Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

BACLOFEN 10 MG TABLET

Facility

$390.45

Service Code	NDC 60687081501
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$245.98
Max. Negotiated Rate	$351.40
Rate for Payer: Aetna Commercial	$331.88
Rate for Payer: Aetna New Business (MI Preferred)	$253.79
Rate for Payer: Cash Price	$312.36
Rate for Payer: Cofinity Advantage	$273.31
Rate for Payer: Cofinity Commercial	$335.79
Rate for Payer: Encore Health Key Benefits Commercial	$312.36
Rate for Payer: Healthscope Commercial	$351.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$331.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$292.84
Rate for Payer: PHP Commercial	$331.88
Rate for Payer: Priority Health SBD	$245.98

BACLOFEN 10 MG TABLET

Facility

$389.50

Service Code	NDC 58657093101
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$153.07
Max. Negotiated Rate	$350.55
Rate for Payer: Aetna Commercial	$331.07
Rate for Payer: Aetna Medicare	$194.75
Rate for Payer: Aetna New Business (MI Preferred)	$253.18
Rate for Payer: BCBS Complete	$155.80
Rate for Payer: Cash Price	$311.60
Rate for Payer: Cofinity Advantage	$272.65
Rate for Payer: Cofinity Commercial	$334.97
Rate for Payer: Encore Health Key Benefits Commercial	$311.60
Rate for Payer: Healthscope Commercial	$350.55
Rate for Payer: MI Amish Medical Board Commercial	$311.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$331.07
Rate for Payer: Opus (Opus Packaging Group) HMA	$292.12
Rate for Payer: PHP Commercial	$331.07
Rate for Payer: Priority Health SBD	$245.38
Rate for Payer: UHC All Payor (Choice/PPO)	$253.18
Rate for Payer: UHC Core	$202.93
Rate for Payer: UHC Exchange	$153.07

BACLOFEN 10 MG TABLET

Facility

$390.45

Service Code	NDC 60687081501
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$153.45
Max. Negotiated Rate	$351.40
Rate for Payer: Aetna Commercial	$331.88
Rate for Payer: Aetna Medicare	$195.22
Rate for Payer: Aetna New Business (MI Preferred)	$253.79
Rate for Payer: BCBS Complete	$156.18
Rate for Payer: Cash Price	$312.36
Rate for Payer: Cofinity Advantage	$273.31
Rate for Payer: Cofinity Commercial	$335.79
Rate for Payer: Encore Health Key Benefits Commercial	$312.36
Rate for Payer: Healthscope Commercial	$351.40
Rate for Payer: MI Amish Medical Board Commercial	$312.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$331.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$292.84
Rate for Payer: PHP Commercial	$331.88
Rate for Payer: Priority Health SBD	$245.98
Rate for Payer: UHC All Payor (Choice/PPO)	$253.79
Rate for Payer: UHC Core	$203.42
Rate for Payer: UHC Exchange	$153.45

BACLOFEN 10 MG TABLET

Facility

$1,715.50

Service Code	NDC 00172409680
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$674.19
Max. Negotiated Rate	$1,543.95
Rate for Payer: Aetna Commercial	$1,458.17
Rate for Payer: Aetna Medicare	$857.75
Rate for Payer: Aetna New Business (MI Preferred)	$1,115.08
Rate for Payer: BCBS Complete	$686.20
Rate for Payer: Cash Price	$1,372.40
Rate for Payer: Cofinity Advantage	$1,200.85
Rate for Payer: Cofinity Commercial	$1,475.33
Rate for Payer: Encore Health Key Benefits Commercial	$1,372.40
Rate for Payer: Healthscope Commercial	$1,543.95
Rate for Payer: MI Amish Medical Board Commercial	$1,372.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,458.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,286.62
Rate for Payer: PHP Commercial	$1,458.17
Rate for Payer: Priority Health SBD	$1,080.77
Rate for Payer: UHC All Payor (Choice/PPO)	$1,115.08
Rate for Payer: UHC Core	$893.78
Rate for Payer: UHC Exchange	$674.19

BACLOFEN 10 MG TABLET

Facility

$3.35

Service Code	NDC 50268010611
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.02
Rate for Payer: Aetna Commercial	$2.85
Rate for Payer: Aetna New Business (MI Preferred)	$2.18
Rate for Payer: Cash Price	$2.68
Rate for Payer: Cofinity Advantage	$2.35
Rate for Payer: Cofinity Commercial	$2.88
Rate for Payer: Encore Health Key Benefits Commercial	$2.68
Rate for Payer: Healthscope Commercial	$3.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.51
Rate for Payer: PHP Commercial	$2.85
Rate for Payer: Priority Health SBD	$2.11

BACLOFEN 10 MG TABLET

Facility

$3.35

Service Code	NDC 50268010611
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$3.02
Rate for Payer: Aetna Commercial	$2.85
Rate for Payer: Aetna Medicare	$1.68
Rate for Payer: Aetna New Business (MI Preferred)	$2.18
Rate for Payer: BCBS Complete	$1.34
Rate for Payer: Cash Price	$2.68
Rate for Payer: Cofinity Advantage	$2.35
Rate for Payer: Cofinity Commercial	$2.88
Rate for Payer: Encore Health Key Benefits Commercial	$2.68
Rate for Payer: Healthscope Commercial	$3.02
Rate for Payer: MI Amish Medical Board Commercial	$2.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.51
Rate for Payer: PHP Commercial	$2.85
Rate for Payer: Priority Health SBD	$2.11
Rate for Payer: UHC All Payor (Choice/PPO)	$2.18
Rate for Payer: UHC Core	$1.75
Rate for Payer: UHC Exchange	$1.32

BACLOFEN 10 MG TABLET

Facility

$3.91

Service Code	NDC 60687081511
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$3.52
Rate for Payer: Aetna Commercial	$3.32
Rate for Payer: Aetna Medicare	$1.96
Rate for Payer: Aetna New Business (MI Preferred)	$2.54
Rate for Payer: BCBS Complete	$1.56
Rate for Payer: Cash Price	$3.13
Rate for Payer: Cofinity Advantage	$2.74
Rate for Payer: Cofinity Commercial	$3.36
Rate for Payer: Encore Health Key Benefits Commercial	$3.13
Rate for Payer: Healthscope Commercial	$3.52
Rate for Payer: MI Amish Medical Board Commercial	$3.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.32
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.93
Rate for Payer: PHP Commercial	$3.32
Rate for Payer: Priority Health SBD	$2.46
Rate for Payer: UHC All Payor (Choice/PPO)	$2.54
Rate for Payer: UHC Core	$2.04
Rate for Payer: UHC Exchange	$1.54

BACLOFEN 10 MG TABLET

Facility

$254.88

Service Code	NDC 60687050301
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$100.17
Max. Negotiated Rate	$229.39
Rate for Payer: Aetna Commercial	$216.65
Rate for Payer: Aetna Medicare	$127.44
Rate for Payer: Aetna New Business (MI Preferred)	$165.67
Rate for Payer: BCBS Complete	$101.95
Rate for Payer: Cash Price	$203.90
Rate for Payer: Cofinity Advantage	$178.42
Rate for Payer: Cofinity Commercial	$219.20
Rate for Payer: Encore Health Key Benefits Commercial	$203.90
Rate for Payer: Healthscope Commercial	$229.39
Rate for Payer: MI Amish Medical Board Commercial	$203.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$216.65
Rate for Payer: Opus (Opus Packaging Group) HMA	$191.16
Rate for Payer: PHP Commercial	$216.65
Rate for Payer: Priority Health SBD	$160.57
Rate for Payer: UHC All Payor (Choice/PPO)	$165.67
Rate for Payer: UHC Core	$132.79
Rate for Payer: UHC Exchange	$100.17

BACLOFEN 10 MG TABLET

Facility

$389.50

Service Code	NDC 58657093101
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$245.38
Max. Negotiated Rate	$350.55
Rate for Payer: Aetna Commercial	$331.07
Rate for Payer: Aetna New Business (MI Preferred)	$253.18
Rate for Payer: Cash Price	$311.60
Rate for Payer: Cofinity Advantage	$272.65
Rate for Payer: Cofinity Commercial	$334.97
Rate for Payer: Encore Health Key Benefits Commercial	$311.60
Rate for Payer: Healthscope Commercial	$350.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$331.07
Rate for Payer: Opus (Opus Packaging Group) HMA	$292.12
Rate for Payer: PHP Commercial	$331.07
Rate for Payer: Priority Health SBD	$245.38

BACLOFEN 10 MG TABLET

Facility

$131.60

Service Code	NDC 52817032010
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$82.91
Max. Negotiated Rate	$118.44
Rate for Payer: Aetna Commercial	$111.86
Rate for Payer: Aetna New Business (MI Preferred)	$85.54
Rate for Payer: Cash Price	$105.28
Rate for Payer: Cofinity Advantage	$92.12
Rate for Payer: Cofinity Commercial	$113.18
Rate for Payer: Encore Health Key Benefits Commercial	$105.28
Rate for Payer: Healthscope Commercial	$118.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$111.86
Rate for Payer: Opus (Opus Packaging Group) HMA	$98.70
Rate for Payer: PHP Commercial	$111.86
Rate for Payer: Priority Health SBD	$82.91

BACLOFEN 10 MG TABLET

Facility

$96.35

Service Code	NDC 72888001001
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$37.87
Max. Negotiated Rate	$86.72
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: Aetna Medicare	$48.17
Rate for Payer: Aetna New Business (MI Preferred)	$62.63
Rate for Payer: BCBS Complete	$38.54
Rate for Payer: Cash Price	$77.08
Rate for Payer: Cofinity Advantage	$67.44
Rate for Payer: Cofinity Commercial	$82.86
Rate for Payer: Encore Health Key Benefits Commercial	$77.08
Rate for Payer: Healthscope Commercial	$86.72
Rate for Payer: MI Amish Medical Board Commercial	$77.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$81.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$72.26
Rate for Payer: PHP Commercial	$81.90
Rate for Payer: Priority Health SBD	$60.70
Rate for Payer: UHC All Payor (Choice/PPO)	$62.63
Rate for Payer: UHC Core	$50.20
Rate for Payer: UHC Exchange	$37.87

BACLOFEN 10 MG TABLET

Facility

$167.20

Service Code	NDC 50268010615
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$65.71
Max. Negotiated Rate	$150.48
Rate for Payer: Aetna Commercial	$142.12
Rate for Payer: Aetna Medicare	$83.60
Rate for Payer: Aetna New Business (MI Preferred)	$108.68
Rate for Payer: BCBS Complete	$66.88
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cofinity Advantage	$117.04
Rate for Payer: Cofinity Commercial	$143.79
Rate for Payer: Encore Health Key Benefits Commercial	$133.76
Rate for Payer: Healthscope Commercial	$150.48
Rate for Payer: MI Amish Medical Board Commercial	$133.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$142.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$125.40
Rate for Payer: PHP Commercial	$142.12
Rate for Payer: Priority Health SBD	$105.34
Rate for Payer: UHC All Payor (Choice/PPO)	$108.68
Rate for Payer: UHC Core	$87.11
Rate for Payer: UHC Exchange	$65.71

BACLOFEN 10 MG TABLET

Facility

$353.40

Service Code	NDC 00904647561
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$222.64
Max. Negotiated Rate	$318.06
Rate for Payer: Aetna Commercial	$300.39
Rate for Payer: Aetna New Business (MI Preferred)	$229.71
Rate for Payer: Cash Price	$282.72
Rate for Payer: Cofinity Advantage	$247.38
Rate for Payer: Cofinity Commercial	$303.92
Rate for Payer: Encore Health Key Benefits Commercial	$282.72
Rate for Payer: Healthscope Commercial	$318.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$300.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$265.05
Rate for Payer: PHP Commercial	$300.39
Rate for Payer: Priority Health SBD	$222.64

BACLOFEN 10 MG TABLET

Facility

$3.90

Service Code	NDC 58657093110
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna Commercial	$3.31
Rate for Payer: Aetna Medicare	$1.95
Rate for Payer: Aetna New Business (MI Preferred)	$2.54
Rate for Payer: BCBS Complete	$1.56
Rate for Payer: Cash Price	$3.12
Rate for Payer: Cofinity Advantage	$2.73
Rate for Payer: Cofinity Commercial	$3.35
Rate for Payer: Encore Health Key Benefits Commercial	$3.12
Rate for Payer: Healthscope Commercial	$3.51
Rate for Payer: MI Amish Medical Board Commercial	$3.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.31
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.92
Rate for Payer: PHP Commercial	$3.31
Rate for Payer: Priority Health SBD	$2.46
Rate for Payer: UHC All Payor (Choice/PPO)	$2.54
Rate for Payer: UHC Core	$2.03
Rate for Payer: UHC Exchange	$1.53

BACLOFEN 10 MG TABLET

Facility

$167.20

Service Code	NDC 50268010615
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$105.34
Max. Negotiated Rate	$150.48
Rate for Payer: Aetna Commercial	$142.12
Rate for Payer: Aetna New Business (MI Preferred)	$108.68
Rate for Payer: Cash Price	$133.76
Rate for Payer: Cofinity Advantage	$117.04
Rate for Payer: Cofinity Commercial	$143.79
Rate for Payer: Encore Health Key Benefits Commercial	$133.76
Rate for Payer: Healthscope Commercial	$150.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$142.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$125.40
Rate for Payer: PHP Commercial	$142.12
Rate for Payer: Priority Health SBD	$105.34

BACLOFEN 10 MG TABLET

Facility

$3.90

Service Code	NDC 58657093110
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna Commercial	$3.31
Rate for Payer: Aetna New Business (MI Preferred)	$2.54
Rate for Payer: Cash Price	$3.12
Rate for Payer: Cofinity Advantage	$2.73
Rate for Payer: Cofinity Commercial	$3.35
Rate for Payer: Encore Health Key Benefits Commercial	$3.12
Rate for Payer: Healthscope Commercial	$3.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.31
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.92
Rate for Payer: PHP Commercial	$3.31
Rate for Payer: Priority Health SBD	$2.46

BACLOFEN 10 MG TABLET

Facility

$138.65

Service Code	NDC 00172409660
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$87.35
Max. Negotiated Rate	$124.78
Rate for Payer: Aetna Commercial	$117.85
Rate for Payer: Aetna New Business (MI Preferred)	$90.12
Rate for Payer: Cash Price	$110.92
Rate for Payer: Cofinity Advantage	$97.06
Rate for Payer: Cofinity Commercial	$119.24
Rate for Payer: Encore Health Key Benefits Commercial	$110.92
Rate for Payer: Healthscope Commercial	$124.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$117.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$103.99
Rate for Payer: PHP Commercial	$117.85
Rate for Payer: Priority Health SBD	$87.35

BACLOFEN 10 MG TABLET

Facility

$131.60

Service Code	NDC 52817032010
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$51.72
Max. Negotiated Rate	$118.44
Rate for Payer: Aetna Commercial	$111.86
Rate for Payer: Aetna Medicare	$65.80
Rate for Payer: Aetna New Business (MI Preferred)	$85.54
Rate for Payer: BCBS Complete	$52.64
Rate for Payer: Cash Price	$105.28
Rate for Payer: Cofinity Advantage	$92.12
Rate for Payer: Cofinity Commercial	$113.18
Rate for Payer: Encore Health Key Benefits Commercial	$105.28
Rate for Payer: Healthscope Commercial	$118.44
Rate for Payer: MI Amish Medical Board Commercial	$105.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$111.86
Rate for Payer: Opus (Opus Packaging Group) HMA	$98.70
Rate for Payer: PHP Commercial	$111.86
Rate for Payer: Priority Health SBD	$82.91
Rate for Payer: UHC All Payor (Choice/PPO)	$85.54
Rate for Payer: UHC Core	$68.56
Rate for Payer: UHC Exchange	$51.72

BACLOFEN 10 MG TABLET

Facility

$1,715.50

Service Code	NDC 00172409680
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$1,080.77
Max. Negotiated Rate	$1,543.95
Rate for Payer: Aetna Commercial	$1,458.17
Rate for Payer: Aetna New Business (MI Preferred)	$1,115.08
Rate for Payer: Cash Price	$1,372.40
Rate for Payer: Cofinity Advantage	$1,200.85
Rate for Payer: Cofinity Commercial	$1,475.33
Rate for Payer: Encore Health Key Benefits Commercial	$1,372.40
Rate for Payer: Healthscope Commercial	$1,543.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,458.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,286.62
Rate for Payer: PHP Commercial	$1,458.17
Rate for Payer: Priority Health SBD	$1,080.77

BACLOFEN 10 MG TABLET

Facility

$96.35

Service Code	NDC 72888001001
Hospital Charge Code	860
Hospital Revenue Code	637
Min. Negotiated Rate	$60.70
Max. Negotiated Rate	$86.72
Rate for Payer: Aetna Commercial	$81.90
Rate for Payer: Aetna New Business (MI Preferred)	$62.63
Rate for Payer: Cash Price	$77.08
Rate for Payer: Cofinity Advantage	$67.44
Rate for Payer: Cofinity Commercial	$82.86
Rate for Payer: Encore Health Key Benefits Commercial	$77.08
Rate for Payer: Healthscope Commercial	$86.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$81.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$72.26
Rate for Payer: PHP Commercial	$81.90
Rate for Payer: Priority Health SBD	$60.70

BACLOFEN 20 MG TABLET

Facility

$289.92

Service Code	NDC 00904647661
Hospital Charge Code	861
Hospital Revenue Code	637
Min. Negotiated Rate	$182.65
Max. Negotiated Rate	$260.93
Rate for Payer: Aetna Commercial	$246.43
Rate for Payer: Aetna New Business (MI Preferred)	$188.45
Rate for Payer: Cash Price	$231.94
Rate for Payer: Cofinity Advantage	$202.94
Rate for Payer: Cofinity Commercial	$249.33
Rate for Payer: Encore Health Key Benefits Commercial	$231.94
Rate for Payer: Healthscope Commercial	$260.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$246.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$217.44
Rate for Payer: PHP Commercial	$246.43
Rate for Payer: Priority Health SBD	$182.65

BACLOFEN 20 MG TABLET

Facility

$289.92

Service Code	NDC 00904647661
Hospital Charge Code	861
Hospital Revenue Code	637
Min. Negotiated Rate	$113.94
Max. Negotiated Rate	$260.93
Rate for Payer: Aetna Commercial	$246.43
Rate for Payer: Aetna Medicare	$144.96
Rate for Payer: Aetna New Business (MI Preferred)	$188.45
Rate for Payer: BCBS Complete	$115.97
Rate for Payer: Cash Price	$231.94
Rate for Payer: Cofinity Advantage	$202.94
Rate for Payer: Cofinity Commercial	$249.33
Rate for Payer: Encore Health Key Benefits Commercial	$231.94
Rate for Payer: Healthscope Commercial	$260.93
Rate for Payer: MI Amish Medical Board Commercial	$231.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$246.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$217.44
Rate for Payer: PHP Commercial	$246.43
Rate for Payer: Priority Health SBD	$182.65
Rate for Payer: UHC All Payor (Choice/PPO)	$188.45
Rate for Payer: UHC Core	$151.05
Rate for Payer: UHC Exchange	$113.94

BACLOFEN 5 MG TABLET

Facility

$6.68

Service Code	NDC 50268010511
Hospital Charge Code	186653
Hospital Revenue Code	637
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$6.01
Rate for Payer: Aetna Commercial	$5.68
Rate for Payer: Aetna New Business (MI Preferred)	$4.34
Rate for Payer: Cash Price	$5.34
Rate for Payer: Cofinity Advantage	$4.68
Rate for Payer: Cofinity Commercial	$5.74
Rate for Payer: Encore Health Key Benefits Commercial	$5.34
Rate for Payer: Healthscope Commercial	$6.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$5.01
Rate for Payer: PHP Commercial	$5.68
Rate for Payer: Priority Health SBD	$4.21

BACLOFEN 5 MG TABLET

Facility

$333.84

Service Code	NDC 50268010515
Hospital Charge Code	186653
Hospital Revenue Code	637
Min. Negotiated Rate	$131.20
Max. Negotiated Rate	$300.46
Rate for Payer: Aetna Commercial	$283.76
Rate for Payer: Aetna Medicare	$166.92
Rate for Payer: Aetna New Business (MI Preferred)	$217.00
Rate for Payer: BCBS Complete	$133.54
Rate for Payer: Cash Price	$267.07
Rate for Payer: Cofinity Advantage	$233.69
Rate for Payer: Cofinity Commercial	$287.10
Rate for Payer: Encore Health Key Benefits Commercial	$267.07
Rate for Payer: Healthscope Commercial	$300.46
Rate for Payer: MI Amish Medical Board Commercial	$267.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$283.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$250.38
Rate for Payer: PHP Commercial	$283.76
Rate for Payer: Priority Health SBD	$210.32
Rate for Payer: UHC All Payor (Choice/PPO)	$217.00
Rate for Payer: UHC Core	$173.93
Rate for Payer: UHC Exchange	$131.20

BACLOFEN 5 MG TABLET

Facility

$333.84

Service Code	NDC 50268010515
Hospital Charge Code	186653
Hospital Revenue Code	637
Min. Negotiated Rate	$210.32
Max. Negotiated Rate	$300.46
Rate for Payer: Aetna Commercial	$283.76
Rate for Payer: Aetna New Business (MI Preferred)	$217.00
Rate for Payer: Cash Price	$267.07
Rate for Payer: Cofinity Advantage	$233.69
Rate for Payer: Cofinity Commercial	$287.10
Rate for Payer: Encore Health Key Benefits Commercial	$267.07
Rate for Payer: Healthscope Commercial	$300.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$283.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$250.38
Rate for Payer: PHP Commercial	$283.76
Rate for Payer: Priority Health SBD	$210.32

Know your out-of-pocket cost for care.

All Charges