Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.72

Service Code	NDC 51079-306-01
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$4.23
Max. Negotiated Rate	$6.05
Rate for Payer: Aetna Commercial	$5.71
Rate for Payer: Aetna New Business (MI Preferred)	$4.37
Rate for Payer: Cash Price	$5.38
Rate for Payer: Cofinity Commercial	$4.70
Rate for Payer: Cofinity Commercial	$5.78
Rate for Payer: Healthscope Commercial	$6.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5.71
Rate for Payer: PHP Commercial	$5.71
Rate for Payer: Priority Health Cigna Priority Health	$4.70
Rate for Payer: Priority Health SBD	$4.23

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$7.16

Service Code	NDC 45802-868-00
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$4.51
Max. Negotiated Rate	$6.44
Rate for Payer: Aetna Commercial	$6.09
Rate for Payer: Aetna New Business (MI Preferred)	$4.65
Rate for Payer: Cash Price	$5.73
Rate for Payer: Cofinity Commercial	$5.01
Rate for Payer: Cofinity Commercial	$6.16
Rate for Payer: Healthscope Commercial	$6.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.09
Rate for Payer: PHP Commercial	$6.09
Rate for Payer: Priority Health Cigna Priority Health	$5.01
Rate for Payer: Priority Health SBD	$4.51

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$69.89

Service Code	NDC 68084-430-99
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$44.03
Max. Negotiated Rate	$62.90
Rate for Payer: Aetna Commercial	$59.41
Rate for Payer: Aetna New Business (MI Preferred)	$45.43
Rate for Payer: Cash Price	$55.91
Rate for Payer: Cofinity Commercial	$48.92
Rate for Payer: Cofinity Commercial	$60.11
Rate for Payer: Healthscope Commercial	$62.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.41
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health Cigna Priority Health	$48.92
Rate for Payer: Priority Health SBD	$44.03

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$11.06

Service Code	NDC 69784-180-01
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$9.95
Rate for Payer: Aetna Commercial	$9.40
Rate for Payer: Aetna New Business (MI Preferred)	$7.19
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cofinity Commercial	$7.74
Rate for Payer: Cofinity Commercial	$9.51
Rate for Payer: Healthscope Commercial	$9.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$9.40
Rate for Payer: PHP Commercial	$9.40
Rate for Payer: Priority Health Cigna Priority Health	$7.74
Rate for Payer: Priority Health SBD	$6.97

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$605.28

Service Code	NDC 60687-431-92
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$381.33
Max. Negotiated Rate	$544.75
Rate for Payer: Aetna Commercial	$514.49
Rate for Payer: Aetna New Business (MI Preferred)	$393.43
Rate for Payer: Cash Price	$484.22
Rate for Payer: Cofinity Commercial	$423.70
Rate for Payer: Cofinity Commercial	$520.54
Rate for Payer: Healthscope Commercial	$544.75
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$514.49
Rate for Payer: PHP Commercial	$514.49
Rate for Payer: Priority Health Cigna Priority Health	$423.70
Rate for Payer: Priority Health SBD	$381.33

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.06

Service Code	NDC 60687-431-99
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$5.15
Rate for Payer: Aetna New Business (MI Preferred)	$3.94
Rate for Payer: Cash Price	$4.85
Rate for Payer: Cofinity Commercial	$4.24
Rate for Payer: Cofinity Commercial	$5.21
Rate for Payer: Healthscope Commercial	$5.45
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5.15
Rate for Payer: PHP Commercial	$5.15
Rate for Payer: Priority Health Cigna Priority Health	$4.24
Rate for Payer: Priority Health SBD	$3.82

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS

Facility

$35.46

Service Code	NDC 60758-908-10
Hospital Charge Code	109275
Hospital Revenue Code	637
Min. Negotiated Rate	$22.34
Max. Negotiated Rate	$31.91
Rate for Payer: Aetna Commercial	$30.14
Rate for Payer: Aetna New Business (MI Preferred)	$23.05
Rate for Payer: Cash Price	$28.37
Rate for Payer: Cofinity Commercial	$24.82
Rate for Payer: Cofinity Commercial	$30.50
Rate for Payer: Healthscope Commercial	$31.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.14
Rate for Payer: PHP Commercial	$30.14
Rate for Payer: Priority Health Cigna Priority Health	$24.82
Rate for Payer: Priority Health SBD	$22.34

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS

Facility

$35.00

Service Code	NDC 24208-315-10
Hospital Charge Code	109275
Hospital Revenue Code	637
Min. Negotiated Rate	$22.05
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Commercial	$29.75
Rate for Payer: Aetna New Business (MI Preferred)	$22.75
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cofinity Commercial	$24.50
Rate for Payer: Cofinity Commercial	$30.10
Rate for Payer: Healthscope Commercial	$31.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$29.75
Rate for Payer: PHP Commercial	$29.75
Rate for Payer: Priority Health Cigna Priority Health	$24.50
Rate for Payer: Priority Health SBD	$22.05

POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION

Facility

$23.40

Service Code	NDC 55150-234-10
Hospital Charge Code	6393
Hospital Revenue Code	250
Min. Negotiated Rate	$14.74
Max. Negotiated Rate	$21.06
Rate for Payer: Aetna Commercial	$19.89
Rate for Payer: Aetna New Business (MI Preferred)	$15.21
Rate for Payer: Cash Price	$18.72
Rate for Payer: Cofinity Commercial	$16.38
Rate for Payer: Cofinity Commercial	$20.12
Rate for Payer: Healthscope Commercial	$21.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.89
Rate for Payer: PHP Commercial	$19.89
Rate for Payer: Priority Health Cigna Priority Health	$16.38
Rate for Payer: Priority Health SBD	$14.74

POLYVINYL ALCOHOL 1.4 % EYE DROPS

Facility

$92.34

Service Code	NDC 17478-060-12
Hospital Charge Code	27994
Hospital Revenue Code	637
Min. Negotiated Rate	$58.17
Max. Negotiated Rate	$83.11
Rate for Payer: Aetna Commercial	$78.49
Rate for Payer: Aetna New Business (MI Preferred)	$60.02
Rate for Payer: Cash Price	$73.87
Rate for Payer: Cofinity Commercial	$64.64
Rate for Payer: Cofinity Commercial	$79.41
Rate for Payer: Healthscope Commercial	$83.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$78.49
Rate for Payer: PHP Commercial	$78.49
Rate for Payer: Priority Health Cigna Priority Health	$64.64
Rate for Payer: Priority Health SBD	$58.17

POLYVINYL ALCOHOL 1.4 % EYE DROPS

Facility

$58.14

Service Code	NDC 0536-1325-94
Hospital Charge Code	27994
Hospital Revenue Code	637
Min. Negotiated Rate	$36.63
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$40.70
Rate for Payer: Priority Health SBD	$36.63

POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY

Facility

$5,532.19

Service Code	CPT 57250
Hospital Revenue Code	360
Min. Negotiated Rate	$608.71
Max. Negotiated Rate	$5,532.19
Rate for Payer: Aetna Medicare	$4,602.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$5,532.19
Rate for Payer: Amish Plain Church Group Commercial	$5,532.19
Rate for Payer: BCBS Complete	$2,542.15
Rate for Payer: BCBS MAPPO	$4,425.75
Rate for Payer: BCBS Trust/PPO	$2,611.10
Rate for Payer: BCN Medicare Advantage	$4,425.75
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,425.75
Rate for Payer: Mclaren Medicaid	$2,420.89
Rate for Payer: Mclaren Medicare	$4,425.75
Rate for Payer: Meridian Medicaid	$2,542.15
Rate for Payer: Meridian Wellcare - Medicare Advantage	$4,647.04
Rate for Payer: MI Amish Medical Board Commercial	$5,089.61
Rate for Payer: PACE Medicare	$4,204.46
Rate for Payer: PACE SWMI	$4,425.75
Rate for Payer: PHP Medicare Advantage	$4,425.75
Rate for Payer: Priority Health Choice Medicaid	$2,420.89
Rate for Payer: Priority Health Medicare	$4,425.75
Rate for Payer: Railroad Medicare Medicare	$4,425.75
Rate for Payer: UHC All Payor (Choice/PPO)	$669.58
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$4,425.75
Rate for Payer: UHC Exchange	$608.71
Rate for Payer: UHC Medicare Advantage	$4,558.52
Rate for Payer: VA VA	$4,425.75

POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,573.81

Service Code	CPT 22842
Hospital Revenue Code	360
Min. Negotiated Rate	$746.90
Max. Negotiated Rate	$1,573.81
Rate for Payer: BCBS Trust/PPO	$1,573.81
Rate for Payer: UHC All Payor (Choice/PPO)	$821.59
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Exchange	$746.90

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

Facility

$28,097.87

Service Code	MS-DRG 862
Min. Negotiated Rate	$13,070.53
Max. Negotiated Rate	$28,097.87
Rate for Payer: Aetna Medicare	$14,308.79
Rate for Payer: Allen County Amish Medical Aid Commercial	$17,198.06
Rate for Payer: Amish Plain Church Group Commercial	$17,198.06
Rate for Payer: BCBS MAPPO	$13,758.45
Rate for Payer: BCBS Trust/PPO	$20,441.63
Rate for Payer: BCN Medicare Advantage	$13,758.45
Rate for Payer: Health Alliance Plan Medicare Advantage	$13,758.45
Rate for Payer: Mclaren Medicare	$13,758.45
Rate for Payer: Meridian Wellcare - Medicare Advantage	$14,446.37
Rate for Payer: MI Amish Medical Board Commercial	$15,822.22
Rate for Payer: PACE Medicare	$13,070.53
Rate for Payer: PACE SWMI	$13,758.45
Rate for Payer: PHP Medicare Advantage	$13,758.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$26,432.55
Rate for Payer: Priority Health Medicare	$13,758.45
Rate for Payer: Priority Health Narrow Network	$21,146.04
Rate for Payer: Railroad Medicare Medicare	$13,758.45
Rate for Payer: UHC All Payor (Choice/PPO)	$28,097.87
Rate for Payer: UHC Core	$17,241.12
Rate for Payer: UHC Dual Complete DSNP	$13,758.45
Rate for Payer: UHC Exchange	$18,466.05
Rate for Payer: UHC Medicare Advantage	$14,171.20
Rate for Payer: VA VA	$13,758.45

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

Facility

$15,337.90

Service Code	MS-DRG 863
Min. Negotiated Rate	$7,347.42
Max. Negotiated Rate	$15,337.90
Rate for Payer: Aetna Medicare	$8,043.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,667.66
Rate for Payer: Amish Plain Church Group Commercial	$9,667.66
Rate for Payer: BCBS MAPPO	$7,734.13
Rate for Payer: BCBS Trust/PPO	$14,077.91
Rate for Payer: BCN Medicare Advantage	$7,734.13
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,734.13
Rate for Payer: Mclaren Medicare	$7,734.13
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,120.84
Rate for Payer: MI Amish Medical Board Commercial	$8,894.25
Rate for Payer: PACE Medicare	$7,347.42
Rate for Payer: PACE SWMI	$7,734.13
Rate for Payer: PHP Medicare Advantage	$7,734.13
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14,428.84
Rate for Payer: Priority Health Medicare	$7,734.13
Rate for Payer: Priority Health Narrow Network	$11,543.07
Rate for Payer: Railroad Medicare Medicare	$7,734.13
Rate for Payer: UHC All Payor (Choice/PPO)	$15,337.90
Rate for Payer: UHC Core	$9,411.48
Rate for Payer: UHC Dual Complete DSNP	$7,734.13
Rate for Payer: UHC Exchange	$10,080.14
Rate for Payer: UHC Medicare Advantage	$7,966.15
Rate for Payer: VA VA	$7,734.13

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC

Facility

$32,577.97

Service Code	MS-DRG 857
Min. Negotiated Rate	$15,079.92
Max. Negotiated Rate	$32,577.97
Rate for Payer: Aetna Medicare	$16,508.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$19,842.00
Rate for Payer: Amish Plain Church Group Commercial	$19,842.00
Rate for Payer: BCBS MAPPO	$15,873.60
Rate for Payer: BCBS Trust/PPO	$28,946.35
Rate for Payer: BCN Medicare Advantage	$15,873.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$15,873.60
Rate for Payer: Mclaren Medicare	$15,873.60
Rate for Payer: Meridian Wellcare - Medicare Advantage	$16,667.28
Rate for Payer: MI Amish Medical Board Commercial	$18,254.64
Rate for Payer: PACE Medicare	$15,079.92
Rate for Payer: PACE SWMI	$15,873.60
Rate for Payer: PHP Medicare Advantage	$15,873.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$30,647.12
Rate for Payer: Priority Health Medicare	$15,873.60
Rate for Payer: Priority Health Narrow Network	$24,517.70
Rate for Payer: Railroad Medicare Medicare	$15,873.60
Rate for Payer: UHC All Payor (Choice/PPO)	$32,577.97
Rate for Payer: UHC Core	$19,990.15
Rate for Payer: UHC Dual Complete DSNP	$15,873.60
Rate for Payer: UHC Exchange	$21,410.39
Rate for Payer: UHC Medicare Advantage	$16,349.81
Rate for Payer: VA VA	$15,873.60

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC

Facility

$71,384.32

Service Code	MS-DRG 856
Min. Negotiated Rate	$30,765.88
Max. Negotiated Rate	$71,384.32
Rate for Payer: Aetna Medicare	$33,680.55
Rate for Payer: Allen County Amish Medical Aid Commercial	$40,481.42
Rate for Payer: Amish Plain Church Group Commercial	$40,481.42
Rate for Payer: BCBS MAPPO	$32,385.14
Rate for Payer: BCBS Trust/PPO	$71,384.32
Rate for Payer: BCN Medicare Advantage	$32,385.14
Rate for Payer: Health Alliance Plan Medicare Advantage	$32,385.14
Rate for Payer: Mclaren Medicare	$32,385.14
Rate for Payer: Meridian Wellcare - Medicare Advantage	$34,004.40
Rate for Payer: MI Amish Medical Board Commercial	$37,242.91
Rate for Payer: PACE Medicare	$30,765.88
Rate for Payer: PACE SWMI	$32,385.14
Rate for Payer: PHP Medicare Advantage	$32,385.14
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$63,547.19
Rate for Payer: Priority Health Medicare	$32,385.14
Rate for Payer: Priority Health Narrow Network	$50,837.75
Rate for Payer: Railroad Medicare Medicare	$32,385.14
Rate for Payer: UHC All Payor (Choice/PPO)	$67,550.81
Rate for Payer: UHC Core	$41,449.82
Rate for Payer: UHC Dual Complete DSNP	$32,385.14
Rate for Payer: UHC Exchange	$44,394.71
Rate for Payer: UHC Medicare Advantage	$33,356.69
Rate for Payer: VA VA	$32,385.14

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$20,164.95

Service Code	MS-DRG 858
Min. Negotiated Rate	$9,248.74
Max. Negotiated Rate	$20,164.95
Rate for Payer: Aetna Medicare	$10,124.94
Rate for Payer: Allen County Amish Medical Aid Commercial	$12,169.40
Rate for Payer: Amish Plain Church Group Commercial	$12,169.40
Rate for Payer: BCBS MAPPO	$9,735.52
Rate for Payer: BCBS Trust/PPO	$20,164.95
Rate for Payer: BCN Medicare Advantage	$9,735.52
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,735.52
Rate for Payer: Mclaren Medicare	$9,735.52
Rate for Payer: Meridian Wellcare - Medicare Advantage	$10,222.30
Rate for Payer: MI Amish Medical Board Commercial	$11,195.85
Rate for Payer: PACE Medicare	$9,248.74
Rate for Payer: PACE SWMI	$9,735.52
Rate for Payer: PHP Medicare Advantage	$9,735.52
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$18,416.69
Rate for Payer: Priority Health Medicare	$9,735.52
Rate for Payer: Priority Health Narrow Network	$14,733.35
Rate for Payer: Railroad Medicare Medicare	$9,735.52
Rate for Payer: UHC All Payor (Choice/PPO)	$19,576.98
Rate for Payer: UHC Core	$12,012.62
Rate for Payer: UHC Dual Complete DSNP	$9,735.52
Rate for Payer: UHC Exchange	$12,866.09
Rate for Payer: UHC Medicare Advantage	$10,027.59
Rate for Payer: VA VA	$9,735.52

POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES

Facility

$26,129.01

Service Code	MS-DRG 769
Min. Negotiated Rate	$11,030.99
Max. Negotiated Rate	$26,129.01
Rate for Payer: Aetna Medicare	$12,076.03
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,514.46
Rate for Payer: Amish Plain Church Group Commercial	$14,514.46
Rate for Payer: BCBS MAPPO	$11,611.57
Rate for Payer: BCBS Trust/PPO	$26,129.01
Rate for Payer: BCN Medicare Advantage	$11,611.57
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,611.57
Rate for Payer: Mclaren Medicare	$11,611.57
Rate for Payer: Meridian Wellcare - Medicare Advantage	$12,192.15
Rate for Payer: MI Amish Medical Board Commercial	$13,353.31
Rate for Payer: PACE Medicare	$11,030.99
Rate for Payer: PACE SWMI	$11,611.57
Rate for Payer: PHP Medicare Advantage	$11,611.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22,154.84
Rate for Payer: Priority Health Medicare	$11,611.57
Rate for Payer: Priority Health Narrow Network	$17,723.87
Rate for Payer: Railroad Medicare Medicare	$11,611.57
Rate for Payer: UHC All Payor (Choice/PPO)	$23,550.65
Rate for Payer: UHC Core	$14,450.90
Rate for Payer: UHC Dual Complete DSNP	$11,611.57
Rate for Payer: UHC Exchange	$15,477.60
Rate for Payer: UHC Medicare Advantage	$11,959.92
Rate for Payer: VA VA	$11,611.57

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES

Facility

$10,932.54

Service Code	MS-DRG 776
Min. Negotiated Rate	$5,371.54
Max. Negotiated Rate	$10,932.54
Rate for Payer: Aetna Medicare	$5,880.42
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,067.81
Rate for Payer: Amish Plain Church Group Commercial	$7,067.81
Rate for Payer: BCBS MAPPO	$5,654.25
Rate for Payer: BCBS Trust/PPO	$7,165.22
Rate for Payer: BCN Medicare Advantage	$5,654.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,654.25
Rate for Payer: Mclaren Medicare	$5,654.25
Rate for Payer: Meridian Wellcare - Medicare Advantage	$5,936.96
Rate for Payer: MI Amish Medical Board Commercial	$6,502.39
Rate for Payer: PACE Medicare	$5,371.54
Rate for Payer: PACE SWMI	$5,654.25
Rate for Payer: PHP Medicare Advantage	$5,654.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,284.59
Rate for Payer: Priority Health Medicare	$5,654.25
Rate for Payer: Priority Health Narrow Network	$8,227.67
Rate for Payer: Railroad Medicare Medicare	$5,654.25
Rate for Payer: UHC All Payor (Choice/PPO)	$10,932.54
Rate for Payer: UHC Core	$6,708.31
Rate for Payer: UHC Dual Complete DSNP	$5,654.25
Rate for Payer: UHC Exchange	$7,184.92
Rate for Payer: UHC Medicare Advantage	$5,823.88
Rate for Payer: VA VA	$5,654.25

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$38.50

Service Code	NDC 0409-3294-15
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$34.65
Rate for Payer: Aetna Commercial	$32.72
Rate for Payer: Aetna New Business (MI Preferred)	$25.02
Rate for Payer: Cash Price	$30.80
Rate for Payer: Cofinity Commercial	$26.95
Rate for Payer: Cofinity Commercial	$33.11
Rate for Payer: Healthscope Commercial	$34.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$32.72
Rate for Payer: PHP Commercial	$32.72
Rate for Payer: Priority Health Cigna Priority Health	$26.95
Rate for Payer: Priority Health SBD	$24.26

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$38.50

Service Code	NDC 0409-3294-25
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$34.65
Rate for Payer: Aetna Commercial	$32.72
Rate for Payer: Aetna New Business (MI Preferred)	$25.02
Rate for Payer: Cash Price	$30.80
Rate for Payer: Cofinity Commercial	$26.95
Rate for Payer: Cofinity Commercial	$33.11
Rate for Payer: Healthscope Commercial	$34.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$32.72
Rate for Payer: PHP Commercial	$32.72
Rate for Payer: Priority Health Cigna Priority Health	$26.95
Rate for Payer: Priority Health SBD	$24.26

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$38.50

Service Code	NDC 0409-3294-61
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$34.65
Rate for Payer: Aetna Commercial	$32.72
Rate for Payer: Aetna New Business (MI Preferred)	$25.02
Rate for Payer: Cash Price	$30.80
Rate for Payer: Cofinity Commercial	$26.95
Rate for Payer: Cofinity Commercial	$33.11
Rate for Payer: Healthscope Commercial	$34.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$32.72
Rate for Payer: PHP Commercial	$32.72
Rate for Payer: Priority Health Cigna Priority Health	$26.95
Rate for Payer: Priority Health SBD	$24.26

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$38.50

Service Code	NDC 0409-3294-51
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$34.65
Rate for Payer: Aetna Commercial	$32.72
Rate for Payer: Aetna New Business (MI Preferred)	$25.02
Rate for Payer: Cash Price	$30.80
Rate for Payer: Cofinity Commercial	$26.95
Rate for Payer: Cofinity Commercial	$33.11
Rate for Payer: Healthscope Commercial	$34.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$32.72
Rate for Payer: PHP Commercial	$32.72
Rate for Payer: Priority Health Cigna Priority Health	$26.95
Rate for Payer: Priority Health SBD	$24.26

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION (TPN COMPONENT)

Facility

$31.15

Service Code	NDC 9900-0019-17
Hospital Charge Code	300443
Hospital Revenue Code	250
Min. Negotiated Rate	$19.62
Max. Negotiated Rate	$28.04
Rate for Payer: Aetna Commercial	$26.48
Rate for Payer: Aetna New Business (MI Preferred)	$20.25
Rate for Payer: Cash Price	$24.92
Rate for Payer: Cofinity Commercial	$21.80
Rate for Payer: Cofinity Commercial	$26.79
Rate for Payer: Healthscope Commercial	$28.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$26.48
Rate for Payer: PHP Commercial	$26.48
Rate for Payer: Priority Health Cigna Priority Health	$21.80
Rate for Payer: Priority Health SBD	$19.62

Know your out-of-pocket cost for care.

All Charges