Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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

$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

FAMOTIDINE 40 MG TABLET

Facility

$206.80

Service Code	NDC 00172572960
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$130.28
Max. Negotiated Rate	$186.12
Rate for Payer: Aetna Commercial	$175.78
Rate for Payer: Aetna New Business (MI Preferred)	$134.42
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cofinity Commercial	$144.76
Rate for Payer: Cofinity Commercial	$177.85
Rate for Payer: Cofinity Medicare Advantage	$144.76
Rate for Payer: Encore Health Key Benefits Commercial	$165.44
Rate for Payer: Healthscope Commercial	$186.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.78
Rate for Payer: PHP Commercial	$175.78
Rate for Payer: Priority Health Cigna Priority Health	$134.42
Rate for Payer: Priority Health SBD	$130.28

FAMOTIDINE 40 MG TABLET

Facility

$272.60

Service Code	NDC 61442012201
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$171.74
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$231.71
Rate for Payer: Aetna New Business (MI Preferred)	$177.19
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

$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

$2.38

Service Code	NDC 50268030411
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.14
Rate for Payer: Aetna Commercial	$2.02
Rate for Payer: Aetna New Business (MI Preferred)	$1.55
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

$206.80

Service Code	NDC 00172572960
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$82.72
Max. Negotiated Rate	$186.12
Rate for Payer: Aetna Commercial	$175.78
Rate for Payer: Aetna Medicare	$103.40
Rate for Payer: Aetna New Business (MI Preferred)	$134.42
Rate for Payer: BCBS Complete	$82.72
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cofinity Commercial	$144.76
Rate for Payer: Cofinity Commercial	$177.85
Rate for Payer: Cofinity Medicare Advantage	$144.76
Rate for Payer: Encore Health Key Benefits Commercial	$165.44
Rate for Payer: Healthscope Commercial	$186.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.78
Rate for Payer: PHP Commercial	$175.78
Rate for Payer: Priority Health Cigna Priority Health	$134.42
Rate for Payer: Priority Health SBD	$130.28

FAMOTIDINE 40 MG TABLET

Facility

$118.75

Service Code	NDC 50268030415
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$106.88
Rate for Payer: Aetna Commercial	$100.94
Rate for Payer: Aetna Medicare	$59.38
Rate for Payer: Aetna New Business (MI Preferred)	$77.19
Rate for Payer: BCBS Complete	$47.50
Rate for Payer: Cash Price	$95.00
Rate for Payer: Cofinity Commercial	$102.12
Rate for Payer: Cofinity Commercial	$83.12
Rate for Payer: Cofinity Medicare Advantage	$83.12
Rate for Payer: Encore Health Key Benefits Commercial	$95.00
Rate for Payer: Healthscope Commercial	$106.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.94
Rate for Payer: PHP Commercial	$100.94
Rate for Payer: Priority Health Cigna Priority Health	$77.19
Rate for Payer: Priority Health SBD	$74.81

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$15.30

Service Code	NDC 70860075102
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$13.77
Rate for Payer: Aetna Commercial	$13.01
Rate for Payer: Aetna Medicare	$7.65
Rate for Payer: Aetna New Business (MI Preferred)	$9.95
Rate for Payer: BCBS Complete	$6.12
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cofinity Commercial	$10.71
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Cofinity Medicare Advantage	$10.71
Rate for Payer: Encore Health Key Benefits Commercial	$12.24
Rate for Payer: Healthscope Commercial	$13.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.01
Rate for Payer: PHP Commercial	$13.01
Rate for Payer: Priority Health Cigna Priority Health	$9.95
Rate for Payer: Priority Health SBD	$9.64

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$15.30

Service Code	NDC 70860075141
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$13.77
Rate for Payer: Aetna Commercial	$13.01
Rate for Payer: Aetna Medicare	$7.65
Rate for Payer: Aetna New Business (MI Preferred)	$9.95
Rate for Payer: BCBS Complete	$6.12
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cofinity Commercial	$10.71
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Cofinity Medicare Advantage	$10.71
Rate for Payer: Encore Health Key Benefits Commercial	$12.24
Rate for Payer: Healthscope Commercial	$13.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.01
Rate for Payer: PHP Commercial	$13.01
Rate for Payer: Priority Health Cigna Priority Health	$9.95
Rate for Payer: Priority Health SBD	$9.64

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.05

Service Code	NDC 67457043300
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$10.85
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna New Business (MI Preferred)	$7.83
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cofinity Commercial	$10.36
Rate for Payer: Cofinity Commercial	$8.44
Rate for Payer: Cofinity Medicare Advantage	$8.44
Rate for Payer: Encore Health Key Benefits Commercial	$9.64
Rate for Payer: Healthscope Commercial	$10.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.24
Rate for Payer: PHP Commercial	$10.24
Rate for Payer: Priority Health Cigna Priority Health	$7.83
Rate for Payer: Priority Health SBD	$7.59

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$15.30

Service Code	NDC 70860075102
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$13.77
Rate for Payer: Aetna Commercial	$13.01
Rate for Payer: Aetna New Business (MI Preferred)	$9.95
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cofinity Commercial	$10.71
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Cofinity Medicare Advantage	$10.71
Rate for Payer: Encore Health Key Benefits Commercial	$12.24
Rate for Payer: Healthscope Commercial	$13.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.01
Rate for Payer: PHP Commercial	$13.01
Rate for Payer: Priority Health Cigna Priority Health	$9.95
Rate for Payer: Priority Health SBD	$9.64

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.95

Service Code	NDC 00641602201
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.65
Rate for Payer: Aetna Commercial	$11.01
Rate for Payer: Aetna New Business (MI Preferred)	$8.42
Rate for Payer: Cash Price	$10.36
Rate for Payer: Cofinity Commercial	$11.14
Rate for Payer: Cofinity Commercial	$9.06
Rate for Payer: Cofinity Medicare Advantage	$9.06
Rate for Payer: Encore Health Key Benefits Commercial	$10.36
Rate for Payer: Healthscope Commercial	$11.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.01
Rate for Payer: PHP Commercial	$11.01
Rate for Payer: Priority Health Cigna Priority Health	$8.42
Rate for Payer: Priority Health SBD	$8.16

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$16.05

Service Code	NDC 63323073912
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$14.45
Rate for Payer: Aetna Commercial	$13.64
Rate for Payer: Aetna New Business (MI Preferred)	$10.43
Rate for Payer: Cash Price	$12.84
Rate for Payer: Cofinity Commercial	$11.23
Rate for Payer: Cofinity Commercial	$13.80
Rate for Payer: Cofinity Medicare Advantage	$11.23
Rate for Payer: Encore Health Key Benefits Commercial	$12.84
Rate for Payer: Healthscope Commercial	$14.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.64
Rate for Payer: PHP Commercial	$13.64
Rate for Payer: Priority Health Cigna Priority Health	$10.43
Rate for Payer: Priority Health SBD	$10.11

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.05

Service Code	NDC 67457043322
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$10.85
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna Medicare	$6.03
Rate for Payer: Aetna New Business (MI Preferred)	$7.83
Rate for Payer: BCBS Complete	$4.82
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cofinity Commercial	$10.36
Rate for Payer: Cofinity Commercial	$8.44
Rate for Payer: Cofinity Medicare Advantage	$8.44
Rate for Payer: Encore Health Key Benefits Commercial	$9.64
Rate for Payer: Healthscope Commercial	$10.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.24
Rate for Payer: PHP Commercial	$10.24
Rate for Payer: Priority Health Cigna Priority Health	$7.83
Rate for Payer: Priority Health SBD	$7.59

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.95

Service Code	NDC 00641602225
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.65
Rate for Payer: Aetna Commercial	$11.01
Rate for Payer: Aetna New Business (MI Preferred)	$8.42
Rate for Payer: Cash Price	$10.36
Rate for Payer: Cofinity Commercial	$11.14
Rate for Payer: Cofinity Commercial	$9.06
Rate for Payer: Cofinity Medicare Advantage	$9.06
Rate for Payer: Encore Health Key Benefits Commercial	$10.36
Rate for Payer: Healthscope Commercial	$11.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.01
Rate for Payer: PHP Commercial	$11.01
Rate for Payer: Priority Health Cigna Priority Health	$8.42
Rate for Payer: Priority Health SBD	$8.16

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$16.05

Service Code	NDC 63323073912
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$14.45
Rate for Payer: Aetna Commercial	$13.64
Rate for Payer: Aetna Medicare	$8.03
Rate for Payer: Aetna New Business (MI Preferred)	$10.43
Rate for Payer: BCBS Complete	$6.42
Rate for Payer: Cash Price	$12.84
Rate for Payer: Cofinity Commercial	$11.23
Rate for Payer: Cofinity Commercial	$13.80
Rate for Payer: Cofinity Medicare Advantage	$11.23
Rate for Payer: Encore Health Key Benefits Commercial	$12.84
Rate for Payer: Healthscope Commercial	$14.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.64
Rate for Payer: PHP Commercial	$13.64
Rate for Payer: Priority Health Cigna Priority Health	$10.43
Rate for Payer: Priority Health SBD	$10.11

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.05

Service Code	NDC 67457043322
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$10.85
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna New Business (MI Preferred)	$7.83
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cofinity Commercial	$10.36
Rate for Payer: Cofinity Commercial	$8.44
Rate for Payer: Cofinity Medicare Advantage	$8.44
Rate for Payer: Encore Health Key Benefits Commercial	$9.64
Rate for Payer: Healthscope Commercial	$10.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.24
Rate for Payer: PHP Commercial	$10.24
Rate for Payer: Priority Health Cigna Priority Health	$7.83
Rate for Payer: Priority Health SBD	$7.59

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$15.30

Service Code	NDC 70860075141
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$13.77
Rate for Payer: Aetna Commercial	$13.01
Rate for Payer: Aetna New Business (MI Preferred)	$9.95
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cofinity Commercial	$10.71
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Cofinity Medicare Advantage	$10.71
Rate for Payer: Encore Health Key Benefits Commercial	$12.24
Rate for Payer: Healthscope Commercial	$13.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.01
Rate for Payer: PHP Commercial	$13.01
Rate for Payer: Priority Health Cigna Priority Health	$9.95
Rate for Payer: Priority Health SBD	$9.64

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.95

Service Code	NDC 00641602225
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$11.65
Rate for Payer: Aetna Commercial	$11.01
Rate for Payer: Aetna Medicare	$6.47
Rate for Payer: Aetna New Business (MI Preferred)	$8.42
Rate for Payer: BCBS Complete	$5.18
Rate for Payer: Cash Price	$10.36
Rate for Payer: Cofinity Commercial	$11.14
Rate for Payer: Cofinity Commercial	$9.06
Rate for Payer: Cofinity Medicare Advantage	$9.06
Rate for Payer: Encore Health Key Benefits Commercial	$10.36
Rate for Payer: Healthscope Commercial	$11.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.01
Rate for Payer: PHP Commercial	$11.01
Rate for Payer: Priority Health Cigna Priority Health	$8.42
Rate for Payer: Priority Health SBD	$8.16

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.95

Service Code	NDC 00641602201
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$11.65
Rate for Payer: Aetna Commercial	$11.01
Rate for Payer: Aetna Medicare	$6.47
Rate for Payer: Aetna New Business (MI Preferred)	$8.42
Rate for Payer: BCBS Complete	$5.18
Rate for Payer: Cash Price	$10.36
Rate for Payer: Cofinity Commercial	$11.14
Rate for Payer: Cofinity Commercial	$9.06
Rate for Payer: Cofinity Medicare Advantage	$9.06
Rate for Payer: Encore Health Key Benefits Commercial	$10.36
Rate for Payer: Healthscope Commercial	$11.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.01
Rate for Payer: PHP Commercial	$11.01
Rate for Payer: Priority Health Cigna Priority Health	$8.42
Rate for Payer: Priority Health SBD	$8.16

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.05

Service Code	NDC 67457043300
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$10.85
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna Medicare	$6.03
Rate for Payer: Aetna New Business (MI Preferred)	$7.83
Rate for Payer: BCBS Complete	$4.82
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cofinity Commercial	$10.36
Rate for Payer: Cofinity Commercial	$8.44
Rate for Payer: Cofinity Medicare Advantage	$8.44
Rate for Payer: Encore Health Key Benefits Commercial	$9.64
Rate for Payer: Healthscope Commercial	$10.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.24
Rate for Payer: PHP Commercial	$10.24
Rate for Payer: Priority Health Cigna Priority Health	$7.83
Rate for Payer: Priority Health SBD	$7.59

FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION

Facility

$13,177.03

Service Code	HCPCS J9358
Hospital Charge Code	192405
Hospital Revenue Code	636
Min. Negotiated Rate	$8,301.53
Max. Negotiated Rate	$11,859.33
Rate for Payer: Aetna Commercial	$11,200.48
Rate for Payer: Aetna New Business (MI Preferred)	$8,565.07
Rate for Payer: Cash Price	$10,541.62
Rate for Payer: Cofinity Commercial	$11,332.25
Rate for Payer: Cofinity Commercial	$9,223.92
Rate for Payer: Cofinity Medicare Advantage	$9,223.92
Rate for Payer: Encore Health Key Benefits Commercial	$10,541.62
Rate for Payer: Healthscope Commercial	$11,859.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11,200.48
Rate for Payer: PHP Commercial	$11,200.48
Rate for Payer: Priority Health Cigna Priority Health	$8,565.07
Rate for Payer: Priority Health SBD	$8,301.53

FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION

Facility

$13,177.03

Service Code	HCPCS J9358
Hospital Charge Code	192405
Hospital Revenue Code	636
Min. Negotiated Rate	$16.07
Max. Negotiated Rate	$11,859.33
Rate for Payer: Aetna Commercial	$11,200.48
Rate for Payer: Aetna Medicare	$31.18
Rate for Payer: Aetna New Business (MI Preferred)	$8,565.07
Rate for Payer: Allen County Amish Medical Aid Commercial	$37.48
Rate for Payer: Amish Plain Church Group Commercial	$37.48
Rate for Payer: BCBS Complete	$16.87
Rate for Payer: BCBS MAPPO	$29.98
Rate for Payer: BCN Medicare Advantage	$29.98
Rate for Payer: Cash Price	$10,541.62
Rate for Payer: Cash Price	$10,541.62
Rate for Payer: Cofinity Commercial	$9,223.92
Rate for Payer: Cofinity Commercial	$11,332.25
Rate for Payer: Cofinity Medicare Advantage	$9,223.92
Rate for Payer: Encore Health Key Benefits Commercial	$10,541.62
Rate for Payer: Health Alliance Plan Medicare Advantage	$29.98
Rate for Payer: Healthscope Commercial	$11,859.33
Rate for Payer: Mclaren Medicaid	$16.07
Rate for Payer: Mclaren Medicare	$29.98
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$31.48
Rate for Payer: Meridian Medicaid	$16.87
Rate for Payer: MI Amish Medical Board Commercial	$34.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11,200.48
Rate for Payer: PACE Medicare	$28.48
Rate for Payer: PACE SWMI	$29.98
Rate for Payer: PHP Commercial	$11,200.48
Rate for Payer: PHP Medicare Advantage	$29.98
Rate for Payer: Priority Health Choice Medicaid	$16.07
Rate for Payer: Priority Health Cigna Priority Health	$8,565.07
Rate for Payer: Priority Health Medicare	$29.98
Rate for Payer: Priority Health SBD	$8,301.53
Rate for Payer: Railroad Medicare Medicare	$29.98
Rate for Payer: UHC All Payor (Choice/PPO)	$84.39
Rate for Payer: UHC Dual Complete DSNP	$29.98
Rate for Payer: UHC Medicare Advantage	$29.98
Rate for Payer: UHCCP Medicaid	$16.88
Rate for Payer: VA VA	$29.98

FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE, COMPLEX OR SHEET

Facility

$5,021.81

Service Code	CPT 20922
Hospital Revenue Code	360
Min. Negotiated Rate	$956.23
Max. Negotiated Rate	$5,021.81
Rate for Payer: Aetna Medicare	$1,855.37
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,230.01
Rate for Payer: Amish Plain Church Group Commercial	$2,230.01
Rate for Payer: BCBS Complete	$1,004.04
Rate for Payer: BCBS MAPPO	$1,784.01
Rate for Payer: BCN Medicare Advantage	$1,784.01
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,784.01
Rate for Payer: Mclaren Medicaid	$956.23
Rate for Payer: Mclaren Medicare	$1,784.01
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,873.21
Rate for Payer: Meridian Medicaid	$1,004.04
Rate for Payer: MI Amish Medical Board Commercial	$2,051.61
Rate for Payer: PACE Medicare	$1,694.81
Rate for Payer: PACE SWMI	$1,784.01
Rate for Payer: PHP Medicare Advantage	$1,784.01
Rate for Payer: Priority Health Choice Medicaid	$956.23
Rate for Payer: Priority Health Medicare	$1,784.01
Rate for Payer: Railroad Medicare Medicare	$1,784.01
Rate for Payer: UHC All Payor (Choice/PPO)	$5,021.81
Rate for Payer: UHC Dual Complete DSNP	$1,784.01
Rate for Payer: UHC Medicare Advantage	$1,784.01
Rate for Payer: UHCCP Medicaid	$1,004.40
Rate for Payer: VA VA	$1,784.01

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