Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

FAMOTIDINE 20 MG TABLET

Facility

$111.63

Service Code	NDC 00904719306
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$70.33
Max. Negotiated Rate	$100.47
Rate for Payer: Aetna Commercial	$94.89
Rate for Payer: Aetna New Business (MI Preferred)	$72.56
Rate for Payer: Cash Price	$89.30
Rate for Payer: Cofinity Commercial	$78.14
Rate for Payer: Cofinity Commercial	$96.00
Rate for Payer: Cofinity Medicare Advantage	$78.14
Rate for Payer: Encore Health Key Benefits Commercial	$89.30
Rate for Payer: Healthscope Commercial	$100.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$94.89
Rate for Payer: PHP Commercial	$94.89
Rate for Payer: Priority Health Cigna Priority Health	$72.56
Rate for Payer: Priority Health SBD	$70.33

FAMOTIDINE 20 MG TABLET

Facility

$1,386.50

Service Code	NDC 61442012110
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$873.50
Max. Negotiated Rate	$1,247.85
Rate for Payer: Aetna Commercial	$1,178.53
Rate for Payer: Aetna New Business (MI Preferred)	$901.23
Rate for Payer: Cash Price	$1,109.20
Rate for Payer: Cofinity Commercial	$1,192.39
Rate for Payer: Cofinity Commercial	$970.55
Rate for Payer: Cofinity Medicare Advantage	$970.55
Rate for Payer: Encore Health Key Benefits Commercial	$1,109.20
Rate for Payer: Healthscope Commercial	$1,247.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,178.53
Rate for Payer: PHP Commercial	$1,178.53
Rate for Payer: Priority Health Cigna Priority Health	$901.23
Rate for Payer: Priority Health SBD	$873.50

FAMOTIDINE 20 MG TABLET

Facility

$1,386.50

Service Code	NDC 61442012110
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$554.60
Max. Negotiated Rate	$1,247.85
Rate for Payer: Aetna Commercial	$1,178.53
Rate for Payer: Aetna Medicare	$693.25
Rate for Payer: Aetna New Business (MI Preferred)	$901.23
Rate for Payer: BCBS Complete	$554.60
Rate for Payer: Cash Price	$1,109.20
Rate for Payer: Cofinity Commercial	$1,192.39
Rate for Payer: Cofinity Commercial	$970.55
Rate for Payer: Cofinity Medicare Advantage	$970.55
Rate for Payer: Encore Health Key Benefits Commercial	$1,109.20
Rate for Payer: Healthscope Commercial	$1,247.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,178.53
Rate for Payer: PHP Commercial	$1,178.53
Rate for Payer: Priority Health Cigna Priority Health	$901.23
Rate for Payer: Priority Health SBD	$873.50

FAMOTIDINE 20 MG TABLET

Facility

$148.05

Service Code	NDC 51079096620
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$93.27
Max. Negotiated Rate	$133.25
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Cofinity Medicare Advantage	$103.64
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$96.23
Rate for Payer: Priority Health SBD	$93.27

FAMOTIDINE 20 MG TABLET

Facility

$112.80

Service Code	NDC 00172572860
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$71.06
Max. Negotiated Rate	$101.52
Rate for Payer: Aetna Commercial	$95.88
Rate for Payer: Aetna New Business (MI Preferred)	$73.32
Rate for Payer: Cash Price	$90.24
Rate for Payer: Cofinity Commercial	$78.96
Rate for Payer: Cofinity Commercial	$97.01
Rate for Payer: Cofinity Medicare Advantage	$78.96
Rate for Payer: Encore Health Key Benefits Commercial	$90.24
Rate for Payer: Healthscope Commercial	$101.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$95.88
Rate for Payer: PHP Commercial	$95.88
Rate for Payer: Priority Health Cigna Priority Health	$73.32
Rate for Payer: Priority Health SBD	$71.06

FAMOTIDINE 20 MG TABLET

Facility

$218.55

Service Code	NDC 65862085901
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$137.69
Max. Negotiated Rate	$196.69
Rate for Payer: Aetna Commercial	$185.77
Rate for Payer: Aetna New Business (MI Preferred)	$142.06
Rate for Payer: Cash Price	$174.84
Rate for Payer: Cofinity Commercial	$152.99
Rate for Payer: Cofinity Commercial	$187.95
Rate for Payer: Cofinity Medicare Advantage	$152.99
Rate for Payer: Encore Health Key Benefits Commercial	$174.84
Rate for Payer: Healthscope Commercial	$196.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$185.77
Rate for Payer: PHP Commercial	$185.77
Rate for Payer: Priority Health Cigna Priority Health	$142.06
Rate for Payer: Priority Health SBD	$137.69

FAMOTIDINE 20 MG TABLET

Facility

$99.88

Service Code	NDC 00904578017
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$89.89
Rate for Payer: Aetna Commercial	$84.90
Rate for Payer: Aetna Medicare	$49.94
Rate for Payer: Aetna New Business (MI Preferred)	$64.92
Rate for Payer: BCBS Complete	$39.95
Rate for Payer: Cash Price	$79.90
Rate for Payer: Cofinity Commercial	$69.92
Rate for Payer: Cofinity Commercial	$85.90
Rate for Payer: Cofinity Medicare Advantage	$69.92
Rate for Payer: Encore Health Key Benefits Commercial	$79.90
Rate for Payer: Healthscope Commercial	$89.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$84.90
Rate for Payer: PHP Commercial	$84.90
Rate for Payer: Priority Health Cigna Priority Health	$64.92
Rate for Payer: Priority Health SBD	$62.92

FAMOTIDINE 20 MG TABLET

Facility

$399.50

Service Code	NDC 00172572870
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$251.69
Max. Negotiated Rate	$359.55
Rate for Payer: Aetna Commercial	$339.57
Rate for Payer: Aetna New Business (MI Preferred)	$259.68
Rate for Payer: Cash Price	$319.60
Rate for Payer: Cofinity Commercial	$279.65
Rate for Payer: Cofinity Commercial	$343.57
Rate for Payer: Cofinity Medicare Advantage	$279.65
Rate for Payer: Encore Health Key Benefits Commercial	$319.60
Rate for Payer: Healthscope Commercial	$359.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$339.57
Rate for Payer: PHP Commercial	$339.57
Rate for Payer: Priority Health Cigna Priority Health	$259.68
Rate for Payer: Priority Health SBD	$251.69

FAMOTIDINE 20 MG TABLET

Facility

$1,365.08

Service Code	NDC 00187442030
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$860.00
Max. Negotiated Rate	$1,228.57
Rate for Payer: Aetna Commercial	$1,160.32
Rate for Payer: Aetna New Business (MI Preferred)	$887.30
Rate for Payer: Cash Price	$1,092.06
Rate for Payer: Cofinity Commercial	$1,173.97
Rate for Payer: Cofinity Commercial	$955.56
Rate for Payer: Cofinity Medicare Advantage	$955.56
Rate for Payer: Encore Health Key Benefits Commercial	$1,092.06
Rate for Payer: Healthscope Commercial	$1,228.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,160.32
Rate for Payer: PHP Commercial	$1,160.32
Rate for Payer: Priority Health Cigna Priority Health	$887.30
Rate for Payer: Priority Health SBD	$860.00

FAMOTIDINE 20 MG TABLET

Facility

$150.40

Service Code	NDC 61442012101
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$60.16
Max. Negotiated Rate	$135.36
Rate for Payer: Aetna Commercial	$127.84
Rate for Payer: Aetna Medicare	$75.20
Rate for Payer: Aetna New Business (MI Preferred)	$97.76
Rate for Payer: BCBS Complete	$60.16
Rate for Payer: Cash Price	$120.32
Rate for Payer: Cofinity Commercial	$105.28
Rate for Payer: Cofinity Commercial	$129.34
Rate for Payer: Cofinity Medicare Advantage	$105.28
Rate for Payer: Encore Health Key Benefits Commercial	$120.32
Rate for Payer: Healthscope Commercial	$135.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$127.84
Rate for Payer: PHP Commercial	$127.84
Rate for Payer: Priority Health Cigna Priority Health	$97.76
Rate for Payer: Priority Health SBD	$94.75

FAMOTIDINE 20 MG TABLET

Facility

$112.80

Service Code	NDC 00172572860
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$45.12
Max. Negotiated Rate	$101.52
Rate for Payer: Aetna Commercial	$95.88
Rate for Payer: Aetna Medicare	$56.40
Rate for Payer: Aetna New Business (MI Preferred)	$73.32
Rate for Payer: BCBS Complete	$45.12
Rate for Payer: Cash Price	$90.24
Rate for Payer: Cofinity Commercial	$78.96
Rate for Payer: Cofinity Commercial	$97.01
Rate for Payer: Cofinity Medicare Advantage	$78.96
Rate for Payer: Encore Health Key Benefits Commercial	$90.24
Rate for Payer: Healthscope Commercial	$101.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$95.88
Rate for Payer: PHP Commercial	$95.88
Rate for Payer: Priority Health Cigna Priority Health	$73.32
Rate for Payer: Priority Health SBD	$71.06

FAMOTIDINE 20 MG TABLET

Facility

$432.40

Service Code	NDC 60687059501
Hospital Charge Code	10011
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 Commercial	$302.68
Rate for Payer: Cofinity Commercial	$371.86
Rate for Payer: Cofinity Medicare Advantage	$302.68
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: PHP Commercial	$367.54
Rate for Payer: Priority Health Cigna Priority Health	$281.06
Rate for Payer: Priority Health SBD	$272.41

FAMOTIDINE 20 MG TABLET

Facility

$98.80

Service Code	NDC 16837085525
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$39.52
Max. Negotiated Rate	$88.92
Rate for Payer: Aetna Commercial	$83.98
Rate for Payer: Aetna Medicare	$49.40
Rate for Payer: Aetna New Business (MI Preferred)	$64.22
Rate for Payer: BCBS Complete	$39.52
Rate for Payer: Cash Price	$79.04
Rate for Payer: Cofinity Commercial	$69.16
Rate for Payer: Cofinity Commercial	$84.97
Rate for Payer: Cofinity Medicare Advantage	$69.16
Rate for Payer: Encore Health Key Benefits Commercial	$79.04
Rate for Payer: Healthscope Commercial	$88.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$83.98
Rate for Payer: PHP Commercial	$83.98
Rate for Payer: Priority Health Cigna Priority Health	$64.22
Rate for Payer: Priority Health SBD	$62.24

FAMOTIDINE 20 MG TABLET

Facility

$4,550.26

Service Code	NDC 00187442010
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$1,820.10
Max. Negotiated Rate	$4,095.23
Rate for Payer: Aetna Commercial	$3,867.72
Rate for Payer: Aetna Medicare	$2,275.13
Rate for Payer: Aetna New Business (MI Preferred)	$2,957.67
Rate for Payer: BCBS Complete	$1,820.10
Rate for Payer: Cash Price	$3,640.21
Rate for Payer: Cofinity Commercial	$3,185.18
Rate for Payer: Cofinity Commercial	$3,913.22
Rate for Payer: Cofinity Medicare Advantage	$3,185.18
Rate for Payer: Encore Health Key Benefits Commercial	$3,640.21
Rate for Payer: Healthscope Commercial	$4,095.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,867.72
Rate for Payer: PHP Commercial	$3,867.72
Rate for Payer: Priority Health Cigna Priority Health	$2,957.67
Rate for Payer: Priority Health SBD	$2,866.66

FAMOTIDINE 20 MG TABLET

Facility

$218.55

Service Code	NDC 62332000131
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$137.69
Max. Negotiated Rate	$196.69
Rate for Payer: Aetna Commercial	$185.77
Rate for Payer: Aetna New Business (MI Preferred)	$142.06
Rate for Payer: Cash Price	$174.84
Rate for Payer: Cofinity Commercial	$152.99
Rate for Payer: Cofinity Commercial	$187.95
Rate for Payer: Cofinity Medicare Advantage	$152.99
Rate for Payer: Encore Health Key Benefits Commercial	$174.84
Rate for Payer: Healthscope Commercial	$196.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$185.77
Rate for Payer: PHP Commercial	$185.77
Rate for Payer: Priority Health Cigna Priority Health	$142.06
Rate for Payer: Priority Health SBD	$137.69

FAMOTIDINE 20 MG TABLET

Facility

$1.49

Service Code	NDC 51079096601
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna Commercial	$1.27
Rate for Payer: Aetna New Business (MI Preferred)	$0.97
Rate for Payer: Cash Price	$1.19
Rate for Payer: Cofinity Commercial	$1.04
Rate for Payer: Cofinity Commercial	$1.28
Rate for Payer: Cofinity Medicare Advantage	$1.04
Rate for Payer: Encore Health Key Benefits Commercial	$1.19
Rate for Payer: Healthscope Commercial	$1.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.27
Rate for Payer: PHP Commercial	$1.27
Rate for Payer: Priority Health Cigna Priority Health	$0.97
Rate for Payer: Priority Health SBD	$0.94

FAMOTIDINE 20 MG TABLET

Facility

$218.55

Service Code	NDC 62332000131
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$87.42
Max. Negotiated Rate	$196.69
Rate for Payer: Aetna Commercial	$185.77
Rate for Payer: Aetna Medicare	$109.28
Rate for Payer: Aetna New Business (MI Preferred)	$142.06
Rate for Payer: BCBS Complete	$87.42
Rate for Payer: Cash Price	$174.84
Rate for Payer: Cofinity Commercial	$152.99
Rate for Payer: Cofinity Commercial	$187.95
Rate for Payer: Cofinity Medicare Advantage	$152.99
Rate for Payer: Encore Health Key Benefits Commercial	$174.84
Rate for Payer: Healthscope Commercial	$196.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$185.77
Rate for Payer: PHP Commercial	$185.77
Rate for Payer: Priority Health Cigna Priority Health	$142.06
Rate for Payer: Priority Health SBD	$137.69

FAMOTIDINE 20 MG TABLET

Facility

$150.40

Service Code	NDC 61442012101
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$94.75
Max. Negotiated Rate	$135.36
Rate for Payer: Aetna Commercial	$127.84
Rate for Payer: Aetna New Business (MI Preferred)	$97.76
Rate for Payer: Cash Price	$120.32
Rate for Payer: Cofinity Commercial	$105.28
Rate for Payer: Cofinity Commercial	$129.34
Rate for Payer: Cofinity Medicare Advantage	$105.28
Rate for Payer: Encore Health Key Benefits Commercial	$120.32
Rate for Payer: Healthscope Commercial	$135.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$127.84
Rate for Payer: PHP Commercial	$127.84
Rate for Payer: Priority Health Cigna Priority Health	$97.76
Rate for Payer: Priority Health SBD	$94.75

FAMOTIDINE 20 MG TABLET

Facility

$190.35

Service Code	NDC 00536129801
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$76.14
Max. Negotiated Rate	$171.31
Rate for Payer: Aetna Commercial	$161.80
Rate for Payer: Aetna Medicare	$95.17
Rate for Payer: Aetna New Business (MI Preferred)	$123.73
Rate for Payer: BCBS Complete	$76.14
Rate for Payer: Cash Price	$152.28
Rate for Payer: Cofinity Commercial	$133.25
Rate for Payer: Cofinity Commercial	$163.70
Rate for Payer: Cofinity Medicare Advantage	$133.25
Rate for Payer: Encore Health Key Benefits Commercial	$152.28
Rate for Payer: Healthscope Commercial	$171.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.80
Rate for Payer: PHP Commercial	$161.80
Rate for Payer: Priority Health Cigna Priority Health	$123.73
Rate for Payer: Priority Health SBD	$119.92

FAMOTIDINE 20 MG TABLET

Facility

$148.05

Service Code	NDC 51079096620
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$59.22
Max. Negotiated Rate	$133.25
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna Medicare	$74.03
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: BCBS Complete	$59.22
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Cofinity Medicare Advantage	$103.64
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$96.23
Rate for Payer: Priority Health SBD	$93.27

FAMOTIDINE 20 MG TABLET

Facility

$4.33

Service Code	NDC 60687059511
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna Commercial	$3.68
Rate for Payer: Aetna New Business (MI Preferred)	$2.81
Rate for Payer: Cash Price	$3.46
Rate for Payer: Cofinity Commercial	$3.03
Rate for Payer: Cofinity Commercial	$3.72
Rate for Payer: Cofinity Medicare Advantage	$3.03
Rate for Payer: Encore Health Key Benefits Commercial	$3.46
Rate for Payer: Healthscope Commercial	$3.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.68
Rate for Payer: PHP Commercial	$3.68
Rate for Payer: Priority Health Cigna Priority Health	$2.81
Rate for Payer: Priority Health SBD	$2.73

FAMOTIDINE 40 MG TABLET

Facility

$893.00

Service Code	NDC 00172572970
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$562.59
Max. Negotiated Rate	$803.70
Rate for Payer: Aetna Commercial	$759.05
Rate for Payer: Aetna New Business (MI Preferred)	$580.45
Rate for Payer: Cash Price	$714.40
Rate for Payer: Cofinity Commercial	$625.10
Rate for Payer: Cofinity Commercial	$767.98
Rate for Payer: Cofinity Medicare Advantage	$625.10
Rate for Payer: Encore Health Key Benefits Commercial	$714.40
Rate for Payer: Healthscope Commercial	$803.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$759.05
Rate for Payer: PHP Commercial	$759.05
Rate for Payer: Priority Health Cigna Priority Health	$580.45
Rate for Payer: Priority Health SBD	$562.59

FAMOTIDINE 40 MG TABLET

Facility

$2.38

Service Code	NDC 50268030411
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.14
Rate for Payer: Aetna Commercial	$2.02
Rate for Payer: Aetna Medicare	$1.19
Rate for Payer: Aetna New Business (MI Preferred)	$1.55
Rate for Payer: BCBS Complete	$0.95
Rate for Payer: Cash Price	$1.90
Rate for Payer: Cofinity Commercial	$1.67
Rate for Payer: Cofinity Commercial	$2.05
Rate for Payer: Cofinity Medicare Advantage	$1.67
Rate for Payer: Encore Health Key Benefits Commercial	$1.90
Rate for Payer: Healthscope Commercial	$2.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.02
Rate for Payer: PHP Commercial	$2.02
Rate for Payer: Priority Health Cigna Priority Health	$1.55
Rate for Payer: Priority Health SBD	$1.50

FAMOTIDINE 40 MG TABLET

Facility

$272.60

Service Code	NDC 61442012201
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$109.04
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$231.71
Rate for Payer: Aetna Medicare	$136.30
Rate for Payer: Aetna New Business (MI Preferred)	$177.19
Rate for Payer: BCBS Complete	$109.04
Rate for Payer: Cash Price	$218.08
Rate for Payer: Cofinity Commercial	$190.82
Rate for Payer: Cofinity Commercial	$234.44
Rate for Payer: Cofinity Medicare Advantage	$190.82
Rate for Payer: Encore Health Key Benefits Commercial	$218.08
Rate for Payer: Healthscope Commercial	$245.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.71
Rate for Payer: PHP Commercial	$231.71
Rate for Payer: Priority Health Cigna Priority Health	$177.19
Rate for Payer: Priority Health SBD	$171.74

FAMOTIDINE 40 MG TABLET

Facility

$8,794.90

Service Code	NDC 00187444010
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$5,540.79
Max. Negotiated Rate	$7,915.41
Rate for Payer: Aetna Commercial	$7,475.66
Rate for Payer: Aetna New Business (MI Preferred)	$5,716.69
Rate for Payer: Cash Price	$7,035.92
Rate for Payer: Cofinity Commercial	$6,156.43
Rate for Payer: Cofinity Commercial	$7,563.61
Rate for Payer: Cofinity Medicare Advantage	$6,156.43
Rate for Payer: Encore Health Key Benefits Commercial	$7,035.92
Rate for Payer: Healthscope Commercial	$7,915.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,475.66
Rate for Payer: PHP Commercial	$7,475.66
Rate for Payer: Priority Health Cigna Priority Health	$5,716.69
Rate for Payer: Priority Health SBD	$5,540.79

Know your out-of-pocket cost for care.

All Charges