Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$135.60

Service Code	NDC 49230020692
Hospital Charge Code	27796
Hospital Revenue Code	250
Min. Negotiated Rate	$85.43
Max. Negotiated Rate	$122.04
Rate for Payer: Aetna Commercial	$115.26
Rate for Payer: Aetna New Business (MI Preferred)	$88.14
Rate for Payer: Cash Price	$108.48
Rate for Payer: Cofinity Commercial	$116.62
Rate for Payer: Cofinity Commercial	$94.92
Rate for Payer: Cofinity Medicare Advantage	$94.92
Rate for Payer: Encore Health Key Benefits Commercial	$108.48
Rate for Payer: Healthscope Commercial	$122.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$115.26
Rate for Payer: PHP Commercial	$115.26
Rate for Payer: Priority Health Cigna Priority Health	$88.14
Rate for Payer: Priority Health SBD	$85.43

PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$118.65

Service Code	NDC 49230020694
Hospital Charge Code	27796
Hospital Revenue Code	250
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$106.78
Rate for Payer: Aetna Commercial	$100.85
Rate for Payer: Aetna New Business (MI Preferred)	$77.12
Rate for Payer: Cash Price	$94.92
Rate for Payer: Cofinity Commercial	$102.04
Rate for Payer: Cofinity Commercial	$83.06
Rate for Payer: Cofinity Medicare Advantage	$83.06
Rate for Payer: Encore Health Key Benefits Commercial	$94.92
Rate for Payer: Healthscope Commercial	$106.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.85
Rate for Payer: PHP Commercial	$100.85
Rate for Payer: Priority Health Cigna Priority Health	$77.12
Rate for Payer: Priority Health SBD	$74.75

PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$135.60

Service Code	NDC 49230020692
Hospital Charge Code	27796
Hospital Revenue Code	250
Min. Negotiated Rate	$54.24
Max. Negotiated Rate	$122.04
Rate for Payer: Aetna Commercial	$115.26
Rate for Payer: Aetna Medicare	$67.80
Rate for Payer: Aetna New Business (MI Preferred)	$88.14
Rate for Payer: BCBS Complete	$54.24
Rate for Payer: Cash Price	$108.48
Rate for Payer: Cofinity Commercial	$116.62
Rate for Payer: Cofinity Commercial	$94.92
Rate for Payer: Cofinity Medicare Advantage	$94.92
Rate for Payer: Encore Health Key Benefits Commercial	$108.48
Rate for Payer: Healthscope Commercial	$122.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$115.26
Rate for Payer: PHP Commercial	$115.26
Rate for Payer: Priority Health Cigna Priority Health	$88.14
Rate for Payer: Priority Health SBD	$85.43

PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$118.65

Service Code	NDC 49230020694
Hospital Charge Code	27796
Hospital Revenue Code	250
Min. Negotiated Rate	$47.46
Max. Negotiated Rate	$106.78
Rate for Payer: Aetna Commercial	$100.85
Rate for Payer: Aetna Medicare	$59.33
Rate for Payer: Aetna New Business (MI Preferred)	$77.12
Rate for Payer: BCBS Complete	$47.46
Rate for Payer: Cash Price	$94.92
Rate for Payer: Cofinity Commercial	$102.04
Rate for Payer: Cofinity Commercial	$83.06
Rate for Payer: Cofinity Medicare Advantage	$83.06
Rate for Payer: Encore Health Key Benefits Commercial	$94.92
Rate for Payer: Healthscope Commercial	$106.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.85
Rate for Payer: PHP Commercial	$100.85
Rate for Payer: Priority Health Cigna Priority Health	$77.12
Rate for Payer: Priority Health SBD	$74.75

PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$118.65

Service Code	NDC 49230021294
Hospital Charge Code	27803
Hospital Revenue Code	250
Min. Negotiated Rate	$47.46
Max. Negotiated Rate	$106.78
Rate for Payer: Aetna Commercial	$100.85
Rate for Payer: Aetna Medicare	$59.33
Rate for Payer: Aetna New Business (MI Preferred)	$77.12
Rate for Payer: BCBS Complete	$47.46
Rate for Payer: Cash Price	$94.92
Rate for Payer: Cofinity Commercial	$102.04
Rate for Payer: Cofinity Commercial	$83.06
Rate for Payer: Cofinity Medicare Advantage	$83.06
Rate for Payer: Encore Health Key Benefits Commercial	$94.92
Rate for Payer: Healthscope Commercial	$106.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.85
Rate for Payer: PHP Commercial	$100.85
Rate for Payer: Priority Health Cigna Priority Health	$77.12
Rate for Payer: Priority Health SBD	$74.75

PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$118.65

Service Code	NDC 49230021294
Hospital Charge Code	27803
Hospital Revenue Code	250
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$106.78
Rate for Payer: Aetna Commercial	$100.85
Rate for Payer: Aetna New Business (MI Preferred)	$77.12
Rate for Payer: Cash Price	$94.92
Rate for Payer: Cofinity Commercial	$102.04
Rate for Payer: Cofinity Commercial	$83.06
Rate for Payer: Cofinity Medicare Advantage	$83.06
Rate for Payer: Encore Health Key Benefits Commercial	$94.92
Rate for Payer: Healthscope Commercial	$106.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.85
Rate for Payer: PHP Commercial	$100.85
Rate for Payer: Priority Health Cigna Priority Health	$77.12
Rate for Payer: Priority Health SBD	$74.75

PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$135.60

Service Code	NDC 49230020992
Hospital Charge Code	27800
Hospital Revenue Code	250
Min. Negotiated Rate	$54.24
Max. Negotiated Rate	$122.04
Rate for Payer: Aetna Commercial	$115.26
Rate for Payer: Aetna Medicare	$67.80
Rate for Payer: Aetna New Business (MI Preferred)	$88.14
Rate for Payer: BCBS Complete	$54.24
Rate for Payer: Cash Price	$108.48
Rate for Payer: Cofinity Commercial	$116.62
Rate for Payer: Cofinity Commercial	$94.92
Rate for Payer: Cofinity Medicare Advantage	$94.92
Rate for Payer: Encore Health Key Benefits Commercial	$108.48
Rate for Payer: Healthscope Commercial	$122.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$115.26
Rate for Payer: PHP Commercial	$115.26
Rate for Payer: Priority Health Cigna Priority Health	$88.14
Rate for Payer: Priority Health SBD	$85.43

PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$118.65

Service Code	NDC 49230020994
Hospital Charge Code	27800
Hospital Revenue Code	250
Min. Negotiated Rate	$47.46
Max. Negotiated Rate	$106.78
Rate for Payer: Aetna Commercial	$100.85
Rate for Payer: Aetna Medicare	$59.33
Rate for Payer: Aetna New Business (MI Preferred)	$77.12
Rate for Payer: BCBS Complete	$47.46
Rate for Payer: Cash Price	$94.92
Rate for Payer: Cofinity Commercial	$102.04
Rate for Payer: Cofinity Commercial	$83.06
Rate for Payer: Cofinity Medicare Advantage	$83.06
Rate for Payer: Encore Health Key Benefits Commercial	$94.92
Rate for Payer: Healthscope Commercial	$106.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.85
Rate for Payer: PHP Commercial	$100.85
Rate for Payer: Priority Health Cigna Priority Health	$77.12
Rate for Payer: Priority Health SBD	$74.75

PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$162.72

Service Code	NDC 49230020995
Hospital Charge Code	27800
Hospital Revenue Code	250
Min. Negotiated Rate	$65.09
Max. Negotiated Rate	$146.45
Rate for Payer: Aetna Commercial	$138.31
Rate for Payer: Aetna Medicare	$81.36
Rate for Payer: Aetna New Business (MI Preferred)	$105.77
Rate for Payer: BCBS Complete	$65.09
Rate for Payer: Cash Price	$130.18
Rate for Payer: Cofinity Commercial	$113.90
Rate for Payer: Cofinity Commercial	$139.94
Rate for Payer: Cofinity Medicare Advantage	$113.90
Rate for Payer: Encore Health Key Benefits Commercial	$130.18
Rate for Payer: Healthscope Commercial	$146.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$138.31
Rate for Payer: PHP Commercial	$138.31
Rate for Payer: Priority Health Cigna Priority Health	$105.77
Rate for Payer: Priority Health SBD	$102.51

PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$118.65

Service Code	NDC 49230020994
Hospital Charge Code	27800
Hospital Revenue Code	250
Min. Negotiated Rate	$74.75
Max. Negotiated Rate	$106.78
Rate for Payer: Aetna Commercial	$100.85
Rate for Payer: Aetna New Business (MI Preferred)	$77.12
Rate for Payer: Cash Price	$94.92
Rate for Payer: Cofinity Commercial	$102.04
Rate for Payer: Cofinity Commercial	$83.06
Rate for Payer: Cofinity Medicare Advantage	$83.06
Rate for Payer: Encore Health Key Benefits Commercial	$94.92
Rate for Payer: Healthscope Commercial	$106.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.85
Rate for Payer: PHP Commercial	$100.85
Rate for Payer: Priority Health Cigna Priority Health	$77.12
Rate for Payer: Priority Health SBD	$74.75

PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$135.60

Service Code	NDC 49230020992
Hospital Charge Code	27800
Hospital Revenue Code	250
Min. Negotiated Rate	$85.43
Max. Negotiated Rate	$122.04
Rate for Payer: Aetna Commercial	$115.26
Rate for Payer: Aetna New Business (MI Preferred)	$88.14
Rate for Payer: Cash Price	$108.48
Rate for Payer: Cofinity Commercial	$116.62
Rate for Payer: Cofinity Commercial	$94.92
Rate for Payer: Cofinity Medicare Advantage	$94.92
Rate for Payer: Encore Health Key Benefits Commercial	$108.48
Rate for Payer: Healthscope Commercial	$122.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$115.26
Rate for Payer: PHP Commercial	$115.26
Rate for Payer: Priority Health Cigna Priority Health	$88.14
Rate for Payer: Priority Health SBD	$85.43

PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L

Facility

$162.72

Service Code	NDC 49230020995
Hospital Charge Code	27800
Hospital Revenue Code	250
Min. Negotiated Rate	$102.51
Max. Negotiated Rate	$146.45
Rate for Payer: Aetna Commercial	$138.31
Rate for Payer: Aetna New Business (MI Preferred)	$105.77
Rate for Payer: Cash Price	$130.18
Rate for Payer: Cofinity Commercial	$113.90
Rate for Payer: Cofinity Commercial	$139.94
Rate for Payer: Cofinity Medicare Advantage	$113.90
Rate for Payer: Encore Health Key Benefits Commercial	$130.18
Rate for Payer: Healthscope Commercial	$146.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$138.31
Rate for Payer: PHP Commercial	$138.31
Rate for Payer: Priority Health Cigna Priority Health	$105.77
Rate for Payer: Priority Health SBD	$102.51

PERMETHRIN 1 % TOPICAL LIQUID

Facility

$39.65

Service Code	NDC 63736012002
Hospital Charge Code	10918
Hospital Revenue Code	637
Min. Negotiated Rate	$24.98
Max. Negotiated Rate	$35.69
Rate for Payer: Aetna Commercial	$33.70
Rate for Payer: Aetna New Business (MI Preferred)	$25.77
Rate for Payer: Cash Price	$31.72
Rate for Payer: Cofinity Commercial	$27.75
Rate for Payer: Cofinity Commercial	$34.10
Rate for Payer: Cofinity Medicare Advantage	$27.75
Rate for Payer: Encore Health Key Benefits Commercial	$31.72
Rate for Payer: Healthscope Commercial	$35.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.70
Rate for Payer: PHP Commercial	$33.70
Rate for Payer: Priority Health Cigna Priority Health	$25.77
Rate for Payer: Priority Health SBD	$24.98

PERMETHRIN 1 % TOPICAL LIQUID

Facility

$39.65

Service Code	NDC 63736012002
Hospital Charge Code	10918
Hospital Revenue Code	637
Min. Negotiated Rate	$15.86
Max. Negotiated Rate	$35.69
Rate for Payer: Aetna Commercial	$33.70
Rate for Payer: Aetna Medicare	$19.82
Rate for Payer: Aetna New Business (MI Preferred)	$25.77
Rate for Payer: BCBS Complete	$15.86
Rate for Payer: Cash Price	$31.72
Rate for Payer: Cofinity Commercial	$27.75
Rate for Payer: Cofinity Commercial	$34.10
Rate for Payer: Cofinity Medicare Advantage	$27.75
Rate for Payer: Encore Health Key Benefits Commercial	$31.72
Rate for Payer: Healthscope Commercial	$35.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.70
Rate for Payer: PHP Commercial	$33.70
Rate for Payer: Priority Health Cigna Priority Health	$25.77
Rate for Payer: Priority Health SBD	$24.98

PERMETHRIN 5 % TOPICAL CREAM

Facility

$322.35

Service Code	NDC 00472024260
Hospital Charge Code	10917
Hospital Revenue Code	637
Min. Negotiated Rate	$203.08
Max. Negotiated Rate	$290.12
Rate for Payer: Aetna Commercial	$274.00
Rate for Payer: Aetna New Business (MI Preferred)	$209.53
Rate for Payer: Cash Price	$257.88
Rate for Payer: Cofinity Commercial	$225.65
Rate for Payer: Cofinity Commercial	$277.22
Rate for Payer: Cofinity Medicare Advantage	$225.65
Rate for Payer: Encore Health Key Benefits Commercial	$257.88
Rate for Payer: Healthscope Commercial	$290.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$274.00
Rate for Payer: PHP Commercial	$274.00
Rate for Payer: Priority Health Cigna Priority Health	$209.53
Rate for Payer: Priority Health SBD	$203.08

PERMETHRIN 5 % TOPICAL CREAM

Facility

$322.35

Service Code	NDC 00472024260
Hospital Charge Code	10917
Hospital Revenue Code	637
Min. Negotiated Rate	$128.94
Max. Negotiated Rate	$290.12
Rate for Payer: Aetna Commercial	$274.00
Rate for Payer: Aetna Medicare	$161.18
Rate for Payer: Aetna New Business (MI Preferred)	$209.53
Rate for Payer: BCBS Complete	$128.94
Rate for Payer: Cash Price	$257.88
Rate for Payer: Cofinity Commercial	$225.65
Rate for Payer: Cofinity Commercial	$277.22
Rate for Payer: Cofinity Medicare Advantage	$225.65
Rate for Payer: Encore Health Key Benefits Commercial	$257.88
Rate for Payer: Healthscope Commercial	$290.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$274.00
Rate for Payer: PHP Commercial	$274.00
Rate for Payer: Priority Health Cigna Priority Health	$209.53
Rate for Payer: Priority Health SBD	$203.08

PERPHENAZINE 4 MG TABLET

Facility

$456.96

Service Code	HCPCS Q0175
Hospital Charge Code	6158
Hospital Revenue Code	637
Min. Negotiated Rate	$287.88
Max. Negotiated Rate	$411.26
Rate for Payer: Aetna Commercial	$388.42
Rate for Payer: Aetna New Business (MI Preferred)	$297.02
Rate for Payer: Cash Price	$365.57
Rate for Payer: Cofinity Commercial	$319.87
Rate for Payer: Cofinity Commercial	$392.99
Rate for Payer: Cofinity Medicare Advantage	$319.87
Rate for Payer: Encore Health Key Benefits Commercial	$365.57
Rate for Payer: Healthscope Commercial	$411.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$388.42
Rate for Payer: PHP Commercial	$388.42
Rate for Payer: Priority Health Cigna Priority Health	$297.02
Rate for Payer: Priority Health SBD	$287.88

PERPHENAZINE 4 MG TABLET

Facility

$456.96

Service Code	HCPCS Q0175
Hospital Charge Code	6158
Hospital Revenue Code	637
Min. Negotiated Rate	$182.78
Max. Negotiated Rate	$411.26
Rate for Payer: Aetna Commercial	$388.42
Rate for Payer: Aetna Medicare	$228.48
Rate for Payer: Aetna New Business (MI Preferred)	$297.02
Rate for Payer: BCBS Complete	$182.78
Rate for Payer: Cash Price	$365.57
Rate for Payer: Cofinity Commercial	$319.87
Rate for Payer: Cofinity Commercial	$392.99
Rate for Payer: Cofinity Medicare Advantage	$319.87
Rate for Payer: Encore Health Key Benefits Commercial	$365.57
Rate for Payer: Healthscope Commercial	$411.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$388.42
Rate for Payer: PHP Commercial	$388.42
Rate for Payer: Priority Health Cigna Priority Health	$297.02
Rate for Payer: Priority Health SBD	$287.88

PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION

Facility

$30,624.01

Service Code	HCPCS J9306
Hospital Charge Code	160029
Hospital Revenue Code	636
Min. Negotiated Rate	$19,293.13
Max. Negotiated Rate	$27,561.61
Rate for Payer: Aetna Commercial	$26,030.41
Rate for Payer: Aetna New Business (MI Preferred)	$19,905.61
Rate for Payer: Cash Price	$24,499.21
Rate for Payer: Cofinity Commercial	$21,436.81
Rate for Payer: Cofinity Commercial	$26,336.65
Rate for Payer: Cofinity Medicare Advantage	$21,436.81
Rate for Payer: Encore Health Key Benefits Commercial	$24,499.21
Rate for Payer: Healthscope Commercial	$27,561.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26,030.41
Rate for Payer: PHP Commercial	$26,030.41
Rate for Payer: Priority Health Cigna Priority Health	$19,905.61
Rate for Payer: Priority Health SBD	$19,293.13

PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION

Facility

$30,624.01

Service Code	HCPCS J9306
Hospital Charge Code	160029
Hospital Revenue Code	636
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$27,561.61
Rate for Payer: Aetna Commercial	$26,030.41
Rate for Payer: Aetna Medicare	$17.70
Rate for Payer: Aetna New Business (MI Preferred)	$19,905.61
Rate for Payer: Allen County Amish Medical Aid Commercial	$21.27
Rate for Payer: Amish Plain Church Group Commercial	$21.27
Rate for Payer: BCBS Complete	$9.58
Rate for Payer: BCBS MAPPO	$17.02
Rate for Payer: BCN Medicare Advantage	$17.02
Rate for Payer: Cash Price	$24,499.21
Rate for Payer: Cash Price	$24,499.21
Rate for Payer: Cofinity Commercial	$21,436.81
Rate for Payer: Cofinity Commercial	$26,336.65
Rate for Payer: Cofinity Medicare Advantage	$21,436.81
Rate for Payer: Encore Health Key Benefits Commercial	$24,499.21
Rate for Payer: Health Alliance Plan Medicare Advantage	$17.02
Rate for Payer: Healthscope Commercial	$27,561.61
Rate for Payer: Mclaren Medicaid	$9.12
Rate for Payer: Mclaren Medicare	$17.02
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$17.87
Rate for Payer: Meridian Medicaid	$9.58
Rate for Payer: MI Amish Medical Board Commercial	$19.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26,030.41
Rate for Payer: PACE Medicare	$16.17
Rate for Payer: PACE SWMI	$17.02
Rate for Payer: PHP Commercial	$26,030.41
Rate for Payer: PHP Medicare Advantage	$17.02
Rate for Payer: Priority Health Choice Medicaid	$9.12
Rate for Payer: Priority Health Cigna Priority Health	$19,905.61
Rate for Payer: Priority Health Medicare	$17.02
Rate for Payer: Priority Health SBD	$19,293.13
Rate for Payer: Railroad Medicare Medicare	$17.02
Rate for Payer: UHC All Payor (Choice/PPO)	$47.91
Rate for Payer: UHC Dual Complete DSNP	$17.02
Rate for Payer: UHC Medicare Advantage	$17.02
Rate for Payer: UHCCP Medicaid	$9.58
Rate for Payer: VA VA	$17.02

PHENAZOPYRIDINE 100 MG TABLET

Facility

$238.45

Service Code	NDC 75826011410
Hospital Charge Code	6193
Hospital Revenue Code	637
Min. Negotiated Rate	$95.38
Max. Negotiated Rate	$214.60
Rate for Payer: Aetna Commercial	$202.68
Rate for Payer: Aetna Medicare	$119.22
Rate for Payer: Aetna New Business (MI Preferred)	$154.99
Rate for Payer: BCBS Complete	$95.38
Rate for Payer: Cash Price	$190.76
Rate for Payer: Cofinity Commercial	$166.91
Rate for Payer: Cofinity Commercial	$205.07
Rate for Payer: Cofinity Medicare Advantage	$166.91
Rate for Payer: Encore Health Key Benefits Commercial	$190.76
Rate for Payer: Healthscope Commercial	$214.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$202.68
Rate for Payer: PHP Commercial	$202.68
Rate for Payer: Priority Health Cigna Priority Health	$154.99
Rate for Payer: Priority Health SBD	$150.22

PHENAZOPYRIDINE 100 MG TABLET

Facility

$238.45

Service Code	NDC 75826011410
Hospital Charge Code	6193
Hospital Revenue Code	637
Min. Negotiated Rate	$150.22
Max. Negotiated Rate	$214.60
Rate for Payer: Aetna Commercial	$202.68
Rate for Payer: Aetna New Business (MI Preferred)	$154.99
Rate for Payer: Cash Price	$190.76
Rate for Payer: Cofinity Commercial	$166.91
Rate for Payer: Cofinity Commercial	$205.07
Rate for Payer: Cofinity Medicare Advantage	$166.91
Rate for Payer: Encore Health Key Benefits Commercial	$190.76
Rate for Payer: Healthscope Commercial	$214.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$202.68
Rate for Payer: PHP Commercial	$202.68
Rate for Payer: Priority Health Cigna Priority Health	$154.99
Rate for Payer: Priority Health SBD	$150.22

PHENAZOPYRIDINE 200 MG TABLET

Facility

$535.68

Service Code	NDC 69367016304
Hospital Charge Code	6194
Hospital Revenue Code	637
Min. Negotiated Rate	$337.48
Max. Negotiated Rate	$482.11
Rate for Payer: Aetna Commercial	$455.33
Rate for Payer: Aetna New Business (MI Preferred)	$348.19
Rate for Payer: Cash Price	$428.54
Rate for Payer: Cofinity Commercial	$374.98
Rate for Payer: Cofinity Commercial	$460.68
Rate for Payer: Cofinity Medicare Advantage	$374.98
Rate for Payer: Encore Health Key Benefits Commercial	$428.54
Rate for Payer: Healthscope Commercial	$482.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$455.33
Rate for Payer: PHP Commercial	$455.33
Rate for Payer: Priority Health Cigna Priority Health	$348.19
Rate for Payer: Priority Health SBD	$337.48

PHENAZOPYRIDINE 200 MG TABLET

Facility

$535.68

Service Code	NDC 69367016304
Hospital Charge Code	6194
Hospital Revenue Code	637
Min. Negotiated Rate	$214.27
Max. Negotiated Rate	$482.11
Rate for Payer: Aetna Commercial	$455.33
Rate for Payer: Aetna Medicare	$267.84
Rate for Payer: Aetna New Business (MI Preferred)	$348.19
Rate for Payer: BCBS Complete	$214.27
Rate for Payer: Cash Price	$428.54
Rate for Payer: Cofinity Commercial	$374.98
Rate for Payer: Cofinity Commercial	$460.68
Rate for Payer: Cofinity Medicare Advantage	$374.98
Rate for Payer: Encore Health Key Benefits Commercial	$428.54
Rate for Payer: Healthscope Commercial	$482.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$455.33
Rate for Payer: PHP Commercial	$455.33
Rate for Payer: Priority Health Cigna Priority Health	$348.19
Rate for Payer: Priority Health SBD	$337.48

PHENAZOPYRIDINE 200 MG TABLET

Facility

$326.80

Service Code	NDC 75826011510
Hospital Charge Code	6194
Hospital Revenue Code	637
Min. Negotiated Rate	$205.88
Max. Negotiated Rate	$294.12
Rate for Payer: Aetna Commercial	$277.78
Rate for Payer: Aetna New Business (MI Preferred)	$212.42
Rate for Payer: Cash Price	$261.44
Rate for Payer: Cofinity Commercial	$228.76
Rate for Payer: Cofinity Commercial	$281.05
Rate for Payer: Cofinity Medicare Advantage	$228.76
Rate for Payer: Encore Health Key Benefits Commercial	$261.44
Rate for Payer: Healthscope Commercial	$294.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$277.78
Rate for Payer: PHP Commercial	$277.78
Rate for Payer: Priority Health Cigna Priority Health	$212.42
Rate for Payer: Priority Health SBD	$205.88

Know your out-of-pocket cost for care.

All Charges