Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

ISOSORBIDE MONONITRATE 20 MG TABLET

Facility

$1,242.09

Service Code	NDC 81665010310
Hospital Charge Code	10357
Hospital Revenue Code	637
Min. Negotiated Rate	$488.14
Max. Negotiated Rate	$1,117.88
Rate for Payer: Aetna Commercial	$1,055.78
Rate for Payer: Aetna Medicare	$621.04
Rate for Payer: Aetna New Business (MI Preferred)	$807.36
Rate for Payer: BCBS Complete	$496.84
Rate for Payer: Cash Price	$993.67
Rate for Payer: Cofinity Advantage	$869.46
Rate for Payer: Cofinity Commercial	$1,068.20
Rate for Payer: Encore Health Key Benefits Commercial	$993.67
Rate for Payer: Healthscope Commercial	$1,117.88
Rate for Payer: MI Amish Medical Board Commercial	$993.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,055.78
Rate for Payer: Opus (Opus Packaging Group) HMA	$931.57
Rate for Payer: PHP Commercial	$1,055.78
Rate for Payer: Priority Health SBD	$782.52
Rate for Payer: UHC All Payor (Choice/PPO)	$807.36
Rate for Payer: UHC Core	$647.13
Rate for Payer: UHC Exchange	$488.14

ISOSORBIDE MONONITRATE 20 MG TABLET

Facility

$392.45

Service Code	NDC 00228262011
Hospital Charge Code	10357
Hospital Revenue Code	637
Min. Negotiated Rate	$247.24
Max. Negotiated Rate	$353.20
Rate for Payer: Aetna Commercial	$333.58
Rate for Payer: Aetna New Business (MI Preferred)	$255.09
Rate for Payer: Cash Price	$313.96
Rate for Payer: Cofinity Advantage	$274.71
Rate for Payer: Cofinity Commercial	$337.51
Rate for Payer: Encore Health Key Benefits Commercial	$313.96
Rate for Payer: Healthscope Commercial	$353.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$333.58
Rate for Payer: Opus (Opus Packaging Group) HMA	$294.34
Rate for Payer: PHP Commercial	$333.58
Rate for Payer: Priority Health SBD	$247.24

ISOSORBIDE MONONITRATE 20 MG TABLET

Facility

$392.45

Service Code	NDC 00228262011
Hospital Charge Code	10357
Hospital Revenue Code	637
Min. Negotiated Rate	$154.23
Max. Negotiated Rate	$353.20
Rate for Payer: Aetna Commercial	$333.58
Rate for Payer: Aetna Medicare	$196.22
Rate for Payer: Aetna New Business (MI Preferred)	$255.09
Rate for Payer: BCBS Complete	$156.98
Rate for Payer: Cash Price	$313.96
Rate for Payer: Cofinity Advantage	$274.71
Rate for Payer: Cofinity Commercial	$337.51
Rate for Payer: Encore Health Key Benefits Commercial	$313.96
Rate for Payer: Healthscope Commercial	$353.20
Rate for Payer: MI Amish Medical Board Commercial	$313.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$333.58
Rate for Payer: Opus (Opus Packaging Group) HMA	$294.34
Rate for Payer: PHP Commercial	$333.58
Rate for Payer: Priority Health SBD	$247.24
Rate for Payer: UHC All Payor (Choice/PPO)	$255.09
Rate for Payer: UHC Core	$204.47
Rate for Payer: UHC Exchange	$154.23

ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$245.10

Service Code	NDC 00904644961
Hospital Charge Code	24521
Hospital Revenue Code	637
Min. Negotiated Rate	$154.41
Max. Negotiated Rate	$220.59
Rate for Payer: Aetna Commercial	$208.34
Rate for Payer: Aetna New Business (MI Preferred)	$159.31
Rate for Payer: Cash Price	$196.08
Rate for Payer: Cofinity Advantage	$171.57
Rate for Payer: Cofinity Commercial	$210.79
Rate for Payer: Encore Health Key Benefits Commercial	$196.08
Rate for Payer: Healthscope Commercial	$220.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$208.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$183.82
Rate for Payer: PHP Commercial	$208.34
Rate for Payer: Priority Health SBD	$154.41

ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$245.10

Service Code	NDC 00904644961
Hospital Charge Code	24521
Hospital Revenue Code	637
Min. Negotiated Rate	$96.32
Max. Negotiated Rate	$220.59
Rate for Payer: Aetna Commercial	$208.34
Rate for Payer: Aetna Medicare	$122.55
Rate for Payer: Aetna New Business (MI Preferred)	$159.31
Rate for Payer: BCBS Complete	$98.04
Rate for Payer: Cash Price	$196.08
Rate for Payer: Cofinity Advantage	$171.57
Rate for Payer: Cofinity Commercial	$210.79
Rate for Payer: Encore Health Key Benefits Commercial	$196.08
Rate for Payer: Healthscope Commercial	$220.59
Rate for Payer: MI Amish Medical Board Commercial	$196.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$208.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$183.82
Rate for Payer: PHP Commercial	$208.34
Rate for Payer: Priority Health SBD	$154.41
Rate for Payer: UHC All Payor (Choice/PPO)	$159.31
Rate for Payer: UHC Core	$127.70
Rate for Payer: UHC Exchange	$96.32

ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$292.60

Service Code	NDC 00904645061
Hospital Charge Code	24268
Hospital Revenue Code	637
Min. Negotiated Rate	$114.99
Max. Negotiated Rate	$263.34
Rate for Payer: Aetna Commercial	$248.71
Rate for Payer: Aetna Medicare	$146.30
Rate for Payer: Aetna New Business (MI Preferred)	$190.19
Rate for Payer: BCBS Complete	$117.04
Rate for Payer: Cash Price	$234.08
Rate for Payer: Cofinity Advantage	$204.82
Rate for Payer: Cofinity Commercial	$251.64
Rate for Payer: Encore Health Key Benefits Commercial	$234.08
Rate for Payer: Healthscope Commercial	$263.34
Rate for Payer: MI Amish Medical Board Commercial	$234.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$248.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$219.45
Rate for Payer: PHP Commercial	$248.71
Rate for Payer: Priority Health SBD	$184.34
Rate for Payer: UHC All Payor (Choice/PPO)	$190.19
Rate for Payer: UHC Core	$152.44
Rate for Payer: UHC Exchange	$114.99

ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$292.60

Service Code	NDC 00904645061
Hospital Charge Code	24268
Hospital Revenue Code	637
Min. Negotiated Rate	$184.34
Max. Negotiated Rate	$263.34
Rate for Payer: Aetna Commercial	$248.71
Rate for Payer: Aetna New Business (MI Preferred)	$190.19
Rate for Payer: Cash Price	$234.08
Rate for Payer: Cofinity Advantage	$204.82
Rate for Payer: Cofinity Commercial	$251.64
Rate for Payer: Encore Health Key Benefits Commercial	$234.08
Rate for Payer: Healthscope Commercial	$263.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$248.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$219.45
Rate for Payer: PHP Commercial	$248.71
Rate for Payer: Priority Health SBD	$184.34

ISOSOURCE 1.5 BOLUS FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	150768
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05

ISOSOURCE 1.5 BOLUS FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	150768
Hospital Revenue Code	637
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna Commercial	$4.04
Rate for Payer: Aetna Medicare	$2.38
Rate for Payer: Aetna New Business (MI Preferred)	$3.09
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Advantage	$3.33
Rate for Payer: Cofinity Commercial	$4.08
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: PHP Commercial	$4.04
Rate for Payer: Priority Health SBD	$2.99
Rate for Payer: UHC All Payor (Choice/PPO)	$3.09
Rate for Payer: UHC Core	$2.47
Rate for Payer: UHC Exchange	$1.87

ISOSOURCE 1.5 BOLUS FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	150768
Hospital Revenue Code	637
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna Medicare	$4.80
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05
Rate for Payer: UHC All Payor (Choice/PPO)	$6.24
Rate for Payer: UHC Core	$5.00
Rate for Payer: UHC Exchange	$3.77

ISOSOURCE 1.5 BOLUS FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	150768
Hospital Revenue Code	637
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna Commercial	$4.04
Rate for Payer: Aetna New Business (MI Preferred)	$3.09
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Advantage	$3.33
Rate for Payer: Cofinity Commercial	$4.08
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: PHP Commercial	$4.04
Rate for Payer: Priority Health SBD	$2.99

ISOSOURCE 1.5 CONTINUOUS FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	168943
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05

ISOSOURCE 1.5 CONTINUOUS FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	168943
Hospital Revenue Code	637
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna Medicare	$4.80
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05
Rate for Payer: UHC All Payor (Choice/PPO)	$6.24
Rate for Payer: UHC Core	$5.00
Rate for Payer: UHC Exchange	$3.77

ISOSOURCE 1.5 CYCLIC FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	200081
Hospital Revenue Code	637
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna Medicare	$4.80
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05
Rate for Payer: UHC All Payor (Choice/PPO)	$6.24
Rate for Payer: UHC Core	$5.00
Rate for Payer: UHC Exchange	$3.77

ISOSOURCE 1.5 CYCLIC FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	200081
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05

ISOSOURCE 1.5 INTERMITTENT FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	200080
Hospital Revenue Code	637
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna Medicare	$4.80
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05
Rate for Payer: UHC All Payor (Choice/PPO)	$6.24
Rate for Payer: UHC Core	$5.00
Rate for Payer: UHC Exchange	$3.77

ISOSOURCE 1.5 INTERMITTENT FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	200080
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05

ISOSOURCE HN BOLUS FEED

Facility

$9.60

Service Code	NDC 43900018480
Hospital Charge Code	150769
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05

ISOSOURCE HN BOLUS FEED

Facility

$9.60

Service Code	NDC 43900018480
Hospital Charge Code	150769
Hospital Revenue Code	637
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna Medicare	$4.80
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05
Rate for Payer: UHC All Payor (Choice/PPO)	$6.24
Rate for Payer: UHC Core	$5.00
Rate for Payer: UHC Exchange	$3.77

ISOSOURCE HN CONTINUOUS FEED

Facility

$9.60

Service Code	NDC 43900018480
Hospital Charge Code	168942
Hospital Revenue Code	637
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna Medicare	$4.80
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05
Rate for Payer: UHC All Payor (Choice/PPO)	$6.24
Rate for Payer: UHC Core	$5.00
Rate for Payer: UHC Exchange	$3.77

ISOSOURCE HN CONTINUOUS FEED

Facility

$9.60

Service Code	NDC 43900018480
Hospital Charge Code	168942
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05

ISOSOURCE HN CYCLIC FEED

Facility

$9.60

Service Code	NDC 43900018480
Hospital Charge Code	200075
Hospital Revenue Code	637
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna Medicare	$4.80
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05
Rate for Payer: UHC All Payor (Choice/PPO)	$6.24
Rate for Payer: UHC Core	$5.00
Rate for Payer: UHC Exchange	$3.77

ISOSOURCE HN CYCLIC FEED

Facility

$9.60

Service Code	NDC 43900018480
Hospital Charge Code	200075
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05

ISOSOURCE HN INTERMITTENT FEED

Facility

$9.60

Service Code	NDC 43900018480
Hospital Charge Code	200074
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05

ISOSOURCE HN INTERMITTENT FEED

Facility

$9.60

Service Code	NDC 43900018480
Hospital Charge Code	200074
Hospital Revenue Code	637
Min. Negotiated Rate	$3.77
Max. Negotiated Rate	$8.64
Rate for Payer: Aetna Commercial	$8.16
Rate for Payer: Aetna Medicare	$4.80
Rate for Payer: Aetna New Business (MI Preferred)	$6.24
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Advantage	$6.72
Rate for Payer: Cofinity Commercial	$8.26
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: PHP Commercial	$8.16
Rate for Payer: Priority Health SBD	$6.05
Rate for Payer: UHC All Payor (Choice/PPO)	$6.24
Rate for Payer: UHC Core	$5.00
Rate for Payer: UHC Exchange	$3.77

Know your out-of-pocket cost for care.

All Charges