Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$18.23

Service Code	NDC 57237031603
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$11.48
Max. Negotiated Rate	$16.41
Rate for Payer: Aetna Commercial	$15.50
Rate for Payer: Aetna New Business (MI Preferred)	$11.85
Rate for Payer: Cash Price	$14.58
Rate for Payer: Cofinity Commercial	$12.76
Rate for Payer: Cofinity Commercial	$15.68
Rate for Payer: Cofinity Medicare Advantage	$12.76
Rate for Payer: Encore Health Key Benefits Commercial	$14.58
Rate for Payer: Healthscope Commercial	$16.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.50
Rate for Payer: PHP Commercial	$15.50
Rate for Payer: Priority Health Cigna Priority Health	$11.85
Rate for Payer: Priority Health SBD	$11.48

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$15.98

Service Code	NDC 00536129383
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$14.38
Rate for Payer: Aetna Commercial	$13.58
Rate for Payer: Aetna Medicare	$7.99
Rate for Payer: Aetna New Business (MI Preferred)	$10.39
Rate for Payer: BCBS Complete	$6.39
Rate for Payer: Cash Price	$12.78
Rate for Payer: Cofinity Commercial	$11.19
Rate for Payer: Cofinity Commercial	$13.74
Rate for Payer: Cofinity Medicare Advantage	$11.19
Rate for Payer: Encore Health Key Benefits Commercial	$12.78
Rate for Payer: Healthscope Commercial	$14.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.58
Rate for Payer: PHP Commercial	$13.58
Rate for Payer: Priority Health Cigna Priority Health	$10.39
Rate for Payer: Priority Health SBD	$10.07

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$18.23

Service Code	NDC 57237031631
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$11.48
Max. Negotiated Rate	$16.41
Rate for Payer: Aetna Commercial	$15.50
Rate for Payer: Aetna New Business (MI Preferred)	$11.85
Rate for Payer: Cash Price	$14.58
Rate for Payer: Cofinity Commercial	$12.76
Rate for Payer: Cofinity Commercial	$15.68
Rate for Payer: Cofinity Medicare Advantage	$12.76
Rate for Payer: Encore Health Key Benefits Commercial	$14.58
Rate for Payer: Healthscope Commercial	$16.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.50
Rate for Payer: PHP Commercial	$15.50
Rate for Payer: Priority Health Cigna Priority Health	$11.85
Rate for Payer: Priority Health SBD	$11.48

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$12.83

Service Code	NDC 00904732562
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$11.55
Rate for Payer: Aetna Commercial	$10.91
Rate for Payer: Aetna New Business (MI Preferred)	$8.34
Rate for Payer: Cash Price	$10.26
Rate for Payer: Cofinity Commercial	$11.03
Rate for Payer: Cofinity Commercial	$8.98
Rate for Payer: Cofinity Medicare Advantage	$8.98
Rate for Payer: Encore Health Key Benefits Commercial	$10.26
Rate for Payer: Healthscope Commercial	$11.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.91
Rate for Payer: PHP Commercial	$10.91
Rate for Payer: Priority Health Cigna Priority Health	$8.34
Rate for Payer: Priority Health SBD	$8.08

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$14.38

Service Code	NDC 00536131783
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$5.75
Max. Negotiated Rate	$12.94
Rate for Payer: Aetna Commercial	$12.22
Rate for Payer: Aetna Medicare	$7.19
Rate for Payer: Aetna New Business (MI Preferred)	$9.35
Rate for Payer: BCBS Complete	$5.75
Rate for Payer: Cash Price	$11.50
Rate for Payer: Cofinity Commercial	$10.07
Rate for Payer: Cofinity Commercial	$12.37
Rate for Payer: Cofinity Medicare Advantage	$10.07
Rate for Payer: Encore Health Key Benefits Commercial	$11.50
Rate for Payer: Healthscope Commercial	$12.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.22
Rate for Payer: PHP Commercial	$12.22
Rate for Payer: Priority Health Cigna Priority Health	$9.35
Rate for Payer: Priority Health SBD	$9.06

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$10.26

Service Code	NDC 00904683873
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$9.23
Rate for Payer: Aetna Commercial	$8.72
Rate for Payer: Aetna New Business (MI Preferred)	$6.67
Rate for Payer: Cash Price	$8.21
Rate for Payer: Cofinity Commercial	$7.18
Rate for Payer: Cofinity Commercial	$8.82
Rate for Payer: Cofinity Medicare Advantage	$7.18
Rate for Payer: Encore Health Key Benefits Commercial	$8.21
Rate for Payer: Healthscope Commercial	$9.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.72
Rate for Payer: PHP Commercial	$8.72
Rate for Payer: Priority Health Cigna Priority Health	$6.67
Rate for Payer: Priority Health SBD	$6.46

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$18.23

Service Code	NDC 57237031603
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$16.41
Rate for Payer: Aetna Commercial	$15.50
Rate for Payer: Aetna Medicare	$9.12
Rate for Payer: Aetna New Business (MI Preferred)	$11.85
Rate for Payer: BCBS Complete	$7.29
Rate for Payer: Cash Price	$14.58
Rate for Payer: Cofinity Commercial	$12.76
Rate for Payer: Cofinity Commercial	$15.68
Rate for Payer: Cofinity Medicare Advantage	$12.76
Rate for Payer: Encore Health Key Benefits Commercial	$14.58
Rate for Payer: Healthscope Commercial	$16.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.50
Rate for Payer: PHP Commercial	$15.50
Rate for Payer: Priority Health Cigna Priority Health	$11.85
Rate for Payer: Priority Health SBD	$11.48

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$18.23

Service Code	NDC 57237031631
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$16.41
Rate for Payer: Aetna Commercial	$15.50
Rate for Payer: Aetna Medicare	$9.12
Rate for Payer: Aetna New Business (MI Preferred)	$11.85
Rate for Payer: BCBS Complete	$7.29
Rate for Payer: Cash Price	$14.58
Rate for Payer: Cofinity Commercial	$12.76
Rate for Payer: Cofinity Commercial	$15.68
Rate for Payer: Cofinity Medicare Advantage	$12.76
Rate for Payer: Encore Health Key Benefits Commercial	$14.58
Rate for Payer: Healthscope Commercial	$16.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.50
Rate for Payer: PHP Commercial	$15.50
Rate for Payer: Priority Health Cigna Priority Health	$11.85
Rate for Payer: Priority Health SBD	$11.48

ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP

Facility

$13.77

Service Code	NDC 00121176130
Hospital Charge Code	38285
Hospital Revenue Code	637
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$12.39
Rate for Payer: Aetna Commercial	$11.70
Rate for Payer: Aetna New Business (MI Preferred)	$8.95
Rate for Payer: Cash Price	$11.02
Rate for Payer: Cofinity Commercial	$11.84
Rate for Payer: Cofinity Commercial	$9.64
Rate for Payer: Cofinity Medicare Advantage	$9.64
Rate for Payer: Encore Health Key Benefits Commercial	$11.02
Rate for Payer: Healthscope Commercial	$12.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.70
Rate for Payer: PHP Commercial	$11.70
Rate for Payer: Priority Health Cigna Priority Health	$8.95
Rate for Payer: Priority Health SBD	$8.68

ALVIMOPAN 12 MG CAPSULE

Facility

$486.21

Service Code	NDC 00591231245
Hospital Charge Code	91870
Hospital Revenue Code	637
Min. Negotiated Rate	$194.48
Max. Negotiated Rate	$437.59
Rate for Payer: Aetna Commercial	$413.28
Rate for Payer: Aetna Medicare	$243.10
Rate for Payer: Aetna New Business (MI Preferred)	$316.04
Rate for Payer: BCBS Complete	$194.48
Rate for Payer: Cash Price	$388.97
Rate for Payer: Cofinity Commercial	$340.35
Rate for Payer: Cofinity Commercial	$418.14
Rate for Payer: Cofinity Medicare Advantage	$340.35
Rate for Payer: Encore Health Key Benefits Commercial	$388.97
Rate for Payer: Healthscope Commercial	$437.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$413.28
Rate for Payer: PHP Commercial	$413.28
Rate for Payer: Priority Health Cigna Priority Health	$316.04
Rate for Payer: Priority Health SBD	$306.31

ALVIMOPAN 12 MG CAPSULE

Facility

$20,184.24

Service Code	NDC 67919002010
Hospital Charge Code	91870
Hospital Revenue Code	637
Min. Negotiated Rate	$12,716.07
Max. Negotiated Rate	$18,165.82
Rate for Payer: Aetna Commercial	$17,156.60
Rate for Payer: Aetna New Business (MI Preferred)	$13,119.76
Rate for Payer: Cash Price	$16,147.39
Rate for Payer: Cofinity Commercial	$14,128.97
Rate for Payer: Cofinity Commercial	$17,358.45
Rate for Payer: Cofinity Medicare Advantage	$14,128.97
Rate for Payer: Encore Health Key Benefits Commercial	$16,147.39
Rate for Payer: Healthscope Commercial	$18,165.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17,156.60
Rate for Payer: PHP Commercial	$17,156.60
Rate for Payer: Priority Health Cigna Priority Health	$13,119.76
Rate for Payer: Priority Health SBD	$12,716.07

ALVIMOPAN 12 MG CAPSULE

Facility

$14,586.07

Service Code	NDC 00591231215
Hospital Charge Code	91870
Hospital Revenue Code	637
Min. Negotiated Rate	$9,189.22
Max. Negotiated Rate	$13,127.46
Rate for Payer: Aetna Commercial	$12,398.16
Rate for Payer: Aetna New Business (MI Preferred)	$9,480.95
Rate for Payer: Cash Price	$11,668.86
Rate for Payer: Cofinity Commercial	$10,210.25
Rate for Payer: Cofinity Commercial	$12,544.02
Rate for Payer: Cofinity Medicare Advantage	$10,210.25
Rate for Payer: Encore Health Key Benefits Commercial	$11,668.86
Rate for Payer: Healthscope Commercial	$13,127.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12,398.16
Rate for Payer: PHP Commercial	$12,398.16
Rate for Payer: Priority Health Cigna Priority Health	$9,480.95
Rate for Payer: Priority Health SBD	$9,189.22

ALVIMOPAN 12 MG CAPSULE

Facility

$14,586.07

Service Code	NDC 00591231215
Hospital Charge Code	91870
Hospital Revenue Code	637
Min. Negotiated Rate	$5,834.43
Max. Negotiated Rate	$13,127.46
Rate for Payer: Aetna Commercial	$12,398.16
Rate for Payer: Aetna Medicare	$7,293.04
Rate for Payer: Aetna New Business (MI Preferred)	$9,480.95
Rate for Payer: BCBS Complete	$5,834.43
Rate for Payer: Cash Price	$11,668.86
Rate for Payer: Cofinity Commercial	$10,210.25
Rate for Payer: Cofinity Commercial	$12,544.02
Rate for Payer: Cofinity Medicare Advantage	$10,210.25
Rate for Payer: Encore Health Key Benefits Commercial	$11,668.86
Rate for Payer: Healthscope Commercial	$13,127.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12,398.16
Rate for Payer: PHP Commercial	$12,398.16
Rate for Payer: Priority Health Cigna Priority Health	$9,480.95
Rate for Payer: Priority Health SBD	$9,189.22

ALVIMOPAN 12 MG CAPSULE

Facility

$486.21

Service Code	NDC 00591231245
Hospital Charge Code	91870
Hospital Revenue Code	637
Min. Negotiated Rate	$306.31
Max. Negotiated Rate	$437.59
Rate for Payer: Aetna Commercial	$413.28
Rate for Payer: Aetna New Business (MI Preferred)	$316.04
Rate for Payer: Cash Price	$388.97
Rate for Payer: Cofinity Commercial	$340.35
Rate for Payer: Cofinity Commercial	$418.14
Rate for Payer: Cofinity Medicare Advantage	$340.35
Rate for Payer: Encore Health Key Benefits Commercial	$388.97
Rate for Payer: Healthscope Commercial	$437.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$413.28
Rate for Payer: PHP Commercial	$413.28
Rate for Payer: Priority Health Cigna Priority Health	$316.04
Rate for Payer: Priority Health SBD	$306.31

ALVIMOPAN 12 MG CAPSULE

Facility

$20,184.24

Service Code	NDC 67919002010
Hospital Charge Code	91870
Hospital Revenue Code	637
Min. Negotiated Rate	$8,073.70
Max. Negotiated Rate	$18,165.82
Rate for Payer: Aetna Commercial	$17,156.60
Rate for Payer: Aetna Medicare	$10,092.12
Rate for Payer: Aetna New Business (MI Preferred)	$13,119.76
Rate for Payer: BCBS Complete	$8,073.70
Rate for Payer: Cash Price	$16,147.39
Rate for Payer: Cofinity Commercial	$14,128.97
Rate for Payer: Cofinity Commercial	$17,358.45
Rate for Payer: Cofinity Medicare Advantage	$14,128.97
Rate for Payer: Encore Health Key Benefits Commercial	$16,147.39
Rate for Payer: Healthscope Commercial	$18,165.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17,156.60
Rate for Payer: PHP Commercial	$17,156.60
Rate for Payer: Priority Health Cigna Priority Health	$13,119.76
Rate for Payer: Priority Health SBD	$12,716.07

AMANTADINE HCL 100 MG CAPSULE

Facility

$539.04

Service Code	NDC 00904704261
Hospital Charge Code	364
Hospital Revenue Code	637
Min. Negotiated Rate	$339.60
Max. Negotiated Rate	$485.14
Rate for Payer: Aetna Commercial	$458.18
Rate for Payer: Aetna New Business (MI Preferred)	$350.38
Rate for Payer: Cash Price	$431.23
Rate for Payer: Cofinity Commercial	$377.33
Rate for Payer: Cofinity Commercial	$463.57
Rate for Payer: Cofinity Medicare Advantage	$377.33
Rate for Payer: Encore Health Key Benefits Commercial	$431.23
Rate for Payer: Healthscope Commercial	$485.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$458.18
Rate for Payer: PHP Commercial	$458.18
Rate for Payer: Priority Health Cigna Priority Health	$350.38
Rate for Payer: Priority Health SBD	$339.60

AMANTADINE HCL 100 MG CAPSULE

Facility

$539.04

Service Code	NDC 00904704261
Hospital Charge Code	364
Hospital Revenue Code	637
Min. Negotiated Rate	$215.62
Max. Negotiated Rate	$485.14
Rate for Payer: Aetna Commercial	$458.18
Rate for Payer: Aetna Medicare	$269.52
Rate for Payer: Aetna New Business (MI Preferred)	$350.38
Rate for Payer: BCBS Complete	$215.62
Rate for Payer: Cash Price	$431.23
Rate for Payer: Cofinity Commercial	$377.33
Rate for Payer: Cofinity Commercial	$463.57
Rate for Payer: Cofinity Medicare Advantage	$377.33
Rate for Payer: Encore Health Key Benefits Commercial	$431.23
Rate for Payer: Healthscope Commercial	$485.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$458.18
Rate for Payer: PHP Commercial	$458.18
Rate for Payer: Priority Health Cigna Priority Health	$350.38
Rate for Payer: Priority Health SBD	$339.60

AMIKACIN 500 MG/2 ML INJECTION SOLUTION

Facility

$50.73

Service Code	HCPCS J0278
Hospital Charge Code	119785
Hospital Revenue Code	636
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$45.66
Rate for Payer: Aetna Commercial	$43.12
Rate for Payer: Aetna Commercial	$15.88
Rate for Payer: Aetna Commercial	$16.38
Rate for Payer: Aetna Medicare	$9.34
Rate for Payer: Aetna Medicare	$9.64
Rate for Payer: Aetna Medicare	$25.36
Rate for Payer: Aetna New Business (MI Preferred)	$12.53
Rate for Payer: Aetna New Business (MI Preferred)	$12.14
Rate for Payer: Aetna New Business (MI Preferred)	$32.97
Rate for Payer: BCBS Complete	$7.71
Rate for Payer: BCBS Complete	$7.47
Rate for Payer: BCBS Complete	$20.29
Rate for Payer: BCBS Trust/PPO	$2.16
Rate for Payer: BCBS Trust/PPO	$2.16
Rate for Payer: BCBS Trust/PPO	$2.16
Rate for Payer: BCN Commercial	$2.16
Rate for Payer: BCN Commercial	$2.16
Rate for Payer: BCN Commercial	$2.16
Rate for Payer: Cash Price	$15.42
Rate for Payer: Cash Price	$14.94
Rate for Payer: Cash Price	$40.58
Rate for Payer: Cash Price	$15.42
Rate for Payer: Cash Price	$14.94
Rate for Payer: Cash Price	$40.58
Rate for Payer: Cofinity Commercial	$13.49
Rate for Payer: Cofinity Commercial	$13.08
Rate for Payer: Cofinity Commercial	$16.06
Rate for Payer: Cofinity Commercial	$16.57
Rate for Payer: Cofinity Commercial	$35.51
Rate for Payer: Cofinity Commercial	$43.63
Rate for Payer: Cofinity Medicare Advantage	$35.51
Rate for Payer: Cofinity Medicare Advantage	$13.49
Rate for Payer: Cofinity Medicare Advantage	$13.08
Rate for Payer: Encore Health Key Benefits Commercial	$14.94
Rate for Payer: Encore Health Key Benefits Commercial	$15.42
Rate for Payer: Encore Health Key Benefits Commercial	$40.58
Rate for Payer: Healthscope Commercial	$17.34
Rate for Payer: Healthscope Commercial	$16.81
Rate for Payer: Healthscope Commercial	$45.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.12
Rate for Payer: PHP Commercial	$16.38
Rate for Payer: PHP Commercial	$43.12
Rate for Payer: PHP Commercial	$15.88
Rate for Payer: Priority Health Cigna Priority Health	$12.53
Rate for Payer: Priority Health Cigna Priority Health	$32.97
Rate for Payer: Priority Health Cigna Priority Health	$12.14
Rate for Payer: Priority Health SBD	$11.77
Rate for Payer: Priority Health SBD	$31.96
Rate for Payer: Priority Health SBD	$12.14

AMIKACIN 500 MG/2 ML INJECTION SOLUTION

Facility

$19.27

Service Code	HCPCS J0278
Hospital Charge Code	119785
Hospital Revenue Code	636
Min. Negotiated Rate	$12.14
Max. Negotiated Rate	$17.34
Rate for Payer: Aetna Commercial	$16.38
Rate for Payer: Aetna Commercial	$15.88
Rate for Payer: Aetna Commercial	$43.12
Rate for Payer: Aetna New Business (MI Preferred)	$32.97
Rate for Payer: Aetna New Business (MI Preferred)	$12.14
Rate for Payer: Aetna New Business (MI Preferred)	$12.53
Rate for Payer: Cash Price	$15.42
Rate for Payer: Cash Price	$14.94
Rate for Payer: Cash Price	$40.58
Rate for Payer: Cofinity Commercial	$35.51
Rate for Payer: Cofinity Commercial	$43.63
Rate for Payer: Cofinity Commercial	$16.57
Rate for Payer: Cofinity Commercial	$16.06
Rate for Payer: Cofinity Commercial	$13.08
Rate for Payer: Cofinity Commercial	$13.49
Rate for Payer: Cofinity Medicare Advantage	$13.08
Rate for Payer: Cofinity Medicare Advantage	$13.49
Rate for Payer: Cofinity Medicare Advantage	$35.51
Rate for Payer: Encore Health Key Benefits Commercial	$14.94
Rate for Payer: Encore Health Key Benefits Commercial	$15.42
Rate for Payer: Encore Health Key Benefits Commercial	$40.58
Rate for Payer: Healthscope Commercial	$16.81
Rate for Payer: Healthscope Commercial	$17.34
Rate for Payer: Healthscope Commercial	$45.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.12
Rate for Payer: PHP Commercial	$15.88
Rate for Payer: PHP Commercial	$16.38
Rate for Payer: PHP Commercial	$43.12
Rate for Payer: Priority Health Cigna Priority Health	$12.14
Rate for Payer: Priority Health Cigna Priority Health	$12.53
Rate for Payer: Priority Health Cigna Priority Health	$32.97
Rate for Payer: Priority Health SBD	$31.96
Rate for Payer: Priority Health SBD	$11.77
Rate for Payer: Priority Health SBD	$12.14

AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION

Facility

$124.60

Service Code	HCPCS J3490
Hospital Charge Code	27928
Hospital Revenue Code	636
Min. Negotiated Rate	$78.50
Max. Negotiated Rate	$112.14
Rate for Payer: Aetna Commercial	$105.91
Rate for Payer: Aetna New Business (MI Preferred)	$80.99
Rate for Payer: Cash Price	$99.68
Rate for Payer: Cofinity Commercial	$107.16
Rate for Payer: Cofinity Commercial	$87.22
Rate for Payer: Cofinity Medicare Advantage	$87.22
Rate for Payer: Encore Health Key Benefits Commercial	$99.68
Rate for Payer: Healthscope Commercial	$112.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$105.91
Rate for Payer: PHP Commercial	$105.91
Rate for Payer: Priority Health Cigna Priority Health	$80.99
Rate for Payer: Priority Health SBD	$78.50

AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION

Facility

$124.60

Service Code	HCPCS J3490
Hospital Charge Code	27928
Hospital Revenue Code	636
Min. Negotiated Rate	$49.84
Max. Negotiated Rate	$112.14
Rate for Payer: Aetna Commercial	$105.91
Rate for Payer: Aetna Medicare	$62.30
Rate for Payer: Aetna New Business (MI Preferred)	$80.99
Rate for Payer: BCBS Complete	$49.84
Rate for Payer: Cash Price	$99.68
Rate for Payer: Cofinity Commercial	$107.16
Rate for Payer: Cofinity Commercial	$87.22
Rate for Payer: Cofinity Medicare Advantage	$87.22
Rate for Payer: Encore Health Key Benefits Commercial	$99.68
Rate for Payer: Healthscope Commercial	$112.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$105.91
Rate for Payer: PHP Commercial	$105.91
Rate for Payer: Priority Health Cigna Priority Health	$80.99
Rate for Payer: Priority Health SBD	$78.50

AMINO ACID 6 % IN DEXTROSE 5 % WATER INTRAVENOUS SOLUTION

Facility

$155.75

Service Code	NDC 00338019801
Hospital Charge Code	195260
Hospital Revenue Code	250
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$140.18
Rate for Payer: Aetna Commercial	$132.39
Rate for Payer: Aetna Medicare	$77.88
Rate for Payer: Aetna New Business (MI Preferred)	$101.24
Rate for Payer: BCBS Complete	$62.30
Rate for Payer: Cash Price	$124.60
Rate for Payer: Cofinity Commercial	$109.02
Rate for Payer: Cofinity Commercial	$133.94
Rate for Payer: Cofinity Medicare Advantage	$109.02
Rate for Payer: Encore Health Key Benefits Commercial	$124.60
Rate for Payer: Healthscope Commercial	$140.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$132.39
Rate for Payer: PHP Commercial	$132.39
Rate for Payer: Priority Health Cigna Priority Health	$101.24
Rate for Payer: Priority Health SBD	$98.12

AMINO ACID 6 % IN DEXTROSE 5 % WATER INTRAVENOUS SOLUTION

Facility

$155.75

Service Code	NDC 00338019806
Hospital Charge Code	195260
Hospital Revenue Code	250
Min. Negotiated Rate	$98.12
Max. Negotiated Rate	$140.18
Rate for Payer: Aetna Commercial	$132.39
Rate for Payer: Aetna New Business (MI Preferred)	$101.24
Rate for Payer: Cash Price	$124.60
Rate for Payer: Cofinity Commercial	$109.02
Rate for Payer: Cofinity Commercial	$133.94
Rate for Payer: Cofinity Medicare Advantage	$109.02
Rate for Payer: Encore Health Key Benefits Commercial	$124.60
Rate for Payer: Healthscope Commercial	$140.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$132.39
Rate for Payer: PHP Commercial	$132.39
Rate for Payer: Priority Health Cigna Priority Health	$101.24
Rate for Payer: Priority Health SBD	$98.12

AMINO ACID 6 % IN DEXTROSE 5 % WATER INTRAVENOUS SOLUTION

Facility

$155.75

Service Code	NDC 00338019806
Hospital Charge Code	195260
Hospital Revenue Code	250
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$140.18
Rate for Payer: Aetna Commercial	$132.39
Rate for Payer: Aetna Medicare	$77.88
Rate for Payer: Aetna New Business (MI Preferred)	$101.24
Rate for Payer: BCBS Complete	$62.30
Rate for Payer: Cash Price	$124.60
Rate for Payer: Cofinity Commercial	$109.02
Rate for Payer: Cofinity Commercial	$133.94
Rate for Payer: Cofinity Medicare Advantage	$109.02
Rate for Payer: Encore Health Key Benefits Commercial	$124.60
Rate for Payer: Healthscope Commercial	$140.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$132.39
Rate for Payer: PHP Commercial	$132.39
Rate for Payer: Priority Health Cigna Priority Health	$101.24
Rate for Payer: Priority Health SBD	$98.12

AMINO ACID 6 % IN DEXTROSE 5 % WATER INTRAVENOUS SOLUTION

Facility

$155.75

Service Code	NDC 00338019801
Hospital Charge Code	195260
Hospital Revenue Code	250
Min. Negotiated Rate	$98.12
Max. Negotiated Rate	$140.18
Rate for Payer: Aetna Commercial	$132.39
Rate for Payer: Aetna New Business (MI Preferred)	$101.24
Rate for Payer: Cash Price	$124.60
Rate for Payer: Cofinity Commercial	$109.02
Rate for Payer: Cofinity Commercial	$133.94
Rate for Payer: Cofinity Medicare Advantage	$109.02
Rate for Payer: Encore Health Key Benefits Commercial	$124.60
Rate for Payer: Healthscope Commercial	$140.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$132.39
Rate for Payer: PHP Commercial	$132.39
Rate for Payer: Priority Health Cigna Priority Health	$101.24
Rate for Payer: Priority Health SBD	$98.12

Know your out-of-pocket cost for care.

All Charges