Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

NORTRIPTYLINE 10 MG CAPSULE

Facility

$227.95

Service Code	NDC 51672400101
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$89.58
Max. Negotiated Rate	$205.16
Rate for Payer: Aetna Commercial	$193.76
Rate for Payer: Aetna Medicare	$113.97
Rate for Payer: Aetna New Business (MI Preferred)	$148.17
Rate for Payer: BCBS Complete	$91.18
Rate for Payer: Cash Price	$182.36
Rate for Payer: Cofinity Advantage	$159.56
Rate for Payer: Cofinity Commercial	$196.04
Rate for Payer: Encore Health Key Benefits Commercial	$182.36
Rate for Payer: Healthscope Commercial	$205.16
Rate for Payer: MI Amish Medical Board Commercial	$182.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$193.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$170.96
Rate for Payer: PHP Commercial	$193.76
Rate for Payer: Priority Health SBD	$143.61
Rate for Payer: UHC All Payor (Choice/PPO)	$148.17
Rate for Payer: UHC Core	$118.76
Rate for Payer: UHC Exchange	$89.58

NORTRIPTYLINE 10 MG CAPSULE

Facility

$3.47

Service Code	NDC 50268060311
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$3.12
Rate for Payer: PHP Commercial	$2.95
Rate for Payer: Aetna Commercial	$2.95
Rate for Payer: Aetna Medicare	$1.74
Rate for Payer: Aetna New Business (MI Preferred)	$2.26
Rate for Payer: BCBS Complete	$1.39
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cofinity Advantage	$2.43
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Encore Health Key Benefits Commercial	$2.78
Rate for Payer: Healthscope Commercial	$3.12
Rate for Payer: MI Amish Medical Board Commercial	$2.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.60
Rate for Payer: Priority Health SBD	$2.19
Rate for Payer: UHC All Payor (Choice/PPO)	$2.26
Rate for Payer: UHC Core	$1.81
Rate for Payer: UHC Exchange	$1.36

NORTRIPTYLINE 10 MG CAPSULE

Facility

$325.85

Service Code	NDC 60687028101
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$128.06
Max. Negotiated Rate	$293.26
Rate for Payer: Aetna Commercial	$276.97
Rate for Payer: Aetna Medicare	$162.93
Rate for Payer: Aetna New Business (MI Preferred)	$211.80
Rate for Payer: BCBS Complete	$130.34
Rate for Payer: Cash Price	$260.68
Rate for Payer: Cofinity Advantage	$228.09
Rate for Payer: Cofinity Commercial	$280.23
Rate for Payer: Encore Health Key Benefits Commercial	$260.68
Rate for Payer: Healthscope Commercial	$293.26
Rate for Payer: MI Amish Medical Board Commercial	$260.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$276.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$244.39
Rate for Payer: PHP Commercial	$276.97
Rate for Payer: Priority Health SBD	$205.29
Rate for Payer: UHC All Payor (Choice/PPO)	$211.80
Rate for Payer: UHC Core	$169.77
Rate for Payer: UHC Exchange	$128.06

NORTRIPTYLINE 10 MG CAPSULE

Facility

$3.47

Service Code	NDC 50268060311
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$3.12
Rate for Payer: Aetna Commercial	$2.95
Rate for Payer: Aetna New Business (MI Preferred)	$2.26
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cofinity Advantage	$2.43
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Encore Health Key Benefits Commercial	$2.78
Rate for Payer: Healthscope Commercial	$3.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.60
Rate for Payer: PHP Commercial	$2.95
Rate for Payer: Priority Health SBD	$2.19

NORTRIPTYLINE 10 MG CAPSULE

Facility

$325.85

Service Code	NDC 60687028101
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$205.29
Max. Negotiated Rate	$293.26
Rate for Payer: Aetna Commercial	$276.97
Rate for Payer: Aetna New Business (MI Preferred)	$211.80
Rate for Payer: Cash Price	$260.68
Rate for Payer: Cofinity Advantage	$228.09
Rate for Payer: Cofinity Commercial	$280.23
Rate for Payer: Encore Health Key Benefits Commercial	$260.68
Rate for Payer: Healthscope Commercial	$293.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$276.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$244.39
Rate for Payer: PHP Commercial	$276.97
Rate for Payer: Priority Health SBD	$205.29

NORTRIPTYLINE 10 MG CAPSULE

Facility

$3.26

Service Code	NDC 60687028111
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.93
Rate for Payer: Aetna Commercial	$2.77
Rate for Payer: Aetna New Business (MI Preferred)	$2.12
Rate for Payer: Cash Price	$2.61
Rate for Payer: Cofinity Advantage	$2.28
Rate for Payer: Cofinity Commercial	$2.80
Rate for Payer: Encore Health Key Benefits Commercial	$2.61
Rate for Payer: Healthscope Commercial	$2.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.77
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.44
Rate for Payer: PHP Commercial	$2.77
Rate for Payer: Priority Health SBD	$2.05

NORTRIPTYLINE 10 MG CAPSULE

Facility

$227.95

Service Code	NDC 51672400101
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$143.61
Max. Negotiated Rate	$205.16
Rate for Payer: Aetna Commercial	$193.76
Rate for Payer: Aetna New Business (MI Preferred)	$148.17
Rate for Payer: Cash Price	$182.36
Rate for Payer: Cofinity Advantage	$159.56
Rate for Payer: Cofinity Commercial	$196.04
Rate for Payer: Encore Health Key Benefits Commercial	$182.36
Rate for Payer: Healthscope Commercial	$205.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$193.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$170.96
Rate for Payer: PHP Commercial	$193.76
Rate for Payer: Priority Health SBD	$143.61

NORTRIPTYLINE 10 MG CAPSULE

Facility

$173.38

Service Code	NDC 50268060315
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$68.14
Max. Negotiated Rate	$156.04
Rate for Payer: Aetna Commercial	$147.37
Rate for Payer: Aetna Medicare	$86.69
Rate for Payer: Aetna New Business (MI Preferred)	$112.70
Rate for Payer: BCBS Complete	$69.35
Rate for Payer: Cash Price	$138.70
Rate for Payer: Cofinity Advantage	$121.37
Rate for Payer: Cofinity Commercial	$149.11
Rate for Payer: Encore Health Key Benefits Commercial	$138.70
Rate for Payer: Healthscope Commercial	$156.04
Rate for Payer: MI Amish Medical Board Commercial	$138.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$147.37
Rate for Payer: Opus (Opus Packaging Group) HMA	$130.03
Rate for Payer: PHP Commercial	$147.37
Rate for Payer: Priority Health SBD	$109.23
Rate for Payer: UHC All Payor (Choice/PPO)	$112.70
Rate for Payer: UHC Core	$90.33
Rate for Payer: UHC Exchange	$68.14

NORTRIPTYLINE 10 MG CAPSULE

Facility

$324.30

Service Code	NDC 00093081001
Hospital Charge Code	5674
Hospital Revenue Code	637
Min. Negotiated Rate	$204.31
Max. Negotiated Rate	$291.87
Rate for Payer: Aetna Commercial	$275.65
Rate for Payer: Aetna New Business (MI Preferred)	$210.79
Rate for Payer: Cash Price	$259.44
Rate for Payer: Cofinity Advantage	$227.01
Rate for Payer: Cofinity Commercial	$278.90
Rate for Payer: Encore Health Key Benefits Commercial	$259.44
Rate for Payer: Healthscope Commercial	$291.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$275.65
Rate for Payer: Opus (Opus Packaging Group) HMA	$243.22
Rate for Payer: PHP Commercial	$275.65
Rate for Payer: Priority Health SBD	$204.31

NORTRIPTYLINE 25 MG CAPSULE

Facility

$385.40

Service Code	NDC 00093081101
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$242.80
Max. Negotiated Rate	$346.86
Rate for Payer: Aetna Commercial	$327.59
Rate for Payer: Aetna New Business (MI Preferred)	$250.51
Rate for Payer: Cash Price	$308.32
Rate for Payer: Cofinity Advantage	$269.78
Rate for Payer: Cofinity Commercial	$331.44
Rate for Payer: Encore Health Key Benefits Commercial	$308.32
Rate for Payer: Healthscope Commercial	$346.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$327.59
Rate for Payer: Opus (Opus Packaging Group) HMA	$289.05
Rate for Payer: PHP Commercial	$327.59
Rate for Payer: Priority Health SBD	$242.80

NORTRIPTYLINE 25 MG CAPSULE

Facility

$206.80

Service Code	NDC 51672400201
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$81.27
Max. Negotiated Rate	$186.12
Rate for Payer: Aetna Commercial	$175.78
Rate for Payer: Aetna Medicare	$103.40
Rate for Payer: Aetna New Business (MI Preferred)	$134.42
Rate for Payer: BCBS Complete	$82.72
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cofinity Advantage	$144.76
Rate for Payer: Cofinity Commercial	$177.85
Rate for Payer: Encore Health Key Benefits Commercial	$165.44
Rate for Payer: Healthscope Commercial	$186.12
Rate for Payer: MI Amish Medical Board Commercial	$165.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.78
Rate for Payer: Opus (Opus Packaging Group) HMA	$155.10
Rate for Payer: PHP Commercial	$175.78
Rate for Payer: Priority Health SBD	$130.28
Rate for Payer: UHC All Payor (Choice/PPO)	$134.42
Rate for Payer: UHC Core	$107.74
Rate for Payer: UHC Exchange	$81.27

NORTRIPTYLINE 25 MG CAPSULE

Facility

$206.80

Service Code	NDC 51672400201
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$130.28
Max. Negotiated Rate	$186.12
Rate for Payer: Aetna Commercial	$175.78
Rate for Payer: Aetna New Business (MI Preferred)	$134.42
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cofinity Advantage	$144.76
Rate for Payer: Cofinity Commercial	$177.85
Rate for Payer: Encore Health Key Benefits Commercial	$165.44
Rate for Payer: Healthscope Commercial	$186.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.78
Rate for Payer: Opus (Opus Packaging Group) HMA	$155.10
Rate for Payer: PHP Commercial	$175.78
Rate for Payer: Priority Health SBD	$130.28

NORTRIPTYLINE 25 MG CAPSULE

Facility

$356.25

Service Code	NDC 60687029301
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$140.01
Max. Negotiated Rate	$320.62
Rate for Payer: Aetna Commercial	$302.81
Rate for Payer: Aetna Medicare	$178.12
Rate for Payer: Aetna New Business (MI Preferred)	$231.56
Rate for Payer: BCBS Complete	$142.50
Rate for Payer: Cash Price	$285.00
Rate for Payer: Cofinity Advantage	$249.38
Rate for Payer: Cofinity Commercial	$306.38
Rate for Payer: Encore Health Key Benefits Commercial	$285.00
Rate for Payer: Healthscope Commercial	$320.62
Rate for Payer: MI Amish Medical Board Commercial	$285.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$302.81
Rate for Payer: Opus (Opus Packaging Group) HMA	$267.19
Rate for Payer: PHP Commercial	$302.81
Rate for Payer: Priority Health SBD	$224.44
Rate for Payer: UHC All Payor (Choice/PPO)	$231.56
Rate for Payer: UHC Core	$185.61
Rate for Payer: UHC Exchange	$140.01

NORTRIPTYLINE 25 MG CAPSULE

Facility

$3.57

Service Code	NDC 60687029311
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$3.21
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: Aetna Medicare	$1.78
Rate for Payer: Aetna New Business (MI Preferred)	$2.32
Rate for Payer: BCBS Complete	$1.43
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cofinity Advantage	$2.50
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Encore Health Key Benefits Commercial	$2.86
Rate for Payer: Healthscope Commercial	$3.21
Rate for Payer: MI Amish Medical Board Commercial	$2.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.68
Rate for Payer: PHP Commercial	$3.03
Rate for Payer: Priority Health SBD	$2.25
Rate for Payer: UHC All Payor (Choice/PPO)	$2.32
Rate for Payer: UHC Core	$1.86
Rate for Payer: UHC Exchange	$1.40

NORTRIPTYLINE 25 MG CAPSULE

Facility

$356.25

Service Code	NDC 60687029301
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$224.44
Max. Negotiated Rate	$320.62
Rate for Payer: Aetna Commercial	$302.81
Rate for Payer: Aetna New Business (MI Preferred)	$231.56
Rate for Payer: Cash Price	$285.00
Rate for Payer: Cofinity Advantage	$249.38
Rate for Payer: Cofinity Commercial	$306.38
Rate for Payer: Encore Health Key Benefits Commercial	$285.00
Rate for Payer: Healthscope Commercial	$320.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$302.81
Rate for Payer: Opus (Opus Packaging Group) HMA	$267.19
Rate for Payer: PHP Commercial	$302.81
Rate for Payer: Priority Health SBD	$224.44

NORTRIPTYLINE 25 MG CAPSULE

Facility

$385.40

Service Code	NDC 00093081101
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$151.46
Max. Negotiated Rate	$346.86
Rate for Payer: Aetna Commercial	$327.59
Rate for Payer: Aetna Medicare	$192.70
Rate for Payer: Aetna New Business (MI Preferred)	$250.51
Rate for Payer: BCBS Complete	$154.16
Rate for Payer: Cash Price	$308.32
Rate for Payer: Cofinity Advantage	$269.78
Rate for Payer: Cofinity Commercial	$331.44
Rate for Payer: Encore Health Key Benefits Commercial	$308.32
Rate for Payer: Healthscope Commercial	$346.86
Rate for Payer: MI Amish Medical Board Commercial	$308.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$327.59
Rate for Payer: Opus (Opus Packaging Group) HMA	$289.05
Rate for Payer: PHP Commercial	$327.59
Rate for Payer: Priority Health SBD	$242.80
Rate for Payer: UHC All Payor (Choice/PPO)	$250.51
Rate for Payer: UHC Core	$200.79
Rate for Payer: UHC Exchange	$151.46

NORTRIPTYLINE 25 MG CAPSULE

Facility

$3.57

Service Code	NDC 60687029311
Hospital Charge Code	5675
Hospital Revenue Code	637
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$3.21
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: Aetna New Business (MI Preferred)	$2.32
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cofinity Advantage	$2.50
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Encore Health Key Benefits Commercial	$2.86
Rate for Payer: Healthscope Commercial	$3.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.68
Rate for Payer: PHP Commercial	$3.03
Rate for Payer: Priority Health SBD	$2.25

NOVASOURCE RENAL BOLUS FEED

Facility

$22.20

Service Code	NDC 43900035180
Hospital Charge Code	150853
Hospital Revenue Code	637
Min. Negotiated Rate	$8.72
Max. Negotiated Rate	$19.98
Rate for Payer: Aetna Commercial	$18.87
Rate for Payer: Aetna Medicare	$11.10
Rate for Payer: Aetna New Business (MI Preferred)	$14.43
Rate for Payer: BCBS Complete	$8.88
Rate for Payer: Cash Price	$17.76
Rate for Payer: Cofinity Advantage	$15.54
Rate for Payer: Cofinity Commercial	$19.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.76
Rate for Payer: Healthscope Commercial	$19.98
Rate for Payer: MI Amish Medical Board Commercial	$17.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.65
Rate for Payer: PHP Commercial	$18.87
Rate for Payer: Priority Health SBD	$13.99
Rate for Payer: UHC All Payor (Choice/PPO)	$14.43
Rate for Payer: UHC Core	$11.57
Rate for Payer: UHC Exchange	$8.72

NOVASOURCE RENAL BOLUS FEED

Facility

$22.20

Service Code	NDC 43900035180
Hospital Charge Code	150853
Hospital Revenue Code	637
Min. Negotiated Rate	$13.99
Max. Negotiated Rate	$19.98
Rate for Payer: Aetna Commercial	$18.87
Rate for Payer: Aetna New Business (MI Preferred)	$14.43
Rate for Payer: Cash Price	$17.76
Rate for Payer: Cofinity Advantage	$15.54
Rate for Payer: Cofinity Commercial	$19.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.76
Rate for Payer: Healthscope Commercial	$19.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.65
Rate for Payer: PHP Commercial	$18.87
Rate for Payer: Priority Health SBD	$13.99

NOVASOURCE RENAL CONTINUOUS FEED

Facility

$22.20

Service Code	NDC 43900035180
Hospital Charge Code	168945
Hospital Revenue Code	637
Min. Negotiated Rate	$8.72
Max. Negotiated Rate	$19.98
Rate for Payer: Aetna Commercial	$18.87
Rate for Payer: Aetna Medicare	$11.10
Rate for Payer: Aetna New Business (MI Preferred)	$14.43
Rate for Payer: BCBS Complete	$8.88
Rate for Payer: Cash Price	$17.76
Rate for Payer: Cofinity Advantage	$15.54
Rate for Payer: Cofinity Commercial	$19.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.76
Rate for Payer: Healthscope Commercial	$19.98
Rate for Payer: MI Amish Medical Board Commercial	$17.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.65
Rate for Payer: PHP Commercial	$18.87
Rate for Payer: Priority Health SBD	$13.99
Rate for Payer: UHC All Payor (Choice/PPO)	$14.43
Rate for Payer: UHC Core	$11.57
Rate for Payer: UHC Exchange	$8.72

NOVASOURCE RENAL CONTINUOUS FEED

Facility

$22.20

Service Code	NDC 43900035180
Hospital Charge Code	168945
Hospital Revenue Code	637
Min. Negotiated Rate	$13.99
Max. Negotiated Rate	$19.98
Rate for Payer: Aetna Commercial	$18.87
Rate for Payer: Aetna New Business (MI Preferred)	$14.43
Rate for Payer: Cash Price	$17.76
Rate for Payer: Cofinity Advantage	$15.54
Rate for Payer: Cofinity Commercial	$19.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.76
Rate for Payer: Healthscope Commercial	$19.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.65
Rate for Payer: PHP Commercial	$18.87
Rate for Payer: Priority Health SBD	$13.99

NOVASOURCE RENAL CYCLIC FEED

Facility

$22.20

Service Code	NDC 43900035180
Hospital Charge Code	200087
Hospital Revenue Code	637
Min. Negotiated Rate	$13.99
Max. Negotiated Rate	$19.98
Rate for Payer: Aetna Commercial	$18.87
Rate for Payer: Aetna New Business (MI Preferred)	$14.43
Rate for Payer: Cash Price	$17.76
Rate for Payer: Cofinity Advantage	$15.54
Rate for Payer: Cofinity Commercial	$19.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.76
Rate for Payer: Healthscope Commercial	$19.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.65
Rate for Payer: PHP Commercial	$18.87
Rate for Payer: Priority Health SBD	$13.99

NOVASOURCE RENAL CYCLIC FEED

Facility

$22.20

Service Code	NDC 43900035180
Hospital Charge Code	200087
Hospital Revenue Code	637
Min. Negotiated Rate	$8.72
Max. Negotiated Rate	$19.98
Rate for Payer: Aetna Commercial	$18.87
Rate for Payer: Aetna Medicare	$11.10
Rate for Payer: Aetna New Business (MI Preferred)	$14.43
Rate for Payer: BCBS Complete	$8.88
Rate for Payer: Cash Price	$17.76
Rate for Payer: Cofinity Advantage	$15.54
Rate for Payer: Cofinity Commercial	$19.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.76
Rate for Payer: Healthscope Commercial	$19.98
Rate for Payer: MI Amish Medical Board Commercial	$17.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.65
Rate for Payer: PHP Commercial	$18.87
Rate for Payer: Priority Health SBD	$13.99
Rate for Payer: UHC All Payor (Choice/PPO)	$14.43
Rate for Payer: UHC Core	$11.57
Rate for Payer: UHC Exchange	$8.72

NOVASOURCE RENAL INTERMITTENT FEED

Facility

$22.20

Service Code	NDC 43900035180
Hospital Charge Code	200086
Hospital Revenue Code	637
Min. Negotiated Rate	$8.72
Max. Negotiated Rate	$19.98
Rate for Payer: Aetna Commercial	$18.87
Rate for Payer: Aetna Medicare	$11.10
Rate for Payer: Aetna New Business (MI Preferred)	$14.43
Rate for Payer: BCBS Complete	$8.88
Rate for Payer: Cash Price	$17.76
Rate for Payer: Cofinity Advantage	$15.54
Rate for Payer: Cofinity Commercial	$19.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.76
Rate for Payer: Healthscope Commercial	$19.98
Rate for Payer: MI Amish Medical Board Commercial	$17.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.65
Rate for Payer: PHP Commercial	$18.87
Rate for Payer: Priority Health SBD	$13.99
Rate for Payer: UHC All Payor (Choice/PPO)	$14.43
Rate for Payer: UHC Core	$11.57
Rate for Payer: UHC Exchange	$8.72

NOVASOURCE RENAL INTERMITTENT FEED

Facility

$22.20

Service Code	NDC 43900035180
Hospital Charge Code	200086
Hospital Revenue Code	637
Min. Negotiated Rate	$13.99
Max. Negotiated Rate	$19.98
Rate for Payer: Aetna Commercial	$18.87
Rate for Payer: Aetna New Business (MI Preferred)	$14.43
Rate for Payer: Cash Price	$17.76
Rate for Payer: Cofinity Advantage	$15.54
Rate for Payer: Cofinity Commercial	$19.09
Rate for Payer: Encore Health Key Benefits Commercial	$17.76
Rate for Payer: Healthscope Commercial	$19.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$16.65
Rate for Payer: PHP Commercial	$18.87
Rate for Payer: Priority Health SBD	$13.99

Know your out-of-pocket cost for care.

All Charges