Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$57.63

Service Code	NDC 68382-910-01
Hospital Charge Code	2622
Hospital Revenue Code	250
Min. Negotiated Rate	$40.34
Max. Negotiated Rate	$57.63
Rate for Payer: Aetna Commercial	$51.87
Rate for Payer: ASR ASR	$55.90
Rate for Payer: BCBS Trust/PPO	$44.68
Rate for Payer: BCN Commercial	$44.68
Rate for Payer: Cash Price	$46.10
Rate for Payer: Cofinity Commercial	$54.17
Rate for Payer: Encore Health Key Benefits Commercial	$46.10
Rate for Payer: Healthscope Commercial	$57.63
Rate for Payer: Healthscope Whirlpool	$55.90
Rate for Payer: Mclaren Commercial	$51.87
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$48.99
Rate for Payer: Priority Health Cigna Priority Health	$40.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$50.71

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$68.25

Service Code	NDC 63323-130-13
Hospital Charge Code	2622
Hospital Revenue Code	250
Min. Negotiated Rate	$47.78
Max. Negotiated Rate	$68.25
Rate for Payer: Aetna Commercial	$61.42
Rate for Payer: ASR ASR	$66.20
Rate for Payer: BCBS Trust/PPO	$52.91
Rate for Payer: BCN Commercial	$52.91
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cofinity Commercial	$64.16
Rate for Payer: Encore Health Key Benefits Commercial	$54.60
Rate for Payer: Healthscope Commercial	$68.25
Rate for Payer: Healthscope Whirlpool	$66.20
Rate for Payer: Mclaren Commercial	$61.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$58.01
Rate for Payer: Priority Health Cigna Priority Health	$47.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$60.06

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	$16.78
Rate for Payer: BCBS Complete	$6.40
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cash Price	$12.80
Rate for Payer: Priority Health Cigna Priority Health	$11.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.78
Rate for Payer: Priority Health Narrow Network	$16.78

DRUG TEST PRESUMPTIVE USING IMMUNOASSAY

Professional

Both

$80.00

Service Code	HCPCS G0479
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$67.44
Rate for Payer: BCBS Complete	$32.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$67.44
Rate for Payer: Priority Health Narrow Network	$67.44

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	$12.82
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$9.60
Rate for Payer: Priority Health Cigna Priority Health	$8.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12.82
Rate for Payer: Priority Health Narrow Network	$12.82

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE

Facility

$98.70

Service Code	NDC 57237-017-60
Hospital Charge Code	39275
Hospital Revenue Code	637
Min. Negotiated Rate	$69.09
Max. Negotiated Rate	$98.70
Rate for Payer: Aetna Commercial	$88.83
Rate for Payer: ASR ASR	$95.74
Rate for Payer: BCBS Trust/PPO	$76.52
Rate for Payer: BCN Commercial	$76.52
Rate for Payer: Cash Price	$78.96
Rate for Payer: Cofinity Commercial	$92.78
Rate for Payer: Encore Health Key Benefits Commercial	$78.96
Rate for Payer: Healthscope Commercial	$98.70
Rate for Payer: Healthscope Whirlpool	$95.74
Rate for Payer: Mclaren Commercial	$88.83
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$83.90
Rate for Payer: Priority Health Cigna Priority Health	$69.09
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$86.86

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$965.26

Service Code	NDC 0002-3240-30
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$675.68
Max. Negotiated Rate	$965.26
Rate for Payer: Aetna Commercial	$868.73
Rate for Payer: ASR ASR	$936.30
Rate for Payer: BCBS Trust/PPO	$748.37
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 Multiplan/Beech St/PHCS	$820.47
Rate for Payer: Priority Health Cigna Priority Health	$675.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$849.43

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$80.37

Service Code	NDC 57237-018-30
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$56.26
Max. Negotiated Rate	$80.37
Rate for Payer: Aetna Commercial	$72.33
Rate for Payer: ASR ASR	$77.96
Rate for Payer: BCBS Trust/PPO	$62.31
Rate for Payer: BCN Commercial	$62.31
Rate for Payer: Cash Price	$64.30
Rate for Payer: Cofinity Commercial	$75.55
Rate for Payer: Encore Health Key Benefits Commercial	$64.30
Rate for Payer: Healthscope Commercial	$80.37
Rate for Payer: Healthscope Whirlpool	$77.96
Rate for Payer: Mclaren Commercial	$72.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$68.31
Rate for Payer: Priority Health Cigna Priority Health	$56.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$70.73

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$270.72

Service Code	NDC 57237-018-90
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$189.50
Max. Negotiated Rate	$270.72
Rate for Payer: Aetna Commercial	$243.65
Rate for Payer: ASR ASR	$262.60
Rate for Payer: BCBS Trust/PPO	$209.89
Rate for Payer: BCN Commercial	$209.89
Rate for Payer: Cash Price	$216.58
Rate for Payer: Cofinity Commercial	$254.48
Rate for Payer: Encore Health Key Benefits Commercial	$216.58
Rate for Payer: Healthscope Commercial	$270.72
Rate for Payer: Healthscope Whirlpool	$262.60
Rate for Payer: Mclaren Commercial	$243.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$230.11
Rate for Payer: Priority Health Cigna Priority Health	$189.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$238.23

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE

Facility

$349.44

Service Code	NDC 0904-6453-61
Hospital Charge Code	39276
Hospital Revenue Code	637
Min. Negotiated Rate	$244.61
Max. Negotiated Rate	$349.44
Rate for Payer: Aetna Commercial	$314.50
Rate for Payer: ASR ASR	$338.96
Rate for Payer: BCBS Trust/PPO	$270.92
Rate for Payer: BCN Commercial	$270.92
Rate for Payer: Cash Price	$279.55
Rate for Payer: Cofinity Commercial	$328.47
Rate for Payer: Encore Health Key Benefits Commercial	$279.55
Rate for Payer: Healthscope Commercial	$349.44
Rate for Payer: Healthscope Whirlpool	$338.96
Rate for Payer: Mclaren Commercial	$314.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$297.02
Rate for Payer: Priority Health Cigna Priority Health	$244.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$307.51

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	$55.27
Max. Negotiated Rate	$78.96
Rate for Payer: Aetna Commercial	$71.06
Rate for Payer: ASR ASR	$76.59
Rate for Payer: BCBS Trust/PPO	$61.22
Rate for Payer: BCN Commercial	$61.22
Rate for Payer: Cash Price	$63.17
Rate for Payer: Cofinity Commercial	$74.22
Rate for Payer: Encore Health Key Benefits Commercial	$63.17
Rate for Payer: Healthscope Commercial	$78.96
Rate for Payer: Healthscope Whirlpool	$76.59
Rate for Payer: Mclaren Commercial	$71.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$67.12
Rate for Payer: Priority Health Cigna Priority Health	$55.27
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$69.48

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	$276.19
Max. Negotiated Rate	$394.56
Rate for Payer: Aetna Commercial	$355.10
Rate for Payer: ASR ASR	$382.72
Rate for Payer: BCBS Trust/PPO	$305.90
Rate for Payer: BCN Commercial	$305.90
Rate for Payer: Cash Price	$315.65
Rate for Payer: Cofinity Commercial	$370.89
Rate for Payer: Encore Health Key Benefits Commercial	$315.65
Rate for Payer: Healthscope Commercial	$394.56
Rate for Payer: Healthscope Whirlpool	$382.72
Rate for Payer: Mclaren Commercial	$355.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$335.38
Rate for Payer: Priority Health Cigna Priority Health	$276.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$347.21

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	$2.39
Max. Negotiated Rate	$3.42
Rate for Payer: Aetna Commercial	$3.08
Rate for Payer: ASR ASR	$3.32
Rate for Payer: BCBS Trust/PPO	$2.65
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 Multiplan/Beech St/PHCS	$2.91
Rate for Payer: Priority Health Cigna Priority Health	$2.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.01

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	$71.77
Max. Negotiated Rate	$102.53
Rate for Payer: Aetna Commercial	$92.28
Rate for Payer: ASR ASR	$99.45
Rate for Payer: BCBS Trust/PPO	$79.49
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 Multiplan/Beech St/PHCS	$87.15
Rate for Payer: Priority Health Cigna Priority Health	$71.77
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$90.23

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE

Facility

$965.26

Service Code	NDC 0002-3270-30
Hospital Charge Code	39277
Hospital Revenue Code	637
Min. Negotiated Rate	$675.68
Max. Negotiated Rate	$965.26
Rate for Payer: Aetna Commercial	$868.73
Rate for Payer: ASR ASR	$936.30
Rate for Payer: BCBS Trust/PPO	$748.37
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 Multiplan/Beech St/PHCS	$820.47
Rate for Payer: Priority Health Cigna Priority Health	$675.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$849.43

DYSEQUILIBRIUM

Facility

$9,982.32

Service Code	MS-DRG 149
Min. Negotiated Rate	$7,586.57
Max. Negotiated Rate	$9,982.32
Rate for Payer: Aetna Medicare	$7,985.86
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,982.32
Rate for Payer: Amish Plain Church Group Commercial	$9,982.32
Rate for Payer: BCBS MAPPO	$7,985.86
Rate for Payer: BCN Medicare Advantage	$7,985.86
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,985.86
Rate for Payer: Humana Choice PPO Medicare	$7,985.86
Rate for Payer: Mclaren Medicare	$7,985.86
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,385.15
Rate for Payer: MI Amish Medical Board Commercial	$9,183.74
Rate for Payer: PACE Medicare	$7,586.57
Rate for Payer: PACE SWMI	$7,985.86
Rate for Payer: PHP Commercial	$8,784.45
Rate for Payer: PHP Medicare Advantage	$7,985.86
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,561.95
Rate for Payer: Priority Health Medicare	$7,985.86
Rate for Payer: Priority Health Narrow Network	$7,649.56
Rate for Payer: Railroad Medicare Medicare	$7,985.86
Rate for Payer: UHC Medicare Advantage	$8,225.44
Rate for Payer: VA VA	$7,985.86

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$15,867.67

Service Code	MS-DRG 147
Min. Negotiated Rate	$11,536.52
Max. Negotiated Rate	$15,867.67
Rate for Payer: Aetna Medicare	$12,143.70
Rate for Payer: Allen County Amish Medical Aid Commercial	$15,179.62
Rate for Payer: Amish Plain Church Group Commercial	$15,179.62
Rate for Payer: BCBS MAPPO	$12,143.70
Rate for Payer: BCN Medicare Advantage	$12,143.70
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,143.70
Rate for Payer: Humana Choice PPO Medicare	$12,143.70
Rate for Payer: Mclaren Medicare	$12,143.70
Rate for Payer: Meridian Wellcare - Medicare Advantage	$12,750.88
Rate for Payer: MI Amish Medical Board Commercial	$13,965.26
Rate for Payer: PACE Medicare	$11,536.52
Rate for Payer: PACE SWMI	$12,143.70
Rate for Payer: PHP Commercial	$13,358.07
Rate for Payer: PHP Medicare Advantage	$12,143.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15,867.67
Rate for Payer: Priority Health Medicare	$12,143.70
Rate for Payer: Priority Health Narrow Network	$12,694.14
Rate for Payer: Railroad Medicare Medicare	$12,143.70
Rate for Payer: UHC Medicare Advantage	$12,508.01
Rate for Payer: VA VA	$12,143.70

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$27,105.24

Service Code	MS-DRG 146
Min. Negotiated Rate	$18,575.83
Max. Negotiated Rate	$27,105.24
Rate for Payer: Aetna Medicare	$19,553.51
Rate for Payer: Allen County Amish Medical Aid Commercial	$24,441.89
Rate for Payer: Amish Plain Church Group Commercial	$24,441.89
Rate for Payer: BCBS MAPPO	$19,553.51
Rate for Payer: BCN Medicare Advantage	$19,553.51
Rate for Payer: Health Alliance Plan Medicare Advantage	$19,553.51
Rate for Payer: Humana Choice PPO Medicare	$19,553.51
Rate for Payer: Mclaren Medicare	$19,553.51
Rate for Payer: Meridian Wellcare - Medicare Advantage	$20,531.19
Rate for Payer: MI Amish Medical Board Commercial	$22,486.54
Rate for Payer: PACE Medicare	$18,575.83
Rate for Payer: PACE SWMI	$19,553.51
Rate for Payer: PHP Commercial	$21,508.86
Rate for Payer: PHP Medicare Advantage	$19,553.51
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27,105.24
Rate for Payer: Priority Health Medicare	$19,553.51
Rate for Payer: Priority Health Narrow Network	$21,684.19
Rate for Payer: Railroad Medicare Medicare	$19,553.51
Rate for Payer: UHC Medicare Advantage	$20,140.12
Rate for Payer: VA VA	$19,553.51

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

Facility

$11,516.86

Service Code	MS-DRG 148
Min. Negotiated Rate	$8,752.82
Max. Negotiated Rate	$11,516.86
Rate for Payer: Aetna Medicare	$9,213.49
Rate for Payer: Allen County Amish Medical Aid Commercial	$11,516.86
Rate for Payer: Amish Plain Church Group Commercial	$11,516.86
Rate for Payer: BCBS MAPPO	$9,213.49
Rate for Payer: BCN Medicare Advantage	$9,213.49
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,213.49
Rate for Payer: Humana Choice PPO Medicare	$9,213.49
Rate for Payer: Mclaren Medicare	$9,213.49
Rate for Payer: Meridian Wellcare - Medicare Advantage	$9,674.16
Rate for Payer: MI Amish Medical Board Commercial	$10,595.51
Rate for Payer: PACE Medicare	$8,752.82
Rate for Payer: PACE SWMI	$9,213.49
Rate for Payer: PHP Commercial	$10,134.84
Rate for Payer: PHP Medicare Advantage	$9,213.49
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11,423.75
Rate for Payer: Priority Health Medicare	$9,213.49
Rate for Payer: Priority Health Narrow Network	$9,139.00
Rate for Payer: Railroad Medicare Medicare	$9,213.49
Rate for Payer: UHC Medicare Advantage	$9,489.89
Rate for Payer: VA VA	$9,213.49

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

Facility

$273,752.65

Service Code	MS-DRG 003
Min. Negotiated Rate	$173,077.70
Max. Negotiated Rate	$273,752.65
Rate for Payer: Aetna Medicare	$182,187.05
Rate for Payer: Allen County Amish Medical Aid Commercial	$227,733.81
Rate for Payer: Amish Plain Church Group Commercial	$227,733.81
Rate for Payer: BCBS MAPPO	$182,187.05
Rate for Payer: BCN Medicare Advantage	$182,187.05
Rate for Payer: Health Alliance Plan Medicare Advantage	$182,187.05
Rate for Payer: Humana Choice PPO Medicare	$182,187.05
Rate for Payer: Mclaren Medicare	$182,187.05
Rate for Payer: Meridian Wellcare - Medicare Advantage	$191,296.40
Rate for Payer: MI Amish Medical Board Commercial	$209,515.11
Rate for Payer: PACE Medicare	$173,077.70
Rate for Payer: PACE SWMI	$182,187.05
Rate for Payer: PHP Commercial	$200,405.76
Rate for Payer: PHP Medicare Advantage	$182,187.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$273,752.65
Rate for Payer: Priority Health Medicare	$182,187.05
Rate for Payer: Priority Health Narrow Network	$219,002.12
Rate for Payer: Railroad Medicare Medicare	$182,187.05
Rate for Payer: UHC Medicare Advantage	$187,652.66
Rate for Payer: VA VA	$182,187.05

EMPAGLIFLOZIN 10 MG TABLET

Facility

$2,102.78

Service Code	NDC 0597-0152-37
Hospital Charge Code	171967
Hospital Revenue Code	637
Min. Negotiated Rate	$1,471.95
Max. Negotiated Rate	$2,102.78
Rate for Payer: Aetna Commercial	$1,892.50
Rate for Payer: ASR ASR	$2,039.70
Rate for Payer: BCBS Trust/PPO	$1,630.29
Rate for Payer: BCN Commercial	$1,630.29
Rate for Payer: Cash Price	$1,682.23
Rate for Payer: Cofinity Commercial	$1,976.61
Rate for Payer: Encore Health Key Benefits Commercial	$1,682.22
Rate for Payer: Healthscope Commercial	$2,102.78
Rate for Payer: Healthscope Whirlpool	$2,039.70
Rate for Payer: Mclaren Commercial	$1,892.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,787.36
Rate for Payer: Priority Health Cigna Priority Health	$1,471.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,850.45

EMPTY CONTAINER BOTTLE

Facility

$44.52

Service Code	NDC 85412-461-62
Hospital Charge Code	113131
Hospital Revenue Code	250
Min. Negotiated Rate	$31.16
Max. Negotiated Rate	$44.52
Rate for Payer: Aetna Commercial	$40.07
Rate for Payer: ASR ASR	$43.18
Rate for Payer: BCBS Trust/PPO	$34.52
Rate for Payer: BCN Commercial	$34.52
Rate for Payer: Cash Price	$35.62
Rate for Payer: Cofinity Commercial	$41.85
Rate for Payer: Encore Health Key Benefits Commercial	$35.62
Rate for Payer: Healthscope Commercial	$44.52
Rate for Payer: Healthscope Whirlpool	$43.18
Rate for Payer: Mclaren Commercial	$40.07
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$37.84
Rate for Payer: Priority Health Cigna Priority Health	$31.16
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.18

EMPTY CONTAINER BOTTLE

Facility

$50.98

Service Code	NDC 0264-9757-06
Hospital Charge Code	113131
Hospital Revenue Code	250
Min. Negotiated Rate	$35.69
Max. Negotiated Rate	$50.98
Rate for Payer: Aetna Commercial	$45.88
Rate for Payer: ASR ASR	$49.45
Rate for Payer: BCBS Trust/PPO	$39.52
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 Multiplan/Beech St/PHCS	$43.33
Rate for Payer: Priority Health Cigna Priority Health	$35.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$44.86

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET

Facility

$86.26

Service Code	NDC 42385-953-30
Hospital Charge Code	39255
Hospital Revenue Code	637
Min. Negotiated Rate	$60.38
Max. Negotiated Rate	$86.26
Rate for Payer: Aetna Commercial	$77.63
Rate for Payer: ASR ASR	$83.67
Rate for Payer: BCBS Trust/PPO	$66.88
Rate for Payer: BCN Commercial	$66.88
Rate for Payer: Cash Price	$69.00
Rate for Payer: Cofinity Commercial	$81.08
Rate for Payer: Encore Health Key Benefits Commercial	$69.01
Rate for Payer: Healthscope Commercial	$86.26
Rate for Payer: Healthscope Whirlpool	$83.67
Rate for Payer: Mclaren Commercial	$77.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$73.32
Rate for Payer: Priority Health Cigna Priority Health	$60.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$75.91

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET

Facility

$6,646.01

Service Code	NDC 61958-0701-1
Hospital Charge Code	39255
Hospital Revenue Code	637
Min. Negotiated Rate	$4,652.21
Max. Negotiated Rate	$6,646.01
Rate for Payer: Aetna Commercial	$5,981.41
Rate for Payer: ASR ASR	$6,446.63
Rate for Payer: BCBS Trust/PPO	$5,152.65
Rate for Payer: BCN Commercial	$5,152.65
Rate for Payer: Cash Price	$5,316.81
Rate for Payer: Cofinity Commercial	$6,247.25
Rate for Payer: Encore Health Key Benefits Commercial	$5,316.81
Rate for Payer: Healthscope Commercial	$6,646.01
Rate for Payer: Healthscope Whirlpool	$6,446.63
Rate for Payer: Mclaren Commercial	$5,981.41
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5,649.11
Rate for Payer: Priority Health Cigna Priority Health	$4,652.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,848.49

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