11
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: Healthscope Commercial	$3.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.91
Rate for Payer: PHP Commercial	$2.91
Rate for Payer: Priority Health Cigna Priority Health	$2.39
Rate for Payer: Priority Health SBD	$2.15

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$7.15

Service Code	NDC 68084-692-11
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$6.44
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: Healthscope Commercial	$6.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.08
Rate for Payer: PHP Commercial	$6.08
Rate for Payer: Priority Health Cigna Priority Health	$5.00
Rate for Payer: Priority Health SBD	$4.50

DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION

Facility

$18,082.22

Service Code	HCPCS J9173
Hospital Charge Code	183305
Hospital Revenue Code	636
Min. Negotiated Rate	$11,391.80
Max. Negotiated Rate	$16,274.00
Rate for Payer: Aetna Commercial	$15,369.89
Rate for Payer: Aetna New Business (MI Preferred)	$11,753.44
Rate for Payer: Cash Price	$14,465.78
Rate for Payer: Cofinity Commercial	$12,657.55
Rate for Payer: Cofinity Commercial	$15,550.71
Rate for Payer: Healthscope Commercial	$16,274.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15,369.89
Rate for Payer: PHP Commercial	$15,369.89
Rate for Payer: Priority Health Cigna Priority Health	$12,657.55
Rate for Payer: Priority Health SBD	$11,391.80

DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION

Facility

$4,339.73

Service Code	HCPCS J9173
Hospital Charge Code	183305
Hospital Revenue Code	636
Min. Negotiated Rate	$44.15
Max. Negotiated Rate	$3,905.76
Rate for Payer: Aetna Commercial	$3,688.77
Rate for Payer: Aetna Commercial	$15,369.89
Rate for Payer: Aetna Medicare	$83.93
Rate for Payer: Aetna Medicare	$83.93
Rate for Payer: Aetna New Business (MI Preferred)	$2,820.82
Rate for Payer: Aetna New Business (MI Preferred)	$11,753.44
Rate for Payer: Allen County Amish Medical Aid Commercial	$100.88
Rate for Payer: Allen County Amish Medical Aid Commercial	$100.88
Rate for Payer: Amish Plain Church Group Commercial	$100.88
Rate for Payer: Amish Plain Church Group Commercial	$100.88
Rate for Payer: BCBS Complete	$46.36
Rate for Payer: BCBS Complete	$46.36
Rate for Payer: BCBS MAPPO	$80.71
Rate for Payer: BCBS MAPPO	$80.71
Rate for Payer: BCBS Trust/PPO	$238.91
Rate for Payer: BCBS Trust/PPO	$238.91
Rate for Payer: BCN Medicare Advantage	$80.71
Rate for Payer: BCN Medicare Advantage	$80.71
Rate for Payer: Cash Price	$3,471.78
Rate for Payer: Cash Price	$3,471.78
Rate for Payer: Cash Price	$14,465.78
Rate for Payer: Cash Price	$14,465.78
Rate for Payer: Cofinity Commercial	$15,550.71
Rate for Payer: Cofinity Commercial	$3,732.17
Rate for Payer: Cofinity Commercial	$3,037.81
Rate for Payer: Cofinity Commercial	$12,657.55
Rate for Payer: Health Alliance Plan Medicare Advantage	$80.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$80.71
Rate for Payer: Healthscope Commercial	$16,274.00
Rate for Payer: Healthscope Commercial	$3,905.76
Rate for Payer: Mclaren Medicaid	$44.15
Rate for Payer: Mclaren Medicaid	$44.15
Rate for Payer: Mclaren Medicare	$80.71
Rate for Payer: Mclaren Medicare	$80.71
Rate for Payer: Meridian Medicaid	$46.36
Rate for Payer: Meridian Medicaid	$46.36
Rate for Payer: Meridian Wellcare - Medicare Advantage	$84.74
Rate for Payer: Meridian Wellcare - Medicare Advantage	$84.74
Rate for Payer: MI Amish Medical Board Commercial	$92.81
Rate for Payer: MI Amish Medical Board Commercial	$92.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15,369.89
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,688.77
Rate for Payer: PACE Medicare	$76.67
Rate for Payer: PACE Medicare	$76.67
Rate for Payer: PACE SWMI	$80.71
Rate for Payer: PACE SWMI	$80.71
Rate for Payer: PHP Commercial	$3,688.77
Rate for Payer: PHP Commercial	$15,369.89
Rate for Payer: PHP Medicare Advantage	$80.71
Rate for Payer: PHP Medicare Advantage	$80.71
Rate for Payer: Priority Health Choice Medicaid	$44.15
Rate for Payer: Priority Health Choice Medicaid	$44.15
Rate for Payer: Priority Health Cigna Priority Health	$3,037.81
Rate for Payer: Priority Health Cigna Priority Health	$12,657.55
Rate for Payer: Priority Health Medicare	$80.71
Rate for Payer: Priority Health Medicare	$80.71
Rate for Payer: Priority Health SBD	$11,391.80
Rate for Payer: Priority Health SBD	$2,734.03
Rate for Payer: Railroad Medicare Medicare	$80.71
Rate for Payer: Railroad Medicare Medicare	$80.71
Rate for Payer: UHC Dual Complete DSNP	$80.71
Rate for Payer: UHC Dual Complete DSNP	$80.71
Rate for Payer: UHC Medicare Advantage	$83.13
Rate for Payer: UHC Medicare Advantage	$83.13
Rate for Payer: VA VA	$80.71
Rate for Payer: VA VA	$80.71

DYSEQUILIBRIUM

Facility

$14,205.28

Service Code	MS-DRG 149
Min. Negotiated Rate	$5,563.11
Max. Negotiated Rate	$14,205.28
Rate for Payer: Aetna Medicare	$6,090.15
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,319.89
Rate for Payer: Amish Plain Church Group Commercial	$7,319.89
Rate for Payer: BCBS MAPPO	$5,855.91
Rate for Payer: BCBS Trust/PPO	$14,205.28
Rate for Payer: BCN Medicare Advantage	$5,855.91
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,855.91
Rate for Payer: Mclaren Medicare	$5,855.91
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6,148.71
Rate for Payer: MI Amish Medical Board Commercial	$6,734.30
Rate for Payer: PACE Medicare	$5,563.11
Rate for Payer: PACE SWMI	$5,855.91
Rate for Payer: PHP Medicare Advantage	$5,855.91
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,686.39
Rate for Payer: Priority Health Medicare	$5,855.91
Rate for Payer: Priority Health Narrow Network	$8,549.11
Rate for Payer: Railroad Medicare Medicare	$5,855.91
Rate for Payer: UHC All Payor (Choice/PPO)	$11,359.65
Rate for Payer: UHC Core	$6,970.39
Rate for Payer: UHC Dual Complete DSNP	$5,855.91
Rate for Payer: UHC Exchange	$7,465.62
Rate for Payer: UHC Medicare Advantage	$6,031.59
Rate for Payer: VA VA	$5,855.91

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$21,537.39

Service Code	MS-DRG 147
Min. Negotiated Rate	$8,923.06
Max. Negotiated Rate	$21,537.39
Rate for Payer: Aetna Medicare	$9,768.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$11,740.86
Rate for Payer: Amish Plain Church Group Commercial	$11,740.86
Rate for Payer: BCBS MAPPO	$9,392.69
Rate for Payer: BCBS Trust/PPO	$21,537.39
Rate for Payer: BCN Medicare Advantage	$9,392.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,392.69
Rate for Payer: Mclaren Medicare	$9,392.69
Rate for Payer: Meridian Wellcare - Medicare Advantage	$9,862.32
Rate for Payer: MI Amish Medical Board Commercial	$10,801.59
Rate for Payer: PACE Medicare	$8,923.06
Rate for Payer: PACE SWMI	$9,392.69
Rate for Payer: PHP Medicare Advantage	$9,392.69
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17,733.63
Rate for Payer: Priority Health Medicare	$9,392.69
Rate for Payer: Priority Health Narrow Network	$14,186.90
Rate for Payer: Railroad Medicare Medicare	$9,392.69
Rate for Payer: UHC All Payor (Choice/PPO)	$18,850.89
Rate for Payer: UHC Core	$11,567.09
Rate for Payer: UHC Dual Complete DSNP	$9,392.69
Rate for Payer: UHC Exchange	$12,388.90
Rate for Payer: UHC Medicare Advantage	$9,674.47
Rate for Payer: VA VA	$9,392.69

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$32,201.19

Service Code	MS-DRG 146
Min. Negotiated Rate	$14,910.93
Max. Negotiated Rate	$32,201.19
Rate for Payer: Aetna Medicare	$16,323.55
Rate for Payer: Allen County Amish Medical Aid Commercial	$19,619.65
Rate for Payer: Amish Plain Church Group Commercial	$19,619.65
Rate for Payer: BCBS MAPPO	$15,695.72
Rate for Payer: BCBS Trust/PPO	$28,764.09
Rate for Payer: BCN Medicare Advantage	$15,695.72
Rate for Payer: Health Alliance Plan Medicare Advantage	$15,695.72
Rate for Payer: Mclaren Medicare	$15,695.72
Rate for Payer: Meridian Wellcare - Medicare Advantage	$16,480.51
Rate for Payer: MI Amish Medical Board Commercial	$18,050.08
Rate for Payer: PACE Medicare	$14,910.93
Rate for Payer: PACE SWMI	$15,695.72
Rate for Payer: PHP Medicare Advantage	$15,695.72
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$30,292.68
Rate for Payer: Priority Health Medicare	$15,695.72
Rate for Payer: Priority Health Narrow Network	$24,234.14
Rate for Payer: Railroad Medicare Medicare	$15,695.72
Rate for Payer: UHC All Payor (Choice/PPO)	$32,201.19
Rate for Payer: UHC Core	$19,758.96
Rate for Payer: UHC Dual Complete DSNP	$15,695.72
Rate for Payer: UHC Exchange	$21,162.78
Rate for Payer: UHC Medicare Advantage	$16,166.59
Rate for Payer: VA VA	$15,695.72

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$17,900.98

Service Code	MS-DRG 148
Min. Negotiated Rate	$6,555.15
Max. Negotiated Rate	$17,900.98
Rate for Payer: Aetna Medicare	$7,176.17
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,625.20
Rate for Payer: Amish Plain Church Group Commercial	$8,625.20
Rate for Payer: BCBS MAPPO	$6,900.16
Rate for Payer: BCBS Trust/PPO	$17,900.98
Rate for Payer: BCN Medicare Advantage	$6,900.16
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,900.16
Rate for Payer: Mclaren Medicare	$6,900.16
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7,245.17
Rate for Payer: MI Amish Medical Board Commercial	$7,935.18
Rate for Payer: PACE Medicare	$6,555.15
Rate for Payer: PACE SWMI	$6,900.16
Rate for Payer: PHP Medicare Advantage	$6,900.16
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12,767.12
Rate for Payer: Priority Health Medicare	$6,900.16
Rate for Payer: Priority Health Narrow Network	$10,213.70
Rate for Payer: Railroad Medicare Medicare	$6,900.16
Rate for Payer: UHC All Payor (Choice/PPO)	$13,571.48
Rate for Payer: UHC Core	$8,327.59
Rate for Payer: UHC Dual Complete DSNP	$6,900.16
Rate for Payer: UHC Exchange	$8,919.24
Rate for Payer: UHC Medicare Advantage	$7,107.16
Rate for Payer: VA VA	$6,900.16

ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES

Facility

$413,020.24

Service Code	MS-DRG 003
Min. Negotiated Rate	$146,335.24
Max. Negotiated Rate	$413,020.24
Rate for Payer: Aetna Medicare	$160,198.58
Rate for Payer: Allen County Amish Medical Aid Commercial	$192,546.38
Rate for Payer: Amish Plain Church Group Commercial	$192,546.38
Rate for Payer: BCBS MAPPO	$154,037.10
Rate for Payer: BCBS Trust/PPO	$413,020.24
Rate for Payer: BCN Medicare Advantage	$154,037.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$154,037.10
Rate for Payer: Mclaren Medicare	$154,037.10
Rate for Payer: Meridian Wellcare - Medicare Advantage	$161,738.96
Rate for Payer: MI Amish Medical Board Commercial	$177,142.66
Rate for Payer: PACE Medicare	$146,335.24
Rate for Payer: PACE SWMI	$154,037.10
Rate for Payer: PHP Medicare Advantage	$154,037.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$305,944.60
Rate for Payer: Priority Health Medicare	$154,037.10
Rate for Payer: Priority Health Narrow Network	$244,755.68
Rate for Payer: Railroad Medicare Medicare	$154,037.10
Rate for Payer: UHC All Payor (Choice/PPO)	$325,219.86
Rate for Payer: UHC Core	$199,558.01
Rate for Payer: UHC Dual Complete DSNP	$154,037.10
Rate for Payer: UHC Exchange	$213,736.01
Rate for Payer: UHC Medicare Advantage	$158,658.21
Rate for Payer: VA VA	$154,037.10

ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION

Facility

$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: Healthscope Commercial	$15,263.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14,415.81
Rate for Payer: PHP Commercial	$14,415.81
Rate for Payer: Priority Health Cigna Priority Health	$11,871.85
Rate for Payer: Priority Health SBD	$10,684.66

EFGARTIGIMOD ALFA-FCAB 20 MG/ML INTRAVENOUS SOLUTION

Facility

$15,779.40

Service Code	HCPCS J9332
Hospital Charge Code	198972
Hospital Revenue Code	636
Min. Negotiated Rate	$9,941.02
Max. Negotiated Rate	$14,201.46
Rate for Payer: Aetna Commercial	$13,412.49
Rate for Payer: Aetna New Business (MI Preferred)	$10,256.61
Rate for Payer: Cash Price	$12,623.52
Rate for Payer: Cofinity Commercial	$11,045.58
Rate for Payer: Cofinity Commercial	$13,570.28
Rate for Payer: Healthscope Commercial	$14,201.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13,412.49
Rate for Payer: PHP Commercial	$13,412.49
Rate for Payer: Priority Health Cigna Priority Health	$11,045.58
Rate for Payer: Priority Health SBD	$9,941.02

ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION

Facility

$5,686.96

Service Code	HCPCS J9176
Hospital Charge Code	176616
Hospital Revenue Code	636
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$5,118.26
Rate for Payer: Aetna Commercial	$4,833.92
Rate for Payer: Aetna Medicare	$7.68
Rate for Payer: Aetna New Business (MI Preferred)	$3,696.52
Rate for Payer: Allen County Amish Medical Aid Commercial	$9.22
Rate for Payer: Amish Plain Church Group Commercial	$9.22
Rate for Payer: BCBS Complete	$4.24
Rate for Payer: BCBS MAPPO	$7.38
Rate for Payer: BCBS Trust/PPO	$21.82
Rate for Payer: BCN Medicare Advantage	$7.38
Rate for Payer: Cash Price	$4,549.57
Rate for Payer: Cash Price	$4,549.57
Rate for Payer: Cofinity Commercial	$4,890.79
Rate for Payer: Cofinity Commercial	$3,980.87
Rate for Payer: Health Alliance Plan Medicare Advantage	$7.38
Rate for Payer: Healthscope Commercial	$5,118.26
Rate for Payer: Mclaren Medicaid	$4.04
Rate for Payer: Mclaren Medicare	$7.38
Rate for Payer: Meridian Medicaid	$4.24
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7.75
Rate for Payer: MI Amish Medical Board Commercial	$8.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,833.92
Rate for Payer: PACE Medicare	$7.01
Rate for Payer: PACE SWMI	$7.38
Rate for Payer: PHP Commercial	$4,833.92
Rate for Payer: PHP Medicare Advantage	$7.38
Rate for Payer: Priority Health Choice Medicaid	$4.04
Rate for Payer: Priority Health Cigna Priority Health	$3,980.87
Rate for Payer: Priority Health Medicare	$7.38
Rate for Payer: Priority Health SBD	$3,582.78
Rate for Payer: Railroad Medicare Medicare	$7.38
Rate for Payer: UHC Dual Complete DSNP	$7.38
Rate for Payer: UHC Medicare Advantage	$7.60
Rate for Payer: VA VA	$7.38

ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION

Facility

$7,582.54

Service Code	HCPCS J9176
Hospital Charge Code	176617
Hospital Revenue Code	636
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$6,824.29
Rate for Payer: Aetna Commercial	$6,445.16
Rate for Payer: Aetna Medicare	$7.68
Rate for Payer: Aetna New Business (MI Preferred)	$4,928.65
Rate for Payer: Allen County Amish Medical Aid Commercial	$9.22
Rate for Payer: Amish Plain Church Group Commercial	$9.22
Rate for Payer: BCBS Complete	$4.24
Rate for Payer: BCBS MAPPO	$7.38
Rate for Payer: BCBS Trust/PPO	$21.82
Rate for Payer: BCN Medicare Advantage	$7.38
Rate for Payer: Cash Price	$6,066.03
Rate for Payer: Cash Price	$6,066.03
Rate for Payer: Cofinity Commercial	$6,520.98
Rate for Payer: Cofinity Commercial	$5,307.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$7.38
Rate for Payer: Healthscope Commercial	$6,824.29
Rate for Payer: Mclaren Medicaid	$4.04
Rate for Payer: Mclaren Medicare	$7.38
Rate for Payer: Meridian Medicaid	$4.24
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7.75
Rate for Payer: MI Amish Medical Board Commercial	$8.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6,445.16
Rate for Payer: PACE Medicare	$7.01
Rate for Payer: PACE SWMI	$7.38
Rate for Payer: PHP Commercial	$6,445.16
Rate for Payer: PHP Medicare Advantage	$7.38
Rate for Payer: Priority Health Choice Medicaid	$4.04
Rate for Payer: Priority Health Cigna Priority Health	$5,307.78
Rate for Payer: Priority Health Medicare	$7.38
Rate for Payer: Priority Health SBD	$4,777.00
Rate for Payer: Railroad Medicare Medicare	$7.38
Rate for Payer: UHC Dual Complete DSNP	$7.38
Rate for Payer: UHC Medicare Advantage	$7.60
Rate for Payer: VA VA	$7.38

ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION

Facility

$7,582.54

Service Code	HCPCS J9176
Hospital Charge Code	176617
Hospital Revenue Code	636
Min. Negotiated Rate	$4,777.00
Max. Negotiated Rate	$6,824.29
Rate for Payer: Aetna Commercial	$6,445.16
Rate for Payer: Aetna New Business (MI Preferred)	$4,928.65
Rate for Payer: Cash Price	$6,066.03
Rate for Payer: Cofinity Commercial	$5,307.78
Rate for Payer: Cofinity Commercial	$6,520.98
Rate for Payer: Healthscope Commercial	$6,824.29
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6,445.16
Rate for Payer: PHP Commercial	$6,445.16
Rate for Payer: Priority Health Cigna Priority Health	$5,307.78
Rate for Payer: Priority Health SBD	$4,777.00

ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET

Facility

$14,362.18

Service Code	NDC 61958-1901-1
Hospital Charge Code	176485
Hospital Revenue Code	637
Min. Negotiated Rate	$9,048.17
Max. Negotiated Rate	$12,925.96
Rate for Payer: Aetna Commercial	$12,207.85
Rate for Payer: Aetna New Business (MI Preferred)	$9,335.42
Rate for Payer: Cash Price	$11,489.74
Rate for Payer: Cofinity Commercial	$10,053.53
Rate for Payer: Cofinity Commercial	$12,351.47
Rate for Payer: Healthscope Commercial	$12,925.96
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12,207.85
Rate for Payer: PHP Commercial	$12,207.85
Rate for Payer: Priority Health Cigna Priority Health	$10,053.53
Rate for Payer: Priority Health SBD	$9,048.17

EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; RENAL, CELIAC, MESENTERY, AORTOILIAC ARTERY, BY ABDOMINAL INCISION

Facility

$3,138.00

Service Code	CPT 34151
Hospital Revenue Code	360
Min. Negotiated Rate	$1,334.98
Max. Negotiated Rate	$3,138.00
Rate for Payer: BCBS Trust/PPO	$2,892.03
Rate for Payer: UHC All Payor (Choice/PPO)	$1,468.48
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Exchange	$1,334.98

EMPAGLIFLOZIN 10 MG TABLET

Facility

$1,387.84

Service Code	NDC 0597-0152-37
Hospital Charge Code	171967
Hospital Revenue Code	637
Min. Negotiated Rate	$874.34
Max. Negotiated Rate	$1,249.06
Rate for Payer: Aetna Commercial	$1,179.66
Rate for Payer: Aetna New Business (MI Preferred)	$902.10
Rate for Payer: Cash Price	$1,110.27
Rate for Payer: Cofinity Commercial	$1,193.54
Rate for Payer: Cofinity Commercial	$971.49
Rate for Payer: Healthscope Commercial	$1,249.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,179.66
Rate for Payer: PHP Commercial	$1,179.66
Rate for Payer: Priority Health Cigna Priority Health	$971.49
Rate for Payer: Priority Health SBD	$874.34

EMPAGLIFLOZIN 10 MG TABLET

Facility

$1,387.84

Service Code	NDC 0597-0152-30
Hospital Charge Code	171967
Hospital Revenue Code	637
Min. Negotiated Rate	$874.34
Max. Negotiated Rate	$1,249.06
Rate for Payer: Aetna Commercial	$1,179.66
Rate for Payer: Aetna New Business (MI Preferred)	$902.10
Rate for Payer: Cash Price	$1,110.27
Rate for Payer: Cofinity Commercial	$1,193.54
Rate for Payer: Cofinity Commercial	$971.49
Rate for Payer: Healthscope Commercial	$1,249.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,179.66
Rate for Payer: PHP Commercial	$1,179.66
Rate for Payer: Priority Health Cigna Priority Health	$971.49
Rate for Payer: Priority Health SBD	$874.34

EMPAGLIFLOZIN 25 MG TABLET

Facility

$1,387.84

Service Code	NDC 0597-0153-30
Hospital Charge Code	171966
Hospital Revenue Code	637
Min. Negotiated Rate	$874.34
Max. Negotiated Rate	$1,249.06
Rate for Payer: Aetna Commercial	$1,179.66
Rate for Payer: Aetna New Business (MI Preferred)	$902.10
Rate for Payer: Cash Price	$1,110.27
Rate for Payer: Cofinity Commercial	$1,193.54
Rate for Payer: Cofinity Commercial	$971.49
Rate for Payer: Healthscope Commercial	$1,249.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,179.66
Rate for Payer: PHP Commercial	$1,179.66
Rate for Payer: Priority Health Cigna Priority Health	$971.49
Rate for Payer: Priority Health SBD	$874.34

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