Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CALCIUM GLUCONATE (BULK) POWDER

Facility

$366.00

Service Code	NDC 38779182608
Hospital Charge Code	1316
Hospital Revenue Code	637
Min. Negotiated Rate	$146.40
Max. Negotiated Rate	$329.40
Rate for Payer: Aetna Commercial	$311.10
Rate for Payer: Aetna Medicare	$183.00
Rate for Payer: Aetna New Business (MI Preferred)	$237.90
Rate for Payer: BCBS Complete	$146.40
Rate for Payer: Cash Price	$292.80
Rate for Payer: Cofinity Commercial	$256.20
Rate for Payer: Cofinity Commercial	$314.76
Rate for Payer: Cofinity Medicare Advantage	$256.20
Rate for Payer: Encore Health Key Benefits Commercial	$292.80
Rate for Payer: Healthscope Commercial	$329.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$311.10
Rate for Payer: PHP Commercial	$311.10
Rate for Payer: Priority Health Cigna Priority Health	$237.90
Rate for Payer: Priority Health SBD	$230.58

CALCIUM GLUCONATE (BULK) POWDER

Facility

$366.00

Service Code	NDC 38779182608
Hospital Charge Code	1316
Hospital Revenue Code	637
Min. Negotiated Rate	$230.58
Max. Negotiated Rate	$329.40
Rate for Payer: Aetna Commercial	$311.10
Rate for Payer: Aetna New Business (MI Preferred)	$237.90
Rate for Payer: Cash Price	$292.80
Rate for Payer: Cofinity Commercial	$256.20
Rate for Payer: Cofinity Commercial	$314.76
Rate for Payer: Cofinity Medicare Advantage	$256.20
Rate for Payer: Encore Health Key Benefits Commercial	$292.80
Rate for Payer: Healthscope Commercial	$329.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$311.10
Rate for Payer: PHP Commercial	$311.10
Rate for Payer: Priority Health Cigna Priority Health	$237.90
Rate for Payer: Priority Health SBD	$230.58

CAPSAICIN 0.025 % TOPICAL CREAM

Facility

$15.12

Service Code	NDC 00536252525
Hospital Charge Code	1350
Hospital Revenue Code	637
Min. Negotiated Rate	$9.53
Max. Negotiated Rate	$13.61
Rate for Payer: Aetna Commercial	$12.85
Rate for Payer: Aetna New Business (MI Preferred)	$9.83
Rate for Payer: Cash Price	$12.10
Rate for Payer: Cofinity Commercial	$10.58
Rate for Payer: Cofinity Commercial	$13.00
Rate for Payer: Cofinity Medicare Advantage	$10.58
Rate for Payer: Encore Health Key Benefits Commercial	$12.10
Rate for Payer: Healthscope Commercial	$13.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.85
Rate for Payer: PHP Commercial	$12.85
Rate for Payer: Priority Health Cigna Priority Health	$9.83
Rate for Payer: Priority Health SBD	$9.53

CAPSAICIN 0.025 % TOPICAL CREAM

Facility

$15.12

Service Code	NDC 00536252525
Hospital Charge Code	1350
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$13.61
Rate for Payer: Aetna Commercial	$12.85
Rate for Payer: Aetna Medicare	$7.56
Rate for Payer: Aetna New Business (MI Preferred)	$9.83
Rate for Payer: BCBS Complete	$6.05
Rate for Payer: Cash Price	$12.10
Rate for Payer: Cofinity Commercial	$10.58
Rate for Payer: Cofinity Commercial	$13.00
Rate for Payer: Cofinity Medicare Advantage	$10.58
Rate for Payer: Encore Health Key Benefits Commercial	$12.10
Rate for Payer: Healthscope Commercial	$13.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.85
Rate for Payer: PHP Commercial	$12.85
Rate for Payer: Priority Health Cigna Priority Health	$9.83
Rate for Payer: Priority Health SBD	$9.53

CAPSAICIN 0.075 % TOPICAL CREAM

Facility

$18.99

Service Code	NDC 00536111825
Hospital Charge Code	9399
Hospital Revenue Code	637
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$17.09
Rate for Payer: Aetna Commercial	$16.14
Rate for Payer: Aetna Medicare	$9.50
Rate for Payer: Aetna New Business (MI Preferred)	$12.34
Rate for Payer: BCBS Complete	$7.60
Rate for Payer: Cash Price	$15.19
Rate for Payer: Cofinity Commercial	$13.29
Rate for Payer: Cofinity Commercial	$16.33
Rate for Payer: Cofinity Medicare Advantage	$13.29
Rate for Payer: Encore Health Key Benefits Commercial	$15.19
Rate for Payer: Healthscope Commercial	$17.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.14
Rate for Payer: PHP Commercial	$16.14
Rate for Payer: Priority Health Cigna Priority Health	$12.34
Rate for Payer: Priority Health SBD	$11.96

CAPSAICIN 0.075 % TOPICAL CREAM

Facility

$18.99

Service Code	NDC 00536111825
Hospital Charge Code	9399
Hospital Revenue Code	637
Min. Negotiated Rate	$11.96
Max. Negotiated Rate	$17.09
Rate for Payer: Aetna Commercial	$16.14
Rate for Payer: Aetna New Business (MI Preferred)	$12.34
Rate for Payer: Cash Price	$15.19
Rate for Payer: Cofinity Commercial	$13.29
Rate for Payer: Cofinity Commercial	$16.33
Rate for Payer: Cofinity Medicare Advantage	$13.29
Rate for Payer: Encore Health Key Benefits Commercial	$15.19
Rate for Payer: Healthscope Commercial	$17.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.14
Rate for Payer: PHP Commercial	$16.14
Rate for Payer: Priority Health Cigna Priority Health	$12.34
Rate for Payer: Priority Health SBD	$11.96

CAPSULORRHAPHY, ANTERIOR; WITH LABRAL REPAIR (EG, BANKART PROCEDURE)

Facility

$21,998.64

Service Code	CPT 23455
Hospital Revenue Code	360
Min. Negotiated Rate	$1,052.13
Max. Negotiated Rate	$21,998.64
Rate for Payer: Aetna Medicare	$7,279.25
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,749.10
Rate for Payer: Amish Plain Church Group Commercial	$8,749.10
Rate for Payer: BCBS Complete	$3,939.19
Rate for Payer: BCBS MAPPO	$6,999.28
Rate for Payer: BCBS Trust/PPO	$3,095.20
Rate for Payer: BCN Commercial	$3,095.20
Rate for Payer: BCN Medicare Advantage	$6,999.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,999.28
Rate for Payer: Mclaren Medicaid	$3,751.61
Rate for Payer: Mclaren Medicare	$6,999.28
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,349.24
Rate for Payer: Meridian Medicaid	$3,939.19
Rate for Payer: MI Amish Medical Board Commercial	$8,049.17
Rate for Payer: Nomi Health Commercial	$14,698.49
Rate for Payer: PACE Medicare	$6,649.32
Rate for Payer: PACE SWMI	$6,999.28
Rate for Payer: PHP Medicare Advantage	$6,999.28
Rate for Payer: Priority Health Choice Medicaid	$3,751.61
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$21,998.64
Rate for Payer: Priority Health Medicare	$6,999.28
Rate for Payer: Priority Health Narrow Network	$17,598.91
Rate for Payer: Railroad Medicare Medicare	$6,999.28
Rate for Payer: UHC All Payor (Choice/PPO)	$1,052.13
Rate for Payer: UHC Core	$7,632.00
Rate for Payer: UHC Dual Complete DSNP	$6,999.28
Rate for Payer: UHC Exchange	$8,174.00
Rate for Payer: UHC Medicare Advantage	$6,999.28
Rate for Payer: UHCCP Medicaid	$3,940.59
Rate for Payer: VA VA	$6,999.28

CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)

Facility

$9,991.56

Service Code	CPT 28270
Hospital Revenue Code	360
Min. Negotiated Rate	$352.82
Max. Negotiated Rate	$9,991.56
Rate for Payer: Aetna Medicare	$3,306.16
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,973.75
Rate for Payer: Amish Plain Church Group Commercial	$3,973.75
Rate for Payer: BCBS Complete	$1,789.14
Rate for Payer: BCBS MAPPO	$3,179.00
Rate for Payer: BCBS Trust/PPO	$1,089.51
Rate for Payer: BCN Commercial	$1,089.51
Rate for Payer: BCN Medicare Advantage	$3,179.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,179.00
Rate for Payer: Mclaren Medicaid	$1,703.94
Rate for Payer: Mclaren Medicare	$3,179.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,337.95
Rate for Payer: Meridian Medicaid	$1,789.14
Rate for Payer: MI Amish Medical Board Commercial	$3,655.85
Rate for Payer: Nomi Health Commercial	$6,675.90
Rate for Payer: PACE Medicare	$3,020.05
Rate for Payer: PACE SWMI	$3,179.00
Rate for Payer: PHP Medicare Advantage	$3,179.00
Rate for Payer: Priority Health Choice Medicaid	$1,703.94
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,991.56
Rate for Payer: Priority Health Medicare	$3,179.00
Rate for Payer: Priority Health Narrow Network	$7,993.25
Rate for Payer: Railroad Medicare Medicare	$3,179.00
Rate for Payer: UHC All Payor (Choice/PPO)	$352.82
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,179.00
Rate for Payer: UHC Exchange	$4,450.00
Rate for Payer: UHC Medicare Advantage	$3,179.00
Rate for Payer: UHCCP Medicaid	$1,789.78
Rate for Payer: VA VA	$3,179.00

CAPSULOTOMY, POSTERIOR CAPSULAR RELEASE, KNEE

Facility

$9,991.56

Service Code	CPT 27435
Hospital Revenue Code	360
Min. Negotiated Rate	$860.96
Max. Negotiated Rate	$9,991.56
Rate for Payer: Aetna Medicare	$3,306.16
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,973.75
Rate for Payer: Amish Plain Church Group Commercial	$3,973.75
Rate for Payer: BCBS Complete	$1,789.14
Rate for Payer: BCBS MAPPO	$3,179.00
Rate for Payer: BCBS Trust/PPO	$1,407.29
Rate for Payer: BCN Commercial	$1,407.29
Rate for Payer: BCN Medicare Advantage	$3,179.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,179.00
Rate for Payer: Mclaren Medicaid	$1,703.94
Rate for Payer: Mclaren Medicare	$3,179.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,337.95
Rate for Payer: Meridian Medicaid	$1,789.14
Rate for Payer: MI Amish Medical Board Commercial	$3,655.85
Rate for Payer: Nomi Health Commercial	$6,675.90
Rate for Payer: PACE Medicare	$3,020.05
Rate for Payer: PACE SWMI	$3,179.00
Rate for Payer: PHP Medicare Advantage	$3,179.00
Rate for Payer: Priority Health Choice Medicaid	$1,703.94
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,991.56
Rate for Payer: Priority Health Medicare	$3,179.00
Rate for Payer: Priority Health Narrow Network	$7,993.25
Rate for Payer: Railroad Medicare Medicare	$3,179.00
Rate for Payer: UHC All Payor (Choice/PPO)	$860.96
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$3,179.00
Rate for Payer: UHC Exchange	$5,811.00
Rate for Payer: UHC Medicare Advantage	$3,179.00
Rate for Payer: UHCCP Medicaid	$1,789.78
Rate for Payer: VA VA	$3,179.00

CAPTOPRIL 12.5 MG TABLET

Facility

$5.80

Service Code	NDC 51079086301
Hospital Charge Code	9401
Hospital Revenue Code	637
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$5.22
Rate for Payer: Aetna Commercial	$4.93
Rate for Payer: Aetna Medicare	$2.90
Rate for Payer: Aetna New Business (MI Preferred)	$3.77
Rate for Payer: BCBS Complete	$2.32
Rate for Payer: Cash Price	$4.64
Rate for Payer: Cofinity Commercial	$4.06
Rate for Payer: Cofinity Commercial	$4.99
Rate for Payer: Cofinity Medicare Advantage	$4.06
Rate for Payer: Encore Health Key Benefits Commercial	$4.64
Rate for Payer: Healthscope Commercial	$5.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.93
Rate for Payer: PHP Commercial	$4.93
Rate for Payer: Priority Health Cigna Priority Health	$3.77
Rate for Payer: Priority Health SBD	$3.65

CAPTOPRIL 12.5 MG TABLET

Facility

$5.80

Service Code	NDC 51079086301
Hospital Charge Code	9401
Hospital Revenue Code	637
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$5.22
Rate for Payer: Aetna Commercial	$4.93
Rate for Payer: Aetna New Business (MI Preferred)	$3.77
Rate for Payer: Cash Price	$4.64
Rate for Payer: Cofinity Commercial	$4.06
Rate for Payer: Cofinity Commercial	$4.99
Rate for Payer: Cofinity Medicare Advantage	$4.06
Rate for Payer: Encore Health Key Benefits Commercial	$4.64
Rate for Payer: Healthscope Commercial	$5.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.93
Rate for Payer: PHP Commercial	$4.93
Rate for Payer: Priority Health Cigna Priority Health	$3.77
Rate for Payer: Priority Health SBD	$3.65

CAPTOPRIL 12.5 MG TABLET

Facility

$533.76

Service Code	NDC 00904710561
Hospital Charge Code	9401
Hospital Revenue Code	637
Min. Negotiated Rate	$336.27
Max. Negotiated Rate	$480.38
Rate for Payer: Aetna Commercial	$453.70
Rate for Payer: Aetna New Business (MI Preferred)	$346.94
Rate for Payer: Cash Price	$427.01
Rate for Payer: Cofinity Commercial	$373.63
Rate for Payer: Cofinity Commercial	$459.03
Rate for Payer: Cofinity Medicare Advantage	$373.63
Rate for Payer: Encore Health Key Benefits Commercial	$427.01
Rate for Payer: Healthscope Commercial	$480.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$453.70
Rate for Payer: PHP Commercial	$453.70
Rate for Payer: Priority Health Cigna Priority Health	$346.94
Rate for Payer: Priority Health SBD	$336.27

CAPTOPRIL 12.5 MG TABLET

Facility

$579.84

Service Code	NDC 51079086320
Hospital Charge Code	9401
Hospital Revenue Code	637
Min. Negotiated Rate	$231.94
Max. Negotiated Rate	$521.86
Rate for Payer: Aetna Commercial	$492.86
Rate for Payer: Aetna Medicare	$289.92
Rate for Payer: Aetna New Business (MI Preferred)	$376.90
Rate for Payer: BCBS Complete	$231.94
Rate for Payer: Cash Price	$463.87
Rate for Payer: Cofinity Commercial	$405.89
Rate for Payer: Cofinity Commercial	$498.66
Rate for Payer: Cofinity Medicare Advantage	$405.89
Rate for Payer: Encore Health Key Benefits Commercial	$463.87
Rate for Payer: Healthscope Commercial	$521.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$492.86
Rate for Payer: PHP Commercial	$492.86
Rate for Payer: Priority Health Cigna Priority Health	$376.90
Rate for Payer: Priority Health SBD	$365.30

CAPTOPRIL 12.5 MG TABLET

Facility

$579.84

Service Code	NDC 51079086320
Hospital Charge Code	9401
Hospital Revenue Code	637
Min. Negotiated Rate	$365.30
Max. Negotiated Rate	$521.86
Rate for Payer: Aetna Commercial	$492.86
Rate for Payer: Aetna New Business (MI Preferred)	$376.90
Rate for Payer: Cash Price	$463.87
Rate for Payer: Cofinity Commercial	$405.89
Rate for Payer: Cofinity Commercial	$498.66
Rate for Payer: Cofinity Medicare Advantage	$405.89
Rate for Payer: Encore Health Key Benefits Commercial	$463.87
Rate for Payer: Healthscope Commercial	$521.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$492.86
Rate for Payer: PHP Commercial	$492.86
Rate for Payer: Priority Health Cigna Priority Health	$376.90
Rate for Payer: Priority Health SBD	$365.30

CAPTOPRIL 12.5 MG TABLET

Facility

$533.76

Service Code	NDC 00904710561
Hospital Charge Code	9401
Hospital Revenue Code	637
Min. Negotiated Rate	$213.50
Max. Negotiated Rate	$480.38
Rate for Payer: Aetna Commercial	$453.70
Rate for Payer: Aetna Medicare	$266.88
Rate for Payer: Aetna New Business (MI Preferred)	$346.94
Rate for Payer: BCBS Complete	$213.50
Rate for Payer: Cash Price	$427.01
Rate for Payer: Cofinity Commercial	$373.63
Rate for Payer: Cofinity Commercial	$459.03
Rate for Payer: Cofinity Medicare Advantage	$373.63
Rate for Payer: Encore Health Key Benefits Commercial	$427.01
Rate for Payer: Healthscope Commercial	$480.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$453.70
Rate for Payer: PHP Commercial	$453.70
Rate for Payer: Priority Health Cigna Priority Health	$346.94
Rate for Payer: Priority Health SBD	$336.27

CARBAMAZEPINE 100 MG/5 ML (5 ML) ORAL SUSPENSION

Facility

$13.59

Service Code	NDC 68094000759
Hospital Charge Code	119222
Hospital Revenue Code	637
Min. Negotiated Rate	$8.56
Max. Negotiated Rate	$12.23
Rate for Payer: Aetna Commercial	$11.55
Rate for Payer: Aetna New Business (MI Preferred)	$8.83
Rate for Payer: Cash Price	$10.87
Rate for Payer: Cofinity Commercial	$11.69
Rate for Payer: Cofinity Commercial	$9.51
Rate for Payer: Cofinity Medicare Advantage	$9.51
Rate for Payer: Encore Health Key Benefits Commercial	$10.87
Rate for Payer: Healthscope Commercial	$12.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.55
Rate for Payer: PHP Commercial	$11.55
Rate for Payer: Priority Health Cigna Priority Health	$8.83
Rate for Payer: Priority Health SBD	$8.56

CARBAMAZEPINE 100 MG/5 ML (5 ML) ORAL SUSPENSION

Facility

$13.59

Service Code	NDC 68094000759
Hospital Charge Code	119222
Hospital Revenue Code	637
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$12.23
Rate for Payer: Aetna Commercial	$11.55
Rate for Payer: Aetna Medicare	$6.80
Rate for Payer: Aetna New Business (MI Preferred)	$8.83
Rate for Payer: BCBS Complete	$5.44
Rate for Payer: Cash Price	$10.87
Rate for Payer: Cofinity Commercial	$11.69
Rate for Payer: Cofinity Commercial	$9.51
Rate for Payer: Cofinity Medicare Advantage	$9.51
Rate for Payer: Encore Health Key Benefits Commercial	$10.87
Rate for Payer: Healthscope Commercial	$12.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.55
Rate for Payer: PHP Commercial	$11.55
Rate for Payer: Priority Health Cigna Priority Health	$8.83
Rate for Payer: Priority Health SBD	$8.56

CARBAMAZEPINE 100 MG/5 ML (5 ML) ORAL SUSPENSION

Facility

$13.59

Service Code	NDC 68094000762
Hospital Charge Code	119222
Hospital Revenue Code	637
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$12.23
Rate for Payer: Aetna Commercial	$11.55
Rate for Payer: Aetna Medicare	$6.80
Rate for Payer: Aetna New Business (MI Preferred)	$8.83
Rate for Payer: BCBS Complete	$5.44
Rate for Payer: Cash Price	$10.87
Rate for Payer: Cofinity Commercial	$11.69
Rate for Payer: Cofinity Commercial	$9.51
Rate for Payer: Cofinity Medicare Advantage	$9.51
Rate for Payer: Encore Health Key Benefits Commercial	$10.87
Rate for Payer: Healthscope Commercial	$12.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.55
Rate for Payer: PHP Commercial	$11.55
Rate for Payer: Priority Health Cigna Priority Health	$8.83
Rate for Payer: Priority Health SBD	$8.56

CARBAMAZEPINE 100 MG/5 ML (5 ML) ORAL SUSPENSION

Facility

$13.59

Service Code	NDC 68094000762
Hospital Charge Code	119222
Hospital Revenue Code	637
Min. Negotiated Rate	$8.56
Max. Negotiated Rate	$12.23
Rate for Payer: Aetna Commercial	$11.55
Rate for Payer: Aetna New Business (MI Preferred)	$8.83
Rate for Payer: Cash Price	$10.87
Rate for Payer: Cofinity Commercial	$11.69
Rate for Payer: Cofinity Commercial	$9.51
Rate for Payer: Cofinity Medicare Advantage	$9.51
Rate for Payer: Encore Health Key Benefits Commercial	$10.87
Rate for Payer: Healthscope Commercial	$12.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.55
Rate for Payer: PHP Commercial	$11.55
Rate for Payer: Priority Health Cigna Priority Health	$8.83
Rate for Payer: Priority Health SBD	$8.56

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION

Facility

$1,714.28

Service Code	NDC 00078050883
Hospital Charge Code	109663
Hospital Revenue Code	637
Min. Negotiated Rate	$685.71
Max. Negotiated Rate	$1,542.85
Rate for Payer: Aetna Commercial	$1,457.14
Rate for Payer: Aetna Medicare	$857.14
Rate for Payer: Aetna New Business (MI Preferred)	$1,114.28
Rate for Payer: BCBS Complete	$685.71
Rate for Payer: Cash Price	$1,371.42
Rate for Payer: Cofinity Commercial	$1,200.00
Rate for Payer: Cofinity Commercial	$1,474.28
Rate for Payer: Cofinity Medicare Advantage	$1,200.00
Rate for Payer: Encore Health Key Benefits Commercial	$1,371.42
Rate for Payer: Healthscope Commercial	$1,542.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,457.14
Rate for Payer: PHP Commercial	$1,457.14
Rate for Payer: Priority Health Cigna Priority Health	$1,114.28
Rate for Payer: Priority Health SBD	$1,080.00

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION

Facility

$13.75

Service Code	NDC 09900000935
Hospital Charge Code	109663
Hospital Revenue Code	637
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$12.38
Rate for Payer: Aetna Commercial	$11.69
Rate for Payer: Aetna New Business (MI Preferred)	$8.94
Rate for Payer: Cash Price	$11.00
Rate for Payer: Cofinity Commercial	$11.82
Rate for Payer: Cofinity Commercial	$9.62
Rate for Payer: Cofinity Medicare Advantage	$9.62
Rate for Payer: Encore Health Key Benefits Commercial	$11.00
Rate for Payer: Healthscope Commercial	$12.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.69
Rate for Payer: PHP Commercial	$11.69
Rate for Payer: Priority Health Cigna Priority Health	$8.94
Rate for Payer: Priority Health SBD	$8.66

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION

Facility

$1,300.73

Service Code	NDC 60432012916
Hospital Charge Code	109663
Hospital Revenue Code	637
Min. Negotiated Rate	$819.46
Max. Negotiated Rate	$1,170.66
Rate for Payer: Aetna Commercial	$1,105.62
Rate for Payer: Aetna New Business (MI Preferred)	$845.47
Rate for Payer: Cash Price	$1,040.58
Rate for Payer: Cofinity Commercial	$1,118.63
Rate for Payer: Cofinity Commercial	$910.51
Rate for Payer: Cofinity Medicare Advantage	$910.51
Rate for Payer: Encore Health Key Benefits Commercial	$1,040.58
Rate for Payer: Healthscope Commercial	$1,170.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,105.62
Rate for Payer: PHP Commercial	$1,105.62
Rate for Payer: Priority Health Cigna Priority Health	$845.47
Rate for Payer: Priority Health SBD	$819.46

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION

Facility

$1,290.15

Service Code	NDC 51672404709
Hospital Charge Code	109663
Hospital Revenue Code	637
Min. Negotiated Rate	$516.06
Max. Negotiated Rate	$1,161.14
Rate for Payer: Aetna Commercial	$1,096.63
Rate for Payer: Aetna Medicare	$645.08
Rate for Payer: Aetna New Business (MI Preferred)	$838.60
Rate for Payer: BCBS Complete	$516.06
Rate for Payer: Cash Price	$1,032.12
Rate for Payer: Cofinity Commercial	$1,109.53
Rate for Payer: Cofinity Commercial	$903.10
Rate for Payer: Cofinity Medicare Advantage	$903.10
Rate for Payer: Encore Health Key Benefits Commercial	$1,032.12
Rate for Payer: Healthscope Commercial	$1,161.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,096.63
Rate for Payer: PHP Commercial	$1,096.63
Rate for Payer: Priority Health Cigna Priority Health	$838.60
Rate for Payer: Priority Health SBD	$812.79

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION

Facility

$13.75

Service Code	NDC 09900000935
Hospital Charge Code	109663
Hospital Revenue Code	637
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$12.38
Rate for Payer: Aetna Commercial	$11.69
Rate for Payer: Aetna Medicare	$6.88
Rate for Payer: Aetna New Business (MI Preferred)	$8.94
Rate for Payer: BCBS Complete	$5.50
Rate for Payer: Cash Price	$11.00
Rate for Payer: Cofinity Commercial	$11.82
Rate for Payer: Cofinity Commercial	$9.62
Rate for Payer: Cofinity Medicare Advantage	$9.62
Rate for Payer: Encore Health Key Benefits Commercial	$11.00
Rate for Payer: Healthscope Commercial	$12.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.69
Rate for Payer: PHP Commercial	$11.69
Rate for Payer: Priority Health Cigna Priority Health	$8.94
Rate for Payer: Priority Health SBD	$8.66

CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION

Facility

$1,714.28

Service Code	NDC 00078050883
Hospital Charge Code	109663
Hospital Revenue Code	637
Min. Negotiated Rate	$1,080.00
Max. Negotiated Rate	$1,542.85
Rate for Payer: Aetna Commercial	$1,457.14
Rate for Payer: Aetna New Business (MI Preferred)	$1,114.28
Rate for Payer: Cash Price	$1,371.42
Rate for Payer: Cofinity Commercial	$1,200.00
Rate for Payer: Cofinity Commercial	$1,474.28
Rate for Payer: Cofinity Medicare Advantage	$1,200.00
Rate for Payer: Encore Health Key Benefits Commercial	$1,371.42
Rate for Payer: Healthscope Commercial	$1,542.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,457.14
Rate for Payer: PHP Commercial	$1,457.14
Rate for Payer: Priority Health Cigna Priority Health	$1,114.28
Rate for Payer: Priority Health SBD	$1,080.00

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