Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET

Facility

$816.05

Service Code	NDC 65862093190
Hospital Charge Code	99695
Hospital Revenue Code	637
Min. Negotiated Rate	$514.11
Max. Negotiated Rate	$734.44
Rate for Payer: Aetna Commercial	$693.64
Rate for Payer: Aetna New Business (MI Preferred)	$530.43
Rate for Payer: Cash Price	$652.84
Rate for Payer: Cofinity Commercial	$571.24
Rate for Payer: Cofinity Commercial	$701.80
Rate for Payer: Cofinity Medicare Advantage	$571.24
Rate for Payer: Encore Health Key Benefits Commercial	$652.84
Rate for Payer: Healthscope Commercial	$734.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$693.64
Rate for Payer: PHP Commercial	$693.64
Rate for Payer: Priority Health Cigna Priority Health	$530.43
Rate for Payer: Priority Health SBD	$514.11

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET

Facility

$9.07

Service Code	NDC 65862093108
Hospital Charge Code	99695
Hospital Revenue Code	637
Min. Negotiated Rate	$3.63
Max. Negotiated Rate	$8.16
Rate for Payer: Aetna Commercial	$7.71
Rate for Payer: Aetna Medicare	$4.54
Rate for Payer: Aetna New Business (MI Preferred)	$5.90
Rate for Payer: BCBS Complete	$3.63
Rate for Payer: Cash Price	$7.26
Rate for Payer: Cofinity Commercial	$6.35
Rate for Payer: Cofinity Commercial	$7.80
Rate for Payer: Cofinity Medicare Advantage	$6.35
Rate for Payer: Encore Health Key Benefits Commercial	$7.26
Rate for Payer: Healthscope Commercial	$8.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.71
Rate for Payer: PHP Commercial	$7.71
Rate for Payer: Priority Health Cigna Priority Health	$5.90
Rate for Payer: Priority Health SBD	$5.71

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET

Facility

$816.05

Service Code	NDC 65862093190
Hospital Charge Code	99695
Hospital Revenue Code	637
Min. Negotiated Rate	$326.42
Max. Negotiated Rate	$734.44
Rate for Payer: Aetna Commercial	$693.64
Rate for Payer: Aetna Medicare	$408.02
Rate for Payer: Aetna New Business (MI Preferred)	$530.43
Rate for Payer: BCBS Complete	$326.42
Rate for Payer: Cash Price	$652.84
Rate for Payer: Cofinity Commercial	$571.24
Rate for Payer: Cofinity Commercial	$701.80
Rate for Payer: Cofinity Medicare Advantage	$571.24
Rate for Payer: Encore Health Key Benefits Commercial	$652.84
Rate for Payer: Healthscope Commercial	$734.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$693.64
Rate for Payer: PHP Commercial	$693.64
Rate for Payer: Priority Health Cigna Priority Health	$530.43
Rate for Payer: Priority Health SBD	$514.11

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET

Facility

$9.07

Service Code	NDC 65862093108
Hospital Charge Code	99695
Hospital Revenue Code	637
Min. Negotiated Rate	$5.71
Max. Negotiated Rate	$8.16
Rate for Payer: Aetna Commercial	$7.71
Rate for Payer: Aetna New Business (MI Preferred)	$5.90
Rate for Payer: Cash Price	$7.26
Rate for Payer: Cofinity Commercial	$6.35
Rate for Payer: Cofinity Commercial	$7.80
Rate for Payer: Cofinity Medicare Advantage	$6.35
Rate for Payer: Encore Health Key Benefits Commercial	$7.26
Rate for Payer: Healthscope Commercial	$8.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.71
Rate for Payer: PHP Commercial	$7.71
Rate for Payer: Priority Health Cigna Priority Health	$5.90
Rate for Payer: Priority Health SBD	$5.71

SEVELAMER CARBONATE 800 MG TABLET

Facility

$10.56

Service Code	NDC 60687032811
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$9.50
Rate for Payer: Aetna Commercial	$8.98
Rate for Payer: Aetna Medicare	$5.28
Rate for Payer: Aetna New Business (MI Preferred)	$6.86
Rate for Payer: BCBS Complete	$4.22
Rate for Payer: Cash Price	$8.45
Rate for Payer: Cofinity Commercial	$7.39
Rate for Payer: Cofinity Commercial	$9.08
Rate for Payer: Cofinity Medicare Advantage	$7.39
Rate for Payer: Encore Health Key Benefits Commercial	$8.45
Rate for Payer: Healthscope Commercial	$9.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.98
Rate for Payer: PHP Commercial	$8.98
Rate for Payer: Priority Health Cigna Priority Health	$6.86
Rate for Payer: Priority Health SBD	$6.65

SEVELAMER CARBONATE 800 MG TABLET

Facility

$5,499.50

Service Code	NDC 58468013001
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$3,464.68
Max. Negotiated Rate	$4,949.55
Rate for Payer: Aetna Commercial	$4,674.58
Rate for Payer: Aetna New Business (MI Preferred)	$3,574.68
Rate for Payer: Cash Price	$4,399.60
Rate for Payer: Cofinity Commercial	$3,849.65
Rate for Payer: Cofinity Commercial	$4,729.57
Rate for Payer: Cofinity Medicare Advantage	$3,849.65
Rate for Payer: Encore Health Key Benefits Commercial	$4,399.60
Rate for Payer: Healthscope Commercial	$4,949.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,674.58
Rate for Payer: PHP Commercial	$4,674.58
Rate for Payer: Priority Health Cigna Priority Health	$3,574.68
Rate for Payer: Priority Health SBD	$3,464.68

SEVELAMER CARBONATE 800 MG TABLET

Facility

$763.35

Service Code	NDC 68094003464
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$305.34
Max. Negotiated Rate	$687.02
Rate for Payer: Aetna Commercial	$648.85
Rate for Payer: Aetna Medicare	$381.68
Rate for Payer: Aetna New Business (MI Preferred)	$496.18
Rate for Payer: BCBS Complete	$305.34
Rate for Payer: Cash Price	$610.68
Rate for Payer: Cofinity Commercial	$534.34
Rate for Payer: Cofinity Commercial	$656.48
Rate for Payer: Cofinity Medicare Advantage	$534.34
Rate for Payer: Encore Health Key Benefits Commercial	$610.68
Rate for Payer: Healthscope Commercial	$687.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$648.85
Rate for Payer: PHP Commercial	$648.85
Rate for Payer: Priority Health Cigna Priority Health	$496.18
Rate for Payer: Priority Health SBD	$480.91

SEVELAMER CARBONATE 800 MG TABLET

Facility

$527.62

Service Code	NDC 60687032865
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$211.05
Max. Negotiated Rate	$474.86
Rate for Payer: Aetna Commercial	$448.48
Rate for Payer: Aetna Medicare	$263.81
Rate for Payer: Aetna New Business (MI Preferred)	$342.95
Rate for Payer: BCBS Complete	$211.05
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cofinity Commercial	$369.33
Rate for Payer: Cofinity Commercial	$453.75
Rate for Payer: Cofinity Medicare Advantage	$369.33
Rate for Payer: Encore Health Key Benefits Commercial	$422.10
Rate for Payer: Healthscope Commercial	$474.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$448.48
Rate for Payer: PHP Commercial	$448.48
Rate for Payer: Priority Health Cigna Priority Health	$342.95
Rate for Payer: Priority Health SBD	$332.40

SEVELAMER CARBONATE 800 MG TABLET

Facility

$928.53

Service Code	NDC 65162005827
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$371.41
Max. Negotiated Rate	$835.68
Rate for Payer: Aetna Commercial	$789.25
Rate for Payer: Aetna Medicare	$464.26
Rate for Payer: Aetna New Business (MI Preferred)	$603.54
Rate for Payer: BCBS Complete	$371.41
Rate for Payer: Cash Price	$742.82
Rate for Payer: Cofinity Commercial	$649.97
Rate for Payer: Cofinity Commercial	$798.54
Rate for Payer: Cofinity Medicare Advantage	$649.97
Rate for Payer: Encore Health Key Benefits Commercial	$742.82
Rate for Payer: Healthscope Commercial	$835.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$789.25
Rate for Payer: PHP Commercial	$789.25
Rate for Payer: Priority Health Cigna Priority Health	$603.54
Rate for Payer: Priority Health SBD	$584.97

SEVELAMER CARBONATE 800 MG TABLET

Facility

$2,051.57

Service Code	NDC 00955105027
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$820.63
Max. Negotiated Rate	$1,846.41
Rate for Payer: Aetna Commercial	$1,743.83
Rate for Payer: Aetna Medicare	$1,025.78
Rate for Payer: Aetna New Business (MI Preferred)	$1,333.52
Rate for Payer: BCBS Complete	$820.63
Rate for Payer: Cash Price	$1,641.26
Rate for Payer: Cofinity Commercial	$1,436.10
Rate for Payer: Cofinity Commercial	$1,764.35
Rate for Payer: Cofinity Medicare Advantage	$1,436.10
Rate for Payer: Encore Health Key Benefits Commercial	$1,641.26
Rate for Payer: Healthscope Commercial	$1,846.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,743.83
Rate for Payer: PHP Commercial	$1,743.83
Rate for Payer: Priority Health Cigna Priority Health	$1,333.52
Rate for Payer: Priority Health SBD	$1,292.49

SEVELAMER CARBONATE 800 MG TABLET

Facility

$763.35

Service Code	NDC 68094003464
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$480.91
Max. Negotiated Rate	$687.02
Rate for Payer: Aetna Commercial	$648.85
Rate for Payer: Aetna New Business (MI Preferred)	$496.18
Rate for Payer: Cash Price	$610.68
Rate for Payer: Cofinity Commercial	$534.34
Rate for Payer: Cofinity Commercial	$656.48
Rate for Payer: Cofinity Medicare Advantage	$534.34
Rate for Payer: Encore Health Key Benefits Commercial	$610.68
Rate for Payer: Healthscope Commercial	$687.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$648.85
Rate for Payer: PHP Commercial	$648.85
Rate for Payer: Priority Health Cigna Priority Health	$496.18
Rate for Payer: Priority Health SBD	$480.91

SEVELAMER CARBONATE 800 MG TABLET

Facility

$928.53

Service Code	NDC 65162005827
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$584.97
Max. Negotiated Rate	$835.68
Rate for Payer: Aetna Commercial	$789.25
Rate for Payer: Aetna New Business (MI Preferred)	$603.54
Rate for Payer: Cash Price	$742.82
Rate for Payer: Cofinity Commercial	$649.97
Rate for Payer: Cofinity Commercial	$798.54
Rate for Payer: Cofinity Medicare Advantage	$649.97
Rate for Payer: Encore Health Key Benefits Commercial	$742.82
Rate for Payer: Healthscope Commercial	$835.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$789.25
Rate for Payer: PHP Commercial	$789.25
Rate for Payer: Priority Health Cigna Priority Health	$603.54
Rate for Payer: Priority Health SBD	$584.97

SEVELAMER CARBONATE 800 MG TABLET

Facility

$8.49

Service Code	NDC 68094003459
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$7.64
Rate for Payer: Aetna Commercial	$7.22
Rate for Payer: Aetna New Business (MI Preferred)	$5.52
Rate for Payer: Cash Price	$6.79
Rate for Payer: Cofinity Commercial	$5.94
Rate for Payer: Cofinity Commercial	$7.30
Rate for Payer: Cofinity Medicare Advantage	$5.94
Rate for Payer: Encore Health Key Benefits Commercial	$6.79
Rate for Payer: Healthscope Commercial	$7.64
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	$5.35

SEVELAMER CARBONATE 800 MG TABLET

Facility

$8.49

Service Code	NDC 68094003459
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$7.64
Rate for Payer: Aetna Commercial	$7.22
Rate for Payer: Aetna Medicare	$4.24
Rate for Payer: Aetna New Business (MI Preferred)	$5.52
Rate for Payer: BCBS Complete	$3.40
Rate for Payer: Cash Price	$6.79
Rate for Payer: Cofinity Commercial	$5.94
Rate for Payer: Cofinity Commercial	$7.30
Rate for Payer: Cofinity Medicare Advantage	$5.94
Rate for Payer: Encore Health Key Benefits Commercial	$6.79
Rate for Payer: Healthscope Commercial	$7.64
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	$5.35

SEVELAMER CARBONATE 800 MG TABLET

Facility

$5,499.50

Service Code	NDC 58468013001
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$2,199.80
Max. Negotiated Rate	$4,949.55
Rate for Payer: Aetna Commercial	$4,674.58
Rate for Payer: Aetna Medicare	$2,749.75
Rate for Payer: Aetna New Business (MI Preferred)	$3,574.68
Rate for Payer: BCBS Complete	$2,199.80
Rate for Payer: Cash Price	$4,399.60
Rate for Payer: Cofinity Commercial	$3,849.65
Rate for Payer: Cofinity Commercial	$4,729.57
Rate for Payer: Cofinity Medicare Advantage	$3,849.65
Rate for Payer: Encore Health Key Benefits Commercial	$4,399.60
Rate for Payer: Healthscope Commercial	$4,949.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,674.58
Rate for Payer: PHP Commercial	$4,674.58
Rate for Payer: Priority Health Cigna Priority Health	$3,574.68
Rate for Payer: Priority Health SBD	$3,464.68

SEVELAMER CARBONATE 800 MG TABLET

Facility

$527.62

Service Code	NDC 60687032865
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$332.40
Max. Negotiated Rate	$474.86
Rate for Payer: Aetna Commercial	$448.48
Rate for Payer: Aetna New Business (MI Preferred)	$342.95
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cofinity Commercial	$369.33
Rate for Payer: Cofinity Commercial	$453.75
Rate for Payer: Cofinity Medicare Advantage	$369.33
Rate for Payer: Encore Health Key Benefits Commercial	$422.10
Rate for Payer: Healthscope Commercial	$474.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$448.48
Rate for Payer: PHP Commercial	$448.48
Rate for Payer: Priority Health Cigna Priority Health	$342.95
Rate for Payer: Priority Health SBD	$332.40

SEVELAMER CARBONATE 800 MG TABLET

Facility

$2,051.57

Service Code	NDC 00955105027
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$1,292.49
Max. Negotiated Rate	$1,846.41
Rate for Payer: Aetna Commercial	$1,743.83
Rate for Payer: Aetna New Business (MI Preferred)	$1,333.52
Rate for Payer: Cash Price	$1,641.26
Rate for Payer: Cofinity Commercial	$1,436.10
Rate for Payer: Cofinity Commercial	$1,764.35
Rate for Payer: Cofinity Medicare Advantage	$1,436.10
Rate for Payer: Encore Health Key Benefits Commercial	$1,641.26
Rate for Payer: Healthscope Commercial	$1,846.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,743.83
Rate for Payer: PHP Commercial	$1,743.83
Rate for Payer: Priority Health Cigna Priority Health	$1,333.52
Rate for Payer: Priority Health SBD	$1,292.49

SEVELAMER CARBONATE 800 MG TABLET

Facility

$10.56

Service Code	NDC 60687032811
Hospital Charge Code	89201
Hospital Revenue Code	637
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$9.50
Rate for Payer: Aetna Commercial	$8.98
Rate for Payer: Aetna New Business (MI Preferred)	$6.86
Rate for Payer: Cash Price	$8.45
Rate for Payer: Cofinity Commercial	$7.39
Rate for Payer: Cofinity Commercial	$9.08
Rate for Payer: Cofinity Medicare Advantage	$7.39
Rate for Payer: Encore Health Key Benefits Commercial	$8.45
Rate for Payer: Healthscope Commercial	$9.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.98
Rate for Payer: PHP Commercial	$8.98
Rate for Payer: Priority Health Cigna Priority Health	$6.86
Rate for Payer: Priority Health SBD	$6.65

SEVELAMER HCL 800 MG TABLET

Facility

$4,583.42

Service Code	NDC 58468002101
Hospital Charge Code	28715
Hospital Revenue Code	637
Min. Negotiated Rate	$1,833.37
Max. Negotiated Rate	$4,125.08
Rate for Payer: Aetna Commercial	$3,895.91
Rate for Payer: Aetna Medicare	$2,291.71
Rate for Payer: Aetna New Business (MI Preferred)	$2,979.22
Rate for Payer: BCBS Complete	$1,833.37
Rate for Payer: Cash Price	$3,666.74
Rate for Payer: Cofinity Commercial	$3,208.39
Rate for Payer: Cofinity Commercial	$3,941.74
Rate for Payer: Cofinity Medicare Advantage	$3,208.39
Rate for Payer: Encore Health Key Benefits Commercial	$3,666.74
Rate for Payer: Healthscope Commercial	$4,125.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,895.91
Rate for Payer: PHP Commercial	$3,895.91
Rate for Payer: Priority Health Cigna Priority Health	$2,979.22
Rate for Payer: Priority Health SBD	$2,887.55

SEVELAMER HCL 800 MG TABLET

Facility

$4,583.42

Service Code	NDC 58468002101
Hospital Charge Code	28715
Hospital Revenue Code	637
Min. Negotiated Rate	$2,887.55
Max. Negotiated Rate	$4,125.08
Rate for Payer: Aetna Commercial	$3,895.91
Rate for Payer: Aetna New Business (MI Preferred)	$2,979.22
Rate for Payer: Cash Price	$3,666.74
Rate for Payer: Cofinity Commercial	$3,208.39
Rate for Payer: Cofinity Commercial	$3,941.74
Rate for Payer: Cofinity Medicare Advantage	$3,208.39
Rate for Payer: Encore Health Key Benefits Commercial	$3,666.74
Rate for Payer: Healthscope Commercial	$4,125.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,895.91
Rate for Payer: PHP Commercial	$3,895.91
Rate for Payer: Priority Health Cigna Priority Health	$2,979.22
Rate for Payer: Priority Health SBD	$2,887.55

SEVOFLURANE INHALATION LIQUID

Facility

$223.13

Service Code	NDC 10019065164
Hospital Charge Code	15119
Hospital Revenue Code	637
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$200.82
Rate for Payer: Aetna Commercial	$189.66
Rate for Payer: Aetna Medicare	$111.56
Rate for Payer: Aetna New Business (MI Preferred)	$145.03
Rate for Payer: BCBS Complete	$89.25
Rate for Payer: Cash Price	$178.50
Rate for Payer: Cofinity Commercial	$156.19
Rate for Payer: Cofinity Commercial	$191.89
Rate for Payer: Cofinity Medicare Advantage	$156.19
Rate for Payer: Encore Health Key Benefits Commercial	$178.50
Rate for Payer: Healthscope Commercial	$200.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$189.66
Rate for Payer: PHP Commercial	$189.66
Rate for Payer: Priority Health Cigna Priority Health	$145.03
Rate for Payer: Priority Health SBD	$140.57

SEVOFLURANE INHALATION LIQUID

Facility

$211.75

Service Code	NDC 66794002225
Hospital Charge Code	15119
Hospital Revenue Code	637
Min. Negotiated Rate	$133.40
Max. Negotiated Rate	$190.58
Rate for Payer: Aetna Commercial	$179.99
Rate for Payer: Aetna New Business (MI Preferred)	$137.64
Rate for Payer: Cash Price	$169.40
Rate for Payer: Cofinity Commercial	$148.22
Rate for Payer: Cofinity Commercial	$182.10
Rate for Payer: Cofinity Medicare Advantage	$148.22
Rate for Payer: Encore Health Key Benefits Commercial	$169.40
Rate for Payer: Healthscope Commercial	$190.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$179.99
Rate for Payer: PHP Commercial	$179.99
Rate for Payer: Priority Health Cigna Priority Health	$137.64
Rate for Payer: Priority Health SBD	$133.40

SEVOFLURANE INHALATION LIQUID

Facility

$214.38

Service Code	NDC 00074445604
Hospital Charge Code	15119
Hospital Revenue Code	637
Min. Negotiated Rate	$135.06
Max. Negotiated Rate	$192.94
Rate for Payer: Aetna Commercial	$182.22
Rate for Payer: Aetna New Business (MI Preferred)	$139.35
Rate for Payer: Cash Price	$171.50
Rate for Payer: Cofinity Commercial	$150.07
Rate for Payer: Cofinity Commercial	$184.37
Rate for Payer: Cofinity Medicare Advantage	$150.07
Rate for Payer: Encore Health Key Benefits Commercial	$171.50
Rate for Payer: Healthscope Commercial	$192.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$182.22
Rate for Payer: PHP Commercial	$182.22
Rate for Payer: Priority Health Cigna Priority Health	$139.35
Rate for Payer: Priority Health SBD	$135.06

SEVOFLURANE INHALATION LIQUID

Facility

$211.75

Service Code	NDC 66794002225
Hospital Charge Code	15119
Hospital Revenue Code	637
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$190.58
Rate for Payer: Aetna Commercial	$179.99
Rate for Payer: Aetna Medicare	$105.88
Rate for Payer: Aetna New Business (MI Preferred)	$137.64
Rate for Payer: BCBS Complete	$84.70
Rate for Payer: Cash Price	$169.40
Rate for Payer: Cofinity Commercial	$148.22
Rate for Payer: Cofinity Commercial	$182.10
Rate for Payer: Cofinity Medicare Advantage	$148.22
Rate for Payer: Encore Health Key Benefits Commercial	$169.40
Rate for Payer: Healthscope Commercial	$190.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$179.99
Rate for Payer: PHP Commercial	$179.99
Rate for Payer: Priority Health Cigna Priority Health	$137.64
Rate for Payer: Priority Health SBD	$133.40

SEVOFLURANE INHALATION LIQUID

Facility

$214.38

Service Code	NDC 00074445604
Hospital Charge Code	15119
Hospital Revenue Code	637
Min. Negotiated Rate	$85.75
Max. Negotiated Rate	$192.94
Rate for Payer: Aetna Commercial	$182.22
Rate for Payer: Aetna Medicare	$107.19
Rate for Payer: Aetna New Business (MI Preferred)	$139.35
Rate for Payer: BCBS Complete	$85.75
Rate for Payer: Cash Price	$171.50
Rate for Payer: Cofinity Commercial	$150.07
Rate for Payer: Cofinity Commercial	$184.37
Rate for Payer: Cofinity Medicare Advantage	$150.07
Rate for Payer: Encore Health Key Benefits Commercial	$171.50
Rate for Payer: Healthscope Commercial	$192.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$182.22
Rate for Payer: PHP Commercial	$182.22
Rate for Payer: Priority Health Cigna Priority Health	$139.35
Rate for Payer: Priority Health SBD	$135.06

Know your out-of-pocket cost for care.

All Charges