Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HYDROCORTISONE 1 % TOPICAL OINTMENT

Facility

$25.14

Service Code	NDC 0168-0020-31
Hospital Charge Code	3731
Hospital Revenue Code	637
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$22.63
Rate for Payer: Aetna Commercial	$21.37
Rate for Payer: Aetna New Business (MI Preferred)	$16.34
Rate for Payer: Cash Price	$20.11
Rate for Payer: Cofinity Commercial	$17.60
Rate for Payer: Cofinity Commercial	$21.62
Rate for Payer: Healthscope Commercial	$22.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.37
Rate for Payer: PHP Commercial	$21.37
Rate for Payer: Priority Health Cigna Priority Health	$17.60
Rate for Payer: Priority Health SBD	$15.84

HYDROCORTISONE 2.5 % LOTION

Facility

$24.99

Service Code	NDC 45802-937-16
Hospital Charge Code	3729
Hospital Revenue Code	637
Min. Negotiated Rate	$15.74
Max. Negotiated Rate	$22.49
Rate for Payer: Aetna Commercial	$21.24
Rate for Payer: Aetna New Business (MI Preferred)	$16.24
Rate for Payer: Cash Price	$19.99
Rate for Payer: Cofinity Commercial	$17.49
Rate for Payer: Cofinity Commercial	$21.49
Rate for Payer: Healthscope Commercial	$22.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.24
Rate for Payer: PHP Commercial	$21.24
Rate for Payer: Priority Health Cigna Priority Health	$17.49
Rate for Payer: Priority Health SBD	$15.74

HYDROCORTISONE 2.5 % TOPICAL CREAM

Facility

$9.18

Service Code	NDC 0168-0080-31
Hospital Charge Code	3727
Hospital Revenue Code	637
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$8.26
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: Aetna New Business (MI Preferred)	$5.97
Rate for Payer: Cash Price	$7.34
Rate for Payer: Cofinity Commercial	$6.43
Rate for Payer: Cofinity Commercial	$7.89
Rate for Payer: Healthscope Commercial	$8.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7.80
Rate for Payer: PHP Commercial	$7.80
Rate for Payer: Priority Health Cigna Priority Health	$6.43
Rate for Payer: Priority Health SBD	$5.78

HYDROCORTISONE 2.5 % TOPICAL CREAM

Facility

$17.42

Service Code	NDC 0316-0193-30
Hospital Charge Code	3727
Hospital Revenue Code	637
Min. Negotiated Rate	$10.97
Max. Negotiated Rate	$15.68
Rate for Payer: Aetna Commercial	$14.81
Rate for Payer: Aetna New Business (MI Preferred)	$11.32
Rate for Payer: Cash Price	$13.94
Rate for Payer: Cofinity Commercial	$12.19
Rate for Payer: Cofinity Commercial	$14.98
Rate for Payer: Healthscope Commercial	$15.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.81
Rate for Payer: PHP Commercial	$14.81
Rate for Payer: Priority Health Cigna Priority Health	$12.19
Rate for Payer: Priority Health SBD	$10.97

HYDROCORTISONE 2.5 % TOPICAL CREAM

Facility

$21.21

Service Code	NDC 0472-0337-30
Hospital Charge Code	3727
Hospital Revenue Code	637
Min. Negotiated Rate	$13.36
Max. Negotiated Rate	$19.09
Rate for Payer: Aetna Commercial	$18.03
Rate for Payer: Aetna New Business (MI Preferred)	$13.79
Rate for Payer: Cash Price	$16.97
Rate for Payer: Cofinity Commercial	$14.85
Rate for Payer: Cofinity Commercial	$18.24
Rate for Payer: Healthscope Commercial	$19.09
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.03
Rate for Payer: PHP Commercial	$18.03
Rate for Payer: Priority Health Cigna Priority Health	$14.85
Rate for Payer: Priority Health SBD	$13.36

HYDROCORTISONE 2.5 % TOPICAL CREAM

Facility

$12.38

Service Code	NDC 51672-3003-2
Hospital Charge Code	3727
Hospital Revenue Code	637
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$11.14
Rate for Payer: Aetna Commercial	$10.52
Rate for Payer: Aetna New Business (MI Preferred)	$8.05
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cofinity Commercial	$10.65
Rate for Payer: Cofinity Commercial	$8.67
Rate for Payer: Healthscope Commercial	$11.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.52
Rate for Payer: PHP Commercial	$10.52
Rate for Payer: Priority Health Cigna Priority Health	$8.67
Rate for Payer: Priority Health SBD	$7.80

HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR

Facility

$155.30

Service Code	NDC 64980-301-30
Hospital Charge Code	28824
Hospital Revenue Code	637
Min. Negotiated Rate	$97.84
Max. Negotiated Rate	$139.77
Rate for Payer: Aetna Commercial	$132.00
Rate for Payer: Aetna New Business (MI Preferred)	$100.94
Rate for Payer: Cash Price	$124.24
Rate for Payer: Cofinity Commercial	$108.71
Rate for Payer: Cofinity Commercial	$133.56
Rate for Payer: Healthscope Commercial	$139.77
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$132.00
Rate for Payer: PHP Commercial	$132.00
Rate for Payer: Priority Health Cigna Priority Health	$108.71
Rate for Payer: Priority Health SBD	$97.84

HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR

Facility

$230.48

Service Code	NDC 62559-431-30
Hospital Charge Code	28824
Hospital Revenue Code	637
Min. Negotiated Rate	$145.20
Max. Negotiated Rate	$207.43
Rate for Payer: Aetna Commercial	$195.91
Rate for Payer: Aetna New Business (MI Preferred)	$149.81
Rate for Payer: Cash Price	$184.38
Rate for Payer: Cofinity Commercial	$161.34
Rate for Payer: Cofinity Commercial	$198.21
Rate for Payer: Healthscope Commercial	$207.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$195.91
Rate for Payer: PHP Commercial	$195.91
Rate for Payer: Priority Health Cigna Priority Health	$161.34
Rate for Payer: Priority Health SBD	$145.20

HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR

Facility

$26.76

Service Code	NDC 69315-312-28
Hospital Charge Code	28824
Hospital Revenue Code	637
Min. Negotiated Rate	$16.86
Max. Negotiated Rate	$24.08
Rate for Payer: Aetna Commercial	$22.75
Rate for Payer: Aetna New Business (MI Preferred)	$17.39
Rate for Payer: Cash Price	$21.41
Rate for Payer: Cofinity Commercial	$18.73
Rate for Payer: Cofinity Commercial	$23.01
Rate for Payer: Healthscope Commercial	$24.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.75
Rate for Payer: PHP Commercial	$22.75
Rate for Payer: Priority Health Cigna Priority Health	$18.73
Rate for Payer: Priority Health SBD	$16.86

HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR

Facility

$28.88

Service Code	NDC 64980-324-30
Hospital Charge Code	28824
Hospital Revenue Code	637
Min. Negotiated Rate	$18.19
Max. Negotiated Rate	$25.99
Rate for Payer: Aetna Commercial	$24.55
Rate for Payer: Aetna New Business (MI Preferred)	$18.77
Rate for Payer: Cash Price	$23.10
Rate for Payer: Cofinity Commercial	$20.22
Rate for Payer: Cofinity Commercial	$24.84
Rate for Payer: Healthscope Commercial	$25.99
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$24.55
Rate for Payer: PHP Commercial	$24.55
Rate for Payer: Priority Health Cigna Priority Health	$20.22
Rate for Payer: Priority Health SBD	$18.19

HYDROCORTISONE 2.5 % TOPICAL OINTMENT

Facility

$13.78

Service Code	NDC 0168-0146-30
Hospital Charge Code	3732
Hospital Revenue Code	637
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$12.40
Rate for Payer: Aetna Commercial	$11.71
Rate for Payer: Aetna New Business (MI Preferred)	$8.96
Rate for Payer: Cash Price	$11.02
Rate for Payer: Cofinity Commercial	$11.85
Rate for Payer: Cofinity Commercial	$9.65
Rate for Payer: Healthscope Commercial	$12.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.71
Rate for Payer: PHP Commercial	$11.71
Rate for Payer: Priority Health Cigna Priority Health	$9.65
Rate for Payer: Priority Health SBD	$8.68

HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY

Facility

$116.73

Service Code	NDC 59741-301-12
Hospital Charge Code	3738
Hospital Revenue Code	637
Min. Negotiated Rate	$73.54
Max. Negotiated Rate	$105.06
Rate for Payer: Aetna Commercial	$99.22
Rate for Payer: Aetna New Business (MI Preferred)	$75.87
Rate for Payer: Cash Price	$93.38
Rate for Payer: Cofinity Commercial	$81.71
Rate for Payer: Cofinity Commercial	$100.39
Rate for Payer: Healthscope Commercial	$105.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$99.22
Rate for Payer: PHP Commercial	$99.22
Rate for Payer: Priority Health Cigna Priority Health	$81.71
Rate for Payer: Priority Health SBD	$73.54

HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY

Facility

$902.21

Service Code	NDC 0713-0503-24
Hospital Charge Code	3738
Hospital Revenue Code	637
Min. Negotiated Rate	$568.39
Max. Negotiated Rate	$811.99
Rate for Payer: Aetna Commercial	$766.88
Rate for Payer: Aetna New Business (MI Preferred)	$586.44
Rate for Payer: Cash Price	$721.77
Rate for Payer: Cofinity Commercial	$631.55
Rate for Payer: Cofinity Commercial	$775.90
Rate for Payer: Healthscope Commercial	$811.99
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$766.88
Rate for Payer: PHP Commercial	$766.88
Rate for Payer: Priority Health Cigna Priority Health	$631.55
Rate for Payer: Priority Health SBD	$568.39

HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY

Facility

$39.57

Service Code	NDC 0713-0503-06
Hospital Charge Code	3738
Hospital Revenue Code	637
Min. Negotiated Rate	$24.93
Max. Negotiated Rate	$35.61
Rate for Payer: Aetna Commercial	$33.63
Rate for Payer: Aetna New Business (MI Preferred)	$25.72
Rate for Payer: Cash Price	$31.66
Rate for Payer: Cofinity Commercial	$27.70
Rate for Payer: Cofinity Commercial	$34.03
Rate for Payer: Healthscope Commercial	$35.61
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$33.63
Rate for Payer: PHP Commercial	$33.63
Rate for Payer: Priority Health Cigna Priority Health	$27.70
Rate for Payer: Priority Health SBD	$24.93

HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY

Facility

$474.82

Service Code	NDC 0713-0503-12
Hospital Charge Code	3738
Hospital Revenue Code	637
Min. Negotiated Rate	$299.14
Max. Negotiated Rate	$427.34
Rate for Payer: Aetna Commercial	$403.60
Rate for Payer: Aetna New Business (MI Preferred)	$308.63
Rate for Payer: Cash Price	$379.86
Rate for Payer: Cofinity Commercial	$332.37
Rate for Payer: Cofinity Commercial	$408.35
Rate for Payer: Healthscope Commercial	$427.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$403.60
Rate for Payer: PHP Commercial	$403.60
Rate for Payer: Priority Health Cigna Priority Health	$332.37
Rate for Payer: Priority Health SBD	$299.14

HYDROCORTISONE-ALOE VERA 1 % TOPICAL CREAM

Facility

$8.07

Service Code	NDC 0536-1277-80
Hospital Charge Code	14190
Hospital Revenue Code	637
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$7.26
Rate for Payer: Aetna Commercial	$6.86
Rate for Payer: Aetna New Business (MI Preferred)	$5.25
Rate for Payer: Cash Price	$6.46
Rate for Payer: Cofinity Commercial	$5.65
Rate for Payer: Cofinity Commercial	$6.94
Rate for Payer: Healthscope Commercial	$7.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.86
Rate for Payer: PHP Commercial	$6.86
Rate for Payer: Priority Health Cigna Priority Health	$5.65
Rate for Payer: Priority Health SBD	$5.08

HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION

Facility

$61.46

Service Code	HCPCS J1720
Hospital Charge Code	108970
Hospital Revenue Code	636
Min. Negotiated Rate	$38.72
Max. Negotiated Rate	$55.31
Rate for Payer: Aetna Commercial	$52.24
Rate for Payer: Aetna New Business (MI Preferred)	$39.95
Rate for Payer: Cash Price	$49.17
Rate for Payer: Cofinity Commercial	$43.02
Rate for Payer: Cofinity Commercial	$52.86
Rate for Payer: Healthscope Commercial	$55.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$52.24
Rate for Payer: PHP Commercial	$52.24
Rate for Payer: Priority Health Cigna Priority Health	$43.02
Rate for Payer: Priority Health SBD	$38.72

HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION

Facility

$84.42

Service Code	HCPCS J1720
Hospital Charge Code	119665
Hospital Revenue Code	636
Min. Negotiated Rate	$33.77
Max. Negotiated Rate	$75.98
Rate for Payer: Aetna Commercial	$71.76
Rate for Payer: Aetna New Business (MI Preferred)	$54.87
Rate for Payer: BCBS Complete	$33.77
Rate for Payer: BCBS Trust/PPO	$52.83
Rate for Payer: Cash Price	$67.54
Rate for Payer: Cash Price	$67.54
Rate for Payer: Cofinity Commercial	$59.09
Rate for Payer: Cofinity Commercial	$72.60
Rate for Payer: Healthscope Commercial	$75.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$71.76
Rate for Payer: PHP Commercial	$71.76
Rate for Payer: Priority Health Cigna Priority Health	$59.09
Rate for Payer: Priority Health SBD	$53.18

HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION

Facility

$83.40

Service Code	HCPCS J1720
Hospital Charge Code	119665
Hospital Revenue Code	636
Min. Negotiated Rate	$52.54
Max. Negotiated Rate	$75.06
Rate for Payer: Aetna Commercial	$70.89
Rate for Payer: Aetna New Business (MI Preferred)	$54.21
Rate for Payer: Cash Price	$66.72
Rate for Payer: Cofinity Commercial	$58.38
Rate for Payer: Cofinity Commercial	$71.72
Rate for Payer: Healthscope Commercial	$75.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$70.89
Rate for Payer: PHP Commercial	$70.89
Rate for Payer: Priority Health Cigna Priority Health	$58.38
Rate for Payer: Priority Health SBD	$52.54

HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE

Facility

$21.41

Service Code	HCPCS J1170
Hospital Charge Code	166819
Hospital Revenue Code	636
Min. Negotiated Rate	$8.56
Max. Negotiated Rate	$19.27
Rate for Payer: Aetna Commercial	$18.20
Rate for Payer: Aetna New Business (MI Preferred)	$13.92
Rate for Payer: BCBS Complete	$8.56
Rate for Payer: BCBS Trust/PPO	$13.57
Rate for Payer: Cash Price	$17.13
Rate for Payer: Cash Price	$17.13
Rate for Payer: Cofinity Commercial	$14.99
Rate for Payer: Cofinity Commercial	$18.41
Rate for Payer: Healthscope Commercial	$19.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.20
Rate for Payer: PHP Commercial	$18.20
Rate for Payer: Priority Health Cigna Priority Health	$14.99
Rate for Payer: Priority Health SBD	$13.49

HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE

Facility

$21.41

Service Code	HCPCS J1170
Hospital Charge Code	166819
Hospital Revenue Code	636
Min. Negotiated Rate	$13.49
Max. Negotiated Rate	$19.27
Rate for Payer: Aetna Commercial	$18.20
Rate for Payer: Aetna Commercial	$11.96
Rate for Payer: Aetna Commercial	$14.01
Rate for Payer: Aetna New Business (MI Preferred)	$9.15
Rate for Payer: Aetna New Business (MI Preferred)	$10.71
Rate for Payer: Aetna New Business (MI Preferred)	$13.92
Rate for Payer: Cash Price	$17.13
Rate for Payer: Cash Price	$11.26
Rate for Payer: Cash Price	$13.18
Rate for Payer: Cofinity Commercial	$9.85
Rate for Payer: Cofinity Commercial	$12.10
Rate for Payer: Cofinity Commercial	$11.54
Rate for Payer: Cofinity Commercial	$14.17
Rate for Payer: Cofinity Commercial	$18.41
Rate for Payer: Cofinity Commercial	$14.99
Rate for Payer: Healthscope Commercial	$19.27
Rate for Payer: Healthscope Commercial	$12.66
Rate for Payer: Healthscope Commercial	$14.83
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.96
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.20
Rate for Payer: PHP Commercial	$11.96
Rate for Payer: PHP Commercial	$14.01
Rate for Payer: PHP Commercial	$18.20
Rate for Payer: Priority Health Cigna Priority Health	$11.54
Rate for Payer: Priority Health Cigna Priority Health	$9.85
Rate for Payer: Priority Health Cigna Priority Health	$14.99
Rate for Payer: Priority Health SBD	$10.38
Rate for Payer: Priority Health SBD	$8.86
Rate for Payer: Priority Health SBD	$13.49

HYDROMORPHONE 1 MG/ML INJECTION SYRINGE

Facility

$29.60

Service Code	HCPCS J1170
Hospital Charge Code	112193
Hospital Revenue Code	636
Min. Negotiated Rate	$11.84
Max. Negotiated Rate	$26.64
Rate for Payer: Aetna Commercial	$25.16
Rate for Payer: Aetna New Business (MI Preferred)	$19.24
Rate for Payer: BCBS Complete	$11.84
Rate for Payer: BCBS Trust/PPO	$13.57
Rate for Payer: Cash Price	$23.68
Rate for Payer: Cash Price	$23.68
Rate for Payer: Cofinity Commercial	$25.46
Rate for Payer: Cofinity Commercial	$20.72
Rate for Payer: Healthscope Commercial	$26.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$25.16
Rate for Payer: PHP Commercial	$25.16
Rate for Payer: Priority Health Cigna Priority Health	$20.72
Rate for Payer: Priority Health SBD	$18.65

HYDROMORPHONE 1 MG/ML INJECTION SYRINGE

Facility

$21.87

Service Code	HCPCS J1170
Hospital Charge Code	112193
Hospital Revenue Code	636
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$19.68
Rate for Payer: Aetna Commercial	$18.59
Rate for Payer: Aetna Commercial	$25.16
Rate for Payer: Aetna New Business (MI Preferred)	$14.22
Rate for Payer: Aetna New Business (MI Preferred)	$19.24
Rate for Payer: Cash Price	$23.68
Rate for Payer: Cash Price	$17.50
Rate for Payer: Cofinity Commercial	$18.81
Rate for Payer: Cofinity Commercial	$25.46
Rate for Payer: Cofinity Commercial	$20.72
Rate for Payer: Cofinity Commercial	$15.31
Rate for Payer: Healthscope Commercial	$26.64
Rate for Payer: Healthscope Commercial	$19.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.59
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$25.16
Rate for Payer: PHP Commercial	$18.59
Rate for Payer: PHP Commercial	$25.16
Rate for Payer: Priority Health Cigna Priority Health	$20.72
Rate for Payer: Priority Health Cigna Priority Health	$15.31
Rate for Payer: Priority Health SBD	$18.65
Rate for Payer: Priority Health SBD	$13.78

HYDROMORPHONE 2 MG/ML INJECTION SYRINGE

Facility

$31.49

Service Code	HCPCS J1170
Hospital Charge Code	110943
Hospital Revenue Code	636
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$28.34
Rate for Payer: Aetna Commercial	$26.77
Rate for Payer: Aetna Commercial	$19.13
Rate for Payer: Aetna New Business (MI Preferred)	$14.63
Rate for Payer: Aetna New Business (MI Preferred)	$20.47
Rate for Payer: Cash Price	$18.01
Rate for Payer: Cash Price	$25.19
Rate for Payer: Cofinity Commercial	$22.04
Rate for Payer: Cofinity Commercial	$15.76
Rate for Payer: Cofinity Commercial	$19.36
Rate for Payer: Cofinity Commercial	$27.08
Rate for Payer: Healthscope Commercial	$20.26
Rate for Payer: Healthscope Commercial	$28.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$26.77
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.13
Rate for Payer: PHP Commercial	$26.77
Rate for Payer: PHP Commercial	$19.13
Rate for Payer: Priority Health Cigna Priority Health	$15.76
Rate for Payer: Priority Health Cigna Priority Health	$22.04
Rate for Payer: Priority Health SBD	$14.18
Rate for Payer: Priority Health SBD	$19.84

HYDROMORPHONE 2 MG/ML INJECTION SYRINGE

Facility

$31.49

Service Code	HCPCS J1170
Hospital Charge Code	110943
Hospital Revenue Code	636
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$28.34
Rate for Payer: Aetna Commercial	$26.77
Rate for Payer: Aetna New Business (MI Preferred)	$20.47
Rate for Payer: BCBS Complete	$12.60
Rate for Payer: BCBS Trust/PPO	$13.57
Rate for Payer: Cash Price	$25.19
Rate for Payer: Cash Price	$25.19
Rate for Payer: Cofinity Commercial	$27.08
Rate for Payer: Cofinity Commercial	$22.04
Rate for Payer: Healthscope Commercial	$28.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$26.77
Rate for Payer: PHP Commercial	$26.77
Rate for Payer: Priority Health Cigna Priority Health	$22.04
Rate for Payer: Priority Health SBD	$19.84

Know your out-of-pocket cost for care.

All Charges