Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK

Facility

$80.41

Service Code	HCPCS J1580
Hospital Charge Code	114156
Hospital Revenue Code	636
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$72.37
Rate for Payer: Aetna Commercial	$68.35
Rate for Payer: Aetna Medicare	$40.20
Rate for Payer: Aetna New Business (MI Preferred)	$52.27
Rate for Payer: BCBS Complete	$32.16
Rate for Payer: Cash Price	$64.33
Rate for Payer: Cofinity Commercial	$56.29
Rate for Payer: Cofinity Commercial	$69.15
Rate for Payer: Cofinity Medicare Advantage	$56.29
Rate for Payer: Encore Health Key Benefits Commercial	$64.33
Rate for Payer: Healthscope Commercial	$72.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$68.35
Rate for Payer: PHP Commercial	$68.35
Rate for Payer: Priority Health Cigna Priority Health	$52.27
Rate for Payer: Priority Health SBD	$50.66

GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK

Facility

$80.41

Service Code	HCPCS J1580
Hospital Charge Code	114156
Hospital Revenue Code	636
Min. Negotiated Rate	$50.66
Max. Negotiated Rate	$72.37
Rate for Payer: Aetna Commercial	$68.35
Rate for Payer: Aetna New Business (MI Preferred)	$52.27
Rate for Payer: Cash Price	$64.33
Rate for Payer: Cofinity Commercial	$56.29
Rate for Payer: Cofinity Commercial	$69.15
Rate for Payer: Cofinity Medicare Advantage	$56.29
Rate for Payer: Encore Health Key Benefits Commercial	$64.33
Rate for Payer: Healthscope Commercial	$72.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$68.35
Rate for Payer: PHP Commercial	$68.35
Rate for Payer: Priority Health Cigna Priority Health	$52.27
Rate for Payer: Priority Health SBD	$50.66

GENTAMICIN 40 MG/ML FOR INHALATION

Facility

$45.85

Service Code	HCPCS J1580
Hospital Charge Code	180596
Hospital Revenue Code	636
Min. Negotiated Rate	$28.89
Max. Negotiated Rate	$41.27
Rate for Payer: Aetna Commercial	$38.97
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna New Business (MI Preferred)	$22.52
Rate for Payer: Aetna New Business (MI Preferred)	$29.80
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$36.68
Rate for Payer: Cofinity Commercial	$24.25
Rate for Payer: Cofinity Commercial	$32.09
Rate for Payer: Cofinity Commercial	$39.43
Rate for Payer: Cofinity Commercial	$29.80
Rate for Payer: Cofinity Medicare Advantage	$32.09
Rate for Payer: Cofinity Medicare Advantage	$24.25
Rate for Payer: Encore Health Key Benefits Commercial	$27.72
Rate for Payer: Encore Health Key Benefits Commercial	$36.68
Rate for Payer: Healthscope Commercial	$31.18
Rate for Payer: Healthscope Commercial	$41.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$29.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.97
Rate for Payer: PHP Commercial	$29.45
Rate for Payer: PHP Commercial	$38.97
Rate for Payer: Priority Health Cigna Priority Health	$29.80
Rate for Payer: Priority Health Cigna Priority Health	$22.52
Rate for Payer: Priority Health SBD	$28.89
Rate for Payer: Priority Health SBD	$21.83

GENTAMICIN 40 MG/ML FOR INHALATION

Facility

$45.85

Service Code	HCPCS J1580
Hospital Charge Code	180596
Hospital Revenue Code	636
Min. Negotiated Rate	$18.34
Max. Negotiated Rate	$41.27
Rate for Payer: Aetna Commercial	$38.97
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$17.32
Rate for Payer: Aetna Medicare	$22.93
Rate for Payer: Aetna New Business (MI Preferred)	$22.52
Rate for Payer: Aetna New Business (MI Preferred)	$29.80
Rate for Payer: BCBS Complete	$18.34
Rate for Payer: BCBS Complete	$13.86
Rate for Payer: Cash Price	$27.72
Rate for Payer: Cash Price	$36.68
Rate for Payer: Cofinity Commercial	$24.25
Rate for Payer: Cofinity Commercial	$32.09
Rate for Payer: Cofinity Commercial	$39.43
Rate for Payer: Cofinity Commercial	$29.80
Rate for Payer: Cofinity Medicare Advantage	$32.09
Rate for Payer: Cofinity Medicare Advantage	$24.25
Rate for Payer: Encore Health Key Benefits Commercial	$27.72
Rate for Payer: Encore Health Key Benefits Commercial	$36.68
Rate for Payer: Healthscope Commercial	$31.18
Rate for Payer: Healthscope Commercial	$41.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$29.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.97
Rate for Payer: PHP Commercial	$38.97
Rate for Payer: PHP Commercial	$29.45
Rate for Payer: Priority Health Cigna Priority Health	$22.52
Rate for Payer: Priority Health Cigna Priority Health	$29.80
Rate for Payer: Priority Health SBD	$28.89
Rate for Payer: Priority Health SBD	$21.83

GENTAMICIN 40 MG/ML INJECTION SOLUTION

Facility

$19.55

Service Code	HCPCS J1580
Hospital Charge Code	3426
Hospital Revenue Code	636
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$17.59
Rate for Payer: Aetna Commercial	$16.62
Rate for Payer: Aetna Commercial	$38.97
Rate for Payer: Aetna Commercial	$285.94
Rate for Payer: Aetna Medicare	$22.93
Rate for Payer: Aetna Medicare	$9.78
Rate for Payer: Aetna Medicare	$168.20
Rate for Payer: Aetna New Business (MI Preferred)	$29.80
Rate for Payer: Aetna New Business (MI Preferred)	$12.71
Rate for Payer: Aetna New Business (MI Preferred)	$218.66
Rate for Payer: BCBS Complete	$134.56
Rate for Payer: BCBS Complete	$7.82
Rate for Payer: BCBS Complete	$18.34
Rate for Payer: Cash Price	$36.68
Rate for Payer: Cash Price	$15.64
Rate for Payer: Cash Price	$269.12
Rate for Payer: Cofinity Commercial	$39.43
Rate for Payer: Cofinity Commercial	$16.81
Rate for Payer: Cofinity Commercial	$13.69
Rate for Payer: Cofinity Commercial	$289.30
Rate for Payer: Cofinity Commercial	$235.48
Rate for Payer: Cofinity Commercial	$32.09
Rate for Payer: Cofinity Medicare Advantage	$235.48
Rate for Payer: Cofinity Medicare Advantage	$13.69
Rate for Payer: Cofinity Medicare Advantage	$32.09
Rate for Payer: Encore Health Key Benefits Commercial	$269.12
Rate for Payer: Encore Health Key Benefits Commercial	$36.68
Rate for Payer: Encore Health Key Benefits Commercial	$15.64
Rate for Payer: Healthscope Commercial	$302.76
Rate for Payer: Healthscope Commercial	$17.59
Rate for Payer: Healthscope Commercial	$41.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$285.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.62
Rate for Payer: PHP Commercial	$285.94
Rate for Payer: PHP Commercial	$16.62
Rate for Payer: PHP Commercial	$38.97
Rate for Payer: Priority Health Cigna Priority Health	$12.71
Rate for Payer: Priority Health Cigna Priority Health	$29.80
Rate for Payer: Priority Health Cigna Priority Health	$218.66
Rate for Payer: Priority Health SBD	$28.89
Rate for Payer: Priority Health SBD	$211.93
Rate for Payer: Priority Health SBD	$12.32

GENTAMICIN 40 MG/ML INJECTION SOLUTION

Facility

$336.40

Service Code	HCPCS J1580
Hospital Charge Code	3426
Hospital Revenue Code	636
Min. Negotiated Rate	$211.93
Max. Negotiated Rate	$302.76
Rate for Payer: Aetna Commercial	$285.94
Rate for Payer: Aetna Commercial	$16.62
Rate for Payer: Aetna Commercial	$38.97
Rate for Payer: Aetna New Business (MI Preferred)	$218.66
Rate for Payer: Aetna New Business (MI Preferred)	$12.71
Rate for Payer: Aetna New Business (MI Preferred)	$29.80
Rate for Payer: Cash Price	$15.64
Rate for Payer: Cash Price	$36.68
Rate for Payer: Cash Price	$269.12
Rate for Payer: Cofinity Commercial	$13.69
Rate for Payer: Cofinity Commercial	$16.81
Rate for Payer: Cofinity Commercial	$235.48
Rate for Payer: Cofinity Commercial	$289.30
Rate for Payer: Cofinity Commercial	$32.09
Rate for Payer: Cofinity Commercial	$39.43
Rate for Payer: Cofinity Medicare Advantage	$13.69
Rate for Payer: Cofinity Medicare Advantage	$32.09
Rate for Payer: Cofinity Medicare Advantage	$235.48
Rate for Payer: Encore Health Key Benefits Commercial	$15.64
Rate for Payer: Encore Health Key Benefits Commercial	$269.12
Rate for Payer: Encore Health Key Benefits Commercial	$36.68
Rate for Payer: Healthscope Commercial	$17.59
Rate for Payer: Healthscope Commercial	$302.76
Rate for Payer: Healthscope Commercial	$41.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$285.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.97
Rate for Payer: PHP Commercial	$285.94
Rate for Payer: PHP Commercial	$38.97
Rate for Payer: PHP Commercial	$16.62
Rate for Payer: Priority Health Cigna Priority Health	$29.80
Rate for Payer: Priority Health Cigna Priority Health	$218.66
Rate for Payer: Priority Health Cigna Priority Health	$12.71
Rate for Payer: Priority Health SBD	$28.89
Rate for Payer: Priority Health SBD	$211.93
Rate for Payer: Priority Health SBD	$12.32

GENTAMICIN 80 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK

Facility

$66.43

Service Code	NDC 00338050941
Hospital Charge Code	15911
Hospital Revenue Code	250
Min. Negotiated Rate	$41.85
Max. Negotiated Rate	$59.79
Rate for Payer: Aetna Commercial	$56.47
Rate for Payer: Aetna New Business (MI Preferred)	$43.18
Rate for Payer: Cash Price	$53.14
Rate for Payer: Cofinity Commercial	$46.50
Rate for Payer: Cofinity Commercial	$57.13
Rate for Payer: Cofinity Medicare Advantage	$46.50
Rate for Payer: Encore Health Key Benefits Commercial	$53.14
Rate for Payer: Healthscope Commercial	$59.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$56.47
Rate for Payer: PHP Commercial	$56.47
Rate for Payer: Priority Health Cigna Priority Health	$43.18
Rate for Payer: Priority Health SBD	$41.85

GENTAMICIN 80 MG/50 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK

Facility

$66.43

Service Code	NDC 00338050941
Hospital Charge Code	15911
Hospital Revenue Code	250
Min. Negotiated Rate	$26.57
Max. Negotiated Rate	$59.79
Rate for Payer: Aetna Commercial	$56.47
Rate for Payer: Aetna Medicare	$33.22
Rate for Payer: Aetna New Business (MI Preferred)	$43.18
Rate for Payer: BCBS Complete	$26.57
Rate for Payer: Cash Price	$53.14
Rate for Payer: Cofinity Commercial	$46.50
Rate for Payer: Cofinity Commercial	$57.13
Rate for Payer: Cofinity Medicare Advantage	$46.50
Rate for Payer: Encore Health Key Benefits Commercial	$53.14
Rate for Payer: Healthscope Commercial	$59.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$56.47
Rate for Payer: PHP Commercial	$56.47
Rate for Payer: Priority Health Cigna Priority Health	$43.18
Rate for Payer: Priority Health SBD	$41.85

GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION

Facility

$27.93

Service Code	HCPCS J1580
Hospital Charge Code	117665
Hospital Revenue Code	636
Min. Negotiated Rate	$11.17
Max. Negotiated Rate	$25.14
Rate for Payer: Aetna Commercial	$23.74
Rate for Payer: Aetna Medicare	$13.96
Rate for Payer: Aetna New Business (MI Preferred)	$18.15
Rate for Payer: BCBS Complete	$11.17
Rate for Payer: Cash Price	$22.34
Rate for Payer: Cofinity Commercial	$19.55
Rate for Payer: Cofinity Commercial	$24.02
Rate for Payer: Cofinity Medicare Advantage	$19.55
Rate for Payer: Encore Health Key Benefits Commercial	$22.34
Rate for Payer: Healthscope Commercial	$25.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.74
Rate for Payer: PHP Commercial	$23.74
Rate for Payer: Priority Health Cigna Priority Health	$18.15
Rate for Payer: Priority Health SBD	$17.60

GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION

Facility

$27.93

Service Code	HCPCS J1580
Hospital Charge Code	117665
Hospital Revenue Code	636
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$25.14
Rate for Payer: Aetna Commercial	$23.74
Rate for Payer: Aetna New Business (MI Preferred)	$18.15
Rate for Payer: Cash Price	$22.34
Rate for Payer: Cofinity Commercial	$19.55
Rate for Payer: Cofinity Commercial	$24.02
Rate for Payer: Cofinity Medicare Advantage	$19.55
Rate for Payer: Encore Health Key Benefits Commercial	$22.34
Rate for Payer: Healthscope Commercial	$25.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.74
Rate for Payer: PHP Commercial	$23.74
Rate for Payer: Priority Health Cigna Priority Health	$18.15
Rate for Payer: Priority Health SBD	$17.60

GLASSIA (ALPHA-1-PROTEINASE INHIBITOR) 1 GRAM/50 ML(2 %) IV SOLN

Facility

$1.57

Service Code	HCPCS J0257
Hospital Charge Code	106274
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$15.88
Rate for Payer: Aetna Commercial	$1.33
Rate for Payer: Aetna Medicare	$5.87
Rate for Payer: Aetna New Business (MI Preferred)	$1.02
Rate for Payer: Allen County Amish Medical Aid Commercial	$7.05
Rate for Payer: Amish Plain Church Group Commercial	$7.05
Rate for Payer: BCBS Complete	$3.17
Rate for Payer: BCBS MAPPO	$5.64
Rate for Payer: BCN Medicare Advantage	$5.64
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cofinity Commercial	$1.35
Rate for Payer: Cofinity Commercial	$1.10
Rate for Payer: Cofinity Medicare Advantage	$1.10
Rate for Payer: Encore Health Key Benefits Commercial	$1.26
Rate for Payer: Health Alliance Plan Medicare Advantage	$5.64
Rate for Payer: Healthscope Commercial	$1.41
Rate for Payer: Mclaren Medicaid	$3.02
Rate for Payer: Mclaren Medicare	$5.64
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5.92
Rate for Payer: Meridian Medicaid	$3.17
Rate for Payer: MI Amish Medical Board Commercial	$6.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.33
Rate for Payer: PACE Medicare	$5.36
Rate for Payer: PACE SWMI	$5.64
Rate for Payer: PHP Commercial	$1.33
Rate for Payer: PHP Medicare Advantage	$5.64
Rate for Payer: Priority Health Choice Medicaid	$3.02
Rate for Payer: Priority Health Cigna Priority Health	$1.02
Rate for Payer: Priority Health Medicare	$5.64
Rate for Payer: Priority Health SBD	$0.99
Rate for Payer: Railroad Medicare Medicare	$5.64
Rate for Payer: UHC All Payor (Choice/PPO)	$15.88
Rate for Payer: UHC Dual Complete DSNP	$5.64
Rate for Payer: UHC Medicare Advantage	$5.64
Rate for Payer: UHCCP Medicaid	$3.18
Rate for Payer: VA VA	$5.64

GLASSIA (ALPHA-1-PROTEINASE INHIBITOR) 1 GRAM/50 ML(2 %) IV SOLN

Facility

$1.57

Service Code	HCPCS J0257
Hospital Charge Code	106274
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna Commercial	$1.33
Rate for Payer: Aetna New Business (MI Preferred)	$1.02
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cofinity Commercial	$1.10
Rate for Payer: Cofinity Commercial	$1.35
Rate for Payer: Cofinity Medicare Advantage	$1.10
Rate for Payer: Encore Health Key Benefits Commercial	$1.26
Rate for Payer: Healthscope Commercial	$1.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.33
Rate for Payer: PHP Commercial	$1.33
Rate for Payer: Priority Health Cigna Priority Health	$1.02
Rate for Payer: Priority Health SBD	$0.99

GLIMEPIRIDE 1 MG TABLET

Facility

$3.57

Service Code	NDC 50268035811
Hospital Charge Code	16355
Hospital Revenue Code	637
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$3.21
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: Aetna New Business (MI Preferred)	$2.32
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cofinity Commercial	$2.50
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Cofinity Medicare Advantage	$2.50
Rate for Payer: Encore Health Key Benefits Commercial	$2.86
Rate for Payer: Healthscope Commercial	$3.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.03
Rate for Payer: PHP Commercial	$3.03
Rate for Payer: Priority Health Cigna Priority Health	$2.32
Rate for Payer: Priority Health SBD	$2.25

GLIMEPIRIDE 1 MG TABLET

Facility

$195.05

Service Code	NDC 16729000101
Hospital Charge Code	16355
Hospital Revenue Code	637
Min. Negotiated Rate	$122.88
Max. Negotiated Rate	$175.54
Rate for Payer: Aetna Commercial	$165.79
Rate for Payer: Aetna New Business (MI Preferred)	$126.78
Rate for Payer: Cash Price	$156.04
Rate for Payer: Cofinity Commercial	$136.53
Rate for Payer: Cofinity Commercial	$167.74
Rate for Payer: Cofinity Medicare Advantage	$136.53
Rate for Payer: Encore Health Key Benefits Commercial	$156.04
Rate for Payer: Healthscope Commercial	$175.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$165.79
Rate for Payer: PHP Commercial	$165.79
Rate for Payer: Priority Health Cigna Priority Health	$126.78
Rate for Payer: Priority Health SBD	$122.88

GLIMEPIRIDE 1 MG TABLET

Facility

$195.05

Service Code	NDC 16729000101
Hospital Charge Code	16355
Hospital Revenue Code	637
Min. Negotiated Rate	$78.02
Max. Negotiated Rate	$175.54
Rate for Payer: Aetna Commercial	$165.79
Rate for Payer: Aetna Medicare	$97.53
Rate for Payer: Aetna New Business (MI Preferred)	$126.78
Rate for Payer: BCBS Complete	$78.02
Rate for Payer: Cash Price	$156.04
Rate for Payer: Cofinity Commercial	$136.53
Rate for Payer: Cofinity Commercial	$167.74
Rate for Payer: Cofinity Medicare Advantage	$136.53
Rate for Payer: Encore Health Key Benefits Commercial	$156.04
Rate for Payer: Healthscope Commercial	$175.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$165.79
Rate for Payer: PHP Commercial	$165.79
Rate for Payer: Priority Health Cigna Priority Health	$126.78
Rate for Payer: Priority Health SBD	$122.88

GLIMEPIRIDE 1 MG TABLET

Facility

$178.13

Service Code	NDC 50268035815
Hospital Charge Code	16355
Hospital Revenue Code	637
Min. Negotiated Rate	$71.25
Max. Negotiated Rate	$160.32
Rate for Payer: Aetna Commercial	$151.41
Rate for Payer: Aetna Medicare	$89.06
Rate for Payer: Aetna New Business (MI Preferred)	$115.78
Rate for Payer: BCBS Complete	$71.25
Rate for Payer: Cash Price	$142.50
Rate for Payer: Cofinity Commercial	$124.69
Rate for Payer: Cofinity Commercial	$153.19
Rate for Payer: Cofinity Medicare Advantage	$124.69
Rate for Payer: Encore Health Key Benefits Commercial	$142.50
Rate for Payer: Healthscope Commercial	$160.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$151.41
Rate for Payer: PHP Commercial	$151.41
Rate for Payer: Priority Health Cigna Priority Health	$115.78
Rate for Payer: Priority Health SBD	$112.22

GLIMEPIRIDE 1 MG TABLET

Facility

$3.57

Service Code	NDC 50268035811
Hospital Charge Code	16355
Hospital Revenue Code	637
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$3.21
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: Aetna Medicare	$1.78
Rate for Payer: Aetna New Business (MI Preferred)	$2.32
Rate for Payer: BCBS Complete	$1.43
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cofinity Commercial	$2.50
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Cofinity Medicare Advantage	$2.50
Rate for Payer: Encore Health Key Benefits Commercial	$2.86
Rate for Payer: Healthscope Commercial	$3.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.03
Rate for Payer: PHP Commercial	$3.03
Rate for Payer: Priority Health Cigna Priority Health	$2.32
Rate for Payer: Priority Health SBD	$2.25

GLIMEPIRIDE 1 MG TABLET

Facility

$178.13

Service Code	NDC 50268035815
Hospital Charge Code	16355
Hospital Revenue Code	637
Min. Negotiated Rate	$112.22
Max. Negotiated Rate	$160.32
Rate for Payer: Aetna Commercial	$151.41
Rate for Payer: Aetna New Business (MI Preferred)	$115.78
Rate for Payer: Cash Price	$142.50
Rate for Payer: Cofinity Commercial	$124.69
Rate for Payer: Cofinity Commercial	$153.19
Rate for Payer: Cofinity Medicare Advantage	$124.69
Rate for Payer: Encore Health Key Benefits Commercial	$142.50
Rate for Payer: Healthscope Commercial	$160.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$151.41
Rate for Payer: PHP Commercial	$151.41
Rate for Payer: Priority Health Cigna Priority Health	$115.78
Rate for Payer: Priority Health SBD	$112.22

GLIPIZIDE 10 MG TABLET

Facility

$2.42

Service Code	NDC 50268036211
Hospital Charge Code	10116
Hospital Revenue Code	637
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna Commercial	$2.06
Rate for Payer: Aetna Medicare	$1.21
Rate for Payer: Aetna New Business (MI Preferred)	$1.57
Rate for Payer: BCBS Complete	$0.97
Rate for Payer: Cash Price	$1.94
Rate for Payer: Cofinity Commercial	$1.69
Rate for Payer: Cofinity Commercial	$2.08
Rate for Payer: Cofinity Medicare Advantage	$1.69
Rate for Payer: Encore Health Key Benefits Commercial	$1.94
Rate for Payer: Healthscope Commercial	$2.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.06
Rate for Payer: PHP Commercial	$2.06
Rate for Payer: Priority Health Cigna Priority Health	$1.57
Rate for Payer: Priority Health SBD	$1.52

GLIPIZIDE 10 MG TABLET

Facility

$105.75

Service Code	NDC 60505014200
Hospital Charge Code	10116
Hospital Revenue Code	637
Min. Negotiated Rate	$66.62
Max. Negotiated Rate	$95.17
Rate for Payer: Aetna Commercial	$89.89
Rate for Payer: Aetna New Business (MI Preferred)	$68.74
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cofinity Commercial	$74.03
Rate for Payer: Cofinity Commercial	$90.94
Rate for Payer: Cofinity Medicare Advantage	$74.03
Rate for Payer: Encore Health Key Benefits Commercial	$84.60
Rate for Payer: Healthscope Commercial	$95.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$89.89
Rate for Payer: PHP Commercial	$89.89
Rate for Payer: Priority Health Cigna Priority Health	$68.74
Rate for Payer: Priority Health SBD	$66.62

GLIPIZIDE 10 MG TABLET

Facility

$461.70

Service Code	NDC 51079081120
Hospital Charge Code	10116
Hospital Revenue Code	637
Min. Negotiated Rate	$184.68
Max. Negotiated Rate	$415.53
Rate for Payer: Aetna Commercial	$392.44
Rate for Payer: Aetna Medicare	$230.85
Rate for Payer: Aetna New Business (MI Preferred)	$300.11
Rate for Payer: BCBS Complete	$184.68
Rate for Payer: Cash Price	$369.36
Rate for Payer: Cofinity Commercial	$323.19
Rate for Payer: Cofinity Commercial	$397.06
Rate for Payer: Cofinity Medicare Advantage	$323.19
Rate for Payer: Encore Health Key Benefits Commercial	$369.36
Rate for Payer: Healthscope Commercial	$415.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$392.44
Rate for Payer: PHP Commercial	$392.44
Rate for Payer: Priority Health Cigna Priority Health	$300.11
Rate for Payer: Priority Health SBD	$290.87

GLIPIZIDE 10 MG TABLET

Facility

$136.30

Service Code	NDC 00591046101
Hospital Charge Code	10116
Hospital Revenue Code	637
Min. Negotiated Rate	$54.52
Max. Negotiated Rate	$122.67
Rate for Payer: Aetna Commercial	$115.86
Rate for Payer: Aetna Medicare	$68.15
Rate for Payer: Aetna New Business (MI Preferred)	$88.59
Rate for Payer: BCBS Complete	$54.52
Rate for Payer: Cash Price	$109.04
Rate for Payer: Cofinity Commercial	$117.22
Rate for Payer: Cofinity Commercial	$95.41
Rate for Payer: Cofinity Medicare Advantage	$95.41
Rate for Payer: Encore Health Key Benefits Commercial	$109.04
Rate for Payer: Healthscope Commercial	$122.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$115.86
Rate for Payer: PHP Commercial	$115.86
Rate for Payer: Priority Health Cigna Priority Health	$88.59
Rate for Payer: Priority Health SBD	$85.87

GLIPIZIDE 10 MG TABLET

Facility

$4.62

Service Code	NDC 51079081101
Hospital Charge Code	10116
Hospital Revenue Code	637
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$4.16
Rate for Payer: Aetna Commercial	$3.93
Rate for Payer: Aetna New Business (MI Preferred)	$3.00
Rate for Payer: Cash Price	$3.70
Rate for Payer: Cofinity Commercial	$3.23
Rate for Payer: Cofinity Commercial	$3.97
Rate for Payer: Cofinity Medicare Advantage	$3.23
Rate for Payer: Encore Health Key Benefits Commercial	$3.70
Rate for Payer: Healthscope Commercial	$4.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.93
Rate for Payer: PHP Commercial	$3.93
Rate for Payer: Priority Health Cigna Priority Health	$3.00
Rate for Payer: Priority Health SBD	$2.91

GLIPIZIDE 10 MG TABLET

Facility

$120.72

Service Code	NDC 50268036215
Hospital Charge Code	10116
Hospital Revenue Code	637
Min. Negotiated Rate	$76.05
Max. Negotiated Rate	$108.65
Rate for Payer: Aetna Commercial	$102.61
Rate for Payer: Aetna New Business (MI Preferred)	$78.47
Rate for Payer: Cash Price	$96.58
Rate for Payer: Cofinity Commercial	$103.82
Rate for Payer: Cofinity Commercial	$84.50
Rate for Payer: Cofinity Medicare Advantage	$84.50
Rate for Payer: Encore Health Key Benefits Commercial	$96.58
Rate for Payer: Healthscope Commercial	$108.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$102.61
Rate for Payer: PHP Commercial	$102.61
Rate for Payer: Priority Health Cigna Priority Health	$78.47
Rate for Payer: Priority Health SBD	$76.05

GLIPIZIDE 10 MG TABLET

Facility

$461.70

Service Code	NDC 51079081120
Hospital Charge Code	10116
Hospital Revenue Code	637
Min. Negotiated Rate	$290.87
Max. Negotiated Rate	$415.53
Rate for Payer: Aetna Commercial	$392.44
Rate for Payer: Aetna New Business (MI Preferred)	$300.11
Rate for Payer: Cash Price	$369.36
Rate for Payer: Cofinity Commercial	$323.19
Rate for Payer: Cofinity Commercial	$397.06
Rate for Payer: Cofinity Medicare Advantage	$323.19
Rate for Payer: Encore Health Key Benefits Commercial	$369.36
Rate for Payer: Healthscope Commercial	$415.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$392.44
Rate for Payer: PHP Commercial	$392.44
Rate for Payer: Priority Health Cigna Priority Health	$300.11
Rate for Payer: Priority Health SBD	$290.87

Know your out-of-pocket cost for care.

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