Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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	$11.66
Rate for Payer: Aetna Commercial	$11.01
Rate for Payer: Aetna Medicare	$6.48
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	$11.66
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

$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	$13.00
Rate for Payer: Aetna Medicare	$7.65
Rate for Payer: Aetna New Business (MI Preferred)	$9.94
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	$13.00
Rate for Payer: PHP Commercial	$13.00
Rate for Payer: Priority Health Cigna Priority Health	$9.94
Rate for Payer: Priority Health SBD	$9.64

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	$10.84
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	$10.84
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

$16.05

Service Code	NDC 63323073912
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$14.44
Rate for Payer: Aetna Commercial	$13.64
Rate for Payer: Aetna Medicare	$8.02
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	$11.24
Rate for Payer: Cofinity Commercial	$13.80
Rate for Payer: Cofinity Medicare Advantage	$11.24
Rate for Payer: Encore Health Key Benefits Commercial	$12.84
Rate for Payer: Healthscope Commercial	$14.44
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

$12.95

Service Code	NDC 00641602201
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.66
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	$11.66
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

$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	$13.00
Rate for Payer: Aetna New Business (MI Preferred)	$9.94
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	$13.00
Rate for Payer: PHP Commercial	$13.00
Rate for Payer: Priority Health Cigna Priority Health	$9.94
Rate for Payer: Priority Health SBD	$9.64

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	$14.44
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	$11.24
Rate for Payer: Cofinity Commercial	$13.80
Rate for Payer: Cofinity Medicare Advantage	$11.24
Rate for Payer: Encore Health Key Benefits Commercial	$12.84
Rate for Payer: Healthscope Commercial	$14.44
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 67457043300
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$10.84
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna Medicare	$6.02
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	$10.84
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 00641602201
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$11.66
Rate for Payer: Aetna Commercial	$11.01
Rate for Payer: Aetna Medicare	$6.48
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	$11.66
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

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	$15.44
Max. Negotiated Rate	$11,859.33
Rate for Payer: Aetna Commercial	$11,200.48
Rate for Payer: Aetna Medicare	$29.96
Rate for Payer: Aetna New Business (MI Preferred)	$8,565.07
Rate for Payer: Allen County Amish Medical Aid Commercial	$36.01
Rate for Payer: Amish Plain Church Group Commercial	$36.01
Rate for Payer: BCBS Complete	$16.21
Rate for Payer: BCBS MAPPO	$28.81
Rate for Payer: BCBS Trust/PPO	$81.37
Rate for Payer: BCN Commercial	$81.37
Rate for Payer: BCN Medicare Advantage	$28.81
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	$28.81
Rate for Payer: Healthscope Commercial	$11,859.33
Rate for Payer: Mclaren Medicaid	$15.44
Rate for Payer: Mclaren Medicare	$28.81
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$30.25
Rate for Payer: Meridian Medicaid	$16.21
Rate for Payer: MI Amish Medical Board Commercial	$33.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11,200.48
Rate for Payer: Nomi Health Commercial	$86.43
Rate for Payer: PACE Medicare	$27.37
Rate for Payer: PACE SWMI	$28.81
Rate for Payer: PHP Commercial	$11,200.48
Rate for Payer: PHP Medicare Advantage	$28.81
Rate for Payer: Priority Health Choice Medicaid	$15.44
Rate for Payer: Priority Health Cigna Priority Health	$8,565.07
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$80.04
Rate for Payer: Priority Health Medicare	$28.81
Rate for Payer: Priority Health Narrow Network	$64.03
Rate for Payer: Priority Health SBD	$8,301.53
Rate for Payer: Railroad Medicare Medicare	$28.81
Rate for Payer: UHC All Payor (Choice/PPO)	$81.10
Rate for Payer: UHC Dual Complete DSNP	$28.81
Rate for Payer: UHC Medicare Advantage	$28.81
Rate for Payer: UHCCP Medicaid	$16.22
Rate for Payer: VA VA	$28.81

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

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

Facility

$5,632.99

Service Code	CPT 20922
Hospital Revenue Code	360
Min. Negotiated Rate	$532.84
Max. Negotiated Rate	$5,632.99
Rate for Payer: Aetna Medicare	$1,863.93
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,240.30
Rate for Payer: Amish Plain Church Group Commercial	$2,240.30
Rate for Payer: BCBS Complete	$1,008.67
Rate for Payer: BCBS MAPPO	$1,792.24
Rate for Payer: BCBS Trust/PPO	$1,209.86
Rate for Payer: BCN Commercial	$1,209.86
Rate for Payer: BCN Medicare Advantage	$1,792.24
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,792.24
Rate for Payer: Mclaren Medicaid	$960.64
Rate for Payer: Mclaren Medicare	$1,792.24
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,881.85
Rate for Payer: Meridian Medicaid	$1,008.67
Rate for Payer: MI Amish Medical Board Commercial	$2,061.08
Rate for Payer: Nomi Health Commercial	$3,763.70
Rate for Payer: PACE Medicare	$1,702.63
Rate for Payer: PACE SWMI	$1,792.24
Rate for Payer: PHP Medicare Advantage	$1,792.24
Rate for Payer: Priority Health Choice Medicaid	$960.64
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,632.99
Rate for Payer: Priority Health Medicare	$1,792.24
Rate for Payer: Priority Health Narrow Network	$4,506.39
Rate for Payer: Railroad Medicare Medicare	$1,792.24
Rate for Payer: UHC All Payor (Choice/PPO)	$532.84
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,792.24
Rate for Payer: UHC Exchange	$4,450.00
Rate for Payer: UHC Medicare Advantage	$1,792.24
Rate for Payer: UHCCP Medicaid	$1,009.03
Rate for Payer: VA VA	$1,792.24

FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT);

Facility

$9,991.56

Service Code	CPT 26123
Hospital Revenue Code	360
Min. Negotiated Rate	$892.26
Max. Negotiated Rate	$9,991.56
Rate for Payer: Aetna Medicare	$3,306.16
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,973.75
Rate for Payer: Amish Plain Church Group Commercial	$3,973.75
Rate for Payer: BCBS Complete	$1,789.14
Rate for Payer: BCBS MAPPO	$3,179.00
Rate for Payer: BCBS Trust/PPO	$1,866.67
Rate for Payer: BCN Commercial	$1,866.67
Rate for Payer: BCN Medicare Advantage	$3,179.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,179.00
Rate for Payer: Mclaren Medicaid	$1,703.94
Rate for Payer: Mclaren Medicare	$3,179.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,337.95
Rate for Payer: Meridian Medicaid	$1,789.14
Rate for Payer: MI Amish Medical Board Commercial	$3,655.85
Rate for Payer: Nomi Health Commercial	$6,675.90
Rate for Payer: PACE Medicare	$3,020.05
Rate for Payer: PACE SWMI	$3,179.00
Rate for Payer: PHP Medicare Advantage	$3,179.00
Rate for Payer: Priority Health Choice Medicaid	$1,703.94
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,991.56
Rate for Payer: Priority Health Medicare	$3,179.00
Rate for Payer: Priority Health Narrow Network	$7,993.25
Rate for Payer: Railroad Medicare Medicare	$3,179.00
Rate for Payer: UHC All Payor (Choice/PPO)	$892.26
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$3,179.00
Rate for Payer: UHC Exchange	$5,811.00
Rate for Payer: UHC Medicare Advantage	$3,179.00
Rate for Payer: UHCCP Medicaid	$1,789.78
Rate for Payer: VA VA	$3,179.00

Facility

$940.00

Service Code	CPT 26125
Hospital Revenue Code	360
Min. Negotiated Rate	$285.46
Max. Negotiated Rate	$940.00
Rate for Payer: BCBS Trust/PPO	$574.30
Rate for Payer: BCN Commercial	$574.30
Rate for Payer: UHC All Payor (Choice/PPO)	$285.46
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Exchange	$940.00

FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE)

Facility

$9,991.56

Service Code	CPT 28060
Hospital Revenue Code	360
Min. Negotiated Rate	$381.11
Max. Negotiated Rate	$9,991.56
Rate for Payer: Aetna Medicare	$3,306.16
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,973.75
Rate for Payer: Amish Plain Church Group Commercial	$3,973.75
Rate for Payer: BCBS Complete	$1,789.14
Rate for Payer: BCBS MAPPO	$3,179.00
Rate for Payer: BCBS Trust/PPO	$1,387.66
Rate for Payer: BCN Commercial	$1,387.66
Rate for Payer: BCN Medicare Advantage	$3,179.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,179.00
Rate for Payer: Mclaren Medicaid	$1,703.94
Rate for Payer: Mclaren Medicare	$3,179.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,337.95
Rate for Payer: Meridian Medicaid	$1,789.14
Rate for Payer: MI Amish Medical Board Commercial	$3,655.85
Rate for Payer: Nomi Health Commercial	$6,675.90
Rate for Payer: PACE Medicare	$3,020.05
Rate for Payer: PACE SWMI	$3,179.00
Rate for Payer: PHP Medicare Advantage	$3,179.00
Rate for Payer: Priority Health Choice Medicaid	$1,703.94
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,991.56
Rate for Payer: Priority Health Medicare	$3,179.00
Rate for Payer: Priority Health Narrow Network	$7,993.25
Rate for Payer: Railroad Medicare Medicare	$3,179.00
Rate for Payer: UHC All Payor (Choice/PPO)	$381.11
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,179.00
Rate for Payer: UHC Exchange	$4,450.00
Rate for Payer: UHC Medicare Advantage	$3,179.00
Rate for Payer: UHCCP Medicaid	$1,789.78
Rate for Payer: VA VA	$3,179.00

FAT EMULSION 20 % INTRAVENOUS

Facility

$100.00

Service Code	NDC 00338051909
Hospital Charge Code	10014
Hospital Revenue Code	250
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.00
Rate for Payer: Aetna New Business (MI Preferred)	$65.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cofinity Commercial	$70.00
Rate for Payer: Cofinity Commercial	$86.00
Rate for Payer: Cofinity Medicare Advantage	$70.00
Rate for Payer: Encore Health Key Benefits Commercial	$80.00
Rate for Payer: Healthscope Commercial	$90.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$85.00
Rate for Payer: PHP Commercial	$85.00
Rate for Payer: Priority Health Cigna Priority Health	$65.00
Rate for Payer: Priority Health SBD	$63.00

FAT EMULSION 20 % INTRAVENOUS

Facility

$100.00

Service Code	NDC 00338051909
Hospital Charge Code	10014
Hospital Revenue Code	250
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.00
Rate for Payer: Aetna Medicare	$50.00
Rate for Payer: Aetna New Business (MI Preferred)	$65.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cofinity Commercial	$70.00
Rate for Payer: Cofinity Commercial	$86.00
Rate for Payer: Cofinity Medicare Advantage	$70.00
Rate for Payer: Encore Health Key Benefits Commercial	$80.00
Rate for Payer: Healthscope Commercial	$90.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$85.00
Rate for Payer: PHP Commercial	$85.00
Rate for Payer: Priority Health Cigna Priority Health	$65.00
Rate for Payer: Priority Health SBD	$63.00

FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS

Facility

$13.50

Service Code	NDC 00338954003
Hospital Charge Code	191280
Hospital Revenue Code	250
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$12.15
Rate for Payer: Aetna Commercial	$11.48
Rate for Payer: Aetna New Business (MI Preferred)	$8.78
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cofinity Commercial	$11.61
Rate for Payer: Cofinity Commercial	$9.45
Rate for Payer: Cofinity Medicare Advantage	$9.45
Rate for Payer: Encore Health Key Benefits Commercial	$10.80
Rate for Payer: Healthscope Commercial	$12.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.48
Rate for Payer: PHP Commercial	$11.48
Rate for Payer: Priority Health Cigna Priority Health	$8.78
Rate for Payer: Priority Health SBD	$8.50

FAT EMULSION-OLIVE OIL-SOYBEAN OIL-EGG PHOSPHOLIPID 20 % INTRAVENOUS

Facility

$13.50

Service Code	NDC 00338954003
Hospital Charge Code	191280
Hospital Revenue Code	250
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$12.15
Rate for Payer: Aetna Commercial	$11.48
Rate for Payer: Aetna Medicare	$6.75
Rate for Payer: Aetna New Business (MI Preferred)	$8.78
Rate for Payer: BCBS Complete	$5.40
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cofinity Commercial	$11.61
Rate for Payer: Cofinity Commercial	$9.45
Rate for Payer: Cofinity Medicare Advantage	$9.45
Rate for Payer: Encore Health Key Benefits Commercial	$10.80
Rate for Payer: Healthscope Commercial	$12.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.48
Rate for Payer: PHP Commercial	$11.48
Rate for Payer: Priority Health Cigna Priority Health	$8.78
Rate for Payer: Priority Health SBD	$8.50

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS

Facility

$24.00

Service Code	NDC 63323082074
Hospital Charge Code	179808
Hospital Revenue Code	250
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna Commercial	$20.40
Rate for Payer: Aetna Medicare	$12.00
Rate for Payer: Aetna New Business (MI Preferred)	$15.60
Rate for Payer: BCBS Complete	$9.60
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cofinity Commercial	$16.80
Rate for Payer: Cofinity Commercial	$20.64
Rate for Payer: Cofinity Medicare Advantage	$16.80
Rate for Payer: Encore Health Key Benefits Commercial	$19.20
Rate for Payer: Healthscope Commercial	$21.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.40
Rate for Payer: PHP Commercial	$20.40
Rate for Payer: Priority Health Cigna Priority Health	$15.60
Rate for Payer: Priority Health SBD	$15.12

FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS

Facility

$24.00

Service Code	NDC 63323082074
Hospital Charge Code	179808
Hospital Revenue Code	250
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna Commercial	$20.40
Rate for Payer: Aetna New Business (MI Preferred)	$15.60
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cofinity Commercial	$16.80
Rate for Payer: Cofinity Commercial	$20.64
Rate for Payer: Cofinity Medicare Advantage	$16.80
Rate for Payer: Encore Health Key Benefits Commercial	$19.20
Rate for Payer: Healthscope Commercial	$21.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.40
Rate for Payer: PHP Commercial	$20.40
Rate for Payer: Priority Health Cigna Priority Health	$15.60
Rate for Payer: Priority Health SBD	$15.12

FECAL MICROBIOTA PRODUCT

Facility

$2,499.70

Service Code	NDC 09900001129
Hospital Charge Code	300149
Hospital Revenue Code	250
Min. Negotiated Rate	$999.88
Max. Negotiated Rate	$2,249.73
Rate for Payer: Aetna Commercial	$2,124.74
Rate for Payer: Aetna Medicare	$1,249.85
Rate for Payer: Aetna New Business (MI Preferred)	$1,624.80
Rate for Payer: BCBS Complete	$999.88
Rate for Payer: Cash Price	$1,999.76
Rate for Payer: Cofinity Commercial	$1,749.79
Rate for Payer: Cofinity Commercial	$2,149.74
Rate for Payer: Cofinity Medicare Advantage	$1,749.79
Rate for Payer: Encore Health Key Benefits Commercial	$1,999.76
Rate for Payer: Healthscope Commercial	$2,249.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,124.74
Rate for Payer: PHP Commercial	$2,124.74
Rate for Payer: Priority Health Cigna Priority Health	$1,624.80
Rate for Payer: Priority Health SBD	$1,574.81

FECAL MICROBIOTA PRODUCT

Facility

$2,499.70

Service Code	NDC 09900001129
Hospital Charge Code	300149
Hospital Revenue Code	250
Min. Negotiated Rate	$1,574.81
Max. Negotiated Rate	$2,249.73
Rate for Payer: Aetna Commercial	$2,124.74
Rate for Payer: Aetna New Business (MI Preferred)	$1,624.80
Rate for Payer: Cash Price	$1,999.76
Rate for Payer: Cofinity Commercial	$1,749.79
Rate for Payer: Cofinity Commercial	$2,149.74
Rate for Payer: Cofinity Medicare Advantage	$1,749.79
Rate for Payer: Encore Health Key Benefits Commercial	$1,999.76
Rate for Payer: Healthscope Commercial	$2,249.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,124.74
Rate for Payer: PHP Commercial	$2,124.74
Rate for Payer: Priority Health Cigna Priority Health	$1,624.80
Rate for Payer: Priority Health SBD	$1,574.81

FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET

Facility

$952.75

Service Code	NDC 51079060820
Hospital Charge Code	40010
Hospital Revenue Code	637
Min. Negotiated Rate	$600.23
Max. Negotiated Rate	$857.48
Rate for Payer: Aetna Commercial	$809.84
Rate for Payer: Aetna New Business (MI Preferred)	$619.29
Rate for Payer: Cash Price	$762.20
Rate for Payer: Cofinity Commercial	$666.92
Rate for Payer: Cofinity Commercial	$819.36
Rate for Payer: Cofinity Medicare Advantage	$666.92
Rate for Payer: Encore Health Key Benefits Commercial	$762.20
Rate for Payer: Healthscope Commercial	$857.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$809.84
Rate for Payer: PHP Commercial	$809.84
Rate for Payer: Priority Health Cigna Priority Health	$619.29
Rate for Payer: Priority Health SBD	$600.23

FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET

Facility

$952.75

Service Code	NDC 51079060820
Hospital Charge Code	40010
Hospital Revenue Code	637
Min. Negotiated Rate	$381.10
Max. Negotiated Rate	$857.48
Rate for Payer: Aetna Commercial	$809.84
Rate for Payer: Aetna Medicare	$476.38
Rate for Payer: Aetna New Business (MI Preferred)	$619.29
Rate for Payer: BCBS Complete	$381.10
Rate for Payer: Cash Price	$762.20
Rate for Payer: Cofinity Commercial	$666.92
Rate for Payer: Cofinity Commercial	$819.36
Rate for Payer: Cofinity Medicare Advantage	$666.92
Rate for Payer: Encore Health Key Benefits Commercial	$762.20
Rate for Payer: Healthscope Commercial	$857.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$809.84
Rate for Payer: PHP Commercial	$809.84
Rate for Payer: Priority Health Cigna Priority Health	$619.29
Rate for Payer: Priority Health SBD	$600.23

Know your out-of-pocket cost for care.

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