Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

ESTRADIOL 1 MG TABLET

Facility

$7.62

Service Code	NDC 60687087611
Hospital Charge Code	9967
Hospital Revenue Code	637
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$6.86
Rate for Payer: Aetna Commercial	$6.48
Rate for Payer: Aetna Medicare	$3.81
Rate for Payer: Aetna New Business (MI Preferred)	$4.95
Rate for Payer: BCBS Complete	$3.05
Rate for Payer: Cash Price	$6.10
Rate for Payer: Cofinity Advantage	$5.33
Rate for Payer: Cofinity Commercial	$6.55
Rate for Payer: Encore Health Key Benefits Commercial	$6.10
Rate for Payer: Healthscope Commercial	$6.86
Rate for Payer: MI Amish Medical Board Commercial	$6.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$5.71
Rate for Payer: PHP Commercial	$6.48
Rate for Payer: Priority Health SBD	$4.80
Rate for Payer: UHC All Payor (Choice/PPO)	$4.95
Rate for Payer: UHC Core	$3.97
Rate for Payer: UHC Exchange	$2.99

ESTRADIOL 1 MG TABLET

Facility

$271.70

Service Code	NDC 00555088602
Hospital Charge Code	9967
Hospital Revenue Code	637
Min. Negotiated Rate	$106.78
Max. Negotiated Rate	$244.53
Rate for Payer: Aetna Commercial	$230.94
Rate for Payer: Aetna Medicare	$135.85
Rate for Payer: Aetna New Business (MI Preferred)	$176.60
Rate for Payer: BCBS Complete	$108.68
Rate for Payer: Cash Price	$217.36
Rate for Payer: Cofinity Advantage	$190.19
Rate for Payer: Cofinity Commercial	$233.66
Rate for Payer: Encore Health Key Benefits Commercial	$217.36
Rate for Payer: Healthscope Commercial	$244.53
Rate for Payer: MI Amish Medical Board Commercial	$217.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$230.94
Rate for Payer: Opus (Opus Packaging Group) HMA	$203.78
Rate for Payer: PHP Commercial	$230.94
Rate for Payer: Priority Health SBD	$171.17
Rate for Payer: UHC All Payor (Choice/PPO)	$176.60
Rate for Payer: UHC Core	$141.56
Rate for Payer: UHC Exchange	$106.78

ESTRADIOL 1 MG TABLET

Facility

$7.62

Service Code	NDC 60687087611
Hospital Charge Code	9967
Hospital Revenue Code	637
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$6.86
Rate for Payer: Aetna Commercial	$6.48
Rate for Payer: Aetna New Business (MI Preferred)	$4.95
Rate for Payer: Cash Price	$6.10
Rate for Payer: Cofinity Advantage	$5.33
Rate for Payer: Cofinity Commercial	$6.55
Rate for Payer: Encore Health Key Benefits Commercial	$6.10
Rate for Payer: Healthscope Commercial	$6.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$5.71
Rate for Payer: PHP Commercial	$6.48
Rate for Payer: Priority Health SBD	$4.80

ESTRADIOL CYPIONATE 5 MG/ML INTRAMUSCULAR OIL

Facility

$834.57

Service Code	HCPCS J1000
Hospital Charge Code	2929
Hospital Revenue Code	636
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$751.11
Rate for Payer: Aetna Commercial	$709.38
Rate for Payer: Aetna Medicare	$417.29
Rate for Payer: Aetna New Business (MI Preferred)	$542.47
Rate for Payer: BCBS Complete	$333.83
Rate for Payer: BCBS Trust/PPO	$129.99
Rate for Payer: BCN Commercial	$129.99
Rate for Payer: Cash Price	$667.66
Rate for Payer: Cash Price	$667.66
Rate for Payer: Cofinity Advantage	$584.20
Rate for Payer: Cofinity Commercial	$717.73
Rate for Payer: Encore Health Key Benefits Commercial	$667.66
Rate for Payer: Healthscope Commercial	$751.11
Rate for Payer: MI Amish Medical Board Commercial	$667.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$709.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$625.93
Rate for Payer: PHP Commercial	$709.38
Rate for Payer: Priority Health SBD	$525.78
Rate for Payer: UHC All Payor (Choice/PPO)	$85.50
Rate for Payer: UHC Core	$85.50
Rate for Payer: UHC Exchange	$85.50

ESTRADIOL CYPIONATE 5 MG/ML INTRAMUSCULAR OIL

Facility

$834.57

Service Code	HCPCS J1000
Hospital Charge Code	2929
Hospital Revenue Code	636
Min. Negotiated Rate	$525.78
Max. Negotiated Rate	$751.11
Rate for Payer: Aetna Commercial	$709.38
Rate for Payer: Aetna New Business (MI Preferred)	$542.47
Rate for Payer: Cash Price	$667.66
Rate for Payer: Cofinity Advantage	$584.20
Rate for Payer: Cofinity Commercial	$717.73
Rate for Payer: Encore Health Key Benefits Commercial	$667.66
Rate for Payer: Healthscope Commercial	$751.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$709.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$625.93
Rate for Payer: PHP Commercial	$709.38
Rate for Payer: Priority Health SBD	$525.78

ESTRADIOL VALERATE 10 MG/ML INTRAMUSCULAR OIL

Facility

$575.88

Service Code	HCPCS J1380
Hospital Charge Code	2930
Hospital Revenue Code	636
Min. Negotiated Rate	$362.80
Max. Negotiated Rate	$518.29
Rate for Payer: Aetna Commercial	$489.50
Rate for Payer: Aetna New Business (MI Preferred)	$374.32
Rate for Payer: Cash Price	$460.70
Rate for Payer: Cofinity Advantage	$403.12
Rate for Payer: Cofinity Commercial	$495.26
Rate for Payer: Encore Health Key Benefits Commercial	$460.70
Rate for Payer: Healthscope Commercial	$518.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$489.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$431.91
Rate for Payer: PHP Commercial	$489.50
Rate for Payer: Priority Health SBD	$362.80

ESTRADIOL VALERATE 10 MG/ML INTRAMUSCULAR OIL

Facility

$575.88

Service Code	HCPCS J1380
Hospital Charge Code	2930
Hospital Revenue Code	636
Min. Negotiated Rate	$12.29
Max. Negotiated Rate	$518.29
Rate for Payer: Aetna Commercial	$489.50
Rate for Payer: Aetna Medicare	$287.94
Rate for Payer: Aetna New Business (MI Preferred)	$374.32
Rate for Payer: BCBS Complete	$230.35
Rate for Payer: BCBS Trust/PPO	$18.66
Rate for Payer: BCN Commercial	$18.66
Rate for Payer: Cash Price	$460.70
Rate for Payer: Cash Price	$460.70
Rate for Payer: Cofinity Advantage	$403.12
Rate for Payer: Cofinity Commercial	$495.26
Rate for Payer: Encore Health Key Benefits Commercial	$460.70
Rate for Payer: Healthscope Commercial	$518.29
Rate for Payer: MI Amish Medical Board Commercial	$460.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$489.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$431.91
Rate for Payer: PHP Commercial	$489.50
Rate for Payer: Priority Health SBD	$362.80
Rate for Payer: UHC All Payor (Choice/PPO)	$12.29
Rate for Payer: UHC Core	$12.29
Rate for Payer: UHC Exchange	$12.29

ETHAMBUTOL 400 MG TABLET

Facility

$350.40

Service Code	NDC 68850001202
Hospital Charge Code	9983
Hospital Revenue Code	637
Min. Negotiated Rate	$220.75
Max. Negotiated Rate	$315.36
Rate for Payer: Aetna Commercial	$297.84
Rate for Payer: Aetna New Business (MI Preferred)	$227.76
Rate for Payer: Cash Price	$280.32
Rate for Payer: Cofinity Advantage	$245.28
Rate for Payer: Cofinity Commercial	$301.34
Rate for Payer: Encore Health Key Benefits Commercial	$280.32
Rate for Payer: Healthscope Commercial	$315.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$297.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$262.80
Rate for Payer: PHP Commercial	$297.84
Rate for Payer: Priority Health SBD	$220.75

ETHAMBUTOL 400 MG TABLET

Facility

$6.04

Service Code	NDC 68084028011
Hospital Charge Code	9983
Hospital Revenue Code	637
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$5.44
Rate for Payer: Aetna Commercial	$5.13
Rate for Payer: Aetna New Business (MI Preferred)	$3.93
Rate for Payer: Cash Price	$4.83
Rate for Payer: Cofinity Advantage	$4.23
Rate for Payer: Cofinity Commercial	$5.19
Rate for Payer: Encore Health Key Benefits Commercial	$4.83
Rate for Payer: Healthscope Commercial	$5.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.13
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.53
Rate for Payer: PHP Commercial	$5.13
Rate for Payer: Priority Health SBD	$3.81

ETHAMBUTOL 400 MG TABLET

Facility

$350.40

Service Code	NDC 68850001201
Hospital Charge Code	9983
Hospital Revenue Code	637
Min. Negotiated Rate	$137.71
Max. Negotiated Rate	$315.36
Rate for Payer: Aetna Commercial	$297.84
Rate for Payer: Aetna Medicare	$175.20
Rate for Payer: Aetna New Business (MI Preferred)	$227.76
Rate for Payer: BCBS Complete	$140.16
Rate for Payer: Cash Price	$280.32
Rate for Payer: Cofinity Advantage	$245.28
Rate for Payer: Cofinity Commercial	$301.34
Rate for Payer: Encore Health Key Benefits Commercial	$280.32
Rate for Payer: Healthscope Commercial	$315.36
Rate for Payer: MI Amish Medical Board Commercial	$280.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$297.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$262.80
Rate for Payer: PHP Commercial	$297.84
Rate for Payer: Priority Health SBD	$220.75
Rate for Payer: UHC All Payor (Choice/PPO)	$227.76
Rate for Payer: UHC Core	$182.56
Rate for Payer: UHC Exchange	$137.71

ETHAMBUTOL 400 MG TABLET

Facility

$350.40

Service Code	NDC 68850001202
Hospital Charge Code	9983
Hospital Revenue Code	637
Min. Negotiated Rate	$137.71
Max. Negotiated Rate	$315.36
Rate for Payer: Aetna Commercial	$297.84
Rate for Payer: Aetna Medicare	$175.20
Rate for Payer: Aetna New Business (MI Preferred)	$227.76
Rate for Payer: BCBS Complete	$140.16
Rate for Payer: Cash Price	$280.32
Rate for Payer: Cofinity Advantage	$245.28
Rate for Payer: Cofinity Commercial	$301.34
Rate for Payer: Encore Health Key Benefits Commercial	$280.32
Rate for Payer: Healthscope Commercial	$315.36
Rate for Payer: MI Amish Medical Board Commercial	$280.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$297.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$262.80
Rate for Payer: PHP Commercial	$297.84
Rate for Payer: Priority Health SBD	$220.75
Rate for Payer: UHC All Payor (Choice/PPO)	$227.76
Rate for Payer: UHC Core	$182.56
Rate for Payer: UHC Exchange	$137.71

ETHAMBUTOL 400 MG TABLET

Facility

$6.04

Service Code	NDC 68084028011
Hospital Charge Code	9983
Hospital Revenue Code	637
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$5.44
Rate for Payer: Aetna Commercial	$5.13
Rate for Payer: Aetna Medicare	$3.02
Rate for Payer: Aetna New Business (MI Preferred)	$3.93
Rate for Payer: BCBS Complete	$2.42
Rate for Payer: Cash Price	$4.83
Rate for Payer: Cofinity Advantage	$4.23
Rate for Payer: Cofinity Commercial	$5.19
Rate for Payer: Encore Health Key Benefits Commercial	$4.83
Rate for Payer: Healthscope Commercial	$5.44
Rate for Payer: MI Amish Medical Board Commercial	$4.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.13
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.53
Rate for Payer: PHP Commercial	$5.13
Rate for Payer: Priority Health SBD	$3.81
Rate for Payer: UHC All Payor (Choice/PPO)	$3.93
Rate for Payer: UHC Core	$3.15
Rate for Payer: UHC Exchange	$2.37

ETHAMBUTOL 400 MG TABLET

Facility

$350.40

Service Code	NDC 68850001201
Hospital Charge Code	9983
Hospital Revenue Code	637
Min. Negotiated Rate	$220.75
Max. Negotiated Rate	$315.36
Rate for Payer: Aetna Commercial	$297.84
Rate for Payer: Aetna New Business (MI Preferred)	$227.76
Rate for Payer: Cash Price	$280.32
Rate for Payer: Cofinity Advantage	$245.28
Rate for Payer: Cofinity Commercial	$301.34
Rate for Payer: Encore Health Key Benefits Commercial	$280.32
Rate for Payer: Healthscope Commercial	$315.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$297.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$262.80
Rate for Payer: PHP Commercial	$297.84
Rate for Payer: Priority Health SBD	$220.75

ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION

Facility

$1,573.12

Service Code	HCPCS J1430
Hospital Charge Code	9984
Hospital Revenue Code	636
Min. Negotiated Rate	$991.07
Max. Negotiated Rate	$1,415.81
Rate for Payer: Aetna Commercial	$1,337.15
Rate for Payer: Aetna New Business (MI Preferred)	$1,022.53
Rate for Payer: Cash Price	$1,258.50
Rate for Payer: Cofinity Advantage	$1,101.18
Rate for Payer: Cofinity Commercial	$1,352.88
Rate for Payer: Encore Health Key Benefits Commercial	$1,258.50
Rate for Payer: Healthscope Commercial	$1,415.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,337.15
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,179.84
Rate for Payer: PHP Commercial	$1,337.15
Rate for Payer: Priority Health SBD	$991.07

ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION

Facility

$1,573.12

Service Code	HCPCS J1430
Hospital Charge Code	9984
Hospital Revenue Code	636
Min. Negotiated Rate	$271.24
Max. Negotiated Rate	$1,605.25
Rate for Payer: Aetna Commercial	$1,337.15
Rate for Payer: Aetna Medicare	$539.38
Rate for Payer: Aetna New Business (MI Preferred)	$1,022.53
Rate for Payer: Allen County Amish Medical Aid Commercial	$648.29
Rate for Payer: Amish Plain Church Group Commercial	$648.29
Rate for Payer: BCBS Complete	$284.83
Rate for Payer: BCBS MAPPO	$518.63
Rate for Payer: BCBS Trust/PPO	$1,297.27
Rate for Payer: BCN Commercial	$1,297.27
Rate for Payer: BCN Medicare Advantage	$518.63
Rate for Payer: Cash Price	$1,258.50
Rate for Payer: Cash Price	$1,258.50
Rate for Payer: Cofinity Advantage	$1,101.18
Rate for Payer: Cofinity Commercial	$1,352.88
Rate for Payer: Encore Health Key Benefits Commercial	$1,258.50
Rate for Payer: Health Alliance Plan Medicare Advantage	$518.63
Rate for Payer: Healthscope Commercial	$1,415.81
Rate for Payer: Mclaren Medicaid	$271.24
Rate for Payer: Mclaren Medicare	$518.63
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$544.56
Rate for Payer: Meridian Medicaid	$544.56
Rate for Payer: MI Amish Medical Board Commercial	$596.42
Rate for Payer: Molina Medicare/Medicaid	$570.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,337.15
Rate for Payer: Nomi Health Commercial	$1,555.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,179.84
Rate for Payer: PACE Medicare	$492.70
Rate for Payer: PACE SWMI	$518.63
Rate for Payer: PHP Commercial	$1,337.15
Rate for Payer: PHP Medicare Advantage	$518.63
Rate for Payer: Priority Health Choice Medicaid	$271.24
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$1,605.25
Rate for Payer: Priority Health Medicare	$518.63
Rate for Payer: Priority Health SBD	$991.07
Rate for Payer: Priority Health Tiered Network	$1,284.20
Rate for Payer: Railroad Medicare Medicare	$518.63
Rate for Payer: UHC All Payor (Choice/PPO)	$853.18
Rate for Payer: UHC Core	$853.18
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$518.63
Rate for Payer: UHC Exchange	$853.18
Rate for Payer: UHC Medicaid	$271.24
Rate for Payer: UHCCP Medicaid	$271.24
Rate for Payer: VA VA	$518.63

ETHOSUXIMIDE 250 MG CAPSULE

Facility

$535.68

Service Code	NDC 61748002501
Hospital Charge Code	9989
Hospital Revenue Code	637
Min. Negotiated Rate	$210.52
Max. Negotiated Rate	$482.11
Rate for Payer: Aetna Commercial	$455.33
Rate for Payer: Aetna Medicare	$267.84
Rate for Payer: Aetna New Business (MI Preferred)	$348.19
Rate for Payer: BCBS Complete	$214.27
Rate for Payer: Cash Price	$428.54
Rate for Payer: Cofinity Advantage	$374.98
Rate for Payer: Cofinity Commercial	$460.68
Rate for Payer: Encore Health Key Benefits Commercial	$428.54
Rate for Payer: Healthscope Commercial	$482.11
Rate for Payer: MI Amish Medical Board Commercial	$428.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$455.33
Rate for Payer: Opus (Opus Packaging Group) HMA	$401.76
Rate for Payer: PHP Commercial	$455.33
Rate for Payer: Priority Health SBD	$337.48
Rate for Payer: UHC All Payor (Choice/PPO)	$348.19
Rate for Payer: UHC Core	$279.09
Rate for Payer: UHC Exchange	$210.52

ETHOSUXIMIDE 250 MG CAPSULE

Facility

$535.68

Service Code	NDC 23155053201
Hospital Charge Code	9989
Hospital Revenue Code	637
Min. Negotiated Rate	$210.52
Max. Negotiated Rate	$482.11
Rate for Payer: Aetna Commercial	$455.33
Rate for Payer: Aetna Medicare	$267.84
Rate for Payer: Aetna New Business (MI Preferred)	$348.19
Rate for Payer: BCBS Complete	$214.27
Rate for Payer: Cash Price	$428.54
Rate for Payer: Cofinity Advantage	$374.98
Rate for Payer: Cofinity Commercial	$460.68
Rate for Payer: Encore Health Key Benefits Commercial	$428.54
Rate for Payer: Healthscope Commercial	$482.11
Rate for Payer: MI Amish Medical Board Commercial	$428.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$455.33
Rate for Payer: Opus (Opus Packaging Group) HMA	$401.76
Rate for Payer: PHP Commercial	$455.33
Rate for Payer: Priority Health SBD	$337.48
Rate for Payer: UHC All Payor (Choice/PPO)	$348.19
Rate for Payer: UHC Core	$279.09
Rate for Payer: UHC Exchange	$210.52

ETHOSUXIMIDE 250 MG CAPSULE

Facility

$264.10

Service Code	NDC 64380087806
Hospital Charge Code	9989
Hospital Revenue Code	637
Min. Negotiated Rate	$166.38
Max. Negotiated Rate	$237.69
Rate for Payer: Aetna Commercial	$224.49
Rate for Payer: Aetna New Business (MI Preferred)	$171.66
Rate for Payer: Cash Price	$211.28
Rate for Payer: Cofinity Advantage	$184.87
Rate for Payer: Cofinity Commercial	$227.13
Rate for Payer: Encore Health Key Benefits Commercial	$211.28
Rate for Payer: Healthscope Commercial	$237.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$224.49
Rate for Payer: Opus (Opus Packaging Group) HMA	$198.07
Rate for Payer: PHP Commercial	$224.49
Rate for Payer: Priority Health SBD	$166.38

ETHOSUXIMIDE 250 MG CAPSULE

Facility

$264.10

Service Code	NDC 64380087806
Hospital Charge Code	9989
Hospital Revenue Code	637
Min. Negotiated Rate	$103.79
Max. Negotiated Rate	$237.69
Rate for Payer: Aetna Commercial	$224.49
Rate for Payer: Aetna Medicare	$132.05
Rate for Payer: Aetna New Business (MI Preferred)	$171.66
Rate for Payer: BCBS Complete	$105.64
Rate for Payer: Cash Price	$211.28
Rate for Payer: Cofinity Advantage	$184.87
Rate for Payer: Cofinity Commercial	$227.13
Rate for Payer: Encore Health Key Benefits Commercial	$211.28
Rate for Payer: Healthscope Commercial	$237.69
Rate for Payer: MI Amish Medical Board Commercial	$211.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$224.49
Rate for Payer: Opus (Opus Packaging Group) HMA	$198.07
Rate for Payer: PHP Commercial	$224.49
Rate for Payer: Priority Health SBD	$166.38
Rate for Payer: UHC All Payor (Choice/PPO)	$171.66
Rate for Payer: UHC Core	$137.60
Rate for Payer: UHC Exchange	$103.79

ETHOSUXIMIDE 250 MG CAPSULE

Facility

$535.68

Service Code	NDC 23155053201
Hospital Charge Code	9989
Hospital Revenue Code	637
Min. Negotiated Rate	$337.48
Max. Negotiated Rate	$482.11
Rate for Payer: Aetna Commercial	$455.33
Rate for Payer: Aetna New Business (MI Preferred)	$348.19
Rate for Payer: Cash Price	$428.54
Rate for Payer: Cofinity Advantage	$374.98
Rate for Payer: Cofinity Commercial	$460.68
Rate for Payer: Encore Health Key Benefits Commercial	$428.54
Rate for Payer: Healthscope Commercial	$482.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$455.33
Rate for Payer: Opus (Opus Packaging Group) HMA	$401.76
Rate for Payer: PHP Commercial	$455.33
Rate for Payer: Priority Health SBD	$337.48

ETHOSUXIMIDE 250 MG CAPSULE

Facility

$535.68

Service Code	NDC 61748002501
Hospital Charge Code	9989
Hospital Revenue Code	637
Min. Negotiated Rate	$337.48
Max. Negotiated Rate	$482.11
Rate for Payer: Aetna Commercial	$455.33
Rate for Payer: Aetna New Business (MI Preferred)	$348.19
Rate for Payer: Cash Price	$428.54
Rate for Payer: Cofinity Advantage	$374.98
Rate for Payer: Cofinity Commercial	$460.68
Rate for Payer: Encore Health Key Benefits Commercial	$428.54
Rate for Payer: Healthscope Commercial	$482.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$455.33
Rate for Payer: Opus (Opus Packaging Group) HMA	$401.76
Rate for Payer: PHP Commercial	$455.33
Rate for Payer: Priority Health SBD	$337.48

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION

Facility

$1,078.31

Service Code	NDC 16729071045
Hospital Charge Code	189453
Hospital Revenue Code	250
Min. Negotiated Rate	$679.34
Max. Negotiated Rate	$970.48
Rate for Payer: Aetna Commercial	$916.56
Rate for Payer: Aetna New Business (MI Preferred)	$700.90
Rate for Payer: Cash Price	$862.65
Rate for Payer: Cofinity Advantage	$754.82
Rate for Payer: Cofinity Commercial	$927.35
Rate for Payer: Encore Health Key Benefits Commercial	$862.65
Rate for Payer: Healthscope Commercial	$970.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$916.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$808.73
Rate for Payer: PHP Commercial	$916.56
Rate for Payer: Priority Health SBD	$679.34

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION

Facility

$1,078.31

Service Code	NDC 16729071031
Hospital Charge Code	189453
Hospital Revenue Code	250
Min. Negotiated Rate	$423.78
Max. Negotiated Rate	$970.48
Rate for Payer: Aetna Commercial	$916.56
Rate for Payer: Aetna Medicare	$539.15
Rate for Payer: Aetna New Business (MI Preferred)	$700.90
Rate for Payer: BCBS Complete	$431.32
Rate for Payer: Cash Price	$862.65
Rate for Payer: Cofinity Advantage	$754.82
Rate for Payer: Cofinity Commercial	$927.35
Rate for Payer: Encore Health Key Benefits Commercial	$862.65
Rate for Payer: Healthscope Commercial	$970.48
Rate for Payer: MI Amish Medical Board Commercial	$862.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$916.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$808.73
Rate for Payer: PHP Commercial	$916.56
Rate for Payer: Priority Health SBD	$679.34
Rate for Payer: UHC All Payor (Choice/PPO)	$700.90
Rate for Payer: UHC Core	$561.80
Rate for Payer: UHC Exchange	$423.78

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION

Facility

$1,078.31

Service Code	NDC 16729071045
Hospital Charge Code	189453
Hospital Revenue Code	250
Min. Negotiated Rate	$423.78
Max. Negotiated Rate	$970.48
Rate for Payer: Aetna Commercial	$916.56
Rate for Payer: Aetna Medicare	$539.15
Rate for Payer: Aetna New Business (MI Preferred)	$700.90
Rate for Payer: BCBS Complete	$431.32
Rate for Payer: Cash Price	$862.65
Rate for Payer: Cofinity Advantage	$754.82
Rate for Payer: Cofinity Commercial	$927.35
Rate for Payer: Encore Health Key Benefits Commercial	$862.65
Rate for Payer: Healthscope Commercial	$970.48
Rate for Payer: MI Amish Medical Board Commercial	$862.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$916.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$808.73
Rate for Payer: PHP Commercial	$916.56
Rate for Payer: Priority Health SBD	$679.34
Rate for Payer: UHC All Payor (Choice/PPO)	$700.90
Rate for Payer: UHC Core	$561.80
Rate for Payer: UHC Exchange	$423.78

ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION

Facility

$1,078.31

Service Code	NDC 16729071031
Hospital Charge Code	189453
Hospital Revenue Code	250
Min. Negotiated Rate	$679.34
Max. Negotiated Rate	$970.48
Rate for Payer: Aetna Commercial	$916.56
Rate for Payer: Aetna New Business (MI Preferred)	$700.90
Rate for Payer: Cash Price	$862.65
Rate for Payer: Cofinity Advantage	$754.82
Rate for Payer: Cofinity Commercial	$927.35
Rate for Payer: Encore Health Key Benefits Commercial	$862.65
Rate for Payer: Healthscope Commercial	$970.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$916.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$808.73
Rate for Payer: PHP Commercial	$916.56
Rate for Payer: Priority Health SBD	$679.34

Know your out-of-pocket cost for care.

All Charges