Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

ATORVASTATIN 20 MG TABLET

Facility

$253.65

Service Code	NDC 51079020920
Hospital Charge Code	19178
Hospital Revenue Code	637
Min. Negotiated Rate	$159.80
Max. Negotiated Rate	$228.28
Rate for Payer: Aetna Commercial	$215.60
Rate for Payer: Aetna New Business (MI Preferred)	$164.87
Rate for Payer: Cash Price	$202.92
Rate for Payer: Cofinity Commercial	$177.56
Rate for Payer: Cofinity Commercial	$218.14
Rate for Payer: Cofinity Medicare Advantage	$177.56
Rate for Payer: Encore Health Key Benefits Commercial	$202.92
Rate for Payer: Healthscope Commercial	$228.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.60
Rate for Payer: PHP Commercial	$215.60
Rate for Payer: Priority Health Cigna Priority Health	$164.87
Rate for Payer: Priority Health SBD	$159.80

ATORVASTATIN 20 MG TABLET

Facility

$229.90

Service Code	NDC 68084009801
Hospital Charge Code	19178
Hospital Revenue Code	637
Min. Negotiated Rate	$91.96
Max. Negotiated Rate	$206.91
Rate for Payer: Aetna Commercial	$195.42
Rate for Payer: Aetna Medicare	$114.95
Rate for Payer: Aetna New Business (MI Preferred)	$149.44
Rate for Payer: BCBS Complete	$91.96
Rate for Payer: Cash Price	$183.92
Rate for Payer: Cofinity Commercial	$160.93
Rate for Payer: Cofinity Commercial	$197.71
Rate for Payer: Cofinity Medicare Advantage	$160.93
Rate for Payer: Encore Health Key Benefits Commercial	$183.92
Rate for Payer: Healthscope Commercial	$206.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$195.42
Rate for Payer: PHP Commercial	$195.42
Rate for Payer: Priority Health Cigna Priority Health	$149.44
Rate for Payer: Priority Health SBD	$144.84

ATORVASTATIN 20 MG TABLET

Facility

$2.30

Service Code	NDC 68084009811
Hospital Charge Code	19178
Hospital Revenue Code	637
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$2.07
Rate for Payer: Aetna Commercial	$1.96
Rate for Payer: Aetna Medicare	$1.15
Rate for Payer: Aetna New Business (MI Preferred)	$1.50
Rate for Payer: BCBS Complete	$0.92
Rate for Payer: Cash Price	$1.84
Rate for Payer: Cofinity Commercial	$1.61
Rate for Payer: Cofinity Commercial	$1.98
Rate for Payer: Cofinity Medicare Advantage	$1.61
Rate for Payer: Encore Health Key Benefits Commercial	$1.84
Rate for Payer: Healthscope Commercial	$2.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.96
Rate for Payer: PHP Commercial	$1.96
Rate for Payer: Priority Health Cigna Priority Health	$1.50
Rate for Payer: Priority Health SBD	$1.45

ATORVASTATIN 20 MG TABLET

Facility

$209.00

Service Code	NDC 00904629161
Hospital Charge Code	19178
Hospital Revenue Code	637
Min. Negotiated Rate	$83.60
Max. Negotiated Rate	$188.10
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$104.50
Rate for Payer: Aetna New Business (MI Preferred)	$135.85
Rate for Payer: BCBS Complete	$83.60
Rate for Payer: Cash Price	$167.20
Rate for Payer: Cofinity Commercial	$146.30
Rate for Payer: Cofinity Commercial	$179.74
Rate for Payer: Cofinity Medicare Advantage	$146.30
Rate for Payer: Encore Health Key Benefits Commercial	$167.20
Rate for Payer: Healthscope Commercial	$188.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$177.65
Rate for Payer: PHP Commercial	$177.65
Rate for Payer: Priority Health Cigna Priority Health	$135.85
Rate for Payer: Priority Health SBD	$131.67

ATORVASTATIN 20 MG TABLET

Facility

$2.30

Service Code	NDC 68084009811
Hospital Charge Code	19178
Hospital Revenue Code	637
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$2.07
Rate for Payer: Aetna Commercial	$1.96
Rate for Payer: Aetna New Business (MI Preferred)	$1.50
Rate for Payer: Cash Price	$1.84
Rate for Payer: Cofinity Commercial	$1.61
Rate for Payer: Cofinity Commercial	$1.98
Rate for Payer: Cofinity Medicare Advantage	$1.61
Rate for Payer: Encore Health Key Benefits Commercial	$1.84
Rate for Payer: Healthscope Commercial	$2.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.96
Rate for Payer: PHP Commercial	$1.96
Rate for Payer: Priority Health Cigna Priority Health	$1.50
Rate for Payer: Priority Health SBD	$1.45

ATORVASTATIN 40 MG TABLET

Facility

$2.09

Service Code	NDC 50268009511
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna Commercial	$1.78
Rate for Payer: Aetna Medicare	$1.04
Rate for Payer: Aetna New Business (MI Preferred)	$1.36
Rate for Payer: BCBS Complete	$0.84
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cofinity Commercial	$1.46
Rate for Payer: Cofinity Commercial	$1.80
Rate for Payer: Cofinity Medicare Advantage	$1.46
Rate for Payer: Encore Health Key Benefits Commercial	$1.67
Rate for Payer: Healthscope Commercial	$1.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.78
Rate for Payer: PHP Commercial	$1.78
Rate for Payer: Priority Health Cigna Priority Health	$1.36
Rate for Payer: Priority Health SBD	$1.32

ATORVASTATIN 40 MG TABLET

Facility

$235.00

Service Code	NDC 00904629206
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$94.00
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna Commercial	$199.75
Rate for Payer: Aetna Medicare	$117.50
Rate for Payer: Aetna New Business (MI Preferred)	$152.75
Rate for Payer: BCBS Complete	$94.00
Rate for Payer: Cash Price	$188.00
Rate for Payer: Cofinity Commercial	$164.50
Rate for Payer: Cofinity Commercial	$202.10
Rate for Payer: Cofinity Medicare Advantage	$164.50
Rate for Payer: Encore Health Key Benefits Commercial	$188.00
Rate for Payer: Healthscope Commercial	$211.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$199.75
Rate for Payer: PHP Commercial	$199.75
Rate for Payer: Priority Health Cigna Priority Health	$152.75
Rate for Payer: Priority Health SBD	$148.05

ATORVASTATIN 40 MG TABLET

Facility

$385.70

Service Code	NDC 51079021020
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$242.99
Max. Negotiated Rate	$347.13
Rate for Payer: Aetna Commercial	$327.84
Rate for Payer: Aetna New Business (MI Preferred)	$250.70
Rate for Payer: Cash Price	$308.56
Rate for Payer: Cofinity Commercial	$269.99
Rate for Payer: Cofinity Commercial	$331.70
Rate for Payer: Cofinity Medicare Advantage	$269.99
Rate for Payer: Encore Health Key Benefits Commercial	$308.56
Rate for Payer: Healthscope Commercial	$347.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$327.84
Rate for Payer: PHP Commercial	$327.84
Rate for Payer: Priority Health Cigna Priority Health	$250.70
Rate for Payer: Priority Health SBD	$242.99

ATORVASTATIN 40 MG TABLET

Facility

$304.56

Service Code	NDC 00378395277
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$121.82
Max. Negotiated Rate	$274.10
Rate for Payer: Aetna Commercial	$258.88
Rate for Payer: Aetna Medicare	$152.28
Rate for Payer: Aetna New Business (MI Preferred)	$197.96
Rate for Payer: BCBS Complete	$121.82
Rate for Payer: Cash Price	$243.65
Rate for Payer: Cofinity Commercial	$213.19
Rate for Payer: Cofinity Commercial	$261.92
Rate for Payer: Cofinity Medicare Advantage	$213.19
Rate for Payer: Encore Health Key Benefits Commercial	$243.65
Rate for Payer: Healthscope Commercial	$274.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$258.88
Rate for Payer: PHP Commercial	$258.88
Rate for Payer: Priority Health Cigna Priority Health	$197.96
Rate for Payer: Priority Health SBD	$191.87

ATORVASTATIN 40 MG TABLET

Facility

$219.45

Service Code	NDC 00904629261
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$87.78
Max. Negotiated Rate	$197.50
Rate for Payer: Aetna Commercial	$186.53
Rate for Payer: Aetna Medicare	$109.72
Rate for Payer: Aetna New Business (MI Preferred)	$142.64
Rate for Payer: BCBS Complete	$87.78
Rate for Payer: Cash Price	$175.56
Rate for Payer: Cofinity Commercial	$153.62
Rate for Payer: Cofinity Commercial	$188.73
Rate for Payer: Cofinity Medicare Advantage	$153.62
Rate for Payer: Encore Health Key Benefits Commercial	$175.56
Rate for Payer: Healthscope Commercial	$197.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$186.53
Rate for Payer: PHP Commercial	$186.53
Rate for Payer: Priority Health Cigna Priority Health	$142.64
Rate for Payer: Priority Health SBD	$138.25

ATORVASTATIN 40 MG TABLET

Facility

$3.86

Service Code	NDC 51079021001
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$3.47
Rate for Payer: Aetna Commercial	$3.28
Rate for Payer: Aetna Medicare	$1.93
Rate for Payer: Aetna New Business (MI Preferred)	$2.51
Rate for Payer: BCBS Complete	$1.54
Rate for Payer: Cash Price	$3.09
Rate for Payer: Cofinity Commercial	$2.70
Rate for Payer: Cofinity Commercial	$3.32
Rate for Payer: Cofinity Medicare Advantage	$2.70
Rate for Payer: Encore Health Key Benefits Commercial	$3.09
Rate for Payer: Healthscope Commercial	$3.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.28
Rate for Payer: PHP Commercial	$3.28
Rate for Payer: Priority Health Cigna Priority Health	$2.51
Rate for Payer: Priority Health SBD	$2.43

ATORVASTATIN 40 MG TABLET

Facility

$2.42

Service Code	NDC 68084009911
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna Commercial	$2.06
Rate for Payer: Aetna Medicare	$1.21
Rate for Payer: Aetna New Business (MI Preferred)	$1.57
Rate for Payer: BCBS Complete	$0.97
Rate for Payer: Cash Price	$1.94
Rate for Payer: Cofinity Commercial	$1.69
Rate for Payer: Cofinity Commercial	$2.08
Rate for Payer: Cofinity Medicare Advantage	$1.69
Rate for Payer: Encore Health Key Benefits Commercial	$1.94
Rate for Payer: Healthscope Commercial	$2.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.06
Rate for Payer: PHP Commercial	$2.06
Rate for Payer: Priority Health Cigna Priority Health	$1.57
Rate for Payer: Priority Health SBD	$1.52

ATORVASTATIN 40 MG TABLET

Facility

$235.00

Service Code	NDC 00904629206
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$148.05
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna Commercial	$199.75
Rate for Payer: Aetna New Business (MI Preferred)	$152.75
Rate for Payer: Cash Price	$188.00
Rate for Payer: Cofinity Commercial	$164.50
Rate for Payer: Cofinity Commercial	$202.10
Rate for Payer: Cofinity Medicare Advantage	$164.50
Rate for Payer: Encore Health Key Benefits Commercial	$188.00
Rate for Payer: Healthscope Commercial	$211.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$199.75
Rate for Payer: PHP Commercial	$199.75
Rate for Payer: Priority Health Cigna Priority Health	$152.75
Rate for Payer: Priority Health SBD	$148.05

ATORVASTATIN 40 MG TABLET

Facility

$3.86

Service Code	NDC 51079021001
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.47
Rate for Payer: Aetna Commercial	$3.28
Rate for Payer: Aetna New Business (MI Preferred)	$2.51
Rate for Payer: Cash Price	$3.09
Rate for Payer: Cofinity Commercial	$2.70
Rate for Payer: Cofinity Commercial	$3.32
Rate for Payer: Cofinity Medicare Advantage	$2.70
Rate for Payer: Encore Health Key Benefits Commercial	$3.09
Rate for Payer: Healthscope Commercial	$3.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.28
Rate for Payer: PHP Commercial	$3.28
Rate for Payer: Priority Health Cigna Priority Health	$2.51
Rate for Payer: Priority Health SBD	$2.43

ATORVASTATIN 40 MG TABLET

Facility

$219.45

Service Code	NDC 00904629261
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$138.25
Max. Negotiated Rate	$197.50
Rate for Payer: Aetna Commercial	$186.53
Rate for Payer: Aetna New Business (MI Preferred)	$142.64
Rate for Payer: Cash Price	$175.56
Rate for Payer: Cofinity Commercial	$153.62
Rate for Payer: Cofinity Commercial	$188.73
Rate for Payer: Cofinity Medicare Advantage	$153.62
Rate for Payer: Encore Health Key Benefits Commercial	$175.56
Rate for Payer: Healthscope Commercial	$197.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$186.53
Rate for Payer: PHP Commercial	$186.53
Rate for Payer: Priority Health Cigna Priority Health	$142.64
Rate for Payer: Priority Health SBD	$138.25

ATORVASTATIN 40 MG TABLET

Facility

$104.03

Service Code	NDC 50268009515
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$41.61
Max. Negotiated Rate	$93.63
Rate for Payer: Aetna Commercial	$88.43
Rate for Payer: Aetna Medicare	$52.02
Rate for Payer: Aetna New Business (MI Preferred)	$67.62
Rate for Payer: BCBS Complete	$41.61
Rate for Payer: Cash Price	$83.22
Rate for Payer: Cofinity Commercial	$72.82
Rate for Payer: Cofinity Commercial	$89.47
Rate for Payer: Cofinity Medicare Advantage	$72.82
Rate for Payer: Encore Health Key Benefits Commercial	$83.22
Rate for Payer: Healthscope Commercial	$93.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$88.43
Rate for Payer: PHP Commercial	$88.43
Rate for Payer: Priority Health Cigna Priority Health	$67.62
Rate for Payer: Priority Health SBD	$65.54

ATORVASTATIN 40 MG TABLET

Facility

$385.70

Service Code	NDC 51079021020
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$154.28
Max. Negotiated Rate	$347.13
Rate for Payer: Aetna Commercial	$327.84
Rate for Payer: Aetna Medicare	$192.85
Rate for Payer: Aetna New Business (MI Preferred)	$250.70
Rate for Payer: BCBS Complete	$154.28
Rate for Payer: Cash Price	$308.56
Rate for Payer: Cofinity Commercial	$269.99
Rate for Payer: Cofinity Commercial	$331.70
Rate for Payer: Cofinity Medicare Advantage	$269.99
Rate for Payer: Encore Health Key Benefits Commercial	$308.56
Rate for Payer: Healthscope Commercial	$347.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$327.84
Rate for Payer: PHP Commercial	$327.84
Rate for Payer: Priority Health Cigna Priority Health	$250.70
Rate for Payer: Priority Health SBD	$242.99

ATORVASTATIN 40 MG TABLET

Facility

$2.09

Service Code	NDC 50268009511
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna Commercial	$1.78
Rate for Payer: Aetna New Business (MI Preferred)	$1.36
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cofinity Commercial	$1.46
Rate for Payer: Cofinity Commercial	$1.80
Rate for Payer: Cofinity Medicare Advantage	$1.46
Rate for Payer: Encore Health Key Benefits Commercial	$1.67
Rate for Payer: Healthscope Commercial	$1.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.78
Rate for Payer: PHP Commercial	$1.78
Rate for Payer: Priority Health Cigna Priority Health	$1.36
Rate for Payer: Priority Health SBD	$1.32

ATORVASTATIN 40 MG TABLET

Facility

$304.56

Service Code	NDC 00378395277
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$191.87
Max. Negotiated Rate	$274.10
Rate for Payer: Aetna Commercial	$258.88
Rate for Payer: Aetna New Business (MI Preferred)	$197.96
Rate for Payer: Cash Price	$243.65
Rate for Payer: Cofinity Commercial	$213.19
Rate for Payer: Cofinity Commercial	$261.92
Rate for Payer: Cofinity Medicare Advantage	$213.19
Rate for Payer: Encore Health Key Benefits Commercial	$243.65
Rate for Payer: Healthscope Commercial	$274.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$258.88
Rate for Payer: PHP Commercial	$258.88
Rate for Payer: Priority Health Cigna Priority Health	$197.96
Rate for Payer: Priority Health SBD	$191.87

ATORVASTATIN 40 MG TABLET

Facility

$241.30

Service Code	NDC 68084009901
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$96.52
Max. Negotiated Rate	$217.17
Rate for Payer: Aetna Commercial	$205.10
Rate for Payer: Aetna Medicare	$120.65
Rate for Payer: Aetna New Business (MI Preferred)	$156.84
Rate for Payer: BCBS Complete	$96.52
Rate for Payer: Cash Price	$193.04
Rate for Payer: Cofinity Commercial	$168.91
Rate for Payer: Cofinity Commercial	$207.52
Rate for Payer: Cofinity Medicare Advantage	$168.91
Rate for Payer: Encore Health Key Benefits Commercial	$193.04
Rate for Payer: Healthscope Commercial	$217.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$205.10
Rate for Payer: PHP Commercial	$205.10
Rate for Payer: Priority Health Cigna Priority Health	$156.84
Rate for Payer: Priority Health SBD	$152.02

ATORVASTATIN 40 MG TABLET

Facility

$104.03

Service Code	NDC 50268009515
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$65.54
Max. Negotiated Rate	$93.63
Rate for Payer: Aetna Commercial	$88.43
Rate for Payer: Aetna New Business (MI Preferred)	$67.62
Rate for Payer: Cash Price	$83.22
Rate for Payer: Cofinity Commercial	$72.82
Rate for Payer: Cofinity Commercial	$89.47
Rate for Payer: Cofinity Medicare Advantage	$72.82
Rate for Payer: Encore Health Key Benefits Commercial	$83.22
Rate for Payer: Healthscope Commercial	$93.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$88.43
Rate for Payer: PHP Commercial	$88.43
Rate for Payer: Priority Health Cigna Priority Health	$67.62
Rate for Payer: Priority Health SBD	$65.54

ATORVASTATIN 40 MG TABLET

Facility

$241.30

Service Code	NDC 68084009901
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$152.02
Max. Negotiated Rate	$217.17
Rate for Payer: Aetna Commercial	$205.10
Rate for Payer: Aetna New Business (MI Preferred)	$156.84
Rate for Payer: Cash Price	$193.04
Rate for Payer: Cofinity Commercial	$168.91
Rate for Payer: Cofinity Commercial	$207.52
Rate for Payer: Cofinity Medicare Advantage	$168.91
Rate for Payer: Encore Health Key Benefits Commercial	$193.04
Rate for Payer: Healthscope Commercial	$217.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$205.10
Rate for Payer: PHP Commercial	$205.10
Rate for Payer: Priority Health Cigna Priority Health	$156.84
Rate for Payer: Priority Health SBD	$152.02

ATORVASTATIN 40 MG TABLET

Facility

$2.42

Service Code	NDC 68084009911
Hospital Charge Code	19177
Hospital Revenue Code	637
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna Commercial	$2.06
Rate for Payer: Aetna New Business (MI Preferred)	$1.57
Rate for Payer: Cash Price	$1.94
Rate for Payer: Cofinity Commercial	$1.69
Rate for Payer: Cofinity Commercial	$2.08
Rate for Payer: Cofinity Medicare Advantage	$1.69
Rate for Payer: Encore Health Key Benefits Commercial	$1.94
Rate for Payer: Healthscope Commercial	$2.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.06
Rate for Payer: PHP Commercial	$2.06
Rate for Payer: Priority Health Cigna Priority Health	$1.57
Rate for Payer: Priority Health SBD	$1.52

ATORVASTATIN 80 MG TABLET

Facility

$196.70

Service Code	NDC 69097094705
Hospital Charge Code	28645
Hospital Revenue Code	637
Min. Negotiated Rate	$78.68
Max. Negotiated Rate	$177.03
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$98.35
Rate for Payer: Aetna New Business (MI Preferred)	$127.86
Rate for Payer: BCBS Complete	$78.68
Rate for Payer: Cash Price	$157.36
Rate for Payer: Cofinity Commercial	$137.69
Rate for Payer: Cofinity Commercial	$169.16
Rate for Payer: Cofinity Medicare Advantage	$137.69
Rate for Payer: Encore Health Key Benefits Commercial	$157.36
Rate for Payer: Healthscope Commercial	$177.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.20
Rate for Payer: PHP Commercial	$167.20
Rate for Payer: Priority Health Cigna Priority Health	$127.86
Rate for Payer: Priority Health SBD	$123.92

ATORVASTATIN 80 MG TABLET

Facility

$114.57

Service Code	NDC 00904629304
Hospital Charge Code	28645
Hospital Revenue Code	637
Min. Negotiated Rate	$45.83
Max. Negotiated Rate	$103.11
Rate for Payer: Aetna Commercial	$97.38
Rate for Payer: Aetna Medicare	$57.28
Rate for Payer: Aetna New Business (MI Preferred)	$74.47
Rate for Payer: BCBS Complete	$45.83
Rate for Payer: Cash Price	$91.66
Rate for Payer: Cofinity Commercial	$80.20
Rate for Payer: Cofinity Commercial	$98.53
Rate for Payer: Cofinity Medicare Advantage	$80.20
Rate for Payer: Encore Health Key Benefits Commercial	$91.66
Rate for Payer: Healthscope Commercial	$103.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$97.38
Rate for Payer: PHP Commercial	$97.38
Rate for Payer: Priority Health Cigna Priority Health	$74.47
Rate for Payer: Priority Health SBD	$72.18

Know your out-of-pocket cost for care.

All Charges