Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)

Facility

$69.92

Service Code	NDC 00338002304
Hospital Charge Code	300135
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$45.45
Rate for Payer: UHC Core	$36.43
Rate for Payer: UHC Exchange	$27.48

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION (DOSE REQUIRED)

Facility

$61.18

Service Code	NDC 00338002302
Hospital Charge Code	300135
Hospital Revenue Code	250
Min. Negotiated Rate	$38.54
Max. Negotiated Rate	$55.06
Rate for Payer: Aetna Commercial	$52.00
Rate for Payer: Aetna New Business (MI Preferred)	$39.77
Rate for Payer: Cash Price	$48.94
Rate for Payer: Cofinity Advantage	$42.83
Rate for Payer: Cofinity Commercial	$52.61
Rate for Payer: Encore Health Key Benefits Commercial	$48.94
Rate for Payer: Healthscope Commercial	$55.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$52.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$45.88
Rate for Payer: PHP Commercial	$52.00
Rate for Payer: Priority Health SBD	$38.54

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION MAXIMUM RATE 250 MR

Facility

$69.92

Service Code	NDC 00338002304
Hospital Charge Code	300148
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$45.45
Rate for Payer: UHC Core	$36.43
Rate for Payer: UHC Exchange	$27.48

DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION MAXIMUM RATE 250 MR

Facility

$69.92

Service Code	NDC 00338002304
Hospital Charge Code	300148
Hospital Revenue Code	250
Min. Negotiated Rate	$44.05
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05

DEXTROSE 10 % IV BOLUS

Facility

$63.80

Service Code	NDC 00264752020
Hospital Charge Code	400302
Hospital Revenue Code	250
Min. Negotiated Rate	$25.07
Max. Negotiated Rate	$57.42
Rate for Payer: Aetna Commercial	$54.23
Rate for Payer: Aetna Medicare	$31.90
Rate for Payer: Aetna New Business (MI Preferred)	$41.47
Rate for Payer: BCBS Complete	$25.52
Rate for Payer: Cash Price	$51.04
Rate for Payer: Cofinity Advantage	$44.66
Rate for Payer: Cofinity Commercial	$54.87
Rate for Payer: Encore Health Key Benefits Commercial	$51.04
Rate for Payer: Healthscope Commercial	$57.42
Rate for Payer: MI Amish Medical Board Commercial	$51.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.23
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.85
Rate for Payer: PHP Commercial	$54.23
Rate for Payer: Priority Health SBD	$40.19
Rate for Payer: UHC All Payor (Choice/PPO)	$41.47
Rate for Payer: UHC Core	$33.24
Rate for Payer: UHC Exchange	$25.07

DEXTROSE 10 % IV BOLUS

Facility

$63.80

Service Code	NDC 00264752020
Hospital Charge Code	400302
Hospital Revenue Code	250
Min. Negotiated Rate	$40.19
Max. Negotiated Rate	$57.42
Rate for Payer: Aetna Commercial	$54.23
Rate for Payer: Aetna New Business (MI Preferred)	$41.47
Rate for Payer: Cash Price	$51.04
Rate for Payer: Cofinity Advantage	$44.66
Rate for Payer: Cofinity Commercial	$54.87
Rate for Payer: Encore Health Key Benefits Commercial	$51.04
Rate for Payer: Healthscope Commercial	$57.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.23
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.85
Rate for Payer: PHP Commercial	$54.23
Rate for Payer: Priority Health SBD	$40.19

DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN

Facility

$79.75

Service Code	NDC 00942064104
Hospital Charge Code	167293
Hospital Revenue Code	250
Min. Negotiated Rate	$50.24
Max. Negotiated Rate	$71.78
Rate for Payer: Aetna Commercial	$67.79
Rate for Payer: Aetna New Business (MI Preferred)	$51.84
Rate for Payer: Cash Price	$63.80
Rate for Payer: Cofinity Advantage	$55.83
Rate for Payer: Cofinity Commercial	$68.58
Rate for Payer: Encore Health Key Benefits Commercial	$63.80
Rate for Payer: Healthscope Commercial	$71.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$67.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$59.81
Rate for Payer: PHP Commercial	$67.79
Rate for Payer: Priority Health SBD	$50.24

DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN

Facility

$79.75

Service Code	NDC 00942064104
Hospital Charge Code	167293
Hospital Revenue Code	250
Min. Negotiated Rate	$31.34
Max. Negotiated Rate	$71.78
Rate for Payer: Aetna Commercial	$67.79
Rate for Payer: Aetna Medicare	$39.88
Rate for Payer: Aetna New Business (MI Preferred)	$51.84
Rate for Payer: BCBS Complete	$31.90
Rate for Payer: Cash Price	$63.80
Rate for Payer: Cofinity Advantage	$55.83
Rate for Payer: Cofinity Commercial	$68.58
Rate for Payer: Encore Health Key Benefits Commercial	$63.80
Rate for Payer: Healthscope Commercial	$71.78
Rate for Payer: MI Amish Medical Board Commercial	$63.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$67.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$59.81
Rate for Payer: PHP Commercial	$67.79
Rate for Payer: Priority Health SBD	$50.24
Rate for Payer: UHC All Payor (Choice/PPO)	$51.84
Rate for Payer: UHC Core	$41.55
Rate for Payer: UHC Exchange	$31.34

DEXTROSE 40 % ORAL GEL

Facility

$2.81

Service Code	NDC 09900001911
Hospital Charge Code	27466
Hospital Revenue Code	637
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: Aetna New Business (MI Preferred)	$1.83
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cofinity Advantage	$1.97
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.25
Rate for Payer: Healthscope Commercial	$2.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.11
Rate for Payer: PHP Commercial	$2.39
Rate for Payer: Priority Health SBD	$1.77

DEXTROSE 40 % ORAL GEL

Facility

$16.20

Service Code	NDC 00574007030
Hospital Charge Code	27466
Hospital Revenue Code	637
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: Aetna New Business (MI Preferred)	$10.53
Rate for Payer: BCBS Complete	$6.48
Rate for Payer: Cash Price	$12.96
Rate for Payer: Cofinity Advantage	$11.34
Rate for Payer: Cofinity Commercial	$13.93
Rate for Payer: Encore Health Key Benefits Commercial	$12.96
Rate for Payer: Healthscope Commercial	$14.58
Rate for Payer: MI Amish Medical Board Commercial	$12.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.15
Rate for Payer: PHP Commercial	$13.77
Rate for Payer: Priority Health SBD	$10.21
Rate for Payer: UHC All Payor (Choice/PPO)	$10.53
Rate for Payer: UHC Core	$8.44
Rate for Payer: UHC Exchange	$6.37

DEXTROSE 40 % ORAL GEL

Facility

$16.37

Service Code	NDC 00574006915
Hospital Charge Code	27466
Hospital Revenue Code	637
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$14.73
Rate for Payer: Aetna Commercial	$13.91
Rate for Payer: Aetna Medicare	$8.19
Rate for Payer: Aetna New Business (MI Preferred)	$10.64
Rate for Payer: BCBS Complete	$6.55
Rate for Payer: Cash Price	$13.10
Rate for Payer: Cofinity Advantage	$11.46
Rate for Payer: Cofinity Commercial	$14.08
Rate for Payer: Encore Health Key Benefits Commercial	$13.10
Rate for Payer: Healthscope Commercial	$14.73
Rate for Payer: MI Amish Medical Board Commercial	$13.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.28
Rate for Payer: PHP Commercial	$13.91
Rate for Payer: Priority Health SBD	$10.31
Rate for Payer: UHC All Payor (Choice/PPO)	$10.64
Rate for Payer: UHC Core	$8.53
Rate for Payer: UHC Exchange	$6.43

DEXTROSE 40 % ORAL GEL

Facility

$16.20

Service Code	NDC 00574006930
Hospital Charge Code	27466
Hospital Revenue Code	637
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: Aetna New Business (MI Preferred)	$10.53
Rate for Payer: BCBS Complete	$6.48
Rate for Payer: Cash Price	$12.96
Rate for Payer: Cofinity Advantage	$11.34
Rate for Payer: Cofinity Commercial	$13.93
Rate for Payer: Encore Health Key Benefits Commercial	$12.96
Rate for Payer: Healthscope Commercial	$14.58
Rate for Payer: MI Amish Medical Board Commercial	$12.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.15
Rate for Payer: PHP Commercial	$13.77
Rate for Payer: Priority Health SBD	$10.21
Rate for Payer: UHC All Payor (Choice/PPO)	$10.53
Rate for Payer: UHC Core	$8.44
Rate for Payer: UHC Exchange	$6.37

DEXTROSE 40 % ORAL GEL

Facility

$16.20

Service Code	NDC 00574007030
Hospital Charge Code	27466
Hospital Revenue Code	637
Min. Negotiated Rate	$10.21
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: Aetna New Business (MI Preferred)	$10.53
Rate for Payer: Cash Price	$12.96
Rate for Payer: Cofinity Advantage	$11.34
Rate for Payer: Cofinity Commercial	$13.93
Rate for Payer: Encore Health Key Benefits Commercial	$12.96
Rate for Payer: Healthscope Commercial	$14.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.15
Rate for Payer: PHP Commercial	$13.77
Rate for Payer: Priority Health SBD	$10.21

DEXTROSE 40 % ORAL GEL

Facility

$2.81

Service Code	NDC 09900001911
Hospital Charge Code	27466
Hospital Revenue Code	637
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: Aetna Medicare	$1.41
Rate for Payer: Aetna New Business (MI Preferred)	$1.83
Rate for Payer: BCBS Complete	$1.12
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cofinity Advantage	$1.97
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.25
Rate for Payer: Healthscope Commercial	$2.53
Rate for Payer: MI Amish Medical Board Commercial	$2.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.11
Rate for Payer: PHP Commercial	$2.39
Rate for Payer: Priority Health SBD	$1.77
Rate for Payer: UHC All Payor (Choice/PPO)	$1.83
Rate for Payer: UHC Core	$1.46
Rate for Payer: UHC Exchange	$1.10

DEXTROSE 40 % ORAL GEL

Facility

$16.20

Service Code	NDC 00574006930
Hospital Charge Code	27466
Hospital Revenue Code	637
Min. Negotiated Rate	$10.21
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna Commercial	$13.77
Rate for Payer: Aetna New Business (MI Preferred)	$10.53
Rate for Payer: Cash Price	$12.96
Rate for Payer: Cofinity Advantage	$11.34
Rate for Payer: Cofinity Commercial	$13.93
Rate for Payer: Encore Health Key Benefits Commercial	$12.96
Rate for Payer: Healthscope Commercial	$14.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.15
Rate for Payer: PHP Commercial	$13.77
Rate for Payer: Priority Health SBD	$10.21

DEXTROSE 40 % ORAL GEL

Facility

$16.37

Service Code	NDC 00574006915
Hospital Charge Code	27466
Hospital Revenue Code	637
Min. Negotiated Rate	$10.31
Max. Negotiated Rate	$14.73
Rate for Payer: Aetna Commercial	$13.91
Rate for Payer: Aetna New Business (MI Preferred)	$10.64
Rate for Payer: Cash Price	$13.10
Rate for Payer: Cofinity Advantage	$11.46
Rate for Payer: Cofinity Commercial	$14.08
Rate for Payer: Encore Health Key Benefits Commercial	$13.10
Rate for Payer: Healthscope Commercial	$14.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$12.28
Rate for Payer: PHP Commercial	$13.91
Rate for Payer: Priority Health SBD	$10.31

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION

Facility

$74.97

Service Code	NDC 00409664802
Hospital Charge Code	2365
Hospital Revenue Code	250
Min. Negotiated Rate	$47.23
Max. Negotiated Rate	$67.47
Rate for Payer: Aetna Commercial	$63.72
Rate for Payer: Aetna New Business (MI Preferred)	$48.73
Rate for Payer: Cash Price	$59.98
Rate for Payer: Cofinity Advantage	$52.48
Rate for Payer: Cofinity Commercial	$64.47
Rate for Payer: Encore Health Key Benefits Commercial	$59.98
Rate for Payer: Healthscope Commercial	$67.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$63.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.23
Rate for Payer: PHP Commercial	$63.72
Rate for Payer: Priority Health SBD	$47.23

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION

Facility

$74.97

Service Code	NDC 00409664816
Hospital Charge Code	2365
Hospital Revenue Code	250
Min. Negotiated Rate	$47.23
Max. Negotiated Rate	$67.47
Rate for Payer: Aetna Commercial	$63.72
Rate for Payer: Aetna New Business (MI Preferred)	$48.73
Rate for Payer: Cash Price	$59.98
Rate for Payer: Cofinity Advantage	$52.48
Rate for Payer: Cofinity Commercial	$64.47
Rate for Payer: Encore Health Key Benefits Commercial	$59.98
Rate for Payer: Healthscope Commercial	$67.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$63.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.23
Rate for Payer: PHP Commercial	$63.72
Rate for Payer: Priority Health SBD	$47.23

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION

Facility

$74.97

Service Code	NDC 00409664802
Hospital Charge Code	2365
Hospital Revenue Code	250
Min. Negotiated Rate	$29.46
Max. Negotiated Rate	$67.47
Rate for Payer: Aetna Commercial	$63.72
Rate for Payer: Aetna Medicare	$37.48
Rate for Payer: Aetna New Business (MI Preferred)	$48.73
Rate for Payer: BCBS Complete	$29.99
Rate for Payer: Cash Price	$59.98
Rate for Payer: Cofinity Advantage	$52.48
Rate for Payer: Cofinity Commercial	$64.47
Rate for Payer: Encore Health Key Benefits Commercial	$59.98
Rate for Payer: Healthscope Commercial	$67.47
Rate for Payer: MI Amish Medical Board Commercial	$59.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$63.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.23
Rate for Payer: PHP Commercial	$63.72
Rate for Payer: Priority Health SBD	$47.23
Rate for Payer: UHC All Payor (Choice/PPO)	$48.73
Rate for Payer: UHC Core	$39.06
Rate for Payer: UHC Exchange	$29.46

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION

Facility

$74.97

Service Code	NDC 00409664816
Hospital Charge Code	2365
Hospital Revenue Code	250
Min. Negotiated Rate	$29.46
Max. Negotiated Rate	$67.47
Rate for Payer: Aetna Commercial	$63.72
Rate for Payer: Aetna Medicare	$37.48
Rate for Payer: Aetna New Business (MI Preferred)	$48.73
Rate for Payer: BCBS Complete	$29.99
Rate for Payer: Cash Price	$59.98
Rate for Payer: Cofinity Advantage	$52.48
Rate for Payer: Cofinity Commercial	$64.47
Rate for Payer: Encore Health Key Benefits Commercial	$59.98
Rate for Payer: Healthscope Commercial	$67.47
Rate for Payer: MI Amish Medical Board Commercial	$59.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$63.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.23
Rate for Payer: PHP Commercial	$63.72
Rate for Payer: Priority Health SBD	$47.23
Rate for Payer: UHC All Payor (Choice/PPO)	$48.73
Rate for Payer: UHC Core	$39.06
Rate for Payer: UHC Exchange	$29.46

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION WRAPPER

Facility

$74.97

Service Code	NDC 00409664816
Hospital Charge Code	301983
Hospital Revenue Code	250
Min. Negotiated Rate	$47.23
Max. Negotiated Rate	$67.47
Rate for Payer: Aetna Commercial	$63.72
Rate for Payer: Aetna New Business (MI Preferred)	$48.73
Rate for Payer: Cash Price	$59.98
Rate for Payer: Cofinity Advantage	$52.48
Rate for Payer: Cofinity Commercial	$64.47
Rate for Payer: Encore Health Key Benefits Commercial	$59.98
Rate for Payer: Healthscope Commercial	$67.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$63.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.23
Rate for Payer: PHP Commercial	$63.72
Rate for Payer: Priority Health SBD	$47.23

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION WRAPPER

Facility

$74.97

Service Code	NDC 00409664802
Hospital Charge Code	301983
Hospital Revenue Code	250
Min. Negotiated Rate	$29.46
Max. Negotiated Rate	$67.47
Rate for Payer: Aetna Commercial	$63.72
Rate for Payer: Aetna Medicare	$37.48
Rate for Payer: Aetna New Business (MI Preferred)	$48.73
Rate for Payer: BCBS Complete	$29.99
Rate for Payer: Cash Price	$59.98
Rate for Payer: Cofinity Advantage	$52.48
Rate for Payer: Cofinity Commercial	$64.47
Rate for Payer: Encore Health Key Benefits Commercial	$59.98
Rate for Payer: Healthscope Commercial	$67.47
Rate for Payer: MI Amish Medical Board Commercial	$59.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$63.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.23
Rate for Payer: PHP Commercial	$63.72
Rate for Payer: Priority Health SBD	$47.23
Rate for Payer: UHC All Payor (Choice/PPO)	$48.73
Rate for Payer: UHC Core	$39.06
Rate for Payer: UHC Exchange	$29.46

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION WRAPPER

Facility

$74.97

Service Code	NDC 00409664816
Hospital Charge Code	301983
Hospital Revenue Code	250
Min. Negotiated Rate	$29.46
Max. Negotiated Rate	$67.47
Rate for Payer: Aetna Commercial	$63.72
Rate for Payer: Aetna Medicare	$37.48
Rate for Payer: Aetna New Business (MI Preferred)	$48.73
Rate for Payer: BCBS Complete	$29.99
Rate for Payer: Cash Price	$59.98
Rate for Payer: Cofinity Advantage	$52.48
Rate for Payer: Cofinity Commercial	$64.47
Rate for Payer: Encore Health Key Benefits Commercial	$59.98
Rate for Payer: Healthscope Commercial	$67.47
Rate for Payer: MI Amish Medical Board Commercial	$59.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$63.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.23
Rate for Payer: PHP Commercial	$63.72
Rate for Payer: Priority Health SBD	$47.23
Rate for Payer: UHC All Payor (Choice/PPO)	$48.73
Rate for Payer: UHC Core	$39.06
Rate for Payer: UHC Exchange	$29.46

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION WRAPPER

Facility

$74.97

Service Code	NDC 00409664802
Hospital Charge Code	301983
Hospital Revenue Code	250
Min. Negotiated Rate	$47.23
Max. Negotiated Rate	$67.47
Rate for Payer: Aetna Commercial	$63.72
Rate for Payer: Aetna New Business (MI Preferred)	$48.73
Rate for Payer: Cash Price	$59.98
Rate for Payer: Cofinity Advantage	$52.48
Rate for Payer: Cofinity Commercial	$64.47
Rate for Payer: Encore Health Key Benefits Commercial	$59.98
Rate for Payer: Healthscope Commercial	$67.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$63.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$56.23
Rate for Payer: PHP Commercial	$63.72
Rate for Payer: Priority Health SBD	$47.23

DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE

Facility

$72.54

Service Code	NDC 00409490264
Hospital Charge Code	112012
Hospital Revenue Code	250
Min. Negotiated Rate	$45.70
Max. Negotiated Rate	$65.29
Rate for Payer: Aetna Commercial	$61.66
Rate for Payer: Aetna New Business (MI Preferred)	$47.15
Rate for Payer: Cash Price	$58.03
Rate for Payer: Cofinity Advantage	$50.78
Rate for Payer: Cofinity Commercial	$62.38
Rate for Payer: Encore Health Key Benefits Commercial	$58.03
Rate for Payer: Healthscope Commercial	$65.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$61.66
Rate for Payer: Opus (Opus Packaging Group) HMA	$54.41
Rate for Payer: PHP Commercial	$61.66
Rate for Payer: Priority Health SBD	$45.70

Know your out-of-pocket cost for care.

All Charges