Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

DRUG TEST PRESUMPTIVE READ BY INSTR ASSISTED DIRECT OPTICAL OBS

Professional

Both

$16.00

Service Code	HCPCS G0478
Min. Negotiated Rate	$6.40
Max. Negotiated Rate	$10.40
Rate for Payer: Aetna Medicare	$8.00
Rate for Payer: BCBS Complete	$6.40
Rate for Payer: Cash Price	$12.80
Rate for Payer: Priority Health Cigna Priority Health	$10.40

DRUG TEST PRESUMPTIVE USING IMMUNOASSAY

Professional

Both

$82.00

Service Code	HCPCS G0479
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$53.30
Rate for Payer: Aetna Medicare	$41.00
Rate for Payer: BCBS Complete	$32.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Priority Health Cigna Priority Health	$53.30

DRUG TEST(S), PRESUMPTIVE READ BY DIRECT OPTICAL OBSERVATION

Professional

Both

$12.00

Service Code	HCPCS G0477
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$7.80
Rate for Payer: Aetna Medicare	$6.00
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: Cash Price	$9.60
Rate for Payer: Priority Health Cigna Priority Health	$7.80

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$101.52

Service Code	NDC 57237001760
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$40.61
Max. Negotiated Rate	$101.52
Rate for Payer: Aetna Commercial	$91.37
Rate for Payer: Aetna Medicare	$50.76
Rate for Payer: ASR ASR	$98.47
Rate for Payer: ASR Commercial	$98.47
Rate for Payer: BCBS Complete	$40.61
Rate for Payer: BCBS Trust/PPO	$83.13
Rate for Payer: BCN Commercial	$78.71
Rate for Payer: Cash Price	$81.22
Rate for Payer: Cofinity Commercial	$95.43
Rate for Payer: Encore Health Key Benefits Commercial	$81.22
Rate for Payer: Healthscope Commercial	$101.52
Rate for Payer: Healthscope Whirlpool	$98.47
Rate for Payer: Mclaren Commercial	$91.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.29
Rate for Payer: Nomi Health Commercial	$83.25
Rate for Payer: Priority Health Cigna Priority Health	$65.99
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$88.95
Rate for Payer: Priority Health Narrow Network	$71.17
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.34

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$101.52

Service Code	NDC 57237001760
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$65.99
Max. Negotiated Rate	$101.52
Rate for Payer: Aetna Commercial	$91.37
Rate for Payer: ASR ASR	$98.47
Rate for Payer: ASR Commercial	$98.47
Rate for Payer: BCBS Trust/PPO	$82.73
Rate for Payer: BCN Commercial	$78.71
Rate for Payer: Cash Price	$81.22
Rate for Payer: Cofinity Commercial	$95.43
Rate for Payer: Encore Health Key Benefits Commercial	$81.22
Rate for Payer: Healthscope Commercial	$101.52
Rate for Payer: Healthscope Whirlpool	$98.47
Rate for Payer: Mclaren Commercial	$91.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.29
Rate for Payer: Nomi Health Commercial	$83.25
Rate for Payer: Priority Health Cigna Priority Health	$65.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.34

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$965.26

Service Code	NDC 00002324030
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$627.42
Max. Negotiated Rate	$965.26
Rate for Payer: Aetna Commercial	$868.73
Rate for Payer: ASR ASR	$936.30
Rate for Payer: ASR Commercial	$936.30
Rate for Payer: BCBS Trust/PPO	$786.59
Rate for Payer: BCN Commercial	$748.37
Rate for Payer: Cash Price	$772.20
Rate for Payer: Cofinity Commercial	$907.34
Rate for Payer: Encore Health Key Benefits Commercial	$772.21
Rate for Payer: Healthscope Commercial	$965.26
Rate for Payer: Healthscope Whirlpool	$936.30
Rate for Payer: Mclaren Commercial	$868.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$820.47
Rate for Payer: Nomi Health Commercial	$791.51
Rate for Payer: Priority Health Cigna Priority Health	$627.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$849.43

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$304.56

Service Code	NDC 57237001890
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$197.96
Max. Negotiated Rate	$304.56
Rate for Payer: Aetna Commercial	$274.10
Rate for Payer: ASR ASR	$295.42
Rate for Payer: ASR Commercial	$295.42
Rate for Payer: BCBS Trust/PPO	$248.19
Rate for Payer: BCN Commercial	$236.13
Rate for Payer: Cash Price	$243.65
Rate for Payer: Cofinity Commercial	$286.29
Rate for Payer: Encore Health Key Benefits Commercial	$243.65
Rate for Payer: Healthscope Commercial	$304.56
Rate for Payer: Healthscope Whirlpool	$295.42
Rate for Payer: Mclaren Commercial	$274.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$258.88
Rate for Payer: Nomi Health Commercial	$249.74
Rate for Payer: Priority Health Cigna Priority Health	$197.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$268.01

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$119.14

Service Code	NDC 57237001830
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$77.44
Max. Negotiated Rate	$119.14
Rate for Payer: Aetna Commercial	$107.23
Rate for Payer: ASR ASR	$115.57
Rate for Payer: ASR Commercial	$115.57
Rate for Payer: BCBS Trust/PPO	$97.09
Rate for Payer: BCN Commercial	$92.37
Rate for Payer: Cash Price	$95.32
Rate for Payer: Cofinity Commercial	$111.99
Rate for Payer: Encore Health Key Benefits Commercial	$95.31
Rate for Payer: Healthscope Commercial	$119.14
Rate for Payer: Healthscope Whirlpool	$115.57
Rate for Payer: Mclaren Commercial	$107.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$101.27
Rate for Payer: Nomi Health Commercial	$97.69
Rate for Payer: Priority Health Cigna Priority Health	$77.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$104.84

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$304.56

Service Code	NDC 57237001890
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$121.82
Max. Negotiated Rate	$304.56
Rate for Payer: Aetna Commercial	$274.10
Rate for Payer: Aetna Medicare	$152.28
Rate for Payer: ASR ASR	$295.42
Rate for Payer: ASR Commercial	$295.42
Rate for Payer: BCBS Complete	$121.82
Rate for Payer: BCBS Trust/PPO	$249.40
Rate for Payer: BCN Commercial	$236.13
Rate for Payer: Cash Price	$243.65
Rate for Payer: Cofinity Commercial	$286.29
Rate for Payer: Encore Health Key Benefits Commercial	$243.65
Rate for Payer: Healthscope Commercial	$304.56
Rate for Payer: Healthscope Whirlpool	$295.42
Rate for Payer: Mclaren Commercial	$274.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$258.88
Rate for Payer: Nomi Health Commercial	$249.74
Rate for Payer: Priority Health Cigna Priority Health	$197.96
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$266.86
Rate for Payer: Priority Health Narrow Network	$213.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$268.01

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$965.26

Service Code	NDC 00002324030
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$386.10
Max. Negotiated Rate	$965.26
Rate for Payer: Aetna Commercial	$868.73
Rate for Payer: Aetna Medicare	$482.63
Rate for Payer: ASR ASR	$936.30
Rate for Payer: ASR Commercial	$936.30
Rate for Payer: BCBS Complete	$386.10
Rate for Payer: BCBS Trust/PPO	$790.45
Rate for Payer: BCN Commercial	$748.37
Rate for Payer: Cash Price	$772.20
Rate for Payer: Cofinity Commercial	$907.34
Rate for Payer: Encore Health Key Benefits Commercial	$772.21
Rate for Payer: Healthscope Commercial	$965.26
Rate for Payer: Healthscope Whirlpool	$936.30
Rate for Payer: Mclaren Commercial	$868.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$820.47
Rate for Payer: Nomi Health Commercial	$791.51
Rate for Payer: Priority Health Cigna Priority Health	$627.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$845.76
Rate for Payer: Priority Health Narrow Network	$676.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$849.43

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$119.14

Service Code	NDC 57237001830
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$47.66
Max. Negotiated Rate	$119.14
Rate for Payer: Aetna Commercial	$107.23
Rate for Payer: Aetna Medicare	$59.57
Rate for Payer: ASR ASR	$115.57
Rate for Payer: ASR Commercial	$115.57
Rate for Payer: BCBS Complete	$47.66
Rate for Payer: BCBS Trust/PPO	$97.56
Rate for Payer: BCN Commercial	$92.37
Rate for Payer: Cash Price	$95.32
Rate for Payer: Cofinity Commercial	$111.99
Rate for Payer: Encore Health Key Benefits Commercial	$95.31
Rate for Payer: Healthscope Commercial	$119.14
Rate for Payer: Healthscope Whirlpool	$115.57
Rate for Payer: Mclaren Commercial	$107.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$101.27
Rate for Payer: Nomi Health Commercial	$97.69
Rate for Payer: Priority Health Cigna Priority Health	$77.44
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$104.39
Rate for Payer: Priority Health Narrow Network	$83.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$104.84

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$965.26

Service Code	NDC 00002327030
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$627.42
Max. Negotiated Rate	$965.26
Rate for Payer: Aetna Commercial	$868.73
Rate for Payer: ASR ASR	$936.30
Rate for Payer: ASR Commercial	$936.30
Rate for Payer: BCBS Trust/PPO	$786.59
Rate for Payer: BCN Commercial	$748.37
Rate for Payer: Cash Price	$772.20
Rate for Payer: Cofinity Commercial	$907.34
Rate for Payer: Encore Health Key Benefits Commercial	$772.21
Rate for Payer: Healthscope Commercial	$965.26
Rate for Payer: Healthscope Whirlpool	$936.30
Rate for Payer: Mclaren Commercial	$868.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$820.47
Rate for Payer: Nomi Health Commercial	$791.51
Rate for Payer: Priority Health Cigna Priority Health	$627.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$849.43

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$114.92

Service Code	NDC 57237001930
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$114.92
Rate for Payer: Aetna Commercial	$103.43
Rate for Payer: ASR ASR	$111.47
Rate for Payer: ASR Commercial	$111.47
Rate for Payer: BCBS Trust/PPO	$93.65
Rate for Payer: BCN Commercial	$89.10
Rate for Payer: Cash Price	$91.93
Rate for Payer: Cofinity Commercial	$108.02
Rate for Payer: Encore Health Key Benefits Commercial	$91.94
Rate for Payer: Healthscope Commercial	$114.92
Rate for Payer: Healthscope Whirlpool	$111.47
Rate for Payer: Mclaren Commercial	$103.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$97.68
Rate for Payer: Nomi Health Commercial	$94.23
Rate for Payer: Priority Health Cigna Priority Health	$74.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$101.13

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$114.92

Service Code	NDC 57237001930
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$45.97
Max. Negotiated Rate	$114.92
Rate for Payer: Aetna Commercial	$103.43
Rate for Payer: Aetna Medicare	$57.46
Rate for Payer: ASR ASR	$111.47
Rate for Payer: ASR Commercial	$111.47
Rate for Payer: BCBS Complete	$45.97
Rate for Payer: BCBS Trust/PPO	$94.11
Rate for Payer: BCN Commercial	$89.10
Rate for Payer: Cash Price	$91.93
Rate for Payer: Cofinity Commercial	$108.02
Rate for Payer: Encore Health Key Benefits Commercial	$91.94
Rate for Payer: Healthscope Commercial	$114.92
Rate for Payer: Healthscope Whirlpool	$111.47
Rate for Payer: Mclaren Commercial	$103.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$97.68
Rate for Payer: Nomi Health Commercial	$94.23
Rate for Payer: Priority Health Cigna Priority Health	$74.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$100.69
Rate for Payer: Priority Health Narrow Network	$80.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$101.13

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$965.26

Service Code	NDC 00002327030
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$386.10
Max. Negotiated Rate	$965.26
Rate for Payer: Aetna Commercial	$868.73
Rate for Payer: Aetna Medicare	$482.63
Rate for Payer: ASR ASR	$936.30
Rate for Payer: ASR Commercial	$936.30
Rate for Payer: BCBS Complete	$386.10
Rate for Payer: BCBS Trust/PPO	$790.45
Rate for Payer: BCN Commercial	$748.37
Rate for Payer: Cash Price	$772.20
Rate for Payer: Cofinity Commercial	$907.34
Rate for Payer: Encore Health Key Benefits Commercial	$772.21
Rate for Payer: Healthscope Commercial	$965.26
Rate for Payer: Healthscope Whirlpool	$936.30
Rate for Payer: Mclaren Commercial	$868.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$820.47
Rate for Payer: Nomi Health Commercial	$791.51
Rate for Payer: Priority Health Cigna Priority Health	$627.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$845.76
Rate for Payer: Priority Health Narrow Network	$676.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$849.43

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$102.53

Service Code	NDC 50268028813
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$66.64
Max. Negotiated Rate	$102.53
Rate for Payer: Aetna Commercial	$92.28
Rate for Payer: ASR ASR	$99.45
Rate for Payer: ASR Commercial	$99.45
Rate for Payer: BCBS Trust/PPO	$83.55
Rate for Payer: BCN Commercial	$79.49
Rate for Payer: Cash Price	$82.02
Rate for Payer: Cofinity Commercial	$96.38
Rate for Payer: Encore Health Key Benefits Commercial	$82.02
Rate for Payer: Healthscope Commercial	$102.53
Rate for Payer: Healthscope Whirlpool	$99.45
Rate for Payer: Mclaren Commercial	$92.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$87.15
Rate for Payer: Nomi Health Commercial	$84.07
Rate for Payer: Priority Health Cigna Priority Health	$66.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$90.23

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$3.42

Service Code	NDC 50268028811
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$1.37
Max. Negotiated Rate	$3.42
Rate for Payer: Aetna Commercial	$3.08
Rate for Payer: Aetna Medicare	$1.71
Rate for Payer: ASR ASR	$3.32
Rate for Payer: ASR Commercial	$3.32
Rate for Payer: BCBS Complete	$1.37
Rate for Payer: BCBS Trust/PPO	$2.80
Rate for Payer: BCN Commercial	$2.65
Rate for Payer: Cash Price	$2.73
Rate for Payer: Cofinity Commercial	$3.21
Rate for Payer: Encore Health Key Benefits Commercial	$2.74
Rate for Payer: Healthscope Commercial	$3.42
Rate for Payer: Healthscope Whirlpool	$3.32
Rate for Payer: Mclaren Commercial	$3.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.91
Rate for Payer: Nomi Health Commercial	$2.80
Rate for Payer: Priority Health Cigna Priority Health	$2.22
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.00
Rate for Payer: Priority Health Narrow Network	$2.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.01

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$3.42

Service Code	NDC 50268028811
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.42
Rate for Payer: Aetna Commercial	$3.08
Rate for Payer: ASR ASR	$3.32
Rate for Payer: ASR Commercial	$3.32
Rate for Payer: BCBS Trust/PPO	$2.79
Rate for Payer: BCN Commercial	$2.65
Rate for Payer: Cash Price	$2.73
Rate for Payer: Cofinity Commercial	$3.21
Rate for Payer: Encore Health Key Benefits Commercial	$2.74
Rate for Payer: Healthscope Commercial	$3.42
Rate for Payer: Healthscope Whirlpool	$3.32
Rate for Payer: Mclaren Commercial	$3.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.91
Rate for Payer: Nomi Health Commercial	$2.80
Rate for Payer: Priority Health Cigna Priority Health	$2.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.01

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$102.53

Service Code	NDC 50268028813
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$41.01
Max. Negotiated Rate	$102.53
Rate for Payer: Aetna Commercial	$92.28
Rate for Payer: Aetna Medicare	$51.27
Rate for Payer: ASR ASR	$99.45
Rate for Payer: ASR Commercial	$99.45
Rate for Payer: BCBS Complete	$41.01
Rate for Payer: BCBS Trust/PPO	$83.96
Rate for Payer: BCN Commercial	$79.49
Rate for Payer: Cash Price	$82.02
Rate for Payer: Cofinity Commercial	$96.38
Rate for Payer: Encore Health Key Benefits Commercial	$82.02
Rate for Payer: Healthscope Commercial	$102.53
Rate for Payer: Healthscope Whirlpool	$99.45
Rate for Payer: Mclaren Commercial	$92.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$87.15
Rate for Payer: Nomi Health Commercial	$84.07
Rate for Payer: Priority Health Cigna Priority Health	$66.64
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$89.84
Rate for Payer: Priority Health Narrow Network	$71.87
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$90.23

EMOLLIENT COMBINATION NO.117 TOPICAL CREAM

Facility

$18.95

Service Code	NDC 72140063382
Hospital Charge Code	203300
Hospital Revenue Code	637
Min. Negotiated Rate	$12.32
Max. Negotiated Rate	$18.95
Rate for Payer: Aetna Commercial	$17.05
Rate for Payer: ASR ASR	$18.38
Rate for Payer: ASR Commercial	$18.38
Rate for Payer: BCBS Trust/PPO	$15.44
Rate for Payer: BCN Commercial	$14.69
Rate for Payer: Cash Price	$15.16
Rate for Payer: Cofinity Commercial	$17.81
Rate for Payer: Encore Health Key Benefits Commercial	$15.16
Rate for Payer: Healthscope Commercial	$18.95
Rate for Payer: Healthscope Whirlpool	$18.38
Rate for Payer: Mclaren Commercial	$17.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.11
Rate for Payer: Nomi Health Commercial	$15.54
Rate for Payer: Priority Health Cigna Priority Health	$12.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$16.68

EMOLLIENT COMBINATION NO.117 TOPICAL CREAM

Facility

$18.95

Service Code	NDC 72140063382
Hospital Charge Code	203300
Hospital Revenue Code	637
Min. Negotiated Rate	$7.58
Max. Negotiated Rate	$18.95
Rate for Payer: Aetna Commercial	$17.05
Rate for Payer: Aetna Medicare	$9.47
Rate for Payer: ASR ASR	$18.38
Rate for Payer: ASR Commercial	$18.38
Rate for Payer: BCBS Complete	$7.58
Rate for Payer: BCBS Trust/PPO	$15.52
Rate for Payer: BCN Commercial	$14.69
Rate for Payer: Cash Price	$15.16
Rate for Payer: Cofinity Commercial	$17.81
Rate for Payer: Encore Health Key Benefits Commercial	$15.16
Rate for Payer: Healthscope Commercial	$18.95
Rate for Payer: Healthscope Whirlpool	$18.38
Rate for Payer: Mclaren Commercial	$17.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.11
Rate for Payer: Nomi Health Commercial	$15.54
Rate for Payer: Priority Health Cigna Priority Health	$12.32
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.60
Rate for Payer: Priority Health Narrow Network	$13.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$16.68

EMPAGLIFLOZIN 10 MG TABLET

Facility

$2,165.83

Service Code	NDC 00597015237
Hospital Charge Code	171967
Hospital Revenue Code	637
Min. Negotiated Rate	$866.33
Max. Negotiated Rate	$2,165.83
Rate for Payer: Aetna Commercial	$1,949.25
Rate for Payer: Aetna Medicare	$1,082.91
Rate for Payer: ASR ASR	$2,100.86
Rate for Payer: ASR Commercial	$2,100.86
Rate for Payer: BCBS Complete	$866.33
Rate for Payer: BCBS Trust/PPO	$1,773.60
Rate for Payer: BCN Commercial	$1,679.17
Rate for Payer: Cash Price	$1,732.67
Rate for Payer: Cofinity Commercial	$2,035.88
Rate for Payer: Encore Health Key Benefits Commercial	$1,732.66
Rate for Payer: Healthscope Commercial	$2,165.83
Rate for Payer: Healthscope Whirlpool	$2,100.86
Rate for Payer: Mclaren Commercial	$1,949.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,840.96
Rate for Payer: Nomi Health Commercial	$1,775.98
Rate for Payer: Priority Health Cigna Priority Health	$1,407.79
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,897.70
Rate for Payer: Priority Health Narrow Network	$1,518.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,905.93

EMPAGLIFLOZIN 10 MG TABLET

Facility

$2,165.83

Service Code	NDC 00597015237
Hospital Charge Code	171967
Hospital Revenue Code	637
Min. Negotiated Rate	$1,407.79
Max. Negotiated Rate	$2,165.83
Rate for Payer: Aetna Commercial	$1,949.25
Rate for Payer: ASR ASR	$2,100.86
Rate for Payer: ASR Commercial	$2,100.86
Rate for Payer: BCBS Trust/PPO	$1,764.93
Rate for Payer: BCN Commercial	$1,679.17
Rate for Payer: Cash Price	$1,732.67
Rate for Payer: Cofinity Commercial	$2,035.88
Rate for Payer: Encore Health Key Benefits Commercial	$1,732.66
Rate for Payer: Healthscope Commercial	$2,165.83
Rate for Payer: Healthscope Whirlpool	$2,100.86
Rate for Payer: Mclaren Commercial	$1,949.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,840.96
Rate for Payer: Nomi Health Commercial	$1,775.98
Rate for Payer: Priority Health Cigna Priority Health	$1,407.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,905.93

EMPTY CONTAINER BOTTLE

Facility

$45.41

Service Code	NDC 85412046162
Hospital Charge Code	113131
Hospital Revenue Code	250
Min. Negotiated Rate	$29.52
Max. Negotiated Rate	$45.41
Rate for Payer: Aetna Commercial	$40.87
Rate for Payer: ASR ASR	$44.05
Rate for Payer: ASR Commercial	$44.05
Rate for Payer: BCBS Trust/PPO	$37.00
Rate for Payer: BCN Commercial	$35.21
Rate for Payer: Cash Price	$36.33
Rate for Payer: Cofinity Commercial	$42.69
Rate for Payer: Encore Health Key Benefits Commercial	$36.33
Rate for Payer: Healthscope Commercial	$45.41
Rate for Payer: Healthscope Whirlpool	$44.05
Rate for Payer: Mclaren Commercial	$40.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.60
Rate for Payer: Nomi Health Commercial	$37.24
Rate for Payer: Priority Health Cigna Priority Health	$29.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.96

EMPTY CONTAINER BOTTLE

Facility

$50.98

Service Code	NDC 00264975706
Hospital Charge Code	113131
Hospital Revenue Code	250
Min. Negotiated Rate	$20.39
Max. Negotiated Rate	$50.98
Rate for Payer: Aetna Commercial	$45.88
Rate for Payer: Aetna Medicare	$25.49
Rate for Payer: ASR ASR	$49.45
Rate for Payer: ASR Commercial	$49.45
Rate for Payer: BCBS Complete	$20.39
Rate for Payer: BCBS Trust/PPO	$41.75
Rate for Payer: BCN Commercial	$39.52
Rate for Payer: Cash Price	$40.79
Rate for Payer: Cofinity Commercial	$47.92
Rate for Payer: Encore Health Key Benefits Commercial	$40.78
Rate for Payer: Healthscope Commercial	$50.98
Rate for Payer: Healthscope Whirlpool	$49.45
Rate for Payer: Mclaren Commercial	$45.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.33
Rate for Payer: Nomi Health Commercial	$41.80
Rate for Payer: Priority Health Cigna Priority Health	$33.14
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44.67
Rate for Payer: Priority Health Narrow Network	$35.74
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$44.86

Know your out-of-pocket cost for care.

All Charges