Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION

Facility

$210.58

Service Code	HCPCS J2540
Hospital Charge Code	6085
Hospital Revenue Code	636
Min. Negotiated Rate	$132.67
Max. Negotiated Rate	$189.52
Rate for Payer: Aetna Commercial	$178.99
Rate for Payer: Aetna Commercial	$178.81
Rate for Payer: Aetna New Business (MI Preferred)	$136.73
Rate for Payer: Aetna New Business (MI Preferred)	$136.88
Rate for Payer: Cash Price	$168.29
Rate for Payer: Cash Price	$168.46
Rate for Payer: Cofinity Commercial	$147.25
Rate for Payer: Cofinity Commercial	$147.41
Rate for Payer: Cofinity Commercial	$181.10
Rate for Payer: Cofinity Commercial	$180.91
Rate for Payer: Cofinity Medicare Advantage	$147.41
Rate for Payer: Cofinity Medicare Advantage	$147.25
Rate for Payer: Encore Health Key Benefits Commercial	$168.29
Rate for Payer: Encore Health Key Benefits Commercial	$168.46
Rate for Payer: Healthscope Commercial	$189.32
Rate for Payer: Healthscope Commercial	$189.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$178.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$178.99
Rate for Payer: PHP Commercial	$178.81
Rate for Payer: PHP Commercial	$178.99
Rate for Payer: Priority Health Cigna Priority Health	$136.88
Rate for Payer: Priority Health Cigna Priority Health	$136.73
Rate for Payer: Priority Health SBD	$132.67
Rate for Payer: Priority Health SBD	$132.53

PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION

Facility

$18.34

Service Code	HCPCS J2540
Hospital Charge Code	6086
Hospital Revenue Code	636
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$16.51
Rate for Payer: Aetna Commercial	$15.59
Rate for Payer: Aetna New Business (MI Preferred)	$11.92
Rate for Payer: Cash Price	$14.67
Rate for Payer: Cofinity Commercial	$12.84
Rate for Payer: Cofinity Commercial	$15.77
Rate for Payer: Cofinity Medicare Advantage	$12.84
Rate for Payer: Encore Health Key Benefits Commercial	$14.67
Rate for Payer: Healthscope Commercial	$16.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.59
Rate for Payer: PHP Commercial	$15.59
Rate for Payer: Priority Health Cigna Priority Health	$11.92
Rate for Payer: Priority Health SBD	$11.55

PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION

Facility

$18.34

Service Code	HCPCS J2540
Hospital Charge Code	6086
Hospital Revenue Code	636
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$16.51
Rate for Payer: Aetna Commercial	$15.59
Rate for Payer: Aetna Medicare	$9.17
Rate for Payer: Aetna New Business (MI Preferred)	$11.92
Rate for Payer: BCBS Complete	$7.34
Rate for Payer: Cash Price	$14.67
Rate for Payer: Cofinity Commercial	$12.84
Rate for Payer: Cofinity Commercial	$15.77
Rate for Payer: Cofinity Medicare Advantage	$12.84
Rate for Payer: Encore Health Key Benefits Commercial	$14.67
Rate for Payer: Healthscope Commercial	$16.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.59
Rate for Payer: PHP Commercial	$15.59
Rate for Payer: Priority Health Cigna Priority Health	$11.92
Rate for Payer: Priority Health SBD	$11.55

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION

Facility

$249.10

Service Code	NDC 00093412774
Hospital Charge Code	6091
Hospital Revenue Code	637
Min. Negotiated Rate	$156.93
Max. Negotiated Rate	$224.19
Rate for Payer: Aetna Commercial	$211.74
Rate for Payer: Aetna New Business (MI Preferred)	$161.91
Rate for Payer: Cash Price	$199.28
Rate for Payer: Cofinity Commercial	$174.37
Rate for Payer: Cofinity Commercial	$214.23
Rate for Payer: Cofinity Medicare Advantage	$174.37
Rate for Payer: Encore Health Key Benefits Commercial	$199.28
Rate for Payer: Healthscope Commercial	$224.19
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$211.74
Rate for Payer: PHP Commercial	$211.74
Rate for Payer: Priority Health Cigna Priority Health	$161.91
Rate for Payer: Priority Health SBD	$156.93

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION

Facility

$249.10

Service Code	NDC 00093412774
Hospital Charge Code	6091
Hospital Revenue Code	637
Min. Negotiated Rate	$99.64
Max. Negotiated Rate	$224.19
Rate for Payer: Aetna Commercial	$211.74
Rate for Payer: Aetna Medicare	$124.55
Rate for Payer: Aetna New Business (MI Preferred)	$161.91
Rate for Payer: BCBS Complete	$99.64
Rate for Payer: Cash Price	$199.28
Rate for Payer: Cofinity Commercial	$174.37
Rate for Payer: Cofinity Commercial	$214.23
Rate for Payer: Cofinity Medicare Advantage	$174.37
Rate for Payer: Encore Health Key Benefits Commercial	$199.28
Rate for Payer: Healthscope Commercial	$224.19
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$211.74
Rate for Payer: PHP Commercial	$211.74
Rate for Payer: Priority Health Cigna Priority Health	$161.91
Rate for Payer: Priority Health SBD	$156.93

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION

Facility

$145.70

Service Code	NDC 00093412773
Hospital Charge Code	6091
Hospital Revenue Code	637
Min. Negotiated Rate	$91.79
Max. Negotiated Rate	$131.13
Rate for Payer: Aetna Commercial	$123.84
Rate for Payer: Aetna New Business (MI Preferred)	$94.70
Rate for Payer: Cash Price	$116.56
Rate for Payer: Cofinity Commercial	$101.99
Rate for Payer: Cofinity Commercial	$125.30
Rate for Payer: Cofinity Medicare Advantage	$101.99
Rate for Payer: Encore Health Key Benefits Commercial	$116.56
Rate for Payer: Healthscope Commercial	$131.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$123.84
Rate for Payer: PHP Commercial	$123.84
Rate for Payer: Priority Health Cigna Priority Health	$94.70
Rate for Payer: Priority Health SBD	$91.79

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION

Facility

$145.70

Service Code	NDC 00093412773
Hospital Charge Code	6091
Hospital Revenue Code	637
Min. Negotiated Rate	$58.28
Max. Negotiated Rate	$131.13
Rate for Payer: Aetna Commercial	$123.84
Rate for Payer: Aetna Medicare	$72.85
Rate for Payer: Aetna New Business (MI Preferred)	$94.70
Rate for Payer: BCBS Complete	$58.28
Rate for Payer: Cash Price	$116.56
Rate for Payer: Cofinity Commercial	$101.99
Rate for Payer: Cofinity Commercial	$125.30
Rate for Payer: Cofinity Medicare Advantage	$101.99
Rate for Payer: Encore Health Key Benefits Commercial	$116.56
Rate for Payer: Healthscope Commercial	$131.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$123.84
Rate for Payer: PHP Commercial	$123.84
Rate for Payer: Priority Health Cigna Priority Health	$94.70
Rate for Payer: Priority Health SBD	$91.79

PENICILLIN V POTASSIUM 250 MG TABLET

Facility

$173.90

Service Code	NDC 65862017501
Hospital Charge Code	6092
Hospital Revenue Code	637
Min. Negotiated Rate	$109.56
Max. Negotiated Rate	$156.51
Rate for Payer: Aetna Commercial	$147.81
Rate for Payer: Aetna New Business (MI Preferred)	$113.03
Rate for Payer: Cash Price	$139.12
Rate for Payer: Cofinity Commercial	$121.73
Rate for Payer: Cofinity Commercial	$149.55
Rate for Payer: Cofinity Medicare Advantage	$121.73
Rate for Payer: Encore Health Key Benefits Commercial	$139.12
Rate for Payer: Healthscope Commercial	$156.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$147.81
Rate for Payer: PHP Commercial	$147.81
Rate for Payer: Priority Health Cigna Priority Health	$113.03
Rate for Payer: Priority Health SBD	$109.56

PENICILLIN V POTASSIUM 250 MG TABLET

Facility

$176.25

Service Code	NDC 57237004001
Hospital Charge Code	6092
Hospital Revenue Code	637
Min. Negotiated Rate	$70.50
Max. Negotiated Rate	$158.62
Rate for Payer: Aetna Commercial	$149.81
Rate for Payer: Aetna Medicare	$88.12
Rate for Payer: Aetna New Business (MI Preferred)	$114.56
Rate for Payer: BCBS Complete	$70.50
Rate for Payer: Cash Price	$141.00
Rate for Payer: Cofinity Commercial	$123.38
Rate for Payer: Cofinity Commercial	$151.57
Rate for Payer: Cofinity Medicare Advantage	$123.38
Rate for Payer: Encore Health Key Benefits Commercial	$141.00
Rate for Payer: Healthscope Commercial	$158.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$149.81
Rate for Payer: PHP Commercial	$149.81
Rate for Payer: Priority Health Cigna Priority Health	$114.56
Rate for Payer: Priority Health SBD	$111.04

PENICILLIN V POTASSIUM 250 MG TABLET

Facility

$173.90

Service Code	NDC 65862017501
Hospital Charge Code	6092
Hospital Revenue Code	637
Min. Negotiated Rate	$69.56
Max. Negotiated Rate	$156.51
Rate for Payer: Aetna Commercial	$147.81
Rate for Payer: Aetna Medicare	$86.95
Rate for Payer: Aetna New Business (MI Preferred)	$113.03
Rate for Payer: BCBS Complete	$69.56
Rate for Payer: Cash Price	$139.12
Rate for Payer: Cofinity Commercial	$121.73
Rate for Payer: Cofinity Commercial	$149.55
Rate for Payer: Cofinity Medicare Advantage	$121.73
Rate for Payer: Encore Health Key Benefits Commercial	$139.12
Rate for Payer: Healthscope Commercial	$156.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$147.81
Rate for Payer: PHP Commercial	$147.81
Rate for Payer: Priority Health Cigna Priority Health	$113.03
Rate for Payer: Priority Health SBD	$109.56

PENICILLIN V POTASSIUM 250 MG TABLET

Facility

$176.25

Service Code	NDC 57237004001
Hospital Charge Code	6092
Hospital Revenue Code	637
Min. Negotiated Rate	$111.04
Max. Negotiated Rate	$158.62
Rate for Payer: Aetna Commercial	$149.81
Rate for Payer: Aetna New Business (MI Preferred)	$114.56
Rate for Payer: Cash Price	$141.00
Rate for Payer: Cofinity Commercial	$123.38
Rate for Payer: Cofinity Commercial	$151.57
Rate for Payer: Cofinity Medicare Advantage	$123.38
Rate for Payer: Encore Health Key Benefits Commercial	$141.00
Rate for Payer: Healthscope Commercial	$158.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$149.81
Rate for Payer: PHP Commercial	$149.81
Rate for Payer: Priority Health Cigna Priority Health	$114.56
Rate for Payer: Priority Health SBD	$111.04

PENTAMIDINE 300 MG IM INJECTION

Facility

$168.58

Service Code	NDC 63323011310
Hospital Charge Code	299999
Hospital Revenue Code	250
Min. Negotiated Rate	$67.43
Max. Negotiated Rate	$151.72
Rate for Payer: Aetna Commercial	$143.29
Rate for Payer: Aetna Medicare	$84.29
Rate for Payer: Aetna New Business (MI Preferred)	$109.58
Rate for Payer: BCBS Complete	$67.43
Rate for Payer: Cash Price	$134.86
Rate for Payer: Cofinity Commercial	$118.01
Rate for Payer: Cofinity Commercial	$144.98
Rate for Payer: Cofinity Medicare Advantage	$118.01
Rate for Payer: Encore Health Key Benefits Commercial	$134.86
Rate for Payer: Healthscope Commercial	$151.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.29
Rate for Payer: PHP Commercial	$143.29
Rate for Payer: Priority Health Cigna Priority Health	$109.58
Rate for Payer: Priority Health SBD	$106.21

PENTAMIDINE 300 MG IM INJECTION

Facility

$168.58

Service Code	NDC 63323011310
Hospital Charge Code	299999
Hospital Revenue Code	250
Min. Negotiated Rate	$106.21
Max. Negotiated Rate	$151.72
Rate for Payer: Aetna Commercial	$143.29
Rate for Payer: Aetna New Business (MI Preferred)	$109.58
Rate for Payer: Cash Price	$134.86
Rate for Payer: Cofinity Commercial	$118.01
Rate for Payer: Cofinity Commercial	$144.98
Rate for Payer: Cofinity Medicare Advantage	$118.01
Rate for Payer: Encore Health Key Benefits Commercial	$134.86
Rate for Payer: Healthscope Commercial	$151.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.29
Rate for Payer: PHP Commercial	$143.29
Rate for Payer: Priority Health Cigna Priority Health	$109.58
Rate for Payer: Priority Health SBD	$106.21

PENTAMIDINE 300 MG SOLUTION FOR INHALATION

Facility

$333.34

Service Code	HCPCS J2545
Hospital Charge Code	28235
Hospital Revenue Code	636
Min. Negotiated Rate	$133.34
Max. Negotiated Rate	$300.01
Rate for Payer: Aetna Commercial	$283.34
Rate for Payer: Aetna Commercial	$190.75
Rate for Payer: Aetna Medicare	$112.20
Rate for Payer: Aetna Medicare	$166.67
Rate for Payer: Aetna New Business (MI Preferred)	$145.87
Rate for Payer: Aetna New Business (MI Preferred)	$216.67
Rate for Payer: BCBS Complete	$133.34
Rate for Payer: BCBS Complete	$89.76
Rate for Payer: Cash Price	$179.53
Rate for Payer: Cash Price	$266.67
Rate for Payer: Cofinity Commercial	$157.09
Rate for Payer: Cofinity Commercial	$233.34
Rate for Payer: Cofinity Commercial	$286.67
Rate for Payer: Cofinity Commercial	$192.99
Rate for Payer: Cofinity Medicare Advantage	$233.34
Rate for Payer: Cofinity Medicare Advantage	$157.09
Rate for Payer: Encore Health Key Benefits Commercial	$179.53
Rate for Payer: Encore Health Key Benefits Commercial	$266.67
Rate for Payer: Healthscope Commercial	$201.97
Rate for Payer: Healthscope Commercial	$300.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$190.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$283.34
Rate for Payer: PHP Commercial	$283.34
Rate for Payer: PHP Commercial	$190.75
Rate for Payer: Priority Health Cigna Priority Health	$145.87
Rate for Payer: Priority Health Cigna Priority Health	$216.67
Rate for Payer: Priority Health SBD	$210.00
Rate for Payer: Priority Health SBD	$141.38

PENTAMIDINE 300 MG SOLUTION FOR INHALATION

Facility

$333.34

Service Code	HCPCS J2545
Hospital Charge Code	28235
Hospital Revenue Code	636
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.01
Rate for Payer: Aetna Commercial	$283.34
Rate for Payer: Aetna Commercial	$190.75
Rate for Payer: Aetna New Business (MI Preferred)	$145.87
Rate for Payer: Aetna New Business (MI Preferred)	$216.67
Rate for Payer: Cash Price	$179.53
Rate for Payer: Cash Price	$266.67
Rate for Payer: Cofinity Commercial	$157.09
Rate for Payer: Cofinity Commercial	$233.34
Rate for Payer: Cofinity Commercial	$286.67
Rate for Payer: Cofinity Commercial	$192.99
Rate for Payer: Cofinity Medicare Advantage	$233.34
Rate for Payer: Cofinity Medicare Advantage	$157.09
Rate for Payer: Encore Health Key Benefits Commercial	$179.53
Rate for Payer: Encore Health Key Benefits Commercial	$266.67
Rate for Payer: Healthscope Commercial	$201.97
Rate for Payer: Healthscope Commercial	$300.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$190.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$283.34
Rate for Payer: PHP Commercial	$190.75
Rate for Payer: PHP Commercial	$283.34
Rate for Payer: Priority Health Cigna Priority Health	$216.67
Rate for Payer: Priority Health Cigna Priority Health	$145.87
Rate for Payer: Priority Health SBD	$210.00
Rate for Payer: Priority Health SBD	$141.38

PENTAMIDINE 300 MG SOLUTION FOR INJECTION

Facility

$168.58

Service Code	NDC 63323011310
Hospital Charge Code	27430
Hospital Revenue Code	250
Min. Negotiated Rate	$106.21
Max. Negotiated Rate	$151.72
Rate for Payer: Aetna Commercial	$143.29
Rate for Payer: Aetna New Business (MI Preferred)	$109.58
Rate for Payer: Cash Price	$134.86
Rate for Payer: Cofinity Commercial	$118.01
Rate for Payer: Cofinity Commercial	$144.98
Rate for Payer: Cofinity Medicare Advantage	$118.01
Rate for Payer: Encore Health Key Benefits Commercial	$134.86
Rate for Payer: Healthscope Commercial	$151.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.29
Rate for Payer: PHP Commercial	$143.29
Rate for Payer: Priority Health Cigna Priority Health	$109.58
Rate for Payer: Priority Health SBD	$106.21

PENTAMIDINE 300 MG SOLUTION FOR INJECTION

Facility

$168.58

Service Code	NDC 63323011310
Hospital Charge Code	27430
Hospital Revenue Code	250
Min. Negotiated Rate	$67.43
Max. Negotiated Rate	$151.72
Rate for Payer: Aetna Commercial	$143.29
Rate for Payer: Aetna Medicare	$84.29
Rate for Payer: Aetna New Business (MI Preferred)	$109.58
Rate for Payer: BCBS Complete	$67.43
Rate for Payer: Cash Price	$134.86
Rate for Payer: Cofinity Commercial	$118.01
Rate for Payer: Cofinity Commercial	$144.98
Rate for Payer: Cofinity Medicare Advantage	$118.01
Rate for Payer: Encore Health Key Benefits Commercial	$134.86
Rate for Payer: Healthscope Commercial	$151.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$143.29
Rate for Payer: PHP Commercial	$143.29
Rate for Payer: Priority Health Cigna Priority Health	$109.58
Rate for Payer: Priority Health SBD	$106.21

PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE

Facility

$4,120.69

Service Code	NDC 50458009801
Hospital Charge Code	12912
Hospital Revenue Code	637
Min. Negotiated Rate	$1,648.28
Max. Negotiated Rate	$3,708.62
Rate for Payer: Aetna Commercial	$3,502.59
Rate for Payer: Aetna Medicare	$2,060.34
Rate for Payer: Aetna New Business (MI Preferred)	$2,678.45
Rate for Payer: BCBS Complete	$1,648.28
Rate for Payer: Cash Price	$3,296.55
Rate for Payer: Cofinity Commercial	$2,884.48
Rate for Payer: Cofinity Commercial	$3,543.79
Rate for Payer: Cofinity Medicare Advantage	$2,884.48
Rate for Payer: Encore Health Key Benefits Commercial	$3,296.55
Rate for Payer: Healthscope Commercial	$3,708.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,502.59
Rate for Payer: PHP Commercial	$3,502.59
Rate for Payer: Priority Health Cigna Priority Health	$2,678.45
Rate for Payer: Priority Health SBD	$2,596.03

PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE

Facility

$4,120.69

Service Code	NDC 50458009801
Hospital Charge Code	12912
Hospital Revenue Code	637
Min. Negotiated Rate	$2,596.03
Max. Negotiated Rate	$3,708.62
Rate for Payer: Aetna Commercial	$3,502.59
Rate for Payer: Aetna New Business (MI Preferred)	$2,678.45
Rate for Payer: Cash Price	$3,296.55
Rate for Payer: Cofinity Commercial	$2,884.48
Rate for Payer: Cofinity Commercial	$3,543.79
Rate for Payer: Cofinity Medicare Advantage	$2,884.48
Rate for Payer: Encore Health Key Benefits Commercial	$3,296.55
Rate for Payer: Healthscope Commercial	$3,708.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,502.59
Rate for Payer: PHP Commercial	$3,502.59
Rate for Payer: Priority Health Cigna Priority Health	$2,678.45
Rate for Payer: Priority Health SBD	$2,596.03

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE

Facility

$222.30

Service Code	NDC 00904544861
Hospital Charge Code	10911
Hospital Revenue Code	637
Min. Negotiated Rate	$140.05
Max. Negotiated Rate	$200.07
Rate for Payer: Aetna Commercial	$188.96
Rate for Payer: Aetna New Business (MI Preferred)	$144.50
Rate for Payer: Cash Price	$177.84
Rate for Payer: Cofinity Commercial	$155.61
Rate for Payer: Cofinity Commercial	$191.18
Rate for Payer: Cofinity Medicare Advantage	$155.61
Rate for Payer: Encore Health Key Benefits Commercial	$177.84
Rate for Payer: Healthscope Commercial	$200.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.96
Rate for Payer: PHP Commercial	$188.96
Rate for Payer: Priority Health Cigna Priority Health	$144.50
Rate for Payer: Priority Health SBD	$140.05

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE

Facility

$222.30

Service Code	NDC 00904544861
Hospital Charge Code	10911
Hospital Revenue Code	637
Min. Negotiated Rate	$88.92
Max. Negotiated Rate	$200.07
Rate for Payer: Aetna Commercial	$188.96
Rate for Payer: Aetna Medicare	$111.15
Rate for Payer: Aetna New Business (MI Preferred)	$144.50
Rate for Payer: BCBS Complete	$88.92
Rate for Payer: Cash Price	$177.84
Rate for Payer: Cofinity Commercial	$155.61
Rate for Payer: Cofinity Commercial	$191.18
Rate for Payer: Cofinity Medicare Advantage	$155.61
Rate for Payer: Encore Health Key Benefits Commercial	$177.84
Rate for Payer: Healthscope Commercial	$200.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$188.96
Rate for Payer: PHP Commercial	$188.96
Rate for Payer: Priority Health Cigna Priority Health	$144.50
Rate for Payer: Priority Health SBD	$140.05

PEPTAMEN INTENSE VHP BOLUS FEED

Facility

$15.73

Service Code	NDC 43900043271
Hospital Charge Code	300293
Hospital Revenue Code	637
Min. Negotiated Rate	$9.91
Max. Negotiated Rate	$14.16
Rate for Payer: Aetna Commercial	$13.37
Rate for Payer: Aetna New Business (MI Preferred)	$10.22
Rate for Payer: Cash Price	$12.58
Rate for Payer: Cofinity Commercial	$11.01
Rate for Payer: Cofinity Commercial	$13.53
Rate for Payer: Cofinity Medicare Advantage	$11.01
Rate for Payer: Encore Health Key Benefits Commercial	$12.58
Rate for Payer: Healthscope Commercial	$14.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.37
Rate for Payer: PHP Commercial	$13.37
Rate for Payer: Priority Health Cigna Priority Health	$10.22
Rate for Payer: Priority Health SBD	$9.91

PEPTAMEN INTENSE VHP BOLUS FEED

Facility

$15.73

Service Code	NDC 43900043271
Hospital Charge Code	300293
Hospital Revenue Code	637
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$14.16
Rate for Payer: Aetna Commercial	$13.37
Rate for Payer: Aetna Medicare	$7.87
Rate for Payer: Aetna New Business (MI Preferred)	$10.22
Rate for Payer: BCBS Complete	$6.29
Rate for Payer: Cash Price	$12.58
Rate for Payer: Cofinity Commercial	$11.01
Rate for Payer: Cofinity Commercial	$13.53
Rate for Payer: Cofinity Medicare Advantage	$11.01
Rate for Payer: Encore Health Key Benefits Commercial	$12.58
Rate for Payer: Healthscope Commercial	$14.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.37
Rate for Payer: PHP Commercial	$13.37
Rate for Payer: Priority Health Cigna Priority Health	$10.22
Rate for Payer: Priority Health SBD	$9.91

PEPTAMEN INTENSE VHP CONTINUOUS FEED

Facility

$70.30

Service Code	NDC 43900049322
Hospital Charge Code	181406
Hospital Revenue Code	637
Min. Negotiated Rate	$28.12
Max. Negotiated Rate	$63.27
Rate for Payer: Aetna Commercial	$59.76
Rate for Payer: Aetna Medicare	$35.15
Rate for Payer: Aetna New Business (MI Preferred)	$45.70
Rate for Payer: BCBS Complete	$28.12
Rate for Payer: Cash Price	$56.24
Rate for Payer: Cofinity Commercial	$49.21
Rate for Payer: Cofinity Commercial	$60.46
Rate for Payer: Cofinity Medicare Advantage	$49.21
Rate for Payer: Encore Health Key Benefits Commercial	$56.24
Rate for Payer: Healthscope Commercial	$63.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.76
Rate for Payer: PHP Commercial	$59.76
Rate for Payer: Priority Health Cigna Priority Health	$45.70
Rate for Payer: Priority Health SBD	$44.29

PEPTAMEN INTENSE VHP CONTINUOUS FEED

Facility

$70.30

Service Code	NDC 43900072395
Hospital Charge Code	181406
Hospital Revenue Code	637
Min. Negotiated Rate	$28.12
Max. Negotiated Rate	$63.27
Rate for Payer: Aetna Commercial	$59.76
Rate for Payer: Aetna Medicare	$35.15
Rate for Payer: Aetna New Business (MI Preferred)	$45.70
Rate for Payer: BCBS Complete	$28.12
Rate for Payer: Cash Price	$56.24
Rate for Payer: Cofinity Commercial	$49.21
Rate for Payer: Cofinity Commercial	$60.46
Rate for Payer: Cofinity Medicare Advantage	$49.21
Rate for Payer: Encore Health Key Benefits Commercial	$56.24
Rate for Payer: Healthscope Commercial	$63.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.76
Rate for Payer: PHP Commercial	$59.76
Rate for Payer: Priority Health Cigna Priority Health	$45.70
Rate for Payer: Priority Health SBD	$44.29

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