Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

NICARDIPINE 30 MG CAPSULE

Facility

$1,129.87

Service Code	NDC 42806050209
Hospital Charge Code	10713
Hospital Revenue Code	637
Min. Negotiated Rate	$451.95
Max. Negotiated Rate	$1,016.88
Rate for Payer: Aetna Commercial	$960.39
Rate for Payer: Aetna Medicare	$564.93
Rate for Payer: Aetna New Business (MI Preferred)	$734.42
Rate for Payer: BCBS Complete	$451.95
Rate for Payer: Cash Price	$903.90
Rate for Payer: Cofinity Commercial	$790.91
Rate for Payer: Cofinity Commercial	$971.69
Rate for Payer: Cofinity Medicare Advantage	$790.91
Rate for Payer: Encore Health Key Benefits Commercial	$903.90
Rate for Payer: Healthscope Commercial	$1,016.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$960.39
Rate for Payer: PHP Commercial	$960.39
Rate for Payer: Priority Health Cigna Priority Health	$734.42
Rate for Payer: Priority Health SBD	$711.82

NICARDIPINE 30 MG CAPSULE

Facility

$789.55

Service Code	NDC 00378143077
Hospital Charge Code	10713
Hospital Revenue Code	637
Min. Negotiated Rate	$497.42
Max. Negotiated Rate	$710.60
Rate for Payer: Aetna Commercial	$671.12
Rate for Payer: Aetna New Business (MI Preferred)	$513.21
Rate for Payer: Cash Price	$631.64
Rate for Payer: Cofinity Commercial	$552.68
Rate for Payer: Cofinity Commercial	$679.01
Rate for Payer: Cofinity Medicare Advantage	$552.68
Rate for Payer: Encore Health Key Benefits Commercial	$631.64
Rate for Payer: Healthscope Commercial	$710.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$671.12
Rate for Payer: PHP Commercial	$671.12
Rate for Payer: Priority Health Cigna Priority Health	$513.21
Rate for Payer: Priority Health SBD	$497.42

NICARDIPINE 30 MG CAPSULE

Facility

$1,129.87

Service Code	NDC 42806050209
Hospital Charge Code	10713
Hospital Revenue Code	637
Min. Negotiated Rate	$711.82
Max. Negotiated Rate	$1,016.88
Rate for Payer: Aetna Commercial	$960.39
Rate for Payer: Aetna New Business (MI Preferred)	$734.42
Rate for Payer: Cash Price	$903.90
Rate for Payer: Cofinity Commercial	$790.91
Rate for Payer: Cofinity Commercial	$971.69
Rate for Payer: Cofinity Medicare Advantage	$790.91
Rate for Payer: Encore Health Key Benefits Commercial	$903.90
Rate for Payer: Healthscope Commercial	$1,016.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$960.39
Rate for Payer: PHP Commercial	$960.39
Rate for Payer: Priority Health Cigna Priority Health	$734.42
Rate for Payer: Priority Health SBD	$711.82

NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN

Facility

$270.98

Service Code	HCPCS J2404
Hospital Charge Code	94576
Hospital Revenue Code	636
Min. Negotiated Rate	$108.39
Max. Negotiated Rate	$243.88
Rate for Payer: Aetna Commercial	$230.33
Rate for Payer: Aetna Medicare	$135.49
Rate for Payer: Aetna New Business (MI Preferred)	$176.14
Rate for Payer: BCBS Complete	$108.39
Rate for Payer: Cash Price	$216.78
Rate for Payer: Cofinity Commercial	$189.69
Rate for Payer: Cofinity Commercial	$233.04
Rate for Payer: Cofinity Medicare Advantage	$189.69
Rate for Payer: Encore Health Key Benefits Commercial	$216.78
Rate for Payer: Healthscope Commercial	$243.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$230.33
Rate for Payer: PHP Commercial	$230.33
Rate for Payer: Priority Health Cigna Priority Health	$176.14
Rate for Payer: Priority Health SBD	$170.72

NICARDIPINE 40 MG/200 ML(0.2 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN

Facility

$270.98

Service Code	HCPCS J2404
Hospital Charge Code	94576
Hospital Revenue Code	636
Min. Negotiated Rate	$170.72
Max. Negotiated Rate	$243.88
Rate for Payer: Aetna Commercial	$230.33
Rate for Payer: Aetna New Business (MI Preferred)	$176.14
Rate for Payer: Cash Price	$216.78
Rate for Payer: Cofinity Commercial	$189.69
Rate for Payer: Cofinity Commercial	$233.04
Rate for Payer: Cofinity Medicare Advantage	$189.69
Rate for Payer: Encore Health Key Benefits Commercial	$216.78
Rate for Payer: Healthscope Commercial	$243.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$230.33
Rate for Payer: PHP Commercial	$230.33
Rate for Payer: Priority Health Cigna Priority Health	$176.14
Rate for Payer: Priority Health SBD	$170.72

NICARDIPINE 50 MG/250 ML NS (IV PREMIX)

Facility

$193.50

Service Code	HCPCS J2404
Hospital Charge Code	180442
Hospital Revenue Code	636
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$174.15
Rate for Payer: Aetna Commercial	$164.47
Rate for Payer: Aetna Medicare	$96.75
Rate for Payer: Aetna New Business (MI Preferred)	$125.78
Rate for Payer: BCBS Complete	$77.40
Rate for Payer: Cash Price	$154.80
Rate for Payer: Cofinity Commercial	$135.45
Rate for Payer: Cofinity Commercial	$166.41
Rate for Payer: Cofinity Medicare Advantage	$135.45
Rate for Payer: Encore Health Key Benefits Commercial	$154.80
Rate for Payer: Healthscope Commercial	$174.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$164.47
Rate for Payer: PHP Commercial	$164.47
Rate for Payer: Priority Health Cigna Priority Health	$125.78
Rate for Payer: Priority Health SBD	$121.91

NICARDIPINE 50 MG/250 ML NS (IV PREMIX)

Facility

$193.50

Service Code	HCPCS J2404
Hospital Charge Code	180442
Hospital Revenue Code	636
Min. Negotiated Rate	$121.91
Max. Negotiated Rate	$174.15
Rate for Payer: Aetna Commercial	$164.47
Rate for Payer: Aetna New Business (MI Preferred)	$125.78
Rate for Payer: Cash Price	$154.80
Rate for Payer: Cofinity Commercial	$135.45
Rate for Payer: Cofinity Commercial	$166.41
Rate for Payer: Cofinity Medicare Advantage	$135.45
Rate for Payer: Encore Health Key Benefits Commercial	$154.80
Rate for Payer: Healthscope Commercial	$174.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$164.47
Rate for Payer: PHP Commercial	$164.47
Rate for Payer: Priority Health Cigna Priority Health	$125.78
Rate for Payer: Priority Health SBD	$121.91

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$8.23

Service Code	NDC 43598044771
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$7.41
Rate for Payer: Aetna Commercial	$7.00
Rate for Payer: Aetna New Business (MI Preferred)	$5.35
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cofinity Commercial	$5.76
Rate for Payer: Cofinity Commercial	$7.08
Rate for Payer: Cofinity Medicare Advantage	$5.76
Rate for Payer: Encore Health Key Benefits Commercial	$6.58
Rate for Payer: Healthscope Commercial	$7.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.00
Rate for Payer: PHP Commercial	$7.00
Rate for Payer: Priority Health Cigna Priority Health	$5.35
Rate for Payer: Priority Health SBD	$5.18

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$8.23

Service Code	NDC 43598044771
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$7.41
Rate for Payer: Aetna Commercial	$7.00
Rate for Payer: Aetna Medicare	$4.12
Rate for Payer: Aetna New Business (MI Preferred)	$5.35
Rate for Payer: BCBS Complete	$3.29
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cofinity Commercial	$5.76
Rate for Payer: Cofinity Commercial	$7.08
Rate for Payer: Cofinity Medicare Advantage	$5.76
Rate for Payer: Encore Health Key Benefits Commercial	$6.58
Rate for Payer: Healthscope Commercial	$7.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.00
Rate for Payer: PHP Commercial	$7.00
Rate for Payer: Priority Health Cigna Priority Health	$5.35
Rate for Payer: Priority Health SBD	$5.18

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$111.15

Service Code	NDC 43598044774
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$70.02
Max. Negotiated Rate	$100.03
Rate for Payer: Aetna Commercial	$94.48
Rate for Payer: Aetna New Business (MI Preferred)	$72.25
Rate for Payer: Cash Price	$88.92
Rate for Payer: Cofinity Commercial	$77.81
Rate for Payer: Cofinity Commercial	$95.59
Rate for Payer: Cofinity Medicare Advantage	$77.81
Rate for Payer: Encore Health Key Benefits Commercial	$88.92
Rate for Payer: Healthscope Commercial	$100.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$94.48
Rate for Payer: PHP Commercial	$94.48
Rate for Payer: Priority Health Cigna Priority Health	$72.25
Rate for Payer: Priority Health SBD	$70.02

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$111.15

Service Code	NDC 43598044774
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$44.46
Max. Negotiated Rate	$100.03
Rate for Payer: Aetna Commercial	$94.48
Rate for Payer: Aetna Medicare	$55.58
Rate for Payer: Aetna New Business (MI Preferred)	$72.25
Rate for Payer: BCBS Complete	$44.46
Rate for Payer: Cash Price	$88.92
Rate for Payer: Cofinity Commercial	$77.81
Rate for Payer: Cofinity Commercial	$95.59
Rate for Payer: Cofinity Medicare Advantage	$77.81
Rate for Payer: Encore Health Key Benefits Commercial	$88.92
Rate for Payer: Healthscope Commercial	$100.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$94.48
Rate for Payer: PHP Commercial	$94.48
Rate for Payer: Priority Health Cigna Priority Health	$72.25
Rate for Payer: Priority Health SBD	$70.02

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$106.99

Service Code	NDC 00536589588
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$67.40
Max. Negotiated Rate	$96.29
Rate for Payer: Aetna Commercial	$90.94
Rate for Payer: Aetna New Business (MI Preferred)	$69.54
Rate for Payer: Cash Price	$85.59
Rate for Payer: Cofinity Commercial	$74.89
Rate for Payer: Cofinity Commercial	$92.01
Rate for Payer: Cofinity Medicare Advantage	$74.89
Rate for Payer: Encore Health Key Benefits Commercial	$85.59
Rate for Payer: Healthscope Commercial	$96.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$90.94
Rate for Payer: PHP Commercial	$90.94
Rate for Payer: Priority Health Cigna Priority Health	$69.54
Rate for Payer: Priority Health SBD	$67.40

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$58.70

Service Code	NDC 00536589553
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$23.48
Max. Negotiated Rate	$52.83
Rate for Payer: Aetna Commercial	$49.90
Rate for Payer: Aetna Medicare	$29.35
Rate for Payer: Aetna New Business (MI Preferred)	$38.16
Rate for Payer: BCBS Complete	$23.48
Rate for Payer: Cash Price	$46.96
Rate for Payer: Cofinity Commercial	$41.09
Rate for Payer: Cofinity Commercial	$50.48
Rate for Payer: Cofinity Medicare Advantage	$41.09
Rate for Payer: Encore Health Key Benefits Commercial	$46.96
Rate for Payer: Healthscope Commercial	$52.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.90
Rate for Payer: PHP Commercial	$49.90
Rate for Payer: Priority Health Cigna Priority Health	$38.16
Rate for Payer: Priority Health SBD	$36.98

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$115.12

Service Code	NDC 00536110788
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$72.53
Max. Negotiated Rate	$103.61
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna New Business (MI Preferred)	$74.83
Rate for Payer: Cash Price	$92.10
Rate for Payer: Cofinity Commercial	$80.58
Rate for Payer: Cofinity Commercial	$99.00
Rate for Payer: Cofinity Medicare Advantage	$80.58
Rate for Payer: Encore Health Key Benefits Commercial	$92.10
Rate for Payer: Healthscope Commercial	$103.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$97.85
Rate for Payer: PHP Commercial	$97.85
Rate for Payer: Priority Health Cigna Priority Health	$74.83
Rate for Payer: Priority Health SBD	$72.53

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$115.12

Service Code	NDC 00536110788
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$46.05
Max. Negotiated Rate	$103.61
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$57.56
Rate for Payer: Aetna New Business (MI Preferred)	$74.83
Rate for Payer: BCBS Complete	$46.05
Rate for Payer: Cash Price	$92.10
Rate for Payer: Cofinity Commercial	$80.58
Rate for Payer: Cofinity Commercial	$99.00
Rate for Payer: Cofinity Medicare Advantage	$80.58
Rate for Payer: Encore Health Key Benefits Commercial	$92.10
Rate for Payer: Healthscope Commercial	$103.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$97.85
Rate for Payer: PHP Commercial	$97.85
Rate for Payer: Priority Health Cigna Priority Health	$74.83
Rate for Payer: Priority Health SBD	$72.53

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$58.70

Service Code	NDC 00536589553
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$36.98
Max. Negotiated Rate	$52.83
Rate for Payer: Aetna Commercial	$49.90
Rate for Payer: Aetna New Business (MI Preferred)	$38.16
Rate for Payer: Cash Price	$46.96
Rate for Payer: Cofinity Commercial	$41.09
Rate for Payer: Cofinity Commercial	$50.48
Rate for Payer: Cofinity Medicare Advantage	$41.09
Rate for Payer: Encore Health Key Benefits Commercial	$46.96
Rate for Payer: Healthscope Commercial	$52.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.90
Rate for Payer: PHP Commercial	$49.90
Rate for Payer: Priority Health Cigna Priority Health	$38.16
Rate for Payer: Priority Health SBD	$36.98

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$107.93

Service Code	NDC 48985000150
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$43.17
Max. Negotiated Rate	$97.14
Rate for Payer: Aetna Commercial	$91.74
Rate for Payer: Aetna Medicare	$53.97
Rate for Payer: Aetna New Business (MI Preferred)	$70.15
Rate for Payer: BCBS Complete	$43.17
Rate for Payer: Cash Price	$86.34
Rate for Payer: Cofinity Commercial	$75.55
Rate for Payer: Cofinity Commercial	$92.82
Rate for Payer: Cofinity Medicare Advantage	$75.55
Rate for Payer: Encore Health Key Benefits Commercial	$86.34
Rate for Payer: Healthscope Commercial	$97.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$91.74
Rate for Payer: PHP Commercial	$91.74
Rate for Payer: Priority Health Cigna Priority Health	$70.15
Rate for Payer: Priority Health SBD	$68.00

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$107.93

Service Code	NDC 48985000150
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$68.00
Max. Negotiated Rate	$97.14
Rate for Payer: Aetna Commercial	$91.74
Rate for Payer: Aetna New Business (MI Preferred)	$70.15
Rate for Payer: Cash Price	$86.34
Rate for Payer: Cofinity Commercial	$75.55
Rate for Payer: Cofinity Commercial	$92.82
Rate for Payer: Cofinity Medicare Advantage	$75.55
Rate for Payer: Encore Health Key Benefits Commercial	$86.34
Rate for Payer: Healthscope Commercial	$97.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$91.74
Rate for Payer: PHP Commercial	$91.74
Rate for Payer: Priority Health Cigna Priority Health	$70.15
Rate for Payer: Priority Health SBD	$68.00

NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$106.99

Service Code	NDC 00536589588
Hospital Charge Code	27862
Hospital Revenue Code	637
Min. Negotiated Rate	$42.80
Max. Negotiated Rate	$96.29
Rate for Payer: Aetna Commercial	$90.94
Rate for Payer: Aetna Medicare	$53.49
Rate for Payer: Aetna New Business (MI Preferred)	$69.54
Rate for Payer: BCBS Complete	$42.80
Rate for Payer: Cash Price	$85.59
Rate for Payer: Cofinity Commercial	$74.89
Rate for Payer: Cofinity Commercial	$92.01
Rate for Payer: Cofinity Medicare Advantage	$74.89
Rate for Payer: Encore Health Key Benefits Commercial	$85.59
Rate for Payer: Healthscope Commercial	$96.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$90.94
Rate for Payer: PHP Commercial	$90.94
Rate for Payer: Priority Health Cigna Priority Health	$69.54
Rate for Payer: Priority Health SBD	$67.40

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$111.15

Service Code	NDC 43598044874
Hospital Charge Code	27863
Hospital Revenue Code	637
Min. Negotiated Rate	$70.02
Max. Negotiated Rate	$100.03
Rate for Payer: Aetna Commercial	$94.48
Rate for Payer: Aetna New Business (MI Preferred)	$72.25
Rate for Payer: Cash Price	$88.92
Rate for Payer: Cofinity Commercial	$77.81
Rate for Payer: Cofinity Commercial	$95.59
Rate for Payer: Cofinity Medicare Advantage	$77.81
Rate for Payer: Encore Health Key Benefits Commercial	$88.92
Rate for Payer: Healthscope Commercial	$100.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$94.48
Rate for Payer: PHP Commercial	$94.48
Rate for Payer: Priority Health Cigna Priority Health	$72.25
Rate for Payer: Priority Health SBD	$70.02

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$121.91

Service Code	NDC 48985000152
Hospital Charge Code	27863
Hospital Revenue Code	637
Min. Negotiated Rate	$76.80
Max. Negotiated Rate	$109.72
Rate for Payer: Aetna Commercial	$103.62
Rate for Payer: Aetna New Business (MI Preferred)	$79.24
Rate for Payer: Cash Price	$97.53
Rate for Payer: Cofinity Commercial	$104.84
Rate for Payer: Cofinity Commercial	$85.34
Rate for Payer: Cofinity Medicare Advantage	$85.34
Rate for Payer: Encore Health Key Benefits Commercial	$97.53
Rate for Payer: Healthscope Commercial	$109.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$103.62
Rate for Payer: PHP Commercial	$103.62
Rate for Payer: Priority Health Cigna Priority Health	$79.24
Rate for Payer: Priority Health SBD	$76.80

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$121.91

Service Code	NDC 48985000152
Hospital Charge Code	27863
Hospital Revenue Code	637
Min. Negotiated Rate	$48.76
Max. Negotiated Rate	$109.72
Rate for Payer: Aetna Commercial	$103.62
Rate for Payer: Aetna Medicare	$60.95
Rate for Payer: Aetna New Business (MI Preferred)	$79.24
Rate for Payer: BCBS Complete	$48.76
Rate for Payer: Cash Price	$97.53
Rate for Payer: Cofinity Commercial	$104.84
Rate for Payer: Cofinity Commercial	$85.34
Rate for Payer: Cofinity Medicare Advantage	$85.34
Rate for Payer: Encore Health Key Benefits Commercial	$97.53
Rate for Payer: Healthscope Commercial	$109.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$103.62
Rate for Payer: PHP Commercial	$103.62
Rate for Payer: Priority Health Cigna Priority Health	$79.24
Rate for Payer: Priority Health SBD	$76.80

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$170.53

Service Code	NDC 00766142020
Hospital Charge Code	27863
Hospital Revenue Code	637
Min. Negotiated Rate	$68.21
Max. Negotiated Rate	$153.48
Rate for Payer: Aetna Commercial	$144.95
Rate for Payer: Aetna Medicare	$85.27
Rate for Payer: Aetna New Business (MI Preferred)	$110.84
Rate for Payer: BCBS Complete	$68.21
Rate for Payer: Cash Price	$136.42
Rate for Payer: Cofinity Commercial	$119.37
Rate for Payer: Cofinity Commercial	$146.66
Rate for Payer: Cofinity Medicare Advantage	$119.37
Rate for Payer: Encore Health Key Benefits Commercial	$136.42
Rate for Payer: Healthscope Commercial	$153.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$144.95
Rate for Payer: PHP Commercial	$144.95
Rate for Payer: Priority Health Cigna Priority Health	$110.84
Rate for Payer: Priority Health SBD	$107.43

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$170.53

Service Code	NDC 00766142020
Hospital Charge Code	27863
Hospital Revenue Code	637
Min. Negotiated Rate	$107.43
Max. Negotiated Rate	$153.48
Rate for Payer: Aetna Commercial	$144.95
Rate for Payer: Aetna New Business (MI Preferred)	$110.84
Rate for Payer: Cash Price	$136.42
Rate for Payer: Cofinity Commercial	$119.37
Rate for Payer: Cofinity Commercial	$146.66
Rate for Payer: Cofinity Medicare Advantage	$119.37
Rate for Payer: Encore Health Key Benefits Commercial	$136.42
Rate for Payer: Healthscope Commercial	$153.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$144.95
Rate for Payer: PHP Commercial	$144.95
Rate for Payer: Priority Health Cigna Priority Health	$110.84
Rate for Payer: Priority Health SBD	$107.43

NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH

Facility

$95.09

Service Code	NDC 00536589688
Hospital Charge Code	27863
Hospital Revenue Code	637
Min. Negotiated Rate	$38.04
Max. Negotiated Rate	$85.58
Rate for Payer: Aetna Commercial	$80.83
Rate for Payer: Aetna Medicare	$47.55
Rate for Payer: Aetna New Business (MI Preferred)	$61.81
Rate for Payer: BCBS Complete	$38.04
Rate for Payer: Cash Price	$76.07
Rate for Payer: Cofinity Commercial	$66.56
Rate for Payer: Cofinity Commercial	$81.78
Rate for Payer: Cofinity Medicare Advantage	$66.56
Rate for Payer: Encore Health Key Benefits Commercial	$76.07
Rate for Payer: Healthscope Commercial	$85.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$80.83
Rate for Payer: PHP Commercial	$80.83
Rate for Payer: Priority Health Cigna Priority Health	$61.81
Rate for Payer: Priority Health SBD	$59.91

Know your out-of-pocket cost for care.

All Charges