Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CLOPIDOGREL 75 MG TABLET

Facility

$97.29

Service Code	NDC 16729-218-15
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$61.29
Max. Negotiated Rate	$87.56
Rate for Payer: Aetna Commercial	$82.70
Rate for Payer: Aetna New Business (MI Preferred)	$63.24
Rate for Payer: Cash Price	$77.83
Rate for Payer: Cofinity Commercial	$68.10
Rate for Payer: Cofinity Commercial	$83.67
Rate for Payer: Healthscope Commercial	$87.56
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$82.70
Rate for Payer: PHP Commercial	$82.70
Rate for Payer: Priority Health Cigna Priority Health	$68.10
Rate for Payer: Priority Health SBD	$61.29

CLOPIDOGREL 75 MG TABLET

Facility

$420.65

Service Code	NDC 68084-536-01
Hospital Charge Code	22142
Hospital Revenue Code	637
Min. Negotiated Rate	$265.01
Max. Negotiated Rate	$378.58
Rate for Payer: Aetna Commercial	$357.55
Rate for Payer: Aetna New Business (MI Preferred)	$273.42
Rate for Payer: Cash Price	$336.52
Rate for Payer: Cofinity Commercial	$294.46
Rate for Payer: Cofinity Commercial	$361.76
Rate for Payer: Healthscope Commercial	$378.58
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$357.55
Rate for Payer: PHP Commercial	$357.55
Rate for Payer: Priority Health Cigna Priority Health	$294.46
Rate for Payer: Priority Health SBD	$265.01

CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET

Facility

$446.88

Service Code	NDC 0378-0030-01
Hospital Charge Code	1759
Hospital Revenue Code	637
Min. Negotiated Rate	$281.53
Max. Negotiated Rate	$402.19
Rate for Payer: Aetna Commercial	$379.85
Rate for Payer: Aetna New Business (MI Preferred)	$290.47
Rate for Payer: Cash Price	$357.50
Rate for Payer: Cofinity Commercial	$312.82
Rate for Payer: Cofinity Commercial	$384.32
Rate for Payer: Healthscope Commercial	$402.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$379.85
Rate for Payer: PHP Commercial	$379.85
Rate for Payer: Priority Health Cigna Priority Health	$312.82
Rate for Payer: Priority Health SBD	$281.53

CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET

Facility

$1,134.42

Service Code	NDC 51672-4042-1
Hospital Charge Code	1759
Hospital Revenue Code	637
Min. Negotiated Rate	$714.68
Max. Negotiated Rate	$1,020.98
Rate for Payer: Aetna Commercial	$964.26
Rate for Payer: Aetna New Business (MI Preferred)	$737.37
Rate for Payer: Cash Price	$907.54
Rate for Payer: Cofinity Commercial	$794.09
Rate for Payer: Cofinity Commercial	$975.60
Rate for Payer: Healthscope Commercial	$1,020.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$964.26
Rate for Payer: PHP Commercial	$964.26
Rate for Payer: Priority Health Cigna Priority Health	$794.09
Rate for Payer: Priority Health SBD	$714.68

CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION

Facility

$1,787.60

Service Code	CPT 25605
Hospital Revenue Code	360
Min. Negotiated Rate	$401.32
Max. Negotiated Rate	$1,787.60
Rate for Payer: Aetna Medicare	$1,487.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,787.60
Rate for Payer: Amish Plain Church Group Commercial	$1,787.60
Rate for Payer: BCBS Complete	$821.44
Rate for Payer: BCBS MAPPO	$1,430.08
Rate for Payer: BCBS Trust/PPO	$401.32
Rate for Payer: BCN Medicare Advantage	$1,430.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,430.08
Rate for Payer: Mclaren Medicaid	$782.25
Rate for Payer: Mclaren Medicare	$1,430.08
Rate for Payer: Meridian Medicaid	$821.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,501.58
Rate for Payer: MI Amish Medical Board Commercial	$1,644.59
Rate for Payer: PACE Medicare	$1,358.58
Rate for Payer: PACE SWMI	$1,430.08
Rate for Payer: PHP Medicare Advantage	$1,430.08
Rate for Payer: Priority Health Choice Medicaid	$782.25
Rate for Payer: Priority Health Medicare	$1,430.08
Rate for Payer: Railroad Medicare Medicare	$1,430.08
Rate for Payer: UHC All Payor (Choice/PPO)	$569.81
Rate for Payer: UHC Core	$1,463.00
Rate for Payer: UHC Dual Complete DSNP	$1,430.08
Rate for Payer: UHC Exchange	$518.01
Rate for Payer: UHC Medicare Advantage	$1,472.98
Rate for Payer: VA VA	$1,430.08

CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION

Facility

$4,301.45

Service Code	CPT 27502
Hospital Revenue Code	360
Min. Negotiated Rate	$603.72
Max. Negotiated Rate	$4,301.45
Rate for Payer: Aetna Medicare	$1,487.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,787.60
Rate for Payer: Amish Plain Church Group Commercial	$1,787.60
Rate for Payer: BCBS Complete	$821.44
Rate for Payer: BCBS MAPPO	$1,430.08
Rate for Payer: BCBS Trust/PPO	$603.72
Rate for Payer: BCN Medicare Advantage	$1,430.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,430.08
Rate for Payer: Mclaren Medicaid	$782.25
Rate for Payer: Mclaren Medicare	$1,430.08
Rate for Payer: Meridian Medicaid	$821.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,501.58
Rate for Payer: MI Amish Medical Board Commercial	$1,644.59
Rate for Payer: PACE Medicare	$1,358.58
Rate for Payer: PACE SWMI	$1,430.08
Rate for Payer: PHP Medicare Advantage	$1,430.08
Rate for Payer: Priority Health Choice Medicaid	$782.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,301.45
Rate for Payer: Priority Health Medicare	$1,430.08
Rate for Payer: Priority Health Narrow Network	$3,441.16
Rate for Payer: Railroad Medicare Medicare	$1,430.08
Rate for Payer: UHC All Payor (Choice/PPO)	$823.02
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,430.08
Rate for Payer: UHC Exchange	$748.20
Rate for Payer: UHC Medicare Advantage	$1,472.98
Rate for Payer: VA VA	$1,430.08

CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; REQUIRING ANESTHESIA

Facility

$878.00

Service Code	CPT 26775
Hospital Revenue Code	360
Min. Negotiated Rate	$88.01
Max. Negotiated Rate	$878.00
Rate for Payer: Aetna Medicare	$248.52
Rate for Payer: Allen County Amish Medical Aid Commercial	$298.70
Rate for Payer: Amish Plain Church Group Commercial	$298.70
Rate for Payer: BCBS Complete	$137.26
Rate for Payer: BCBS MAPPO	$238.96
Rate for Payer: BCBS Trust/PPO	$88.01
Rate for Payer: BCN Medicare Advantage	$238.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$238.96
Rate for Payer: Mclaren Medicaid	$130.71
Rate for Payer: Mclaren Medicare	$238.96
Rate for Payer: Meridian Medicaid	$137.26
Rate for Payer: Meridian Wellcare - Medicare Advantage	$250.91
Rate for Payer: MI Amish Medical Board Commercial	$274.80
Rate for Payer: PACE Medicare	$227.01
Rate for Payer: PACE SWMI	$238.96
Rate for Payer: PHP Medicare Advantage	$238.96
Rate for Payer: Priority Health Choice Medicaid	$130.71
Rate for Payer: Priority Health Medicare	$238.96
Rate for Payer: Railroad Medicare Medicare	$238.96
Rate for Payer: UHC All Payor (Choice/PPO)	$399.44
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Dual Complete DSNP	$238.96
Rate for Payer: UHC Exchange	$363.13
Rate for Payer: UHC Medicare Advantage	$246.13
Rate for Payer: VA VA	$238.96

CLOSED TREATMENT OF KNEE DISLOCATION; REQUIRING ANESTHESIA

Facility

$4,301.45

Service Code	CPT 27552
Hospital Revenue Code	360
Min. Negotiated Rate	$635.56
Max. Negotiated Rate	$4,301.45
Rate for Payer: Aetna Medicare	$1,487.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,787.60
Rate for Payer: Amish Plain Church Group Commercial	$1,787.60
Rate for Payer: BCBS Complete	$821.44
Rate for Payer: BCBS MAPPO	$1,430.08
Rate for Payer: BCBS Trust/PPO	$758.50
Rate for Payer: BCN Medicare Advantage	$1,430.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,430.08
Rate for Payer: Mclaren Medicaid	$782.25
Rate for Payer: Mclaren Medicare	$1,430.08
Rate for Payer: Meridian Medicaid	$821.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,501.58
Rate for Payer: MI Amish Medical Board Commercial	$1,644.59
Rate for Payer: PACE Medicare	$1,358.58
Rate for Payer: PACE SWMI	$1,430.08
Rate for Payer: PHP Medicare Advantage	$1,430.08
Rate for Payer: Priority Health Choice Medicaid	$782.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,301.45
Rate for Payer: Priority Health Medicare	$1,430.08
Rate for Payer: Priority Health Narrow Network	$3,441.16
Rate for Payer: Railroad Medicare Medicare	$1,430.08
Rate for Payer: UHC All Payor (Choice/PPO)	$699.12
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,430.08
Rate for Payer: UHC Exchange	$635.56
Rate for Payer: UHC Medicare Advantage	$1,472.98
Rate for Payer: VA VA	$1,430.08

CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION

Facility

$8,530.92

Service Code	CPT 21320
Hospital Revenue Code	360
Min. Negotiated Rate	$93.32
Max. Negotiated Rate	$8,530.92
Rate for Payer: Aetna Medicare	$2,979.38
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,580.99
Rate for Payer: Amish Plain Church Group Commercial	$3,580.99
Rate for Payer: BCBS Complete	$1,645.54
Rate for Payer: BCBS MAPPO	$2,864.79
Rate for Payer: BCBS Trust/PPO	$1,474.05
Rate for Payer: BCN Medicare Advantage	$2,864.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,864.79
Rate for Payer: Mclaren Medicaid	$1,567.04
Rate for Payer: Mclaren Medicare	$2,864.79
Rate for Payer: Meridian Medicaid	$1,645.54
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,008.03
Rate for Payer: MI Amish Medical Board Commercial	$3,294.51
Rate for Payer: PACE Medicare	$2,721.55
Rate for Payer: PACE SWMI	$2,864.79
Rate for Payer: PHP Medicare Advantage	$2,864.79
Rate for Payer: Priority Health Choice Medicaid	$1,567.04
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,530.92
Rate for Payer: Priority Health Medicare	$2,864.79
Rate for Payer: Priority Health Narrow Network	$6,824.74
Rate for Payer: Railroad Medicare Medicare	$2,864.79
Rate for Payer: UHC All Payor (Choice/PPO)	$102.65
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$2,864.79
Rate for Payer: UHC Exchange	$93.32
Rate for Payer: UHC Medicare Advantage	$2,950.73
Rate for Payer: VA VA	$2,864.79

CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION

Facility

$1,787.60

Service Code	CPT 25565
Hospital Revenue Code	360
Min. Negotiated Rate	$471.84
Max. Negotiated Rate	$1,787.60
Rate for Payer: Aetna Medicare	$1,487.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,787.60
Rate for Payer: Amish Plain Church Group Commercial	$1,787.60
Rate for Payer: BCBS Complete	$821.44
Rate for Payer: BCBS MAPPO	$1,430.08
Rate for Payer: BCBS Trust/PPO	$587.48
Rate for Payer: BCN Medicare Advantage	$1,430.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,430.08
Rate for Payer: Mclaren Medicaid	$782.25
Rate for Payer: Mclaren Medicare	$1,430.08
Rate for Payer: Meridian Medicaid	$821.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,501.58
Rate for Payer: MI Amish Medical Board Commercial	$1,644.59
Rate for Payer: PACE Medicare	$1,358.58
Rate for Payer: PACE SWMI	$1,430.08
Rate for Payer: PHP Medicare Advantage	$1,430.08
Rate for Payer: Priority Health Choice Medicaid	$782.25
Rate for Payer: Priority Health Medicare	$1,430.08
Rate for Payer: Railroad Medicare Medicare	$1,430.08
Rate for Payer: UHC All Payor (Choice/PPO)	$519.02
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Dual Complete DSNP	$1,430.08
Rate for Payer: UHC Exchange	$471.84
Rate for Payer: UHC Medicare Advantage	$1,472.98
Rate for Payer: VA VA	$1,430.08

CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, WITH MANIPULATION

Facility

$1,787.60

Service Code	CPT 23665
Hospital Revenue Code	360
Min. Negotiated Rate	$407.99
Max. Negotiated Rate	$1,787.60
Rate for Payer: Aetna Medicare	$1,487.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,787.60
Rate for Payer: Amish Plain Church Group Commercial	$1,787.60
Rate for Payer: BCBS Complete	$821.44
Rate for Payer: BCBS MAPPO	$1,430.08
Rate for Payer: BCBS Trust/PPO	$443.27
Rate for Payer: BCN Medicare Advantage	$1,430.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,430.08
Rate for Payer: Mclaren Medicaid	$782.25
Rate for Payer: Mclaren Medicare	$1,430.08
Rate for Payer: Meridian Medicaid	$821.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,501.58
Rate for Payer: MI Amish Medical Board Commercial	$1,644.59
Rate for Payer: PACE Medicare	$1,358.58
Rate for Payer: PACE SWMI	$1,430.08
Rate for Payer: PHP Medicare Advantage	$1,430.08
Rate for Payer: Priority Health Choice Medicaid	$782.25
Rate for Payer: Priority Health Medicare	$1,430.08
Rate for Payer: Railroad Medicare Medicare	$1,430.08
Rate for Payer: UHC All Payor (Choice/PPO)	$448.79
Rate for Payer: UHC Core	$1,463.00
Rate for Payer: UHC Dual Complete DSNP	$1,430.08
Rate for Payer: UHC Exchange	$407.99
Rate for Payer: UHC Medicare Advantage	$1,472.98
Rate for Payer: VA VA	$1,430.08

CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA

Facility

$3,138.00

Service Code	CPT 23655
Hospital Revenue Code	360
Min. Negotiated Rate	$412.58
Max. Negotiated Rate	$3,138.00
Rate for Payer: Aetna Medicare	$1,487.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,787.60
Rate for Payer: Amish Plain Church Group Commercial	$1,787.60
Rate for Payer: BCBS Complete	$821.44
Rate for Payer: BCBS MAPPO	$1,430.08
Rate for Payer: BCBS Trust/PPO	$519.41
Rate for Payer: BCN Medicare Advantage	$1,430.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,430.08
Rate for Payer: Mclaren Medicaid	$782.25
Rate for Payer: Mclaren Medicare	$1,430.08
Rate for Payer: Meridian Medicaid	$821.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,501.58
Rate for Payer: MI Amish Medical Board Commercial	$1,644.59
Rate for Payer: PACE Medicare	$1,358.58
Rate for Payer: PACE SWMI	$1,430.08
Rate for Payer: PHP Medicare Advantage	$1,430.08
Rate for Payer: Priority Health Choice Medicaid	$782.25
Rate for Payer: Priority Health Medicare	$1,430.08
Rate for Payer: Railroad Medicare Medicare	$1,430.08
Rate for Payer: UHC All Payor (Choice/PPO)	$453.84
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,430.08
Rate for Payer: UHC Exchange	$412.58
Rate for Payer: UHC Medicare Advantage	$1,472.98
Rate for Payer: VA VA	$1,430.08

CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP

Facility

$5,427.00

Service Code	CPT 46288
Hospital Revenue Code	360
Min. Negotiated Rate	$552.72
Max. Negotiated Rate	$5,427.00
Rate for Payer: Aetna Medicare	$2,598.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,122.94
Rate for Payer: Amish Plain Church Group Commercial	$3,122.94
Rate for Payer: BCBS Complete	$1,435.05
Rate for Payer: BCBS MAPPO	$2,498.35
Rate for Payer: BCBS Trust/PPO	$1,249.12
Rate for Payer: BCN Medicare Advantage	$2,498.35
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,498.35
Rate for Payer: Mclaren Medicaid	$1,366.60
Rate for Payer: Mclaren Medicare	$2,498.35
Rate for Payer: Meridian Medicaid	$1,435.05
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,623.27
Rate for Payer: MI Amish Medical Board Commercial	$2,873.10
Rate for Payer: PACE Medicare	$2,373.43
Rate for Payer: PACE SWMI	$2,498.35
Rate for Payer: PHP Medicare Advantage	$2,498.35
Rate for Payer: Priority Health Choice Medicaid	$1,366.60
Rate for Payer: Priority Health Medicare	$2,498.35
Rate for Payer: Railroad Medicare Medicare	$2,498.35
Rate for Payer: UHC All Payor (Choice/PPO)	$607.99
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$2,498.35
Rate for Payer: UHC Exchange	$552.72
Rate for Payer: UHC Medicare Advantage	$2,573.30
Rate for Payer: VA VA	$2,498.35

CLOSURE OF GASTROSTOMY, SURGICAL

Facility

$4,259.61

Service Code	CPT 43870
Hospital Revenue Code	360
Min. Negotiated Rate	$698.76
Max. Negotiated Rate	$4,259.61
Rate for Payer: Aetna Medicare	$3,544.00
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,259.61
Rate for Payer: Amish Plain Church Group Commercial	$4,259.61
Rate for Payer: BCBS Complete	$1,957.38
Rate for Payer: BCBS MAPPO	$3,407.69
Rate for Payer: BCBS Trust/PPO	$1,149.48
Rate for Payer: BCN Medicare Advantage	$3,407.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,407.69
Rate for Payer: Mclaren Medicaid	$1,864.01
Rate for Payer: Mclaren Medicare	$3,407.69
Rate for Payer: Meridian Medicaid	$1,957.38
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,578.07
Rate for Payer: MI Amish Medical Board Commercial	$3,918.84
Rate for Payer: PACE Medicare	$3,237.31
Rate for Payer: PACE SWMI	$3,407.69
Rate for Payer: PHP Medicare Advantage	$3,407.69
Rate for Payer: Priority Health Choice Medicaid	$1,864.01
Rate for Payer: Priority Health Medicare	$3,407.69
Rate for Payer: Railroad Medicare Medicare	$3,407.69
Rate for Payer: UHC All Payor (Choice/PPO)	$768.64
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,407.69
Rate for Payer: UHC Exchange	$698.76
Rate for Payer: UHC Medicare Advantage	$3,509.92
Rate for Payer: VA VA	$3,407.69

CLOTRIMAZOLE 1 % TOPICAL CREAM

Facility

$36.23

Service Code	NDC 51672-1275-6
Hospital Charge Code	1767
Hospital Revenue Code	637
Min. Negotiated Rate	$22.82
Max. Negotiated Rate	$32.61
Rate for Payer: Aetna Commercial	$30.80
Rate for Payer: Aetna New Business (MI Preferred)	$23.55
Rate for Payer: Cash Price	$28.98
Rate for Payer: Cofinity Commercial	$25.36
Rate for Payer: Cofinity Commercial	$31.16
Rate for Payer: Healthscope Commercial	$32.61
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.80
Rate for Payer: PHP Commercial	$30.80
Rate for Payer: Priority Health Cigna Priority Health	$25.36
Rate for Payer: Priority Health SBD	$22.82

CLOTRIMAZOLE 1 % TOPICAL CREAM

Facility

$9.52

Service Code	NDC 0536-1265-26
Hospital Charge Code	1767
Hospital Revenue Code	637
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$8.57
Rate for Payer: Aetna Commercial	$8.09
Rate for Payer: Aetna New Business (MI Preferred)	$6.19
Rate for Payer: Cash Price	$7.62
Rate for Payer: Cofinity Commercial	$6.66
Rate for Payer: Cofinity Commercial	$8.19
Rate for Payer: Healthscope Commercial	$8.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8.09
Rate for Payer: PHP Commercial	$8.09
Rate for Payer: Priority Health Cigna Priority Health	$6.66
Rate for Payer: Priority Health SBD	$6.00

CLOTRIMAZOLE 1 % TOPICAL SOLUTION

Facility

$194.57

Service Code	NDC 51672-1260-3
Hospital Charge Code	1768
Hospital Revenue Code	637
Min. Negotiated Rate	$122.58
Max. Negotiated Rate	$175.11
Rate for Payer: Aetna Commercial	$165.38
Rate for Payer: Aetna New Business (MI Preferred)	$126.47
Rate for Payer: Cash Price	$155.66
Rate for Payer: Cofinity Commercial	$136.20
Rate for Payer: Cofinity Commercial	$167.33
Rate for Payer: Healthscope Commercial	$175.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$165.38
Rate for Payer: PHP Commercial	$165.38
Rate for Payer: Priority Health Cigna Priority Health	$136.20
Rate for Payer: Priority Health SBD	$122.58

CLOZAPINE 100 MG TABLET

Facility

$315.84

Service Code	NDC 0904-7087-61
Hospital Charge Code	9647
Hospital Revenue Code	637
Min. Negotiated Rate	$198.98
Max. Negotiated Rate	$284.26
Rate for Payer: Aetna Commercial	$268.46
Rate for Payer: Aetna New Business (MI Preferred)	$205.30
Rate for Payer: Cash Price	$252.67
Rate for Payer: Cofinity Commercial	$221.09
Rate for Payer: Cofinity Commercial	$271.62
Rate for Payer: Healthscope Commercial	$284.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$268.46
Rate for Payer: PHP Commercial	$268.46
Rate for Payer: Priority Health Cigna Priority Health	$221.09
Rate for Payer: Priority Health SBD	$198.98

CLOZAPINE 100 MG TABLET

Facility

$368.16

Service Code	NDC 51079-922-20
Hospital Charge Code	9647
Hospital Revenue Code	637
Min. Negotiated Rate	$231.94
Max. Negotiated Rate	$331.34
Rate for Payer: Aetna Commercial	$312.94
Rate for Payer: Aetna New Business (MI Preferred)	$239.30
Rate for Payer: Cash Price	$294.53
Rate for Payer: Cofinity Commercial	$257.71
Rate for Payer: Cofinity Commercial	$316.62
Rate for Payer: Healthscope Commercial	$331.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$312.94
Rate for Payer: PHP Commercial	$312.94
Rate for Payer: Priority Health Cigna Priority Health	$257.71
Rate for Payer: Priority Health SBD	$231.94

CLOZAPINE 100 MG TABLET

Facility

$794.76

Service Code	NDC 0093-7772-01
Hospital Charge Code	9647
Hospital Revenue Code	637
Min. Negotiated Rate	$500.70
Max. Negotiated Rate	$715.28
Rate for Payer: Aetna Commercial	$675.55
Rate for Payer: Aetna New Business (MI Preferred)	$516.59
Rate for Payer: Cash Price	$635.81
Rate for Payer: Cofinity Commercial	$556.33
Rate for Payer: Cofinity Commercial	$683.49
Rate for Payer: Healthscope Commercial	$715.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$675.55
Rate for Payer: PHP Commercial	$675.55
Rate for Payer: Priority Health Cigna Priority Health	$556.33
Rate for Payer: Priority Health SBD	$500.70

CLOZAPINE 100 MG TABLET

Facility

$270.24

Service Code	NDC 65862-846-01
Hospital Charge Code	9647
Hospital Revenue Code	637
Min. Negotiated Rate	$170.25
Max. Negotiated Rate	$243.22
Rate for Payer: Aetna Commercial	$229.70
Rate for Payer: Aetna New Business (MI Preferred)	$175.66
Rate for Payer: Cash Price	$216.19
Rate for Payer: Cofinity Commercial	$189.17
Rate for Payer: Cofinity Commercial	$232.41
Rate for Payer: Healthscope Commercial	$243.22
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$229.70
Rate for Payer: PHP Commercial	$229.70
Rate for Payer: Priority Health Cigna Priority Health	$189.17
Rate for Payer: Priority Health SBD	$170.25

CLOZAPINE 100 MG TABLET

Facility

$48.36

Service Code	NDC 0078-0127-61
Hospital Charge Code	9647
Hospital Revenue Code	637
Min. Negotiated Rate	$30.47
Max. Negotiated Rate	$43.52
Rate for Payer: Aetna Commercial	$41.11
Rate for Payer: Aetna New Business (MI Preferred)	$31.43
Rate for Payer: Cash Price	$38.69
Rate for Payer: Cofinity Commercial	$33.85
Rate for Payer: Cofinity Commercial	$41.59
Rate for Payer: Healthscope Commercial	$43.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$41.11
Rate for Payer: PHP Commercial	$41.11
Rate for Payer: Priority Health Cigna Priority Health	$33.85
Rate for Payer: Priority Health SBD	$30.47

CLOZAPINE 100 MG TABLET

Facility

$3.69

Service Code	NDC 51079-922-01
Hospital Charge Code	9647
Hospital Revenue Code	637
Min. Negotiated Rate	$2.32
Max. Negotiated Rate	$3.32
Rate for Payer: Aetna Commercial	$3.14
Rate for Payer: Aetna New Business (MI Preferred)	$2.40
Rate for Payer: Cash Price	$2.95
Rate for Payer: Cofinity Commercial	$2.58
Rate for Payer: Cofinity Commercial	$3.17
Rate for Payer: Healthscope Commercial	$3.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.14
Rate for Payer: PHP Commercial	$3.14
Rate for Payer: Priority Health Cigna Priority Health	$2.58
Rate for Payer: Priority Health SBD	$2.32

CLOZAPINE 25 MG TABLET

Facility

$2.90

Service Code	NDC 51079-921-01
Hospital Charge Code	9648
Hospital Revenue Code	637
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.61
Rate for Payer: Aetna Commercial	$2.46
Rate for Payer: Aetna New Business (MI Preferred)	$1.88
Rate for Payer: Cash Price	$2.32
Rate for Payer: Cofinity Commercial	$2.03
Rate for Payer: Cofinity Commercial	$2.49
Rate for Payer: Healthscope Commercial	$2.61
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.46
Rate for Payer: PHP Commercial	$2.46
Rate for Payer: Priority Health Cigna Priority Health	$2.03
Rate for Payer: Priority Health SBD	$1.83

CLOZAPINE 25 MG TABLET

Facility

$289.75

Service Code	NDC 51079-921-20
Hospital Charge Code	9648
Hospital Revenue Code	637
Min. Negotiated Rate	$182.54
Max. Negotiated Rate	$260.78
Rate for Payer: Aetna Commercial	$246.29
Rate for Payer: Aetna New Business (MI Preferred)	$188.34
Rate for Payer: Cash Price	$231.80
Rate for Payer: Cofinity Commercial	$202.82
Rate for Payer: Cofinity Commercial	$249.18
Rate for Payer: Healthscope Commercial	$260.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$246.29
Rate for Payer: PHP Commercial	$246.29
Rate for Payer: Priority Health Cigna Priority Health	$202.82
Rate for Payer: Priority Health SBD	$182.54

Know your out-of-pocket cost for care.

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