|
EMOLLIENT TOPICAL CREAM
|
Facility
|
OP
|
$23.29
|
|
|
Service Code
|
NDC 00225052053
|
| Hospital Charge Code |
77778
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$20.96 |
| Rate for Payer: Aetna American Axle |
$15.14
|
| Rate for Payer: Aetna Commercial |
$19.80
|
| Rate for Payer: Aetna Medicare |
$11.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.14
|
| Rate for Payer: BCBS Complete |
$9.32
|
| Rate for Payer: Cash Price |
$18.63
|
| Rate for Payer: Cofinity Commercial |
$16.30
|
| Rate for Payer: Cofinity Commercial |
$20.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$20.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.80
|
| Rate for Payer: PHP Commercial |
$19.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.14
|
| Rate for Payer: Priority Health SBD |
$14.67
|
| Rate for Payer: UMR Bronson Commercial |
$8.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.47
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$4,288.38
|
|
|
Service Code
|
NDC 00597015290
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,886.89 |
| Max. Negotiated Rate |
$3,859.54 |
| Rate for Payer: Aetna American Axle |
$2,787.45
|
| Rate for Payer: Aetna Commercial |
$3,645.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,787.45
|
| Rate for Payer: Cash Price |
$3,430.70
|
| Rate for Payer: Cofinity Commercial |
$3,001.87
|
| Rate for Payer: Cofinity Commercial |
$3,688.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,001.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,430.70
|
| Rate for Payer: Healthscope Commercial |
$3,859.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,001.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,216.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,645.12
|
| Rate for Payer: PHP Commercial |
$3,645.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,787.45
|
| Rate for Payer: Priority Health SBD |
$2,701.68
|
| Rate for Payer: UMR Bronson Commercial |
$1,886.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,216.28
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$528.90 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna American Axle |
$929.15
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1,000.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.10
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$528.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.10
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015230
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$628.96 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna American Axle |
$929.15
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1,000.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.10
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$628.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.10
|
|
|
EMPAGLIFLOZIN 10 MG TABLET
|
Facility
|
OP
|
$4,288.38
|
|
|
Service Code
|
NDC 00597015290
|
| Hospital Charge Code |
171967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,586.70 |
| Max. Negotiated Rate |
$3,859.54 |
| Rate for Payer: Aetna American Axle |
$2,787.45
|
| Rate for Payer: Aetna Commercial |
$3,645.12
|
| Rate for Payer: Aetna Medicare |
$2,144.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,787.45
|
| Rate for Payer: BCBS Complete |
$1,715.35
|
| Rate for Payer: Cash Price |
$3,430.70
|
| Rate for Payer: Cofinity Commercial |
$3,001.87
|
| Rate for Payer: Cofinity Commercial |
$3,688.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,001.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,430.70
|
| Rate for Payer: Healthscope Commercial |
$3,859.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,001.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,216.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,645.12
|
| Rate for Payer: PHP Commercial |
$3,645.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,787.45
|
| Rate for Payer: Priority Health SBD |
$2,701.68
|
| Rate for Payer: UMR Bronson Commercial |
$1,586.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,216.28
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
OP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$528.90 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna American Axle |
$929.15
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1,000.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.10
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$528.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.10
|
|
|
EMPAGLIFLOZIN 25 MG TABLET
|
Facility
|
IP
|
$1,429.46
|
|
|
Service Code
|
NDC 00597015330
|
| Hospital Charge Code |
171966
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$628.96 |
| Max. Negotiated Rate |
$1,286.51 |
| Rate for Payer: Aetna American Axle |
$929.15
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1,000.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,072.10
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$628.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,072.10
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
IP
|
$45.41
|
|
|
Service Code
|
NDC 85412046162
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.98 |
| Max. Negotiated Rate |
$40.87 |
| Rate for Payer: Aetna American Axle |
$29.52
|
| Rate for Payer: Aetna Commercial |
$38.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.52
|
| Rate for Payer: Cash Price |
$36.33
|
| Rate for Payer: Cofinity Commercial |
$31.79
|
| Rate for Payer: Cofinity Commercial |
$39.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.33
|
| Rate for Payer: Healthscope Commercial |
$40.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.60
|
| Rate for Payer: PHP Commercial |
$38.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.52
|
| Rate for Payer: Priority Health SBD |
$28.61
|
| Rate for Payer: UMR Bronson Commercial |
$19.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.06
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
IP
|
$22.54
|
|
|
Service Code
|
NDC 33516140505
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$20.29 |
| Rate for Payer: Aetna American Axle |
$14.65
|
| Rate for Payer: Aetna Commercial |
$19.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.65
|
| Rate for Payer: Cash Price |
$18.03
|
| Rate for Payer: Cofinity Commercial |
$15.78
|
| Rate for Payer: Cofinity Commercial |
$19.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.03
|
| Rate for Payer: Healthscope Commercial |
$20.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.16
|
| Rate for Payer: PHP Commercial |
$19.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.65
|
| Rate for Payer: Priority Health SBD |
$14.20
|
| Rate for Payer: UMR Bronson Commercial |
$9.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.90
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
OP
|
$45.41
|
|
|
Service Code
|
NDC 85412046162
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$40.87 |
| Rate for Payer: Aetna American Axle |
$29.52
|
| Rate for Payer: Aetna Commercial |
$38.60
|
| Rate for Payer: Aetna Medicare |
$22.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.52
|
| Rate for Payer: BCBS Complete |
$18.16
|
| Rate for Payer: Cash Price |
$36.33
|
| Rate for Payer: Cofinity Commercial |
$31.79
|
| Rate for Payer: Cofinity Commercial |
$39.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.33
|
| Rate for Payer: Healthscope Commercial |
$40.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.60
|
| Rate for Payer: PHP Commercial |
$38.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.52
|
| Rate for Payer: Priority Health SBD |
$28.61
|
| Rate for Payer: UMR Bronson Commercial |
$16.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.06
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
OP
|
$22.54
|
|
|
Service Code
|
NDC 33516140505
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$20.29 |
| Rate for Payer: Aetna American Axle |
$14.65
|
| Rate for Payer: Aetna Commercial |
$19.16
|
| Rate for Payer: Aetna Medicare |
$11.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.65
|
| Rate for Payer: BCBS Complete |
$9.02
|
| Rate for Payer: Cash Price |
$18.03
|
| Rate for Payer: Cofinity Commercial |
$15.78
|
| Rate for Payer: Cofinity Commercial |
$19.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.03
|
| Rate for Payer: Healthscope Commercial |
$20.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.16
|
| Rate for Payer: PHP Commercial |
$19.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.65
|
| Rate for Payer: Priority Health SBD |
$14.20
|
| Rate for Payer: UMR Bronson Commercial |
$8.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.90
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
IP
|
$35.22
|
|
|
Service Code
|
NDC 00409161402
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$31.70 |
| Rate for Payer: Aetna American Axle |
$22.89
|
| Rate for Payer: Aetna Commercial |
$29.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.89
|
| Rate for Payer: Cash Price |
$28.18
|
| Rate for Payer: Cofinity Commercial |
$24.65
|
| Rate for Payer: Cofinity Commercial |
$30.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.18
|
| Rate for Payer: Healthscope Commercial |
$31.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.94
|
| Rate for Payer: PHP Commercial |
$29.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.89
|
| Rate for Payer: Priority Health SBD |
$22.19
|
| Rate for Payer: UMR Bronson Commercial |
$15.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.42
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
OP
|
$35.22
|
|
|
Service Code
|
NDC 00409161402
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$31.70 |
| Rate for Payer: Aetna American Axle |
$22.89
|
| Rate for Payer: Aetna Commercial |
$29.94
|
| Rate for Payer: Aetna Medicare |
$17.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.89
|
| Rate for Payer: BCBS Complete |
$14.09
|
| Rate for Payer: Cash Price |
$28.18
|
| Rate for Payer: Cofinity Commercial |
$24.65
|
| Rate for Payer: Cofinity Commercial |
$30.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.18
|
| Rate for Payer: Healthscope Commercial |
$31.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.94
|
| Rate for Payer: PHP Commercial |
$29.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.89
|
| Rate for Payer: Priority Health SBD |
$22.19
|
| Rate for Payer: UMR Bronson Commercial |
$13.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.42
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
IP
|
$50.99
|
|
|
Service Code
|
NDC 00264975706
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.44 |
| Max. Negotiated Rate |
$45.89 |
| Rate for Payer: Aetna American Axle |
$33.14
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$35.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.24
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$22.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.24
|
|
|
EMPTY CONTAINER BOTTLE
|
Facility
|
OP
|
$50.99
|
|
|
Service Code
|
NDC 00264975706
|
| Hospital Charge Code |
113131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.87 |
| Max. Negotiated Rate |
$45.89 |
| Rate for Payer: Aetna American Axle |
$33.14
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$35.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.24
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$18.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.24
|
|
|
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 |
$2,939.59 |
| Max. Negotiated Rate |
$7,150.35 |
| Rate for Payer: Aetna American Axle |
$5,164.14
|
| Rate for Payer: Aetna Commercial |
$6,753.11
|
| Rate for Payer: Aetna Medicare |
$3,972.42
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$5,561.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,958.62
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$2,939.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,958.62
|
|
|
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 |
$3,495.73 |
| Max. Negotiated Rate |
$7,150.35 |
| Rate for Payer: Aetna American Axle |
$5,164.14
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$5,561.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,958.62
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$3,495.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,958.62
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
OP
|
$6,646.02
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,459.03 |
| Max. Negotiated Rate |
$5,981.42 |
| Rate for Payer: Aetna American Axle |
$4,319.91
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$4,652.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,984.52
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$2,459.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,984.52
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
IP
|
$87.84
|
|
|
Service Code
|
NDC 42385095330
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.65 |
| Max. Negotiated Rate |
$79.06 |
| Rate for Payer: Aetna American Axle |
$57.10
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$61.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.88
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$38.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.88
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
OP
|
$223.06
|
|
|
Service Code
|
NDC 00904717207
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.53 |
| Max. Negotiated Rate |
$200.75 |
| Rate for Payer: Aetna American Axle |
$144.99
|
| Rate for Payer: Aetna Commercial |
$189.60
|
| Rate for Payer: Aetna Medicare |
$111.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.99
|
| Rate for Payer: BCBS Complete |
$89.22
|
| Rate for Payer: Cash Price |
$178.45
|
| Rate for Payer: Cofinity Commercial |
$156.14
|
| Rate for Payer: Cofinity Commercial |
$191.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.45
|
| Rate for Payer: Healthscope Commercial |
$200.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.60
|
| Rate for Payer: PHP Commercial |
$189.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.99
|
| Rate for Payer: Priority Health SBD |
$140.53
|
| Rate for Payer: UMR Bronson Commercial |
$82.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.30
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
IP
|
$223.06
|
|
|
Service Code
|
NDC 00904717207
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.15 |
| Max. Negotiated Rate |
$200.75 |
| Rate for Payer: Aetna American Axle |
$144.99
|
| Rate for Payer: Aetna Commercial |
$189.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.99
|
| Rate for Payer: Cash Price |
$178.45
|
| Rate for Payer: Cofinity Commercial |
$156.14
|
| Rate for Payer: Cofinity Commercial |
$191.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$178.45
|
| Rate for Payer: Healthscope Commercial |
$200.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$189.60
|
| Rate for Payer: PHP Commercial |
$189.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.99
|
| Rate for Payer: Priority Health SBD |
$140.53
|
| Rate for Payer: UMR Bronson Commercial |
$98.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.30
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
IP
|
$6,646.02
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,924.25 |
| Max. Negotiated Rate |
$5,981.42 |
| Rate for Payer: Aetna American Axle |
$4,319.91
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$4,652.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,984.52
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$2,924.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,984.52
|
|
|
EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET
|
Facility
|
OP
|
$87.84
|
|
|
Service Code
|
NDC 42385095330
|
| Hospital Charge Code |
39255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$79.06 |
| Rate for Payer: Aetna American Axle |
$57.10
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$61.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.88
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$32.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.88
|
|
|
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$23.74
|
|
|
Service Code
|
NDC 55390001010
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$21.37 |
| Rate for Payer: Aetna American Axle |
$15.43
|
| Rate for Payer: Aetna Commercial |
$20.18
|
| Rate for Payer: Aetna Medicare |
$11.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.43
|
| Rate for Payer: BCBS Complete |
$9.50
|
| Rate for Payer: Cash Price |
$18.99
|
| Rate for Payer: Cofinity Commercial |
$16.62
|
| Rate for Payer: Cofinity Commercial |
$20.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.99
|
| Rate for Payer: Healthscope Commercial |
$21.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.18
|
| Rate for Payer: PHP Commercial |
$20.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.43
|
| Rate for Payer: Priority Health SBD |
$14.96
|
| Rate for Payer: UMR Bronson Commercial |
$8.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.80
|
|
|
ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.38
|
|
|
Service Code
|
NDC 00143978710
|
| Hospital Charge Code |
9929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$17.44 |
| Rate for Payer: Aetna American Axle |
$12.60
|
| Rate for Payer: Aetna Commercial |
$16.47
|
| Rate for Payer: Aetna Medicare |
$9.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.60
|
| Rate for Payer: BCBS Complete |
$7.75
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cofinity Commercial |
$13.57
|
| Rate for Payer: Cofinity Commercial |
$16.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.50
|
| Rate for Payer: Healthscope Commercial |
$17.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.47
|
| Rate for Payer: PHP Commercial |
$16.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.60
|
| Rate for Payer: Priority Health SBD |
$12.21
|
| Rate for Payer: UMR Bronson Commercial |
$7.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.54
|
|
