Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

GABAPENTIN 400 MG CAPSULE

Facility

$366.60

Service Code	NDC 00904666761
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$144.07
Max. Negotiated Rate	$329.94
Rate for Payer: Aetna Commercial	$311.61
Rate for Payer: Aetna Medicare	$183.30
Rate for Payer: Aetna New Business (MI Preferred)	$238.29
Rate for Payer: BCBS Complete	$146.64
Rate for Payer: Cash Price	$293.28
Rate for Payer: Cofinity Advantage	$256.62
Rate for Payer: Cofinity Commercial	$315.28
Rate for Payer: Encore Health Key Benefits Commercial	$293.28
Rate for Payer: Healthscope Commercial	$329.94
Rate for Payer: MI Amish Medical Board Commercial	$293.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$311.61
Rate for Payer: Opus (Opus Packaging Group) HMA	$274.95
Rate for Payer: PHP Commercial	$311.61
Rate for Payer: Priority Health SBD	$230.96
Rate for Payer: UHC All Payor (Choice/PPO)	$238.29
Rate for Payer: UHC Core	$191.00
Rate for Payer: UHC Exchange	$144.07

GABAPENTIN 400 MG CAPSULE

Facility

$239.70

Service Code	NDC 63739098410
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$151.01
Max. Negotiated Rate	$215.73
Rate for Payer: Aetna Commercial	$203.75
Rate for Payer: Aetna New Business (MI Preferred)	$155.81
Rate for Payer: Cash Price	$191.76
Rate for Payer: Cofinity Advantage	$167.79
Rate for Payer: Cofinity Commercial	$206.14
Rate for Payer: Encore Health Key Benefits Commercial	$191.76
Rate for Payer: Healthscope Commercial	$215.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$203.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$179.78
Rate for Payer: PHP Commercial	$203.75
Rate for Payer: Priority Health SBD	$151.01

GABAPENTIN 400 MG CAPSULE

Facility

$366.60

Service Code	NDC 00904666761
Hospital Charge Code	18307
Hospital Revenue Code	637
Min. Negotiated Rate	$230.96
Max. Negotiated Rate	$329.94
Rate for Payer: Aetna Commercial	$311.61
Rate for Payer: Aetna New Business (MI Preferred)	$238.29
Rate for Payer: Cash Price	$293.28
Rate for Payer: Cofinity Advantage	$256.62
Rate for Payer: Cofinity Commercial	$315.28
Rate for Payer: Encore Health Key Benefits Commercial	$293.28
Rate for Payer: Healthscope Commercial	$329.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$311.61
Rate for Payer: Opus (Opus Packaging Group) HMA	$274.95
Rate for Payer: PHP Commercial	$311.61
Rate for Payer: Priority Health SBD	$230.96

GABAPENTIN 600 MG TABLET

Facility

$3.20

Service Code	NDC 50268035111
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna Medicare	$1.60
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: BCBS Complete	$1.28
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Advantage	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Encore Health Key Benefits Commercial	$2.56
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: MI Amish Medical Board Commercial	$2.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.40
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health SBD	$2.02
Rate for Payer: UHC All Payor (Choice/PPO)	$2.08
Rate for Payer: UHC Core	$1.67
Rate for Payer: UHC Exchange	$1.26

GABAPENTIN 600 MG TABLET

Facility

$2,162.00

Service Code	NDC 68462012605
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$849.67
Max. Negotiated Rate	$1,945.80
Rate for Payer: Aetna Commercial	$1,837.70
Rate for Payer: Aetna Medicare	$1,081.00
Rate for Payer: Aetna New Business (MI Preferred)	$1,405.30
Rate for Payer: BCBS Complete	$864.80
Rate for Payer: Cash Price	$1,729.60
Rate for Payer: Cofinity Advantage	$1,513.40
Rate for Payer: Cofinity Commercial	$1,859.32
Rate for Payer: Encore Health Key Benefits Commercial	$1,729.60
Rate for Payer: Healthscope Commercial	$1,945.80
Rate for Payer: MI Amish Medical Board Commercial	$1,729.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,837.70
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,621.50
Rate for Payer: PHP Commercial	$1,837.70
Rate for Payer: Priority Health SBD	$1,362.06
Rate for Payer: UHC All Payor (Choice/PPO)	$1,405.30
Rate for Payer: UHC Core	$1,126.40
Rate for Payer: UHC Exchange	$849.67

GABAPENTIN 600 MG TABLET

Facility

$3.43

Service Code	NDC 42292002401
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$3.09
Rate for Payer: Aetna Commercial	$2.92
Rate for Payer: Aetna Medicare	$1.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.23
Rate for Payer: BCBS Complete	$1.37
Rate for Payer: Cash Price	$2.74
Rate for Payer: Cofinity Advantage	$2.40
Rate for Payer: Cofinity Commercial	$2.95
Rate for Payer: Encore Health Key Benefits Commercial	$2.74
Rate for Payer: Healthscope Commercial	$3.09
Rate for Payer: MI Amish Medical Board Commercial	$2.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.57
Rate for Payer: PHP Commercial	$2.92
Rate for Payer: Priority Health SBD	$2.16
Rate for Payer: UHC All Payor (Choice/PPO)	$2.23
Rate for Payer: UHC Core	$1.79
Rate for Payer: UHC Exchange	$1.35

GABAPENTIN 600 MG TABLET

Facility

$342.95

Service Code	NDC 42292002420
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$216.06
Max. Negotiated Rate	$308.65
Rate for Payer: Aetna Commercial	$291.51
Rate for Payer: Aetna New Business (MI Preferred)	$222.92
Rate for Payer: Cash Price	$274.36
Rate for Payer: Cofinity Advantage	$240.06
Rate for Payer: Cofinity Commercial	$294.94
Rate for Payer: Encore Health Key Benefits Commercial	$274.36
Rate for Payer: Healthscope Commercial	$308.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$291.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$257.21
Rate for Payer: PHP Commercial	$291.51
Rate for Payer: Priority Health SBD	$216.06

GABAPENTIN 600 MG TABLET

Facility

$342.95

Service Code	NDC 42292002420
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$134.78
Max. Negotiated Rate	$308.65
Rate for Payer: Aetna Commercial	$291.51
Rate for Payer: Aetna Medicare	$171.47
Rate for Payer: Aetna New Business (MI Preferred)	$222.92
Rate for Payer: BCBS Complete	$137.18
Rate for Payer: Cash Price	$274.36
Rate for Payer: Cofinity Advantage	$240.06
Rate for Payer: Cofinity Commercial	$294.94
Rate for Payer: Encore Health Key Benefits Commercial	$274.36
Rate for Payer: Healthscope Commercial	$308.65
Rate for Payer: MI Amish Medical Board Commercial	$274.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$291.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$257.21
Rate for Payer: PHP Commercial	$291.51
Rate for Payer: Priority Health SBD	$216.06
Rate for Payer: UHC All Payor (Choice/PPO)	$222.92
Rate for Payer: UHC Core	$178.68
Rate for Payer: UHC Exchange	$134.78

GABAPENTIN 600 MG TABLET

Facility

$2,162.00

Service Code	NDC 68462012605
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$1,362.06
Max. Negotiated Rate	$1,945.80
Rate for Payer: Aetna Commercial	$1,837.70
Rate for Payer: Aetna New Business (MI Preferred)	$1,405.30
Rate for Payer: Cash Price	$1,729.60
Rate for Payer: Cofinity Advantage	$1,513.40
Rate for Payer: Cofinity Commercial	$1,859.32
Rate for Payer: Encore Health Key Benefits Commercial	$1,729.60
Rate for Payer: Healthscope Commercial	$1,945.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,837.70
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,621.50
Rate for Payer: PHP Commercial	$1,837.70
Rate for Payer: Priority Health SBD	$1,362.06

GABAPENTIN 600 MG TABLET

Facility

$250.80

Service Code	NDC 00904682361
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$158.00
Max. Negotiated Rate	$225.72
Rate for Payer: Aetna Commercial	$213.18
Rate for Payer: Aetna New Business (MI Preferred)	$163.02
Rate for Payer: Cash Price	$200.64
Rate for Payer: Cofinity Advantage	$175.56
Rate for Payer: Cofinity Commercial	$215.69
Rate for Payer: Encore Health Key Benefits Commercial	$200.64
Rate for Payer: Healthscope Commercial	$225.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$213.18
Rate for Payer: Opus (Opus Packaging Group) HMA	$188.10
Rate for Payer: PHP Commercial	$213.18
Rate for Payer: Priority Health SBD	$158.00

GABAPENTIN 600 MG TABLET

Facility

$159.84

Service Code	NDC 50268035115
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$100.70
Max. Negotiated Rate	$143.86
Rate for Payer: Aetna Commercial	$135.86
Rate for Payer: Aetna New Business (MI Preferred)	$103.90
Rate for Payer: Cash Price	$127.87
Rate for Payer: Cofinity Advantage	$111.89
Rate for Payer: Cofinity Commercial	$137.46
Rate for Payer: Encore Health Key Benefits Commercial	$127.87
Rate for Payer: Healthscope Commercial	$143.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.86
Rate for Payer: Opus (Opus Packaging Group) HMA	$119.88
Rate for Payer: PHP Commercial	$135.86
Rate for Payer: Priority Health SBD	$100.70

GABAPENTIN 600 MG TABLET

Facility

$432.40

Service Code	NDC 68462012601
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$169.93
Max. Negotiated Rate	$389.16
Rate for Payer: Aetna Commercial	$367.54
Rate for Payer: Aetna Medicare	$216.20
Rate for Payer: Aetna New Business (MI Preferred)	$281.06
Rate for Payer: BCBS Complete	$172.96
Rate for Payer: Cash Price	$345.92
Rate for Payer: Cofinity Advantage	$302.68
Rate for Payer: Cofinity Commercial	$371.86
Rate for Payer: Encore Health Key Benefits Commercial	$345.92
Rate for Payer: Healthscope Commercial	$389.16
Rate for Payer: MI Amish Medical Board Commercial	$345.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$367.54
Rate for Payer: Opus (Opus Packaging Group) HMA	$324.30
Rate for Payer: PHP Commercial	$367.54
Rate for Payer: Priority Health SBD	$272.41
Rate for Payer: UHC All Payor (Choice/PPO)	$281.06
Rate for Payer: UHC Core	$225.28
Rate for Payer: UHC Exchange	$169.93

GABAPENTIN 600 MG TABLET

Facility

$159.84

Service Code	NDC 50268035115
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$62.82
Max. Negotiated Rate	$143.86
Rate for Payer: Aetna Commercial	$135.86
Rate for Payer: Aetna Medicare	$79.92
Rate for Payer: Aetna New Business (MI Preferred)	$103.90
Rate for Payer: BCBS Complete	$63.94
Rate for Payer: Cash Price	$127.87
Rate for Payer: Cofinity Advantage	$111.89
Rate for Payer: Cofinity Commercial	$137.46
Rate for Payer: Encore Health Key Benefits Commercial	$127.87
Rate for Payer: Healthscope Commercial	$143.86
Rate for Payer: MI Amish Medical Board Commercial	$127.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.86
Rate for Payer: Opus (Opus Packaging Group) HMA	$119.88
Rate for Payer: PHP Commercial	$135.86
Rate for Payer: Priority Health SBD	$100.70
Rate for Payer: UHC All Payor (Choice/PPO)	$103.90
Rate for Payer: UHC Core	$83.28
Rate for Payer: UHC Exchange	$62.82

GABAPENTIN 600 MG TABLET

Facility

$432.40

Service Code	NDC 68462012601
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$272.41
Max. Negotiated Rate	$389.16
Rate for Payer: Aetna Commercial	$367.54
Rate for Payer: Aetna New Business (MI Preferred)	$281.06
Rate for Payer: Cash Price	$345.92
Rate for Payer: Cofinity Advantage	$302.68
Rate for Payer: Cofinity Commercial	$371.86
Rate for Payer: Encore Health Key Benefits Commercial	$345.92
Rate for Payer: Healthscope Commercial	$389.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$367.54
Rate for Payer: Opus (Opus Packaging Group) HMA	$324.30
Rate for Payer: PHP Commercial	$367.54
Rate for Payer: Priority Health SBD	$272.41

GABAPENTIN 600 MG TABLET

Facility

$250.80

Service Code	NDC 00904682361
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$98.56
Max. Negotiated Rate	$225.72
Rate for Payer: Aetna Commercial	$213.18
Rate for Payer: Aetna Medicare	$125.40
Rate for Payer: Aetna New Business (MI Preferred)	$163.02
Rate for Payer: BCBS Complete	$100.32
Rate for Payer: Cash Price	$200.64
Rate for Payer: Cofinity Advantage	$175.56
Rate for Payer: Cofinity Commercial	$215.69
Rate for Payer: Encore Health Key Benefits Commercial	$200.64
Rate for Payer: Healthscope Commercial	$225.72
Rate for Payer: MI Amish Medical Board Commercial	$200.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$213.18
Rate for Payer: Opus (Opus Packaging Group) HMA	$188.10
Rate for Payer: PHP Commercial	$213.18
Rate for Payer: Priority Health SBD	$158.00
Rate for Payer: UHC All Payor (Choice/PPO)	$163.02
Rate for Payer: UHC Core	$130.67
Rate for Payer: UHC Exchange	$98.56

GABAPENTIN 600 MG TABLET

Facility

$3.20

Service Code	NDC 50268035111
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Advantage	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Encore Health Key Benefits Commercial	$2.56
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.40
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health SBD	$2.02

GABAPENTIN 600 MG TABLET

Facility

$3.43

Service Code	NDC 42292002401
Hospital Charge Code	25855
Hospital Revenue Code	637
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$3.09
Rate for Payer: Aetna Commercial	$2.92
Rate for Payer: Aetna New Business (MI Preferred)	$2.23
Rate for Payer: Cash Price	$2.74
Rate for Payer: Cofinity Advantage	$2.40
Rate for Payer: Cofinity Commercial	$2.95
Rate for Payer: Encore Health Key Benefits Commercial	$2.74
Rate for Payer: Healthscope Commercial	$3.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.57
Rate for Payer: PHP Commercial	$2.92
Rate for Payer: Priority Health SBD	$2.16

GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION

Facility

$20.00

Service Code	HCPCS A9585
Hospital Charge Code	152500
Hospital Revenue Code	636
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.00
Rate for Payer: Aetna New Business (MI Preferred)	$13.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Advantage	$14.00
Rate for Payer: Cofinity Commercial	$17.20
Rate for Payer: Encore Health Key Benefits Commercial	$16.00
Rate for Payer: Healthscope Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.00
Rate for Payer: PHP Commercial	$17.00
Rate for Payer: Priority Health SBD	$12.60

GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) INTRAVENOUS SOLUTION

Facility

$20.00

Service Code	HCPCS A9585
Hospital Charge Code	152500
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.00
Rate for Payer: Aetna Medicare	$10.00
Rate for Payer: Aetna New Business (MI Preferred)	$13.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS Trust/PPO	$0.69
Rate for Payer: BCN Commercial	$0.69
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Advantage	$14.00
Rate for Payer: Cofinity Commercial	$17.20
Rate for Payer: Encore Health Key Benefits Commercial	$16.00
Rate for Payer: Healthscope Commercial	$18.00
Rate for Payer: MI Amish Medical Board Commercial	$16.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.00
Rate for Payer: PHP Commercial	$17.00
Rate for Payer: Priority Health SBD	$12.60
Rate for Payer: UHC All Payor (Choice/PPO)	$0.46
Rate for Payer: UHC Core	$0.46
Rate for Payer: UHC Exchange	$0.46

GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION

Facility

$15.00

Service Code	HCPCS A9585
Hospital Charge Code	152499
Hospital Revenue Code	636
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.75
Rate for Payer: Aetna New Business (MI Preferred)	$9.75
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cofinity Advantage	$10.50
Rate for Payer: Cofinity Commercial	$12.90
Rate for Payer: Encore Health Key Benefits Commercial	$12.00
Rate for Payer: Healthscope Commercial	$13.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.25
Rate for Payer: PHP Commercial	$12.75
Rate for Payer: Priority Health SBD	$9.45

GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION

Facility

$15.00

Service Code	HCPCS A9585
Hospital Charge Code	152499
Hospital Revenue Code	636
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.75
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: Aetna New Business (MI Preferred)	$9.75
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: BCBS Trust/PPO	$0.69
Rate for Payer: BCN Commercial	$0.69
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cofinity Advantage	$10.50
Rate for Payer: Cofinity Commercial	$12.90
Rate for Payer: Encore Health Key Benefits Commercial	$12.00
Rate for Payer: Healthscope Commercial	$13.50
Rate for Payer: MI Amish Medical Board Commercial	$12.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.25
Rate for Payer: PHP Commercial	$12.75
Rate for Payer: Priority Health SBD	$9.45
Rate for Payer: UHC All Payor (Choice/PPO)	$0.46
Rate for Payer: UHC Core	$0.46
Rate for Payer: UHC Exchange	$0.46

GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN

Facility

$77.62

Service Code	HCPCS A9579
Hospital Charge Code	118272
Hospital Revenue Code	636
Min. Negotiated Rate	$48.90
Max. Negotiated Rate	$69.86
Rate for Payer: Aetna Commercial	$65.98
Rate for Payer: Aetna New Business (MI Preferred)	$50.45
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cofinity Advantage	$54.33
Rate for Payer: Cofinity Commercial	$66.75
Rate for Payer: Encore Health Key Benefits Commercial	$62.10
Rate for Payer: Healthscope Commercial	$69.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$58.22
Rate for Payer: PHP Commercial	$65.98
Rate for Payer: Priority Health SBD	$48.90

GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN

Facility

$77.62

Service Code	HCPCS A9579
Hospital Charge Code	118272
Hospital Revenue Code	636
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$69.86
Rate for Payer: Aetna Commercial	$65.98
Rate for Payer: Aetna Medicare	$38.81
Rate for Payer: Aetna New Business (MI Preferred)	$50.45
Rate for Payer: BCBS Complete	$31.05
Rate for Payer: BCBS Trust/PPO	$2.13
Rate for Payer: BCN Commercial	$2.13
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cofinity Advantage	$54.33
Rate for Payer: Cofinity Commercial	$66.75
Rate for Payer: Encore Health Key Benefits Commercial	$62.10
Rate for Payer: Healthscope Commercial	$69.86
Rate for Payer: MI Amish Medical Board Commercial	$62.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$58.22
Rate for Payer: PHP Commercial	$65.98
Rate for Payer: Priority Health SBD	$48.90
Rate for Payer: UHC All Payor (Choice/PPO)	$2.41
Rate for Payer: UHC Core	$2.41
Rate for Payer: UHC Exchange	$2.41

GADOPENTETATE DIMEGLUMINE 2.5 MMOL/5 ML(469.01 MG/ML) INTRAVENOUS SOLN

Facility

$21.62

Service Code	HCPCS A9579
Hospital Charge Code	118269
Hospital Revenue Code	636
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$19.46
Rate for Payer: Aetna Commercial	$18.38
Rate for Payer: Aetna New Business (MI Preferred)	$14.05
Rate for Payer: Cash Price	$17.30
Rate for Payer: Cofinity Advantage	$15.13
Rate for Payer: Cofinity Commercial	$18.59
Rate for Payer: Encore Health Key Benefits Commercial	$17.30
Rate for Payer: Healthscope Commercial	$19.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.21
Rate for Payer: PHP Commercial	$18.38
Rate for Payer: Priority Health SBD	$13.62

GADOPENTETATE DIMEGLUMINE 2.5 MMOL/5 ML(469.01 MG/ML) INTRAVENOUS SOLN

Facility

$21.62

Service Code	HCPCS A9579
Hospital Charge Code	118269
Hospital Revenue Code	636
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$19.46
Rate for Payer: Aetna Commercial	$18.38
Rate for Payer: Aetna Medicare	$10.81
Rate for Payer: Aetna New Business (MI Preferred)	$14.05
Rate for Payer: BCBS Complete	$8.65
Rate for Payer: BCBS Trust/PPO	$2.13
Rate for Payer: BCN Commercial	$2.13
Rate for Payer: Cash Price	$17.30
Rate for Payer: Cash Price	$17.30
Rate for Payer: Cofinity Advantage	$15.13
Rate for Payer: Cofinity Commercial	$18.59
Rate for Payer: Encore Health Key Benefits Commercial	$17.30
Rate for Payer: Healthscope Commercial	$19.46
Rate for Payer: MI Amish Medical Board Commercial	$17.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.21
Rate for Payer: PHP Commercial	$18.38
Rate for Payer: Priority Health SBD	$13.62
Rate for Payer: UHC All Payor (Choice/PPO)	$2.41
Rate for Payer: UHC Core	$2.41
Rate for Payer: UHC Exchange	$2.41

Know your out-of-pocket cost for care.

All Charges