Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET

Facility

$10.65

Service Code	NDC 68084039611
Hospital Charge Code	8958
Hospital Revenue Code	637
Min. Negotiated Rate	$4.26
Max. Negotiated Rate	$9.58
Rate for Payer: Aetna Commercial	$9.05
Rate for Payer: Aetna Medicare	$5.32
Rate for Payer: Aetna New Business (MI Preferred)	$6.92
Rate for Payer: BCBS Complete	$4.26
Rate for Payer: Cash Price	$8.52
Rate for Payer: Cofinity Commercial	$7.46
Rate for Payer: Cofinity Commercial	$9.16
Rate for Payer: Cofinity Medicare Advantage	$7.46
Rate for Payer: Encore Health Key Benefits Commercial	$8.52
Rate for Payer: Healthscope Commercial	$9.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.05
Rate for Payer: PHP Commercial	$9.05
Rate for Payer: Priority Health Cigna Priority Health	$6.92
Rate for Payer: Priority Health SBD	$6.71

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET

Facility

$371.35

Service Code	NDC 00904693806
Hospital Charge Code	8958
Hospital Revenue Code	637
Min. Negotiated Rate	$233.95
Max. Negotiated Rate	$334.22
Rate for Payer: Aetna Commercial	$315.65
Rate for Payer: Aetna New Business (MI Preferred)	$241.38
Rate for Payer: Cash Price	$297.08
Rate for Payer: Cofinity Commercial	$259.94
Rate for Payer: Cofinity Commercial	$319.36
Rate for Payer: Cofinity Medicare Advantage	$259.94
Rate for Payer: Encore Health Key Benefits Commercial	$297.08
Rate for Payer: Healthscope Commercial	$334.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$315.65
Rate for Payer: PHP Commercial	$315.65
Rate for Payer: Priority Health Cigna Priority Health	$241.38
Rate for Payer: Priority Health SBD	$233.95

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET

Facility

$8.17

Service Code	NDC 60687067211
Hospital Charge Code	8958
Hospital Revenue Code	637
Min. Negotiated Rate	$5.15
Max. Negotiated Rate	$7.35
Rate for Payer: Aetna Commercial	$6.94
Rate for Payer: Aetna New Business (MI Preferred)	$5.31
Rate for Payer: Cash Price	$6.54
Rate for Payer: Cofinity Commercial	$5.72
Rate for Payer: Cofinity Commercial	$7.03
Rate for Payer: Cofinity Medicare Advantage	$5.72
Rate for Payer: Encore Health Key Benefits Commercial	$6.54
Rate for Payer: Healthscope Commercial	$7.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.94
Rate for Payer: PHP Commercial	$6.94
Rate for Payer: Priority Health Cigna Priority Health	$5.31
Rate for Payer: Priority Health SBD	$5.15

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET

Facility

$735.70

Service Code	NDC 00603254421
Hospital Charge Code	8958
Hospital Revenue Code	637
Min. Negotiated Rate	$463.49
Max. Negotiated Rate	$662.13
Rate for Payer: Aetna Commercial	$625.34
Rate for Payer: Aetna New Business (MI Preferred)	$478.20
Rate for Payer: Cash Price	$588.56
Rate for Payer: Cofinity Commercial	$514.99
Rate for Payer: Cofinity Commercial	$632.70
Rate for Payer: Cofinity Medicare Advantage	$514.99
Rate for Payer: Encore Health Key Benefits Commercial	$588.56
Rate for Payer: Healthscope Commercial	$662.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$625.34
Rate for Payer: PHP Commercial	$625.34
Rate for Payer: Priority Health Cigna Priority Health	$478.20
Rate for Payer: Priority Health SBD	$463.49

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET

Facility

$10.65

Service Code	NDC 68084039611
Hospital Charge Code	8958
Hospital Revenue Code	637
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$9.58
Rate for Payer: Aetna Commercial	$9.05
Rate for Payer: Aetna New Business (MI Preferred)	$6.92
Rate for Payer: Cash Price	$8.52
Rate for Payer: Cofinity Commercial	$7.46
Rate for Payer: Cofinity Commercial	$9.16
Rate for Payer: Cofinity Medicare Advantage	$7.46
Rate for Payer: Encore Health Key Benefits Commercial	$8.52
Rate for Payer: Healthscope Commercial	$9.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.05
Rate for Payer: PHP Commercial	$9.05
Rate for Payer: Priority Health Cigna Priority Health	$6.92
Rate for Payer: Priority Health SBD	$6.71

BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET

Facility

$408.45

Service Code	NDC 60687067265
Hospital Charge Code	8958
Hospital Revenue Code	637
Min. Negotiated Rate	$163.38
Max. Negotiated Rate	$367.60
Rate for Payer: Aetna Commercial	$347.18
Rate for Payer: Aetna Medicare	$204.22
Rate for Payer: Aetna New Business (MI Preferred)	$265.49
Rate for Payer: BCBS Complete	$163.38
Rate for Payer: Cash Price	$326.76
Rate for Payer: Cofinity Commercial	$285.92
Rate for Payer: Cofinity Commercial	$351.27
Rate for Payer: Cofinity Medicare Advantage	$285.92
Rate for Payer: Encore Health Key Benefits Commercial	$326.76
Rate for Payer: Healthscope Commercial	$367.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$347.18
Rate for Payer: PHP Commercial	$347.18
Rate for Payer: Priority Health Cigna Priority Health	$265.49
Rate for Payer: Priority Health SBD	$257.32

BUTORPHANOL 2 MG/ML INJECTION SOLUTION

Facility

$43.43

Service Code	HCPCS J0595
Hospital Charge Code	9334
Hospital Revenue Code	636
Min. Negotiated Rate	$11.45
Max. Negotiated Rate	$39.09
Rate for Payer: Aetna Commercial	$36.92
Rate for Payer: Aetna Medicare	$21.72
Rate for Payer: Aetna New Business (MI Preferred)	$28.23
Rate for Payer: BCBS Complete	$17.37
Rate for Payer: BCBS Trust/PPO	$11.45
Rate for Payer: BCN Commercial	$11.45
Rate for Payer: Cash Price	$34.74
Rate for Payer: Cash Price	$34.74
Rate for Payer: Cofinity Commercial	$30.40
Rate for Payer: Cofinity Commercial	$37.35
Rate for Payer: Cofinity Medicare Advantage	$30.40
Rate for Payer: Encore Health Key Benefits Commercial	$34.74
Rate for Payer: Healthscope Commercial	$39.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.92
Rate for Payer: PHP Commercial	$36.92
Rate for Payer: Priority Health Cigna Priority Health	$28.23
Rate for Payer: Priority Health SBD	$27.36

BUTORPHANOL 2 MG/ML INJECTION SOLUTION

Facility

$43.43

Service Code	HCPCS J0595
Hospital Charge Code	9334
Hospital Revenue Code	636
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$39.09
Rate for Payer: Aetna Commercial	$36.92
Rate for Payer: Aetna New Business (MI Preferred)	$28.23
Rate for Payer: Cash Price	$34.74
Rate for Payer: Cofinity Commercial	$30.40
Rate for Payer: Cofinity Commercial	$37.35
Rate for Payer: Cofinity Medicare Advantage	$30.40
Rate for Payer: Encore Health Key Benefits Commercial	$34.74
Rate for Payer: Healthscope Commercial	$39.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.92
Rate for Payer: PHP Commercial	$36.92
Rate for Payer: Priority Health Cigna Priority Health	$28.23
Rate for Payer: Priority Health SBD	$27.36

CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION

Facility

$64,470.71

Service Code	HCPCS J9043
Hospital Charge Code	105644
Hospital Revenue Code	636
Min. Negotiated Rate	$40,616.55
Max. Negotiated Rate	$58,023.64
Rate for Payer: Aetna Commercial	$54,800.10
Rate for Payer: Aetna New Business (MI Preferred)	$41,905.96
Rate for Payer: Cash Price	$51,576.57
Rate for Payer: Cofinity Commercial	$45,129.50
Rate for Payer: Cofinity Commercial	$55,444.81
Rate for Payer: Cofinity Medicare Advantage	$45,129.50
Rate for Payer: Encore Health Key Benefits Commercial	$51,576.57
Rate for Payer: Healthscope Commercial	$58,023.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54,800.10
Rate for Payer: PHP Commercial	$54,800.10
Rate for Payer: Priority Health Cigna Priority Health	$41,905.96
Rate for Payer: Priority Health SBD	$40,616.55

CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION

Facility

$64,470.71

Service Code	HCPCS J9043
Hospital Charge Code	105644
Hospital Revenue Code	636
Min. Negotiated Rate	$120.11
Max. Negotiated Rate	$58,023.64
Rate for Payer: Aetna Commercial	$54,800.10
Rate for Payer: Aetna Medicare	$233.05
Rate for Payer: Aetna New Business (MI Preferred)	$41,905.96
Rate for Payer: Allen County Amish Medical Aid Commercial	$280.11
Rate for Payer: Amish Plain Church Group Commercial	$280.11
Rate for Payer: BCBS Complete	$126.12
Rate for Payer: BCBS MAPPO	$224.09
Rate for Payer: BCBS Trust/PPO	$632.99
Rate for Payer: BCN Commercial	$632.99
Rate for Payer: BCN Medicare Advantage	$224.09
Rate for Payer: Cash Price	$51,576.57
Rate for Payer: Cash Price	$51,576.57
Rate for Payer: Cofinity Commercial	$55,444.81
Rate for Payer: Cofinity Commercial	$45,129.50
Rate for Payer: Cofinity Medicare Advantage	$45,129.50
Rate for Payer: Encore Health Key Benefits Commercial	$51,576.57
Rate for Payer: Health Alliance Plan Medicare Advantage	$224.09
Rate for Payer: Healthscope Commercial	$58,023.64
Rate for Payer: Mclaren Medicaid	$120.11
Rate for Payer: Mclaren Medicare	$224.09
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$235.29
Rate for Payer: Meridian Medicaid	$126.12
Rate for Payer: MI Amish Medical Board Commercial	$257.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54,800.10
Rate for Payer: Nomi Health Commercial	$672.27
Rate for Payer: PACE Medicare	$212.89
Rate for Payer: PACE SWMI	$224.09
Rate for Payer: PHP Commercial	$54,800.10
Rate for Payer: PHP Medicare Advantage	$224.09
Rate for Payer: Priority Health Choice Medicaid	$120.11
Rate for Payer: Priority Health Cigna Priority Health	$41,905.96
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$622.97
Rate for Payer: Priority Health Medicare	$224.09
Rate for Payer: Priority Health Narrow Network	$498.38
Rate for Payer: Priority Health SBD	$40,616.55
Rate for Payer: Railroad Medicare Medicare	$224.09
Rate for Payer: UHC All Payor (Choice/PPO)	$630.79
Rate for Payer: UHC Dual Complete DSNP	$224.09
Rate for Payer: UHC Medicare Advantage	$224.09
Rate for Payer: UHCCP Medicaid	$126.16
Rate for Payer: VA VA	$224.09

CABOTEGRAVIR ER 400 MG/2 ML-RILPIVIRINE ER 600 MG/2ML IM SUSPENSION,ER

Facility

$11,768.05

Service Code	HCPCS J0741
Hospital Charge Code	196075
Hospital Revenue Code	636
Min. Negotiated Rate	$7,413.87
Max. Negotiated Rate	$10,591.24
Rate for Payer: Aetna Commercial	$10,002.84
Rate for Payer: Aetna New Business (MI Preferred)	$7,649.23
Rate for Payer: Cash Price	$9,414.44
Rate for Payer: Cofinity Commercial	$10,120.52
Rate for Payer: Cofinity Commercial	$8,237.64
Rate for Payer: Cofinity Medicare Advantage	$8,237.64
Rate for Payer: Encore Health Key Benefits Commercial	$9,414.44
Rate for Payer: Healthscope Commercial	$10,591.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10,002.84
Rate for Payer: PHP Commercial	$10,002.84
Rate for Payer: Priority Health Cigna Priority Health	$7,649.23
Rate for Payer: Priority Health SBD	$7,413.87

CABOTEGRAVIR ER 400 MG/2 ML-RILPIVIRINE ER 600 MG/2ML IM SUSPENSION,ER

Facility

$11,768.05

Service Code	HCPCS J0741
Hospital Charge Code	196075
Hospital Revenue Code	636
Min. Negotiated Rate	$12.42
Max. Negotiated Rate	$10,591.24
Rate for Payer: Aetna Commercial	$10,002.84
Rate for Payer: Aetna Medicare	$24.10
Rate for Payer: Aetna New Business (MI Preferred)	$7,649.23
Rate for Payer: Allen County Amish Medical Aid Commercial	$28.96
Rate for Payer: Amish Plain Church Group Commercial	$28.96
Rate for Payer: BCBS Complete	$13.04
Rate for Payer: BCBS MAPPO	$23.17
Rate for Payer: BCBS Trust/PPO	$65.46
Rate for Payer: BCN Commercial	$65.46
Rate for Payer: BCN Medicare Advantage	$23.17
Rate for Payer: Cash Price	$9,414.44
Rate for Payer: Cash Price	$9,414.44
Rate for Payer: Cofinity Commercial	$10,120.52
Rate for Payer: Cofinity Commercial	$8,237.64
Rate for Payer: Cofinity Medicare Advantage	$8,237.64
Rate for Payer: Encore Health Key Benefits Commercial	$9,414.44
Rate for Payer: Health Alliance Plan Medicare Advantage	$23.17
Rate for Payer: Healthscope Commercial	$10,591.24
Rate for Payer: Mclaren Medicaid	$12.42
Rate for Payer: Mclaren Medicare	$23.17
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$24.33
Rate for Payer: Meridian Medicaid	$13.04
Rate for Payer: MI Amish Medical Board Commercial	$26.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10,002.84
Rate for Payer: Nomi Health Commercial	$69.51
Rate for Payer: PACE Medicare	$22.01
Rate for Payer: PACE SWMI	$23.17
Rate for Payer: PHP Commercial	$10,002.84
Rate for Payer: PHP Medicare Advantage	$23.17
Rate for Payer: Priority Health Choice Medicaid	$12.42
Rate for Payer: Priority Health Cigna Priority Health	$7,649.23
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$65.90
Rate for Payer: Priority Health Medicare	$23.17
Rate for Payer: Priority Health Narrow Network	$52.72
Rate for Payer: Priority Health SBD	$7,413.87
Rate for Payer: Railroad Medicare Medicare	$23.17
Rate for Payer: UHC All Payor (Choice/PPO)	$65.22
Rate for Payer: UHC Dual Complete DSNP	$23.17
Rate for Payer: UHC Medicare Advantage	$23.17
Rate for Payer: UHCCP Medicaid	$13.04
Rate for Payer: VA VA	$23.17

CABOTEGRAVIR ER 600 MG/3 ML-RILPIVIRINE ER 900 MG/3ML IM SUSPENSION,ER

Facility

$17,652.08

Service Code	HCPCS J0741
Hospital Charge Code	196915
Hospital Revenue Code	636
Min. Negotiated Rate	$12.42
Max. Negotiated Rate	$15,886.87
Rate for Payer: Aetna Commercial	$15,004.27
Rate for Payer: Aetna Medicare	$24.10
Rate for Payer: Aetna New Business (MI Preferred)	$11,473.85
Rate for Payer: Allen County Amish Medical Aid Commercial	$28.96
Rate for Payer: Amish Plain Church Group Commercial	$28.96
Rate for Payer: BCBS Complete	$13.04
Rate for Payer: BCBS MAPPO	$23.17
Rate for Payer: BCBS Trust/PPO	$65.46
Rate for Payer: BCN Commercial	$65.46
Rate for Payer: BCN Medicare Advantage	$23.17
Rate for Payer: Cash Price	$14,121.66
Rate for Payer: Cash Price	$14,121.66
Rate for Payer: Cofinity Commercial	$15,180.79
Rate for Payer: Cofinity Commercial	$12,356.46
Rate for Payer: Cofinity Medicare Advantage	$12,356.46
Rate for Payer: Encore Health Key Benefits Commercial	$14,121.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$23.17
Rate for Payer: Healthscope Commercial	$15,886.87
Rate for Payer: Mclaren Medicaid	$12.42
Rate for Payer: Mclaren Medicare	$23.17
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$24.33
Rate for Payer: Meridian Medicaid	$13.04
Rate for Payer: MI Amish Medical Board Commercial	$26.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15,004.27
Rate for Payer: Nomi Health Commercial	$69.51
Rate for Payer: PACE Medicare	$22.01
Rate for Payer: PACE SWMI	$23.17
Rate for Payer: PHP Commercial	$15,004.27
Rate for Payer: PHP Medicare Advantage	$23.17
Rate for Payer: Priority Health Choice Medicaid	$12.42
Rate for Payer: Priority Health Cigna Priority Health	$11,473.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$65.90
Rate for Payer: Priority Health Medicare	$23.17
Rate for Payer: Priority Health Narrow Network	$52.72
Rate for Payer: Priority Health SBD	$11,120.81
Rate for Payer: Railroad Medicare Medicare	$23.17
Rate for Payer: UHC All Payor (Choice/PPO)	$65.22
Rate for Payer: UHC Dual Complete DSNP	$23.17
Rate for Payer: UHC Medicare Advantage	$23.17
Rate for Payer: UHCCP Medicaid	$13.04
Rate for Payer: VA VA	$23.17

CABOTEGRAVIR ER 600 MG/3 ML-RILPIVIRINE ER 900 MG/3ML IM SUSPENSION,ER

Facility

$17,652.08

Service Code	HCPCS J0741
Hospital Charge Code	196915
Hospital Revenue Code	636
Min. Negotiated Rate	$11,120.81
Max. Negotiated Rate	$15,886.87
Rate for Payer: Aetna Commercial	$15,004.27
Rate for Payer: Aetna New Business (MI Preferred)	$11,473.85
Rate for Payer: Cash Price	$14,121.66
Rate for Payer: Cofinity Commercial	$12,356.46
Rate for Payer: Cofinity Commercial	$15,180.79
Rate for Payer: Cofinity Medicare Advantage	$12,356.46
Rate for Payer: Encore Health Key Benefits Commercial	$14,121.66
Rate for Payer: Healthscope Commercial	$15,886.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15,004.27
Rate for Payer: PHP Commercial	$15,004.27
Rate for Payer: Priority Health Cigna Priority Health	$11,473.85
Rate for Payer: Priority Health SBD	$11,120.81

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE INTRAVENOUS SOLUTION

Facility

$44.78

Service Code	HCPCS J0706
Hospital Charge Code	77412
Hospital Revenue Code	636
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$40.30
Rate for Payer: Aetna Commercial	$38.06
Rate for Payer: Aetna Commercial	$40.86
Rate for Payer: Aetna Medicare	$24.04
Rate for Payer: Aetna Medicare	$22.39
Rate for Payer: Aetna New Business (MI Preferred)	$29.11
Rate for Payer: Aetna New Business (MI Preferred)	$31.25
Rate for Payer: BCBS Complete	$19.23
Rate for Payer: BCBS Complete	$17.91
Rate for Payer: BCBS Trust/PPO	$4.57
Rate for Payer: BCBS Trust/PPO	$4.57
Rate for Payer: BCN Commercial	$4.57
Rate for Payer: BCN Commercial	$4.57
Rate for Payer: Cash Price	$38.46
Rate for Payer: Cash Price	$35.82
Rate for Payer: Cash Price	$35.82
Rate for Payer: Cash Price	$38.46
Rate for Payer: Cofinity Commercial	$38.51
Rate for Payer: Cofinity Commercial	$31.35
Rate for Payer: Cofinity Commercial	$33.65
Rate for Payer: Cofinity Commercial	$41.34
Rate for Payer: Cofinity Medicare Advantage	$31.35
Rate for Payer: Cofinity Medicare Advantage	$33.65
Rate for Payer: Encore Health Key Benefits Commercial	$35.82
Rate for Payer: Encore Health Key Benefits Commercial	$38.46
Rate for Payer: Healthscope Commercial	$43.26
Rate for Payer: Healthscope Commercial	$40.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$40.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.06
Rate for Payer: PHP Commercial	$40.86
Rate for Payer: PHP Commercial	$38.06
Rate for Payer: Priority Health Cigna Priority Health	$31.25
Rate for Payer: Priority Health Cigna Priority Health	$29.11
Rate for Payer: Priority Health SBD	$30.28
Rate for Payer: Priority Health SBD	$28.21

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE INTRAVENOUS SOLUTION

Facility

$48.07

Service Code	HCPCS J0706
Hospital Charge Code	77412
Hospital Revenue Code	636
Min. Negotiated Rate	$30.28
Max. Negotiated Rate	$43.26
Rate for Payer: Aetna Commercial	$40.86
Rate for Payer: Aetna Commercial	$38.06
Rate for Payer: Aetna New Business (MI Preferred)	$31.25
Rate for Payer: Aetna New Business (MI Preferred)	$29.11
Rate for Payer: Cash Price	$38.46
Rate for Payer: Cash Price	$35.82
Rate for Payer: Cofinity Commercial	$41.34
Rate for Payer: Cofinity Commercial	$31.35
Rate for Payer: Cofinity Commercial	$38.51
Rate for Payer: Cofinity Commercial	$33.65
Rate for Payer: Cofinity Medicare Advantage	$31.35
Rate for Payer: Cofinity Medicare Advantage	$33.65
Rate for Payer: Encore Health Key Benefits Commercial	$35.82
Rate for Payer: Encore Health Key Benefits Commercial	$38.46
Rate for Payer: Healthscope Commercial	$43.26
Rate for Payer: Healthscope Commercial	$40.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$40.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.06
Rate for Payer: PHP Commercial	$38.06
Rate for Payer: PHP Commercial	$40.86
Rate for Payer: Priority Health Cigna Priority Health	$29.11
Rate for Payer: Priority Health Cigna Priority Health	$31.25
Rate for Payer: Priority Health SBD	$30.28
Rate for Payer: Priority Health SBD	$28.21

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE ORAL SOLUTION

Facility

$37.76

Service Code	HCPCS J0706
Hospital Charge Code	77411
Hospital Revenue Code	636
Min. Negotiated Rate	$23.79
Max. Negotiated Rate	$33.98
Rate for Payer: Aetna Commercial	$32.10
Rate for Payer: Aetna New Business (MI Preferred)	$24.54
Rate for Payer: Cash Price	$30.21
Rate for Payer: Cofinity Commercial	$26.43
Rate for Payer: Cofinity Commercial	$32.47
Rate for Payer: Cofinity Medicare Advantage	$26.43
Rate for Payer: Encore Health Key Benefits Commercial	$30.21
Rate for Payer: Healthscope Commercial	$33.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$32.10
Rate for Payer: PHP Commercial	$32.10
Rate for Payer: Priority Health Cigna Priority Health	$24.54
Rate for Payer: Priority Health SBD	$23.79

CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) MAINTENANCE ORAL SOLUTION

Facility

$37.76

Service Code	HCPCS J0706
Hospital Charge Code	77411
Hospital Revenue Code	636
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$33.98
Rate for Payer: Aetna Commercial	$32.10
Rate for Payer: Aetna Medicare	$18.88
Rate for Payer: Aetna New Business (MI Preferred)	$24.54
Rate for Payer: BCBS Complete	$15.10
Rate for Payer: BCBS Trust/PPO	$4.57
Rate for Payer: BCN Commercial	$4.57
Rate for Payer: Cash Price	$30.21
Rate for Payer: Cash Price	$30.21
Rate for Payer: Cofinity Commercial	$26.43
Rate for Payer: Cofinity Commercial	$32.47
Rate for Payer: Cofinity Medicare Advantage	$26.43
Rate for Payer: Encore Health Key Benefits Commercial	$30.21
Rate for Payer: Healthscope Commercial	$33.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$32.10
Rate for Payer: PHP Commercial	$32.10
Rate for Payer: Priority Health Cigna Priority Health	$24.54
Rate for Payer: Priority Health SBD	$23.79

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN

Facility

$124.20

Service Code	NDC 00517250201
Hospital Charge Code	1262
Hospital Revenue Code	250
Min. Negotiated Rate	$49.68
Max. Negotiated Rate	$111.78
Rate for Payer: Aetna Commercial	$105.57
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: Aetna New Business (MI Preferred)	$80.73
Rate for Payer: BCBS Complete	$49.68
Rate for Payer: Cash Price	$99.36
Rate for Payer: Cofinity Commercial	$106.81
Rate for Payer: Cofinity Commercial	$86.94
Rate for Payer: Cofinity Medicare Advantage	$86.94
Rate for Payer: Encore Health Key Benefits Commercial	$99.36
Rate for Payer: Healthscope Commercial	$111.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$105.57
Rate for Payer: PHP Commercial	$105.57
Rate for Payer: Priority Health Cigna Priority Health	$80.73
Rate for Payer: Priority Health SBD	$78.25

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN

Facility

$124.20

Service Code	NDC 00517250210
Hospital Charge Code	1262
Hospital Revenue Code	250
Min. Negotiated Rate	$78.25
Max. Negotiated Rate	$111.78
Rate for Payer: Aetna Commercial	$105.57
Rate for Payer: Aetna New Business (MI Preferred)	$80.73
Rate for Payer: Cash Price	$99.36
Rate for Payer: Cofinity Commercial	$106.81
Rate for Payer: Cofinity Commercial	$86.94
Rate for Payer: Cofinity Medicare Advantage	$86.94
Rate for Payer: Encore Health Key Benefits Commercial	$99.36
Rate for Payer: Healthscope Commercial	$111.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$105.57
Rate for Payer: PHP Commercial	$105.57
Rate for Payer: Priority Health Cigna Priority Health	$80.73
Rate for Payer: Priority Health SBD	$78.25

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN

Facility

$124.20

Service Code	NDC 00517250210
Hospital Charge Code	1262
Hospital Revenue Code	250
Min. Negotiated Rate	$49.68
Max. Negotiated Rate	$111.78
Rate for Payer: Aetna Commercial	$105.57
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: Aetna New Business (MI Preferred)	$80.73
Rate for Payer: BCBS Complete	$49.68
Rate for Payer: Cash Price	$99.36
Rate for Payer: Cofinity Commercial	$106.81
Rate for Payer: Cofinity Commercial	$86.94
Rate for Payer: Cofinity Medicare Advantage	$86.94
Rate for Payer: Encore Health Key Benefits Commercial	$99.36
Rate for Payer: Healthscope Commercial	$111.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$105.57
Rate for Payer: PHP Commercial	$105.57
Rate for Payer: Priority Health Cigna Priority Health	$80.73
Rate for Payer: Priority Health SBD	$78.25

CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN

Facility

$124.20

Service Code	NDC 00517250201
Hospital Charge Code	1262
Hospital Revenue Code	250
Min. Negotiated Rate	$78.25
Max. Negotiated Rate	$111.78
Rate for Payer: Aetna Commercial	$105.57
Rate for Payer: Aetna New Business (MI Preferred)	$80.73
Rate for Payer: Cash Price	$99.36
Rate for Payer: Cofinity Commercial	$106.81
Rate for Payer: Cofinity Commercial	$86.94
Rate for Payer: Cofinity Medicare Advantage	$86.94
Rate for Payer: Encore Health Key Benefits Commercial	$99.36
Rate for Payer: Healthscope Commercial	$111.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$105.57
Rate for Payer: PHP Commercial	$105.57
Rate for Payer: Priority Health Cigna Priority Health	$80.73
Rate for Payer: Priority Health SBD	$78.25

CALAMINE 8 %-ZINC OXIDE 8 % LOTION

Facility

$8.50

Service Code	NDC 00904253321
Hospital Charge Code	78879
Hospital Revenue Code	637
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$7.65
Rate for Payer: Aetna Commercial	$7.22
Rate for Payer: Aetna New Business (MI Preferred)	$5.52
Rate for Payer: Cash Price	$6.80
Rate for Payer: Cofinity Commercial	$5.95
Rate for Payer: Cofinity Commercial	$7.31
Rate for Payer: Cofinity Medicare Advantage	$5.95
Rate for Payer: Encore Health Key Benefits Commercial	$6.80
Rate for Payer: Healthscope Commercial	$7.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.22
Rate for Payer: PHP Commercial	$7.22
Rate for Payer: Priority Health Cigna Priority Health	$5.52
Rate for Payer: Priority Health SBD	$5.36

CALAMINE 8 %-ZINC OXIDE 8 % LOTION

Facility

$14.34

Service Code	NDC 00395041396
Hospital Charge Code	78879
Hospital Revenue Code	637
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$12.91
Rate for Payer: Aetna Commercial	$12.19
Rate for Payer: Aetna Medicare	$7.17
Rate for Payer: Aetna New Business (MI Preferred)	$9.32
Rate for Payer: BCBS Complete	$5.74
Rate for Payer: Cash Price	$11.47
Rate for Payer: Cofinity Commercial	$10.04
Rate for Payer: Cofinity Commercial	$12.33
Rate for Payer: Cofinity Medicare Advantage	$10.04
Rate for Payer: Encore Health Key Benefits Commercial	$11.47
Rate for Payer: Healthscope Commercial	$12.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.19
Rate for Payer: PHP Commercial	$12.19
Rate for Payer: Priority Health Cigna Priority Health	$9.32
Rate for Payer: Priority Health SBD	$9.03

CALAMINE 8 %-ZINC OXIDE 8 % LOTION

Facility

$8.50

Service Code	NDC 00904253321
Hospital Charge Code	78879
Hospital Revenue Code	637
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$7.65
Rate for Payer: Aetna Commercial	$7.22
Rate for Payer: Aetna Medicare	$4.25
Rate for Payer: Aetna New Business (MI Preferred)	$5.52
Rate for Payer: BCBS Complete	$3.40
Rate for Payer: Cash Price	$6.80
Rate for Payer: Cofinity Commercial	$5.95
Rate for Payer: Cofinity Commercial	$7.31
Rate for Payer: Cofinity Medicare Advantage	$5.95
Rate for Payer: Encore Health Key Benefits Commercial	$6.80
Rate for Payer: Healthscope Commercial	$7.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.22
Rate for Payer: PHP Commercial	$7.22
Rate for Payer: Priority Health Cigna Priority Health	$5.52
Rate for Payer: Priority Health SBD	$5.36

Know your out-of-pocket cost for care.

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