Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$422.39

Service Code	NDC 0121-0799-16
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$266.11
Max. Negotiated Rate	$380.15
Rate for Payer: Aetna Commercial	$359.03
Rate for Payer: Aetna New Business (MI Preferred)	$274.55
Rate for Payer: Cash Price	$337.91
Rate for Payer: Cofinity Commercial	$295.67
Rate for Payer: Cofinity Commercial	$363.26
Rate for Payer: Healthscope Commercial	$380.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$359.03
Rate for Payer: PHP Commercial	$359.03
Rate for Payer: Priority Health Cigna Priority Health	$295.67
Rate for Payer: Priority Health SBD	$266.11

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$266.78

Service Code	NDC 51991-651-16
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$168.07
Max. Negotiated Rate	$240.10
Rate for Payer: Aetna Commercial	$226.76
Rate for Payer: Aetna New Business (MI Preferred)	$173.41
Rate for Payer: Cash Price	$213.42
Rate for Payer: Cofinity Commercial	$186.75
Rate for Payer: Cofinity Commercial	$229.43
Rate for Payer: Healthscope Commercial	$240.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$226.76
Rate for Payer: PHP Commercial	$226.76
Rate for Payer: Priority Health Cigna Priority Health	$186.75
Rate for Payer: Priority Health SBD	$168.07

LEVETIRACETAM 250 MG TABLET

Facility

$345.45

Service Code	NDC 68084-859-01
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$217.63
Max. Negotiated Rate	$310.90
Rate for Payer: Aetna Commercial	$293.63
Rate for Payer: Aetna New Business (MI Preferred)	$224.54
Rate for Payer: Cash Price	$276.36
Rate for Payer: Cofinity Commercial	$241.82
Rate for Payer: Cofinity Commercial	$297.09
Rate for Payer: Healthscope Commercial	$310.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$293.63
Rate for Payer: PHP Commercial	$293.63
Rate for Payer: Priority Health Cigna Priority Health	$241.82
Rate for Payer: Priority Health SBD	$217.63

LEVETIRACETAM 250 MG TABLET

Facility

$263.20

Service Code	NDC 0904-6051-61
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$165.82
Max. Negotiated Rate	$236.88
Rate for Payer: Aetna Commercial	$223.72
Rate for Payer: Aetna New Business (MI Preferred)	$171.08
Rate for Payer: Cash Price	$210.56
Rate for Payer: Cofinity Commercial	$184.24
Rate for Payer: Cofinity Commercial	$226.35
Rate for Payer: Healthscope Commercial	$236.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$223.72
Rate for Payer: PHP Commercial	$223.72
Rate for Payer: Priority Health Cigna Priority Health	$184.24
Rate for Payer: Priority Health SBD	$165.82

LEVETIRACETAM 250 MG TABLET

Facility

$224.20

Service Code	NDC 51079-820-20
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$141.25
Max. Negotiated Rate	$201.78
Rate for Payer: Aetna Commercial	$190.57
Rate for Payer: Aetna New Business (MI Preferred)	$145.73
Rate for Payer: Cash Price	$179.36
Rate for Payer: Cofinity Commercial	$156.94
Rate for Payer: Cofinity Commercial	$192.81
Rate for Payer: Healthscope Commercial	$201.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$190.57
Rate for Payer: PHP Commercial	$190.57
Rate for Payer: Priority Health Cigna Priority Health	$156.94
Rate for Payer: Priority Health SBD	$141.25

LEVETIRACETAM 250 MG TABLET

Facility

$3.46

Service Code	NDC 68084-859-11
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.11
Rate for Payer: Aetna Commercial	$2.94
Rate for Payer: Aetna New Business (MI Preferred)	$2.25
Rate for Payer: Cash Price	$2.77
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Healthscope Commercial	$3.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.94
Rate for Payer: PHP Commercial	$2.94
Rate for Payer: Priority Health Cigna Priority Health	$2.42
Rate for Payer: Priority Health SBD	$2.18

LEVETIRACETAM 250 MG TABLET

Facility

$2.25

Service Code	NDC 51079-820-01
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna Commercial	$1.91
Rate for Payer: Aetna New Business (MI Preferred)	$1.46
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cofinity Commercial	$1.58
Rate for Payer: Cofinity Commercial	$1.94
Rate for Payer: Healthscope Commercial	$2.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.91
Rate for Payer: PHP Commercial	$1.91
Rate for Payer: Priority Health Cigna Priority Health	$1.58
Rate for Payer: Priority Health SBD	$1.42

LEVETIRACETAM 250 MG TABLET

Facility

$284.35

Service Code	NDC 0904-7123-61
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$179.14
Max. Negotiated Rate	$255.92
Rate for Payer: Aetna Commercial	$241.70
Rate for Payer: Aetna New Business (MI Preferred)	$184.83
Rate for Payer: Cash Price	$227.48
Rate for Payer: Cofinity Commercial	$199.04
Rate for Payer: Cofinity Commercial	$244.54
Rate for Payer: Healthscope Commercial	$255.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$241.70
Rate for Payer: PHP Commercial	$241.70
Rate for Payer: Priority Health Cigna Priority Health	$199.04
Rate for Payer: Priority Health SBD	$179.14

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION

Facility

$17.62

Service Code	HCPCS J1953
Hospital Charge Code	77195
Hospital Revenue Code	636
Min. Negotiated Rate	$11.10
Max. Negotiated Rate	$15.86
Rate for Payer: Aetna Commercial	$14.98
Rate for Payer: Aetna Commercial	$22.71
Rate for Payer: Aetna Commercial	$17.52
Rate for Payer: Aetna Commercial	$12.21
Rate for Payer: Aetna Commercial	$21.07
Rate for Payer: Aetna Commercial	$13.06
Rate for Payer: Aetna Commercial	$22.92
Rate for Payer: Aetna New Business (MI Preferred)	$9.99
Rate for Payer: Aetna New Business (MI Preferred)	$13.40
Rate for Payer: Aetna New Business (MI Preferred)	$11.45
Rate for Payer: Aetna New Business (MI Preferred)	$17.37
Rate for Payer: Aetna New Business (MI Preferred)	$16.11
Rate for Payer: Aetna New Business (MI Preferred)	$17.53
Rate for Payer: Aetna New Business (MI Preferred)	$9.33
Rate for Payer: Cash Price	$14.10
Rate for Payer: Cash Price	$21.58
Rate for Payer: Cash Price	$21.38
Rate for Payer: Cash Price	$12.30
Rate for Payer: Cash Price	$16.49
Rate for Payer: Cash Price	$19.83
Rate for Payer: Cash Price	$11.49
Rate for Payer: Cofinity Commercial	$17.72
Rate for Payer: Cofinity Commercial	$10.05
Rate for Payer: Cofinity Commercial	$12.35
Rate for Payer: Cofinity Commercial	$23.19
Rate for Payer: Cofinity Commercial	$18.88
Rate for Payer: Cofinity Commercial	$10.76
Rate for Payer: Cofinity Commercial	$13.22
Rate for Payer: Cofinity Commercial	$22.98
Rate for Payer: Cofinity Commercial	$18.70
Rate for Payer: Cofinity Commercial	$12.33
Rate for Payer: Cofinity Commercial	$15.15
Rate for Payer: Cofinity Commercial	$21.32
Rate for Payer: Cofinity Commercial	$17.35
Rate for Payer: Cofinity Commercial	$14.43
Rate for Payer: Healthscope Commercial	$15.86
Rate for Payer: Healthscope Commercial	$12.92
Rate for Payer: Healthscope Commercial	$13.83
Rate for Payer: Healthscope Commercial	$18.55
Rate for Payer: Healthscope Commercial	$22.31
Rate for Payer: Healthscope Commercial	$24.05
Rate for Payer: Healthscope Commercial	$24.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.07
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.71
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.92
Rate for Payer: PHP Commercial	$12.21
Rate for Payer: PHP Commercial	$17.52
Rate for Payer: PHP Commercial	$21.07
Rate for Payer: PHP Commercial	$22.92
Rate for Payer: PHP Commercial	$22.71
Rate for Payer: PHP Commercial	$14.98
Rate for Payer: PHP Commercial	$13.06
Rate for Payer: Priority Health Cigna Priority Health	$10.05
Rate for Payer: Priority Health Cigna Priority Health	$14.43
Rate for Payer: Priority Health Cigna Priority Health	$10.76
Rate for Payer: Priority Health Cigna Priority Health	$12.33
Rate for Payer: Priority Health Cigna Priority Health	$18.88
Rate for Payer: Priority Health Cigna Priority Health	$17.35
Rate for Payer: Priority Health Cigna Priority Health	$18.70
Rate for Payer: Priority Health SBD	$12.98
Rate for Payer: Priority Health SBD	$9.68
Rate for Payer: Priority Health SBD	$16.99
Rate for Payer: Priority Health SBD	$16.83
Rate for Payer: Priority Health SBD	$15.62
Rate for Payer: Priority Health SBD	$9.05
Rate for Payer: Priority Health SBD	$11.10

LEVETIRACETAM 500 MG TABLET

Facility

$310.20

Service Code	NDC 0904-7124-61
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$195.43
Max. Negotiated Rate	$279.18
Rate for Payer: Aetna Commercial	$263.67
Rate for Payer: Aetna New Business (MI Preferred)	$201.63
Rate for Payer: Cash Price	$248.16
Rate for Payer: Cofinity Commercial	$217.14
Rate for Payer: Cofinity Commercial	$266.77
Rate for Payer: Healthscope Commercial	$279.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$263.67
Rate for Payer: PHP Commercial	$263.67
Rate for Payer: Priority Health Cigna Priority Health	$217.14
Rate for Payer: Priority Health SBD	$195.43

LEVETIRACETAM 500 MG TABLET

Facility

$4.00

Service Code	NDC 60687-657-11
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna Commercial	$3.40
Rate for Payer: Aetna New Business (MI Preferred)	$2.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cofinity Commercial	$2.80
Rate for Payer: Cofinity Commercial	$3.44
Rate for Payer: Healthscope Commercial	$3.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.40
Rate for Payer: PHP Commercial	$3.40
Rate for Payer: Priority Health Cigna Priority Health	$2.80
Rate for Payer: Priority Health SBD	$2.52

LEVETIRACETAM 500 MG TABLET

Facility

$2.39

Service Code	NDC 68084-870-11
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna Commercial	$2.03
Rate for Payer: Aetna New Business (MI Preferred)	$1.55
Rate for Payer: Cash Price	$1.91
Rate for Payer: Cofinity Commercial	$1.67
Rate for Payer: Cofinity Commercial	$2.06
Rate for Payer: Healthscope Commercial	$2.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.03
Rate for Payer: PHP Commercial	$2.03
Rate for Payer: Priority Health Cigna Priority Health	$1.67
Rate for Payer: Priority Health SBD	$1.51

LEVETIRACETAM 500 MG TABLET

Facility

$257.45

Service Code	NDC 51079-821-20
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$162.19
Max. Negotiated Rate	$231.70
Rate for Payer: Aetna Commercial	$218.83
Rate for Payer: Aetna New Business (MI Preferred)	$167.34
Rate for Payer: Cash Price	$205.96
Rate for Payer: Cofinity Commercial	$180.22
Rate for Payer: Cofinity Commercial	$221.41
Rate for Payer: Healthscope Commercial	$231.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$218.83
Rate for Payer: PHP Commercial	$218.83
Rate for Payer: Priority Health Cigna Priority Health	$180.22
Rate for Payer: Priority Health SBD	$162.19

LEVETIRACETAM 500 MG TABLET

Facility

$399.50

Service Code	NDC 60687-657-01
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$251.68
Max. Negotiated Rate	$359.55
Rate for Payer: Aetna Commercial	$339.58
Rate for Payer: Aetna New Business (MI Preferred)	$259.68
Rate for Payer: Cash Price	$319.60
Rate for Payer: Cofinity Commercial	$279.65
Rate for Payer: Cofinity Commercial	$343.57
Rate for Payer: Healthscope Commercial	$359.55
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$339.58
Rate for Payer: PHP Commercial	$339.58
Rate for Payer: Priority Health Cigna Priority Health	$279.65
Rate for Payer: Priority Health SBD	$251.68

LEVETIRACETAM 500 MG TABLET

Facility

$473.76

Service Code	NDC 31722-537-12
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$298.47
Max. Negotiated Rate	$426.38
Rate for Payer: Aetna Commercial	$402.70
Rate for Payer: Aetna New Business (MI Preferred)	$307.94
Rate for Payer: Cash Price	$379.01
Rate for Payer: Cofinity Commercial	$331.63
Rate for Payer: Cofinity Commercial	$407.43
Rate for Payer: Healthscope Commercial	$426.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$402.70
Rate for Payer: PHP Commercial	$402.70
Rate for Payer: Priority Health Cigna Priority Health	$331.63
Rate for Payer: Priority Health SBD	$298.47

LEVETIRACETAM 500 MG TABLET

Facility

$238.45

Service Code	NDC 68084-870-01
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$150.22
Max. Negotiated Rate	$214.60
Rate for Payer: Aetna Commercial	$202.68
Rate for Payer: Aetna New Business (MI Preferred)	$154.99
Rate for Payer: Cash Price	$190.76
Rate for Payer: Cofinity Commercial	$166.92
Rate for Payer: Cofinity Commercial	$205.07
Rate for Payer: Healthscope Commercial	$214.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$202.68
Rate for Payer: PHP Commercial	$202.68
Rate for Payer: Priority Health Cigna Priority Health	$166.92
Rate for Payer: Priority Health SBD	$150.22

LEVETIRACETAM 500 MG TABLET

Facility

$279.65

Service Code	NDC 0904-6052-61
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$176.18
Max. Negotiated Rate	$251.68
Rate for Payer: Aetna Commercial	$237.70
Rate for Payer: Aetna New Business (MI Preferred)	$181.77
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cofinity Commercial	$195.76
Rate for Payer: Cofinity Commercial	$240.50
Rate for Payer: Healthscope Commercial	$251.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$237.70
Rate for Payer: PHP Commercial	$237.70
Rate for Payer: Priority Health Cigna Priority Health	$195.76
Rate for Payer: Priority Health SBD	$176.18

LEVETIRACETAM 500 MG TABLET

Facility

$2.58

Service Code	NDC 51079-821-01
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$2.32
Rate for Payer: Aetna Commercial	$2.19
Rate for Payer: Aetna New Business (MI Preferred)	$1.68
Rate for Payer: Cash Price	$2.06
Rate for Payer: Cofinity Commercial	$1.81
Rate for Payer: Cofinity Commercial	$2.22
Rate for Payer: Healthscope Commercial	$2.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.19
Rate for Payer: PHP Commercial	$2.19
Rate for Payer: Priority Health Cigna Priority Health	$1.81
Rate for Payer: Priority Health SBD	$1.63

LEVETIRACETAM 750 MG TABLET

Facility

$261.25

Service Code	NDC 68084-882-01
Hospital Charge Code	26818
Hospital Revenue Code	637
Min. Negotiated Rate	$164.59
Max. Negotiated Rate	$235.12
Rate for Payer: Aetna Commercial	$222.06
Rate for Payer: Aetna New Business (MI Preferred)	$169.81
Rate for Payer: Cash Price	$209.00
Rate for Payer: Cofinity Commercial	$182.88
Rate for Payer: Cofinity Commercial	$224.68
Rate for Payer: Healthscope Commercial	$235.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$222.06
Rate for Payer: PHP Commercial	$222.06
Rate for Payer: Priority Health Cigna Priority Health	$182.88
Rate for Payer: Priority Health SBD	$164.59

LEVETIRACETAM 750 MG TABLET

Facility

$470.00

Service Code	NDC 0904-7125-61
Hospital Charge Code	26818
Hospital Revenue Code	637
Min. Negotiated Rate	$296.10
Max. Negotiated Rate	$423.00
Rate for Payer: Aetna Commercial	$399.50
Rate for Payer: Aetna New Business (MI Preferred)	$305.50
Rate for Payer: Cash Price	$376.00
Rate for Payer: Cofinity Commercial	$329.00
Rate for Payer: Cofinity Commercial	$404.20
Rate for Payer: Healthscope Commercial	$423.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$399.50
Rate for Payer: PHP Commercial	$399.50
Rate for Payer: Priority Health Cigna Priority Health	$329.00
Rate for Payer: Priority Health SBD	$296.10

LEVETIRACETAM 750 MG TABLET

Facility

$2.62

Service Code	NDC 68084-882-11
Hospital Charge Code	26818
Hospital Revenue Code	637
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.36
Rate for Payer: Aetna Commercial	$2.23
Rate for Payer: Aetna New Business (MI Preferred)	$1.70
Rate for Payer: Cash Price	$2.10
Rate for Payer: Cofinity Commercial	$1.83
Rate for Payer: Cofinity Commercial	$2.25
Rate for Payer: Healthscope Commercial	$2.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.23
Rate for Payer: PHP Commercial	$2.23
Rate for Payer: Priority Health Cigna Priority Health	$1.83
Rate for Payer: Priority Health SBD	$1.65

LEVETIRACETAM 750 MG TABLET

Facility

$458.25

Service Code	NDC 0904-6053-61
Hospital Charge Code	26818
Hospital Revenue Code	637
Min. Negotiated Rate	$288.70
Max. Negotiated Rate	$412.42
Rate for Payer: Aetna Commercial	$389.51
Rate for Payer: Aetna New Business (MI Preferred)	$297.86
Rate for Payer: Cash Price	$366.60
Rate for Payer: Cofinity Commercial	$320.78
Rate for Payer: Cofinity Commercial	$394.10
Rate for Payer: Healthscope Commercial	$412.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$389.51
Rate for Payer: PHP Commercial	$389.51
Rate for Payer: Priority Health Cigna Priority Health	$320.78
Rate for Payer: Priority Health SBD	$288.70

LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION

Facility

$100.15

Service Code	HCPCS J1955
Hospital Charge Code	20954
Hospital Revenue Code	636
Min. Negotiated Rate	$63.09
Max. Negotiated Rate	$90.14
Rate for Payer: Aetna Commercial	$85.13
Rate for Payer: Aetna New Business (MI Preferred)	$65.10
Rate for Payer: Cash Price	$80.12
Rate for Payer: Cofinity Commercial	$70.10
Rate for Payer: Cofinity Commercial	$86.13
Rate for Payer: Healthscope Commercial	$90.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$85.13
Rate for Payer: PHP Commercial	$85.13
Rate for Payer: Priority Health Cigna Priority Health	$70.10
Rate for Payer: Priority Health SBD	$63.09

LEVOCARNITINE 330 MG TABLET

Facility

$342.58

Service Code	NDC 50383-172-90
Hospital Charge Code	20952
Hospital Revenue Code	637
Min. Negotiated Rate	$215.83
Max. Negotiated Rate	$308.32
Rate for Payer: Aetna Commercial	$291.19
Rate for Payer: Aetna New Business (MI Preferred)	$222.68
Rate for Payer: Cash Price	$274.06
Rate for Payer: Cofinity Commercial	$294.62
Rate for Payer: Cofinity Commercial	$239.81
Rate for Payer: Healthscope Commercial	$308.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$291.19
Rate for Payer: PHP Commercial	$291.19
Rate for Payer: Priority Health Cigna Priority Health	$239.81
Rate for Payer: Priority Health SBD	$215.83

LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

Facility

$73.42

Service Code	HCPCS J1956
Hospital Charge Code	112929
Hospital Revenue Code	636
Min. Negotiated Rate	$46.25
Max. Negotiated Rate	$66.08
Rate for Payer: Aetna Commercial	$62.41
Rate for Payer: Aetna Commercial	$53.30
Rate for Payer: Aetna New Business (MI Preferred)	$47.72
Rate for Payer: Aetna New Business (MI Preferred)	$40.76
Rate for Payer: Cash Price	$58.74
Rate for Payer: Cash Price	$50.17
Rate for Payer: Cofinity Commercial	$43.90
Rate for Payer: Cofinity Commercial	$63.14
Rate for Payer: Cofinity Commercial	$51.39
Rate for Payer: Cofinity Commercial	$53.93
Rate for Payer: Healthscope Commercial	$66.08
Rate for Payer: Healthscope Commercial	$56.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$53.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.41
Rate for Payer: PHP Commercial	$53.30
Rate for Payer: PHP Commercial	$62.41
Rate for Payer: Priority Health Cigna Priority Health	$51.39
Rate for Payer: Priority Health Cigna Priority Health	$43.90
Rate for Payer: Priority Health SBD	$39.51
Rate for Payer: Priority Health SBD	$46.25

Know your out-of-pocket cost for care.

All Charges