Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

METRONIDAZOLE 500 MG TABLET

Facility

$4.45

Service Code	NDC 42292000101
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.78
Rate for Payer: Aetna New Business (MI Preferred)	$2.89
Rate for Payer: Cash Price	$3.56
Rate for Payer: Cofinity Commercial	$3.12
Rate for Payer: Cofinity Commercial	$3.83
Rate for Payer: Cofinity Medicare Advantage	$3.12
Rate for Payer: Encore Health Key Benefits Commercial	$3.56
Rate for Payer: Healthscope Commercial	$4.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.78
Rate for Payer: PHP Commercial	$3.78
Rate for Payer: Priority Health Cigna Priority Health	$2.89
Rate for Payer: Priority Health SBD	$2.80

METRONIDAZOLE 500 MG TABLET

Facility

$2.50

Service Code	NDC 60687055011
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna Commercial	$2.12
Rate for Payer: Aetna Medicare	$1.25
Rate for Payer: Aetna New Business (MI Preferred)	$1.62
Rate for Payer: BCBS Complete	$1.00
Rate for Payer: Cash Price	$2.00
Rate for Payer: Cofinity Commercial	$1.75
Rate for Payer: Cofinity Commercial	$2.15
Rate for Payer: Cofinity Medicare Advantage	$1.75
Rate for Payer: Encore Health Key Benefits Commercial	$2.00
Rate for Payer: Healthscope Commercial	$2.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.12
Rate for Payer: PHP Commercial	$2.12
Rate for Payer: Priority Health Cigna Priority Health	$1.62
Rate for Payer: Priority Health SBD	$1.57

METRONIDAZOLE 500 MG TABLET

Facility

$450.30

Service Code	NDC 29300022701
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$180.12
Max. Negotiated Rate	$405.27
Rate for Payer: Aetna Commercial	$382.75
Rate for Payer: Aetna Medicare	$225.15
Rate for Payer: Aetna New Business (MI Preferred)	$292.69
Rate for Payer: BCBS Complete	$180.12
Rate for Payer: Cash Price	$360.24
Rate for Payer: Cofinity Commercial	$315.21
Rate for Payer: Cofinity Commercial	$387.26
Rate for Payer: Cofinity Medicare Advantage	$315.21
Rate for Payer: Encore Health Key Benefits Commercial	$360.24
Rate for Payer: Healthscope Commercial	$405.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$382.75
Rate for Payer: PHP Commercial	$382.75
Rate for Payer: Priority Health Cigna Priority Health	$292.69
Rate for Payer: Priority Health SBD	$283.69

METRONIDAZOLE 500 MG TABLET

Facility

$4.29

Service Code	NDC 50268053511
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$3.86
Rate for Payer: Aetna Commercial	$3.65
Rate for Payer: Aetna Medicare	$2.15
Rate for Payer: Aetna New Business (MI Preferred)	$2.79
Rate for Payer: BCBS Complete	$1.72
Rate for Payer: Cash Price	$3.43
Rate for Payer: Cofinity Commercial	$3.00
Rate for Payer: Cofinity Commercial	$3.69
Rate for Payer: Cofinity Medicare Advantage	$3.00
Rate for Payer: Encore Health Key Benefits Commercial	$3.43
Rate for Payer: Healthscope Commercial	$3.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.65
Rate for Payer: PHP Commercial	$3.65
Rate for Payer: Priority Health Cigna Priority Health	$2.79
Rate for Payer: Priority Health SBD	$2.70

METRONIDAZOLE 500 MG TABLET

Facility

$450.30

Service Code	NDC 29300022701
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$283.69
Max. Negotiated Rate	$405.27
Rate for Payer: Aetna Commercial	$382.75
Rate for Payer: Aetna New Business (MI Preferred)	$292.69
Rate for Payer: Cash Price	$360.24
Rate for Payer: Cofinity Commercial	$315.21
Rate for Payer: Cofinity Commercial	$387.26
Rate for Payer: Cofinity Medicare Advantage	$315.21
Rate for Payer: Encore Health Key Benefits Commercial	$360.24
Rate for Payer: Healthscope Commercial	$405.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$382.75
Rate for Payer: PHP Commercial	$382.75
Rate for Payer: Priority Health Cigna Priority Health	$292.69
Rate for Payer: Priority Health SBD	$283.69

METRONIDAZOLE 500 MG TABLET

Facility

$214.23

Service Code	NDC 50268053515
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$134.96
Max. Negotiated Rate	$192.81
Rate for Payer: Aetna Commercial	$182.10
Rate for Payer: Aetna New Business (MI Preferred)	$139.25
Rate for Payer: Cash Price	$171.38
Rate for Payer: Cofinity Commercial	$149.96
Rate for Payer: Cofinity Commercial	$184.24
Rate for Payer: Cofinity Medicare Advantage	$149.96
Rate for Payer: Encore Health Key Benefits Commercial	$171.38
Rate for Payer: Healthscope Commercial	$192.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$182.10
Rate for Payer: PHP Commercial	$182.10
Rate for Payer: Priority Health Cigna Priority Health	$139.25
Rate for Payer: Priority Health SBD	$134.96

METRONIDAZOLE 500 MG TABLET

Facility

$249.60

Service Code	NDC 60687055001
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$224.64
Rate for Payer: Aetna Commercial	$212.16
Rate for Payer: Aetna New Business (MI Preferred)	$162.24
Rate for Payer: Cash Price	$199.68
Rate for Payer: Cofinity Commercial	$174.72
Rate for Payer: Cofinity Commercial	$214.66
Rate for Payer: Cofinity Medicare Advantage	$174.72
Rate for Payer: Encore Health Key Benefits Commercial	$199.68
Rate for Payer: Healthscope Commercial	$224.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$212.16
Rate for Payer: PHP Commercial	$212.16
Rate for Payer: Priority Health Cigna Priority Health	$162.24
Rate for Payer: Priority Health SBD	$157.25

METRONIDAZOLE 500 MG TABLET

Facility

$4.29

Service Code	NDC 50268053511
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$3.86
Rate for Payer: Aetna Commercial	$3.65
Rate for Payer: Aetna New Business (MI Preferred)	$2.79
Rate for Payer: Cash Price	$3.43
Rate for Payer: Cofinity Commercial	$3.00
Rate for Payer: Cofinity Commercial	$3.69
Rate for Payer: Cofinity Medicare Advantage	$3.00
Rate for Payer: Encore Health Key Benefits Commercial	$3.43
Rate for Payer: Healthscope Commercial	$3.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.65
Rate for Payer: PHP Commercial	$3.65
Rate for Payer: Priority Health Cigna Priority Health	$2.79
Rate for Payer: Priority Health SBD	$2.70

METRONIDAZOLE 500 MG TABLET

Facility

$449.35

Service Code	NDC 00904712661
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$283.09
Max. Negotiated Rate	$404.42
Rate for Payer: Aetna Commercial	$381.95
Rate for Payer: Aetna New Business (MI Preferred)	$292.08
Rate for Payer: Cash Price	$359.48
Rate for Payer: Cofinity Commercial	$314.55
Rate for Payer: Cofinity Commercial	$386.44
Rate for Payer: Cofinity Medicare Advantage	$314.55
Rate for Payer: Encore Health Key Benefits Commercial	$359.48
Rate for Payer: Healthscope Commercial	$404.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$381.95
Rate for Payer: PHP Commercial	$381.95
Rate for Payer: Priority Health Cigna Priority Health	$292.08
Rate for Payer: Priority Health SBD	$283.09

METRONIDAZOLE 500 MG TABLET

Facility

$2.50

Service Code	NDC 60687055011
Hospital Charge Code	5016
Hospital Revenue Code	637
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna Commercial	$2.12
Rate for Payer: Aetna New Business (MI Preferred)	$1.62
Rate for Payer: Cash Price	$2.00
Rate for Payer: Cofinity Commercial	$2.15
Rate for Payer: Cofinity Commercial	$1.75
Rate for Payer: Cofinity Medicare Advantage	$1.75
Rate for Payer: Encore Health Key Benefits Commercial	$2.00
Rate for Payer: Healthscope Commercial	$2.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.12
Rate for Payer: PHP Commercial	$2.12
Rate for Payer: Priority Health Cigna Priority Health	$1.62
Rate for Payer: Priority Health SBD	$1.57

MEXILETINE 150 MG CAPSULE

Facility

$577.44

Service Code	NDC 00093873901
Hospital Charge Code	10595
Hospital Revenue Code	637
Min. Negotiated Rate	$363.79
Max. Negotiated Rate	$519.70
Rate for Payer: Aetna Commercial	$490.82
Rate for Payer: Aetna New Business (MI Preferred)	$375.34
Rate for Payer: Cash Price	$461.95
Rate for Payer: Cofinity Commercial	$404.21
Rate for Payer: Cofinity Commercial	$496.60
Rate for Payer: Cofinity Medicare Advantage	$404.21
Rate for Payer: Encore Health Key Benefits Commercial	$461.95
Rate for Payer: Healthscope Commercial	$519.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$490.82
Rate for Payer: PHP Commercial	$490.82
Rate for Payer: Priority Health Cigna Priority Health	$375.34
Rate for Payer: Priority Health SBD	$363.79

MEXILETINE 150 MG CAPSULE

Facility

$577.44

Service Code	NDC 00093873901
Hospital Charge Code	10595
Hospital Revenue Code	637
Min. Negotiated Rate	$230.98
Max. Negotiated Rate	$519.70
Rate for Payer: Aetna Commercial	$490.82
Rate for Payer: Aetna Medicare	$288.72
Rate for Payer: Aetna New Business (MI Preferred)	$375.34
Rate for Payer: BCBS Complete	$230.98
Rate for Payer: Cash Price	$461.95
Rate for Payer: Cofinity Commercial	$404.21
Rate for Payer: Cofinity Commercial	$496.60
Rate for Payer: Cofinity Medicare Advantage	$404.21
Rate for Payer: Encore Health Key Benefits Commercial	$461.95
Rate for Payer: Healthscope Commercial	$519.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$490.82
Rate for Payer: PHP Commercial	$490.82
Rate for Payer: Priority Health Cigna Priority Health	$375.34
Rate for Payer: Priority Health SBD	$363.79

MEXILETINE 150 MG CAPSULE

Facility

$353.76

Service Code	NDC 00527410737
Hospital Charge Code	10595
Hospital Revenue Code	637
Min. Negotiated Rate	$141.50
Max. Negotiated Rate	$318.38
Rate for Payer: Aetna Commercial	$300.70
Rate for Payer: Aetna Medicare	$176.88
Rate for Payer: Aetna New Business (MI Preferred)	$229.94
Rate for Payer: BCBS Complete	$141.50
Rate for Payer: Cash Price	$283.01
Rate for Payer: Cofinity Commercial	$247.63
Rate for Payer: Cofinity Commercial	$304.23
Rate for Payer: Cofinity Medicare Advantage	$247.63
Rate for Payer: Encore Health Key Benefits Commercial	$283.01
Rate for Payer: Healthscope Commercial	$318.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$300.70
Rate for Payer: PHP Commercial	$300.70
Rate for Payer: Priority Health Cigna Priority Health	$229.94
Rate for Payer: Priority Health SBD	$222.87

MEXILETINE 150 MG CAPSULE

Facility

$353.76

Service Code	NDC 00527410737
Hospital Charge Code	10595
Hospital Revenue Code	637
Min. Negotiated Rate	$222.87
Max. Negotiated Rate	$318.38
Rate for Payer: Aetna Commercial	$300.70
Rate for Payer: Aetna New Business (MI Preferred)	$229.94
Rate for Payer: Cash Price	$283.01
Rate for Payer: Cofinity Commercial	$247.63
Rate for Payer: Cofinity Commercial	$304.23
Rate for Payer: Cofinity Medicare Advantage	$247.63
Rate for Payer: Encore Health Key Benefits Commercial	$283.01
Rate for Payer: Healthscope Commercial	$318.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$300.70
Rate for Payer: PHP Commercial	$300.70
Rate for Payer: Priority Health Cigna Priority Health	$229.94
Rate for Payer: Priority Health SBD	$222.87

MEXILETINE 200 MG CAPSULE

Facility

$702.24

Service Code	NDC 00093874001
Hospital Charge Code	10596
Hospital Revenue Code	637
Min. Negotiated Rate	$280.90
Max. Negotiated Rate	$632.02
Rate for Payer: Aetna Commercial	$596.90
Rate for Payer: Aetna Medicare	$351.12
Rate for Payer: Aetna New Business (MI Preferred)	$456.46
Rate for Payer: BCBS Complete	$280.90
Rate for Payer: Cash Price	$561.79
Rate for Payer: Cofinity Commercial	$491.57
Rate for Payer: Cofinity Commercial	$603.93
Rate for Payer: Cofinity Medicare Advantage	$491.57
Rate for Payer: Encore Health Key Benefits Commercial	$561.79
Rate for Payer: Healthscope Commercial	$632.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$596.90
Rate for Payer: PHP Commercial	$596.90
Rate for Payer: Priority Health Cigna Priority Health	$456.46
Rate for Payer: Priority Health SBD	$442.41

MEXILETINE 200 MG CAPSULE

Facility

$702.24

Service Code	NDC 00093874001
Hospital Charge Code	10596
Hospital Revenue Code	637
Min. Negotiated Rate	$442.41
Max. Negotiated Rate	$632.02
Rate for Payer: Aetna Commercial	$596.90
Rate for Payer: Aetna New Business (MI Preferred)	$456.46
Rate for Payer: Cash Price	$561.79
Rate for Payer: Cofinity Commercial	$491.57
Rate for Payer: Cofinity Commercial	$603.93
Rate for Payer: Cofinity Medicare Advantage	$491.57
Rate for Payer: Encore Health Key Benefits Commercial	$561.79
Rate for Payer: Healthscope Commercial	$632.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$596.90
Rate for Payer: PHP Commercial	$596.90
Rate for Payer: Priority Health Cigna Priority Health	$456.46
Rate for Payer: Priority Health SBD	$442.41

MICAFUNGIN 100 MG INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM

Facility

$140.67

Service Code	HCPCS J2248
Hospital Charge Code	301720
Hospital Revenue Code	636
Min. Negotiated Rate	$56.27
Max. Negotiated Rate	$126.60
Rate for Payer: Aetna Commercial	$119.57
Rate for Payer: Aetna Medicare	$70.33
Rate for Payer: Aetna New Business (MI Preferred)	$91.44
Rate for Payer: BCBS Complete	$56.27
Rate for Payer: Cash Price	$112.54
Rate for Payer: Cofinity Commercial	$120.98
Rate for Payer: Cofinity Commercial	$98.47
Rate for Payer: Cofinity Medicare Advantage	$98.47
Rate for Payer: Encore Health Key Benefits Commercial	$112.54
Rate for Payer: Healthscope Commercial	$126.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.57
Rate for Payer: PHP Commercial	$119.57
Rate for Payer: Priority Health Cigna Priority Health	$91.44
Rate for Payer: Priority Health SBD	$88.62

MICAFUNGIN 100 MG INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM

Facility

$140.67

Service Code	HCPCS J2248
Hospital Charge Code	301720
Hospital Revenue Code	636
Min. Negotiated Rate	$88.62
Max. Negotiated Rate	$126.60
Rate for Payer: Aetna Commercial	$119.57
Rate for Payer: Aetna New Business (MI Preferred)	$91.44
Rate for Payer: Cash Price	$112.54
Rate for Payer: Cofinity Commercial	$120.98
Rate for Payer: Cofinity Commercial	$98.47
Rate for Payer: Cofinity Medicare Advantage	$98.47
Rate for Payer: Encore Health Key Benefits Commercial	$112.54
Rate for Payer: Healthscope Commercial	$126.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.57
Rate for Payer: PHP Commercial	$119.57
Rate for Payer: Priority Health Cigna Priority Health	$91.44
Rate for Payer: Priority Health SBD	$88.62

MICAFUNGIN 100 MG INTRAVENOUS SOLUTION

Facility

$140.67

Service Code	HCPCS J2248
Hospital Charge Code	77685
Hospital Revenue Code	636
Min. Negotiated Rate	$88.62
Max. Negotiated Rate	$126.60
Rate for Payer: Aetna Commercial	$119.57
Rate for Payer: Aetna Commercial	$155.36
Rate for Payer: Aetna Commercial	$524.78
Rate for Payer: Aetna New Business (MI Preferred)	$118.81
Rate for Payer: Aetna New Business (MI Preferred)	$91.44
Rate for Payer: Aetna New Business (MI Preferred)	$401.30
Rate for Payer: Cash Price	$112.54
Rate for Payer: Cash Price	$146.22
Rate for Payer: Cash Price	$493.91
Rate for Payer: Cofinity Commercial	$432.17
Rate for Payer: Cofinity Commercial	$120.98
Rate for Payer: Cofinity Commercial	$98.47
Rate for Payer: Cofinity Commercial	$530.96
Rate for Payer: Cofinity Commercial	$127.95
Rate for Payer: Cofinity Commercial	$157.19
Rate for Payer: Cofinity Medicare Advantage	$127.95
Rate for Payer: Cofinity Medicare Advantage	$432.17
Rate for Payer: Cofinity Medicare Advantage	$98.47
Rate for Payer: Encore Health Key Benefits Commercial	$146.22
Rate for Payer: Encore Health Key Benefits Commercial	$112.54
Rate for Payer: Encore Health Key Benefits Commercial	$493.91
Rate for Payer: Healthscope Commercial	$164.50
Rate for Payer: Healthscope Commercial	$555.65
Rate for Payer: Healthscope Commercial	$126.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$524.78
Rate for Payer: PHP Commercial	$524.78
Rate for Payer: PHP Commercial	$119.57
Rate for Payer: PHP Commercial	$155.36
Rate for Payer: Priority Health Cigna Priority Health	$91.44
Rate for Payer: Priority Health Cigna Priority Health	$401.30
Rate for Payer: Priority Health Cigna Priority Health	$118.81
Rate for Payer: Priority Health SBD	$388.96
Rate for Payer: Priority Health SBD	$88.62
Rate for Payer: Priority Health SBD	$115.15

MICAFUNGIN 100 MG INTRAVENOUS SOLUTION

Facility

$140.67

Service Code	HCPCS J2248
Hospital Charge Code	77685
Hospital Revenue Code	636
Min. Negotiated Rate	$56.27
Max. Negotiated Rate	$126.60
Rate for Payer: Aetna Commercial	$119.57
Rate for Payer: Aetna Commercial	$524.78
Rate for Payer: Aetna Commercial	$155.36
Rate for Payer: Aetna Medicare	$308.69
Rate for Payer: Aetna Medicare	$70.33
Rate for Payer: Aetna Medicare	$91.39
Rate for Payer: Aetna New Business (MI Preferred)	$401.30
Rate for Payer: Aetna New Business (MI Preferred)	$91.44
Rate for Payer: Aetna New Business (MI Preferred)	$118.81
Rate for Payer: BCBS Complete	$73.11
Rate for Payer: BCBS Complete	$56.27
Rate for Payer: BCBS Complete	$246.96
Rate for Payer: Cash Price	$493.91
Rate for Payer: Cash Price	$112.54
Rate for Payer: Cash Price	$146.22
Rate for Payer: Cofinity Commercial	$530.96
Rate for Payer: Cofinity Commercial	$98.47
Rate for Payer: Cofinity Commercial	$120.98
Rate for Payer: Cofinity Commercial	$157.19
Rate for Payer: Cofinity Commercial	$127.95
Rate for Payer: Cofinity Commercial	$432.17
Rate for Payer: Cofinity Medicare Advantage	$127.95
Rate for Payer: Cofinity Medicare Advantage	$98.47
Rate for Payer: Cofinity Medicare Advantage	$432.17
Rate for Payer: Encore Health Key Benefits Commercial	$146.22
Rate for Payer: Encore Health Key Benefits Commercial	$493.91
Rate for Payer: Encore Health Key Benefits Commercial	$112.54
Rate for Payer: Healthscope Commercial	$164.50
Rate for Payer: Healthscope Commercial	$126.60
Rate for Payer: Healthscope Commercial	$555.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$524.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.57
Rate for Payer: PHP Commercial	$155.36
Rate for Payer: PHP Commercial	$119.57
Rate for Payer: PHP Commercial	$524.78
Rate for Payer: Priority Health Cigna Priority Health	$91.44
Rate for Payer: Priority Health Cigna Priority Health	$401.30
Rate for Payer: Priority Health Cigna Priority Health	$118.81
Rate for Payer: Priority Health SBD	$388.96
Rate for Payer: Priority Health SBD	$115.15
Rate for Payer: Priority Health SBD	$88.62

MICONAZOLE NITRATE 100 MG VAGINAL SUPPOSITORY

Facility

$21.24

Service Code	NDC 61269073607
Hospital Charge Code	10603
Hospital Revenue Code	637
Min. Negotiated Rate	$13.38
Max. Negotiated Rate	$19.12
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna New Business (MI Preferred)	$13.81
Rate for Payer: Cash Price	$16.99
Rate for Payer: Cofinity Commercial	$18.27
Rate for Payer: Cofinity Commercial	$14.87
Rate for Payer: Cofinity Medicare Advantage	$14.87
Rate for Payer: Encore Health Key Benefits Commercial	$16.99
Rate for Payer: Healthscope Commercial	$19.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.05
Rate for Payer: PHP Commercial	$18.05
Rate for Payer: Priority Health Cigna Priority Health	$13.81
Rate for Payer: Priority Health SBD	$13.38

MICONAZOLE NITRATE 100 MG VAGINAL SUPPOSITORY

Facility

$21.24

Service Code	NDC 61269073607
Hospital Charge Code	10603
Hospital Revenue Code	637
Min. Negotiated Rate	$8.50
Max. Negotiated Rate	$19.12
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$10.62
Rate for Payer: Aetna New Business (MI Preferred)	$13.81
Rate for Payer: BCBS Complete	$8.50
Rate for Payer: Cash Price	$16.99
Rate for Payer: Cofinity Commercial	$14.87
Rate for Payer: Cofinity Commercial	$18.27
Rate for Payer: Cofinity Medicare Advantage	$14.87
Rate for Payer: Encore Health Key Benefits Commercial	$16.99
Rate for Payer: Healthscope Commercial	$19.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.05
Rate for Payer: PHP Commercial	$18.05
Rate for Payer: Priority Health Cigna Priority Health	$13.81
Rate for Payer: Priority Health SBD	$13.38

MICONAZOLE NITRATE 2 % TOPICAL CREAM

Facility

$15.53

Service Code	NDC 51672200102
Hospital Charge Code	5039
Hospital Revenue Code	637
Min. Negotiated Rate	$6.21
Max. Negotiated Rate	$13.98
Rate for Payer: Aetna Commercial	$13.20
Rate for Payer: Aetna Medicare	$7.76
Rate for Payer: Aetna New Business (MI Preferred)	$10.09
Rate for Payer: BCBS Complete	$6.21
Rate for Payer: Cash Price	$12.42
Rate for Payer: Cofinity Commercial	$10.87
Rate for Payer: Cofinity Commercial	$13.36
Rate for Payer: Cofinity Medicare Advantage	$10.87
Rate for Payer: Encore Health Key Benefits Commercial	$12.42
Rate for Payer: Healthscope Commercial	$13.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.20
Rate for Payer: PHP Commercial	$13.20
Rate for Payer: Priority Health Cigna Priority Health	$10.09
Rate for Payer: Priority Health SBD	$9.78

MICONAZOLE NITRATE 2 % TOPICAL CREAM

Facility

$15.53

Service Code	NDC 51672200102
Hospital Charge Code	5039
Hospital Revenue Code	637
Min. Negotiated Rate	$9.78
Max. Negotiated Rate	$13.98
Rate for Payer: Aetna Commercial	$13.20
Rate for Payer: Aetna New Business (MI Preferred)	$10.09
Rate for Payer: Cash Price	$12.42
Rate for Payer: Cofinity Commercial	$10.87
Rate for Payer: Cofinity Commercial	$13.36
Rate for Payer: Cofinity Medicare Advantage	$10.87
Rate for Payer: Encore Health Key Benefits Commercial	$12.42
Rate for Payer: Healthscope Commercial	$13.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.20
Rate for Payer: PHP Commercial	$13.20
Rate for Payer: Priority Health Cigna Priority Health	$10.09
Rate for Payer: Priority Health SBD	$9.78

MICONAZOLE NITRATE 2 % TOPICAL CREAM

Facility

$25.11

Service Code	NDC 00536113428
Hospital Charge Code	5039
Hospital Revenue Code	637
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$22.60
Rate for Payer: Aetna Commercial	$21.34
Rate for Payer: Aetna Medicare	$12.55
Rate for Payer: Aetna New Business (MI Preferred)	$16.32
Rate for Payer: BCBS Complete	$10.04
Rate for Payer: Cash Price	$20.09
Rate for Payer: Cofinity Commercial	$17.58
Rate for Payer: Cofinity Commercial	$21.59
Rate for Payer: Cofinity Medicare Advantage	$17.58
Rate for Payer: Encore Health Key Benefits Commercial	$20.09
Rate for Payer: Healthscope Commercial	$22.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.34
Rate for Payer: PHP Commercial	$21.34
Rate for Payer: Priority Health Cigna Priority Health	$16.32
Rate for Payer: Priority Health SBD	$15.82

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