Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SERTRALINE 100 MG TABLET

Facility

$88.83

Service Code	NDC 68180035309
Hospital Charge Code	11350
Hospital Revenue Code	637
Min. Negotiated Rate	$55.96
Max. Negotiated Rate	$79.95
Rate for Payer: Aetna Commercial	$75.51
Rate for Payer: Aetna New Business (MI Preferred)	$57.74
Rate for Payer: Cash Price	$71.06
Rate for Payer: Cofinity Commercial	$62.18
Rate for Payer: Cofinity Commercial	$76.39
Rate for Payer: Cofinity Medicare Advantage	$62.18
Rate for Payer: Encore Health Key Benefits Commercial	$71.06
Rate for Payer: Healthscope Commercial	$79.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$75.51
Rate for Payer: PHP Commercial	$75.51
Rate for Payer: Priority Health Cigna Priority Health	$57.74
Rate for Payer: Priority Health SBD	$55.96

SERTRALINE 100 MG TABLET

Facility

$348.65

Service Code	NDC 60687025301
Hospital Charge Code	11350
Hospital Revenue Code	637
Min. Negotiated Rate	$139.46
Max. Negotiated Rate	$313.78
Rate for Payer: Aetna Commercial	$296.35
Rate for Payer: Aetna Medicare	$174.32
Rate for Payer: Aetna New Business (MI Preferred)	$226.62
Rate for Payer: BCBS Complete	$139.46
Rate for Payer: Cash Price	$278.92
Rate for Payer: Cofinity Commercial	$244.06
Rate for Payer: Cofinity Commercial	$299.84
Rate for Payer: Cofinity Medicare Advantage	$244.06
Rate for Payer: Encore Health Key Benefits Commercial	$278.92
Rate for Payer: Healthscope Commercial	$313.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$296.35
Rate for Payer: PHP Commercial	$296.35
Rate for Payer: Priority Health Cigna Priority Health	$226.62
Rate for Payer: Priority Health SBD	$219.65

SERTRALINE 25 MG TABLET

Facility

$267.90

Service Code	NDC 60687023101
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$107.16
Max. Negotiated Rate	$241.11
Rate for Payer: Aetna Commercial	$227.72
Rate for Payer: Aetna Medicare	$133.95
Rate for Payer: Aetna New Business (MI Preferred)	$174.14
Rate for Payer: BCBS Complete	$107.16
Rate for Payer: Cash Price	$214.32
Rate for Payer: Cofinity Commercial	$187.53
Rate for Payer: Cofinity Commercial	$230.39
Rate for Payer: Cofinity Medicare Advantage	$187.53
Rate for Payer: Encore Health Key Benefits Commercial	$214.32
Rate for Payer: Healthscope Commercial	$241.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$227.72
Rate for Payer: PHP Commercial	$227.72
Rate for Payer: Priority Health Cigna Priority Health	$174.14
Rate for Payer: Priority Health SBD	$168.78

SERTRALINE 25 MG TABLET

Facility

$59.22

Service Code	NDC 68180035109
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$23.69
Max. Negotiated Rate	$53.30
Rate for Payer: Aetna Commercial	$50.34
Rate for Payer: Aetna Medicare	$29.61
Rate for Payer: Aetna New Business (MI Preferred)	$38.49
Rate for Payer: BCBS Complete	$23.69
Rate for Payer: Cash Price	$47.38
Rate for Payer: Cofinity Commercial	$41.45
Rate for Payer: Cofinity Commercial	$50.93
Rate for Payer: Cofinity Medicare Advantage	$41.45
Rate for Payer: Encore Health Key Benefits Commercial	$47.38
Rate for Payer: Healthscope Commercial	$53.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$50.34
Rate for Payer: PHP Commercial	$50.34
Rate for Payer: Priority Health Cigna Priority Health	$38.49
Rate for Payer: Priority Health SBD	$37.31

SERTRALINE 25 MG TABLET

Facility

$2.68

Service Code	NDC 60687023111
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$2.41
Rate for Payer: Aetna Commercial	$2.28
Rate for Payer: Aetna Medicare	$1.34
Rate for Payer: Aetna New Business (MI Preferred)	$1.74
Rate for Payer: BCBS Complete	$1.07
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cofinity Commercial	$1.88
Rate for Payer: Cofinity Commercial	$2.30
Rate for Payer: Cofinity Medicare Advantage	$1.88
Rate for Payer: Encore Health Key Benefits Commercial	$2.14
Rate for Payer: Healthscope Commercial	$2.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.28
Rate for Payer: PHP Commercial	$2.28
Rate for Payer: Priority Health Cigna Priority Health	$1.74
Rate for Payer: Priority Health SBD	$1.69

SERTRALINE 25 MG TABLET

Facility

$59.22

Service Code	NDC 68180035109
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$37.31
Max. Negotiated Rate	$53.30
Rate for Payer: Aetna Commercial	$50.34
Rate for Payer: Aetna New Business (MI Preferred)	$38.49
Rate for Payer: Cash Price	$47.38
Rate for Payer: Cofinity Commercial	$41.45
Rate for Payer: Cofinity Commercial	$50.93
Rate for Payer: Cofinity Medicare Advantage	$41.45
Rate for Payer: Encore Health Key Benefits Commercial	$47.38
Rate for Payer: Healthscope Commercial	$53.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$50.34
Rate for Payer: PHP Commercial	$50.34
Rate for Payer: Priority Health Cigna Priority Health	$38.49
Rate for Payer: Priority Health SBD	$37.31

SERTRALINE 25 MG TABLET

Facility

$2.68

Service Code	NDC 60687023111
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.41
Rate for Payer: Aetna Commercial	$2.28
Rate for Payer: Aetna New Business (MI Preferred)	$1.74
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cofinity Commercial	$1.88
Rate for Payer: Cofinity Commercial	$2.30
Rate for Payer: Cofinity Medicare Advantage	$1.88
Rate for Payer: Encore Health Key Benefits Commercial	$2.14
Rate for Payer: Healthscope Commercial	$2.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.28
Rate for Payer: PHP Commercial	$2.28
Rate for Payer: Priority Health Cigna Priority Health	$1.74
Rate for Payer: Priority Health SBD	$1.69

SERTRALINE 25 MG TABLET

Facility

$4.56

Service Code	NDC 51079014901
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$4.10
Rate for Payer: Aetna Commercial	$3.88
Rate for Payer: Aetna Medicare	$2.28
Rate for Payer: Aetna New Business (MI Preferred)	$2.96
Rate for Payer: BCBS Complete	$1.82
Rate for Payer: Cash Price	$3.65
Rate for Payer: Cofinity Commercial	$3.19
Rate for Payer: Cofinity Commercial	$3.92
Rate for Payer: Cofinity Medicare Advantage	$3.19
Rate for Payer: Encore Health Key Benefits Commercial	$3.65
Rate for Payer: Healthscope Commercial	$4.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.88
Rate for Payer: PHP Commercial	$3.88
Rate for Payer: Priority Health Cigna Priority Health	$2.96
Rate for Payer: Priority Health SBD	$2.87

SERTRALINE 25 MG TABLET

Facility

$455.90

Service Code	NDC 51079014920
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$182.36
Max. Negotiated Rate	$410.31
Rate for Payer: Aetna Commercial	$387.52
Rate for Payer: Aetna Medicare	$227.95
Rate for Payer: Aetna New Business (MI Preferred)	$296.34
Rate for Payer: BCBS Complete	$182.36
Rate for Payer: Cash Price	$364.72
Rate for Payer: Cofinity Commercial	$319.13
Rate for Payer: Cofinity Commercial	$392.07
Rate for Payer: Cofinity Medicare Advantage	$319.13
Rate for Payer: Encore Health Key Benefits Commercial	$364.72
Rate for Payer: Healthscope Commercial	$410.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$387.52
Rate for Payer: PHP Commercial	$387.52
Rate for Payer: Priority Health Cigna Priority Health	$296.34
Rate for Payer: Priority Health SBD	$287.22

SERTRALINE 25 MG TABLET

Facility

$267.90

Service Code	NDC 60687023101
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$168.78
Max. Negotiated Rate	$241.11
Rate for Payer: Aetna Commercial	$227.72
Rate for Payer: Aetna New Business (MI Preferred)	$174.14
Rate for Payer: Cash Price	$214.32
Rate for Payer: Cofinity Commercial	$187.53
Rate for Payer: Cofinity Commercial	$230.39
Rate for Payer: Cofinity Medicare Advantage	$187.53
Rate for Payer: Encore Health Key Benefits Commercial	$214.32
Rate for Payer: Healthscope Commercial	$241.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$227.72
Rate for Payer: PHP Commercial	$227.72
Rate for Payer: Priority Health Cigna Priority Health	$174.14
Rate for Payer: Priority Health SBD	$168.78

SERTRALINE 25 MG TABLET

Facility

$4.56

Service Code	NDC 51079014901
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$4.10
Rate for Payer: Aetna Commercial	$3.88
Rate for Payer: Aetna New Business (MI Preferred)	$2.96
Rate for Payer: Cash Price	$3.65
Rate for Payer: Cofinity Commercial	$3.19
Rate for Payer: Cofinity Commercial	$3.92
Rate for Payer: Cofinity Medicare Advantage	$3.19
Rate for Payer: Encore Health Key Benefits Commercial	$3.65
Rate for Payer: Healthscope Commercial	$4.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.88
Rate for Payer: PHP Commercial	$3.88
Rate for Payer: Priority Health Cigna Priority Health	$2.96
Rate for Payer: Priority Health SBD	$2.87

SERTRALINE 25 MG TABLET

Facility

$455.90

Service Code	NDC 51079014920
Hospital Charge Code	19882
Hospital Revenue Code	637
Min. Negotiated Rate	$287.22
Max. Negotiated Rate	$410.31
Rate for Payer: Aetna Commercial	$387.52
Rate for Payer: Aetna New Business (MI Preferred)	$296.34
Rate for Payer: Cash Price	$364.72
Rate for Payer: Cofinity Commercial	$319.13
Rate for Payer: Cofinity Commercial	$392.07
Rate for Payer: Cofinity Medicare Advantage	$319.13
Rate for Payer: Encore Health Key Benefits Commercial	$364.72
Rate for Payer: Healthscope Commercial	$410.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$387.52
Rate for Payer: PHP Commercial	$387.52
Rate for Payer: Priority Health Cigna Priority Health	$296.34
Rate for Payer: Priority Health SBD	$287.22

SERTRALINE 50 MG TABLET

Facility

$277.40

Service Code	NDC 00904692561
Hospital Charge Code	11351
Hospital Revenue Code	637
Min. Negotiated Rate	$110.96
Max. Negotiated Rate	$249.66
Rate for Payer: Aetna Commercial	$235.79
Rate for Payer: Aetna Medicare	$138.70
Rate for Payer: Aetna New Business (MI Preferred)	$180.31
Rate for Payer: BCBS Complete	$110.96
Rate for Payer: Cash Price	$221.92
Rate for Payer: Cofinity Commercial	$194.18
Rate for Payer: Cofinity Commercial	$238.56
Rate for Payer: Cofinity Medicare Advantage	$194.18
Rate for Payer: Encore Health Key Benefits Commercial	$221.92
Rate for Payer: Healthscope Commercial	$249.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.79
Rate for Payer: PHP Commercial	$235.79
Rate for Payer: Priority Health Cigna Priority Health	$180.31
Rate for Payer: Priority Health SBD	$174.76

SERTRALINE 50 MG TABLET

Facility

$225.60

Service Code	NDC 59762490003
Hospital Charge Code	11351
Hospital Revenue Code	637
Min. Negotiated Rate	$142.13
Max. Negotiated Rate	$203.04
Rate for Payer: Aetna Commercial	$191.76
Rate for Payer: Aetna New Business (MI Preferred)	$146.64
Rate for Payer: Cash Price	$180.48
Rate for Payer: Cofinity Commercial	$157.92
Rate for Payer: Cofinity Commercial	$194.02
Rate for Payer: Cofinity Medicare Advantage	$157.92
Rate for Payer: Encore Health Key Benefits Commercial	$180.48
Rate for Payer: Healthscope Commercial	$203.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$191.76
Rate for Payer: PHP Commercial	$191.76
Rate for Payer: Priority Health Cigna Priority Health	$146.64
Rate for Payer: Priority Health SBD	$142.13

SERTRALINE 50 MG TABLET

Facility

$3.05

Service Code	NDC 60687024211
Hospital Charge Code	11351
Hospital Revenue Code	637
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$2.74
Rate for Payer: Aetna Commercial	$2.59
Rate for Payer: Aetna Medicare	$1.52
Rate for Payer: Aetna New Business (MI Preferred)	$1.98
Rate for Payer: BCBS Complete	$1.22
Rate for Payer: Cash Price	$2.44
Rate for Payer: Cofinity Commercial	$2.14
Rate for Payer: Cofinity Commercial	$2.62
Rate for Payer: Cofinity Medicare Advantage	$2.14
Rate for Payer: Encore Health Key Benefits Commercial	$2.44
Rate for Payer: Healthscope Commercial	$2.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.59
Rate for Payer: PHP Commercial	$2.59
Rate for Payer: Priority Health Cigna Priority Health	$1.98
Rate for Payer: Priority Health SBD	$1.92

SERTRALINE 50 MG TABLET

Facility

$225.60

Service Code	NDC 59762490003
Hospital Charge Code	11351
Hospital Revenue Code	637
Min. Negotiated Rate	$90.24
Max. Negotiated Rate	$203.04
Rate for Payer: Aetna Commercial	$191.76
Rate for Payer: Aetna Medicare	$112.80
Rate for Payer: Aetna New Business (MI Preferred)	$146.64
Rate for Payer: BCBS Complete	$90.24
Rate for Payer: Cash Price	$180.48
Rate for Payer: Cofinity Commercial	$157.92
Rate for Payer: Cofinity Commercial	$194.02
Rate for Payer: Cofinity Medicare Advantage	$157.92
Rate for Payer: Encore Health Key Benefits Commercial	$180.48
Rate for Payer: Healthscope Commercial	$203.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$191.76
Rate for Payer: PHP Commercial	$191.76
Rate for Payer: Priority Health Cigna Priority Health	$146.64
Rate for Payer: Priority Health SBD	$142.13

SERTRALINE 50 MG TABLET

Facility

$277.40

Service Code	NDC 00904692561
Hospital Charge Code	11351
Hospital Revenue Code	637
Min. Negotiated Rate	$174.76
Max. Negotiated Rate	$249.66
Rate for Payer: Aetna Commercial	$235.79
Rate for Payer: Aetna New Business (MI Preferred)	$180.31
Rate for Payer: Cash Price	$221.92
Rate for Payer: Cofinity Commercial	$194.18
Rate for Payer: Cofinity Commercial	$238.56
Rate for Payer: Cofinity Medicare Advantage	$194.18
Rate for Payer: Encore Health Key Benefits Commercial	$221.92
Rate for Payer: Healthscope Commercial	$249.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.79
Rate for Payer: PHP Commercial	$235.79
Rate for Payer: Priority Health Cigna Priority Health	$180.31
Rate for Payer: Priority Health SBD	$174.76

SERTRALINE 50 MG TABLET

Facility

$304.95

Service Code	NDC 60687024201
Hospital Charge Code	11351
Hospital Revenue Code	637
Min. Negotiated Rate	$121.98
Max. Negotiated Rate	$274.46
Rate for Payer: Aetna Commercial	$259.21
Rate for Payer: Aetna Medicare	$152.48
Rate for Payer: Aetna New Business (MI Preferred)	$198.22
Rate for Payer: BCBS Complete	$121.98
Rate for Payer: Cash Price	$243.96
Rate for Payer: Cofinity Commercial	$213.46
Rate for Payer: Cofinity Commercial	$262.26
Rate for Payer: Cofinity Medicare Advantage	$213.46
Rate for Payer: Encore Health Key Benefits Commercial	$243.96
Rate for Payer: Healthscope Commercial	$274.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$259.21
Rate for Payer: PHP Commercial	$259.21
Rate for Payer: Priority Health Cigna Priority Health	$198.22
Rate for Payer: Priority Health SBD	$192.12

SERTRALINE 50 MG TABLET

Facility

$304.95

Service Code	NDC 60687024201
Hospital Charge Code	11351
Hospital Revenue Code	637
Min. Negotiated Rate	$192.12
Max. Negotiated Rate	$274.46
Rate for Payer: Aetna Commercial	$259.21
Rate for Payer: Aetna New Business (MI Preferred)	$198.22
Rate for Payer: Cash Price	$243.96
Rate for Payer: Cofinity Commercial	$213.46
Rate for Payer: Cofinity Commercial	$262.26
Rate for Payer: Cofinity Medicare Advantage	$213.46
Rate for Payer: Encore Health Key Benefits Commercial	$243.96
Rate for Payer: Healthscope Commercial	$274.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$259.21
Rate for Payer: PHP Commercial	$259.21
Rate for Payer: Priority Health Cigna Priority Health	$198.22
Rate for Payer: Priority Health SBD	$192.12

SERTRALINE 50 MG TABLET

Facility

$3.05

Service Code	NDC 60687024211
Hospital Charge Code	11351
Hospital Revenue Code	637
Min. Negotiated Rate	$1.92
Max. Negotiated Rate	$2.74
Rate for Payer: Aetna Commercial	$2.59
Rate for Payer: Aetna New Business (MI Preferred)	$1.98
Rate for Payer: Cash Price	$2.44
Rate for Payer: Cofinity Commercial	$2.14
Rate for Payer: Cofinity Commercial	$2.62
Rate for Payer: Cofinity Medicare Advantage	$2.14
Rate for Payer: Encore Health Key Benefits Commercial	$2.44
Rate for Payer: Healthscope Commercial	$2.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.59
Rate for Payer: PHP Commercial	$2.59
Rate for Payer: Priority Health Cigna Priority Health	$1.98
Rate for Payer: Priority Health SBD	$1.92

SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE)

Facility

$9,991.56

Service Code	CPT 28315
Hospital Revenue Code	360
Min. Negotiated Rate	$344.71
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)	$344.71
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

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET

Facility

$32.54

Service Code	NDC 43598047801
Hospital Charge Code	99694
Hospital Revenue Code	637
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$29.29
Rate for Payer: Aetna Commercial	$27.66
Rate for Payer: Aetna New Business (MI Preferred)	$21.15
Rate for Payer: Cash Price	$26.03
Rate for Payer: Cofinity Commercial	$22.78
Rate for Payer: Cofinity Commercial	$27.98
Rate for Payer: Cofinity Medicare Advantage	$22.78
Rate for Payer: Encore Health Key Benefits Commercial	$26.03
Rate for Payer: Healthscope Commercial	$29.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$27.66
Rate for Payer: PHP Commercial	$27.66
Rate for Payer: Priority Health Cigna Priority Health	$21.15
Rate for Payer: Priority Health SBD	$20.50

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET

Facility

$2,928.41

Service Code	NDC 43598047890
Hospital Charge Code	99694
Hospital Revenue Code	637
Min. Negotiated Rate	$1,171.36
Max. Negotiated Rate	$2,635.57
Rate for Payer: Aetna Commercial	$2,489.15
Rate for Payer: Aetna Medicare	$1,464.20
Rate for Payer: Aetna New Business (MI Preferred)	$1,903.47
Rate for Payer: BCBS Complete	$1,171.36
Rate for Payer: Cash Price	$2,342.73
Rate for Payer: Cofinity Commercial	$2,049.89
Rate for Payer: Cofinity Commercial	$2,518.43
Rate for Payer: Cofinity Medicare Advantage	$2,049.89
Rate for Payer: Encore Health Key Benefits Commercial	$2,342.73
Rate for Payer: Healthscope Commercial	$2,635.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,489.15
Rate for Payer: PHP Commercial	$2,489.15
Rate for Payer: Priority Health Cigna Priority Health	$1,903.47
Rate for Payer: Priority Health SBD	$1,844.90

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET

Facility

$32.54

Service Code	NDC 43598047801
Hospital Charge Code	99694
Hospital Revenue Code	637
Min. Negotiated Rate	$13.02
Max. Negotiated Rate	$29.29
Rate for Payer: Aetna Commercial	$27.66
Rate for Payer: Aetna Medicare	$16.27
Rate for Payer: Aetna New Business (MI Preferred)	$21.15
Rate for Payer: BCBS Complete	$13.02
Rate for Payer: Cash Price	$26.03
Rate for Payer: Cofinity Commercial	$22.78
Rate for Payer: Cofinity Commercial	$27.98
Rate for Payer: Cofinity Medicare Advantage	$22.78
Rate for Payer: Encore Health Key Benefits Commercial	$26.03
Rate for Payer: Healthscope Commercial	$29.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$27.66
Rate for Payer: PHP Commercial	$27.66
Rate for Payer: Priority Health Cigna Priority Health	$21.15
Rate for Payer: Priority Health SBD	$20.50

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET

Facility

$2,928.41

Service Code	NDC 43598047890
Hospital Charge Code	99694
Hospital Revenue Code	637
Min. Negotiated Rate	$1,844.90
Max. Negotiated Rate	$2,635.57
Rate for Payer: Aetna Commercial	$2,489.15
Rate for Payer: Aetna New Business (MI Preferred)	$1,903.47
Rate for Payer: Cash Price	$2,342.73
Rate for Payer: Cofinity Commercial	$2,049.89
Rate for Payer: Cofinity Commercial	$2,518.43
Rate for Payer: Cofinity Medicare Advantage	$2,049.89
Rate for Payer: Encore Health Key Benefits Commercial	$2,342.73
Rate for Payer: Healthscope Commercial	$2,635.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,489.15
Rate for Payer: PHP Commercial	$2,489.15
Rate for Payer: Priority Health Cigna Priority Health	$1,903.47
Rate for Payer: Priority Health SBD	$1,844.90

Know your out-of-pocket cost for care.

All Charges