Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE

Facility

$647.52

Service Code	NDC 00071374066
Hospital Charge Code	11019
Hospital Revenue Code	637
Min. Negotiated Rate	$407.94
Max. Negotiated Rate	$582.77
Rate for Payer: Aetna Commercial	$550.39
Rate for Payer: Aetna New Business (MI Preferred)	$420.89
Rate for Payer: Cash Price	$518.02
Rate for Payer: Cofinity Commercial	$453.26
Rate for Payer: Cofinity Commercial	$556.87
Rate for Payer: Cofinity Medicare Advantage	$453.26
Rate for Payer: Encore Health Key Benefits Commercial	$518.02
Rate for Payer: Healthscope Commercial	$582.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$550.39
Rate for Payer: PHP Commercial	$550.39
Rate for Payer: Priority Health Cigna Priority Health	$420.89
Rate for Payer: Priority Health SBD	$407.94

PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE

Facility

$647.52

Service Code	NDC 00071374066
Hospital Charge Code	11019
Hospital Revenue Code	637
Min. Negotiated Rate	$259.01
Max. Negotiated Rate	$582.77
Rate for Payer: Aetna Commercial	$550.39
Rate for Payer: Aetna Medicare	$323.76
Rate for Payer: Aetna New Business (MI Preferred)	$420.89
Rate for Payer: BCBS Complete	$259.01
Rate for Payer: Cash Price	$518.02
Rate for Payer: Cofinity Commercial	$453.26
Rate for Payer: Cofinity Commercial	$556.87
Rate for Payer: Cofinity Medicare Advantage	$453.26
Rate for Payer: Encore Health Key Benefits Commercial	$518.02
Rate for Payer: Healthscope Commercial	$582.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$550.39
Rate for Payer: PHP Commercial	$550.39
Rate for Payer: Priority Health Cigna Priority Health	$420.89
Rate for Payer: Priority Health SBD	$407.94

PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION

Facility

$258.47

Service Code	NDC 17478051002
Hospital Charge Code	6270
Hospital Revenue Code	250
Min. Negotiated Rate	$103.39
Max. Negotiated Rate	$232.62
Rate for Payer: Aetna Commercial	$219.70
Rate for Payer: Aetna Medicare	$129.24
Rate for Payer: Aetna New Business (MI Preferred)	$168.01
Rate for Payer: BCBS Complete	$103.39
Rate for Payer: Cash Price	$206.78
Rate for Payer: Cofinity Commercial	$180.93
Rate for Payer: Cofinity Commercial	$222.28
Rate for Payer: Cofinity Medicare Advantage	$180.93
Rate for Payer: Encore Health Key Benefits Commercial	$206.78
Rate for Payer: Healthscope Commercial	$232.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$219.70
Rate for Payer: PHP Commercial	$219.70
Rate for Payer: Priority Health Cigna Priority Health	$168.01
Rate for Payer: Priority Health SBD	$162.84

PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION

Facility

$258.47

Service Code	NDC 17478051002
Hospital Charge Code	6270
Hospital Revenue Code	250
Min. Negotiated Rate	$162.84
Max. Negotiated Rate	$232.62
Rate for Payer: Aetna Commercial	$219.70
Rate for Payer: Aetna New Business (MI Preferred)	$168.01
Rate for Payer: Cash Price	$206.78
Rate for Payer: Cofinity Commercial	$180.93
Rate for Payer: Cofinity Commercial	$222.28
Rate for Payer: Cofinity Medicare Advantage	$180.93
Rate for Payer: Encore Health Key Benefits Commercial	$206.78
Rate for Payer: Healthscope Commercial	$232.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$219.70
Rate for Payer: PHP Commercial	$219.70
Rate for Payer: Priority Health Cigna Priority Health	$168.01
Rate for Payer: Priority Health SBD	$162.84

PHYTONADIONE ORAL SOLUTION 10 MG/ML

Facility

$88.13

Service Code	NDC 00409915801
Hospital Charge Code	150708
Hospital Revenue Code	250
Min. Negotiated Rate	$55.52
Max. Negotiated Rate	$79.32
Rate for Payer: Aetna Commercial	$74.91
Rate for Payer: Aetna New Business (MI Preferred)	$57.28
Rate for Payer: Cash Price	$70.50
Rate for Payer: Cofinity Commercial	$61.69
Rate for Payer: Cofinity Commercial	$75.79
Rate for Payer: Cofinity Medicare Advantage	$61.69
Rate for Payer: Encore Health Key Benefits Commercial	$70.50
Rate for Payer: Healthscope Commercial	$79.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$74.91
Rate for Payer: PHP Commercial	$74.91
Rate for Payer: Priority Health Cigna Priority Health	$57.28
Rate for Payer: Priority Health SBD	$55.52

PHYTONADIONE ORAL SOLUTION 10 MG/ML

Facility

$88.13

Service Code	NDC 00409915801
Hospital Charge Code	150708
Hospital Revenue Code	250
Min. Negotiated Rate	$35.25
Max. Negotiated Rate	$79.32
Rate for Payer: Aetna Commercial	$74.91
Rate for Payer: Aetna Medicare	$44.06
Rate for Payer: Aetna New Business (MI Preferred)	$57.28
Rate for Payer: BCBS Complete	$35.25
Rate for Payer: Cash Price	$70.50
Rate for Payer: Cofinity Commercial	$61.69
Rate for Payer: Cofinity Commercial	$75.79
Rate for Payer: Cofinity Medicare Advantage	$61.69
Rate for Payer: Encore Health Key Benefits Commercial	$70.50
Rate for Payer: Healthscope Commercial	$79.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$74.91
Rate for Payer: PHP Commercial	$74.91
Rate for Payer: Priority Health Cigna Priority Health	$57.28
Rate for Payer: Priority Health SBD	$55.52

PHYTONADIONE (VITAMIN K1) 1,000 MCG CAPSULE

Facility

$211.50

Service Code	NDC 53191040901
Hospital Charge Code	196288
Hospital Revenue Code	637
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$190.35
Rate for Payer: Aetna Commercial	$179.78
Rate for Payer: Aetna Medicare	$105.75
Rate for Payer: Aetna New Business (MI Preferred)	$137.48
Rate for Payer: BCBS Complete	$84.60
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cofinity Commercial	$148.05
Rate for Payer: Cofinity Commercial	$181.89
Rate for Payer: Cofinity Medicare Advantage	$148.05
Rate for Payer: Encore Health Key Benefits Commercial	$169.20
Rate for Payer: Healthscope Commercial	$190.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$179.78
Rate for Payer: PHP Commercial	$179.78
Rate for Payer: Priority Health Cigna Priority Health	$137.48
Rate for Payer: Priority Health SBD	$133.24

PHYTONADIONE (VITAMIN K1) 1,000 MCG CAPSULE

Facility

$340.75

Service Code	NDC 05105010500
Hospital Charge Code	196288
Hospital Revenue Code	637
Min. Negotiated Rate	$214.67
Max. Negotiated Rate	$306.68
Rate for Payer: Aetna Commercial	$289.64
Rate for Payer: Aetna New Business (MI Preferred)	$221.49
Rate for Payer: Cash Price	$272.60
Rate for Payer: Cofinity Commercial	$238.52
Rate for Payer: Cofinity Commercial	$293.04
Rate for Payer: Cofinity Medicare Advantage	$238.52
Rate for Payer: Encore Health Key Benefits Commercial	$272.60
Rate for Payer: Healthscope Commercial	$306.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$289.64
Rate for Payer: PHP Commercial	$289.64
Rate for Payer: Priority Health Cigna Priority Health	$221.49
Rate for Payer: Priority Health SBD	$214.67

PHYTONADIONE (VITAMIN K1) 1,000 MCG CAPSULE

Facility

$340.75

Service Code	NDC 05105010500
Hospital Charge Code	196288
Hospital Revenue Code	637
Min. Negotiated Rate	$136.30
Max. Negotiated Rate	$306.68
Rate for Payer: Aetna Commercial	$289.64
Rate for Payer: Aetna Medicare	$170.38
Rate for Payer: Aetna New Business (MI Preferred)	$221.49
Rate for Payer: BCBS Complete	$136.30
Rate for Payer: Cash Price	$272.60
Rate for Payer: Cofinity Commercial	$238.52
Rate for Payer: Cofinity Commercial	$293.04
Rate for Payer: Cofinity Medicare Advantage	$238.52
Rate for Payer: Encore Health Key Benefits Commercial	$272.60
Rate for Payer: Healthscope Commercial	$306.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$289.64
Rate for Payer: PHP Commercial	$289.64
Rate for Payer: Priority Health Cigna Priority Health	$221.49
Rate for Payer: Priority Health SBD	$214.67

PHYTONADIONE (VITAMIN K1) 1,000 MCG CAPSULE

Facility

$211.50

Service Code	NDC 53191040901
Hospital Charge Code	196288
Hospital Revenue Code	637
Min. Negotiated Rate	$133.24
Max. Negotiated Rate	$190.35
Rate for Payer: Aetna Commercial	$179.78
Rate for Payer: Aetna New Business (MI Preferred)	$137.48
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cofinity Commercial	$148.05
Rate for Payer: Cofinity Commercial	$181.89
Rate for Payer: Cofinity Medicare Advantage	$148.05
Rate for Payer: Encore Health Key Benefits Commercial	$169.20
Rate for Payer: Healthscope Commercial	$190.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$179.78
Rate for Payer: PHP Commercial	$179.78
Rate for Payer: Priority Health Cigna Priority Health	$137.48
Rate for Payer: Priority Health SBD	$133.24

PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION

Facility

$105.99

Service Code	HCPCS J3430
Hospital Charge Code	11023
Hospital Revenue Code	636
Min. Negotiated Rate	$66.77
Max. Negotiated Rate	$95.39
Rate for Payer: Aetna Commercial	$90.09
Rate for Payer: Aetna Commercial	$67.57
Rate for Payer: Aetna Commercial	$70.38
Rate for Payer: Aetna New Business (MI Preferred)	$51.67
Rate for Payer: Aetna New Business (MI Preferred)	$68.89
Rate for Payer: Aetna New Business (MI Preferred)	$53.82
Rate for Payer: Cash Price	$84.79
Rate for Payer: Cash Price	$63.59
Rate for Payer: Cash Price	$66.24
Rate for Payer: Cofinity Commercial	$57.96
Rate for Payer: Cofinity Commercial	$74.19
Rate for Payer: Cofinity Commercial	$91.15
Rate for Payer: Cofinity Commercial	$71.21
Rate for Payer: Cofinity Commercial	$55.64
Rate for Payer: Cofinity Commercial	$68.36
Rate for Payer: Cofinity Medicare Advantage	$55.64
Rate for Payer: Cofinity Medicare Advantage	$57.96
Rate for Payer: Cofinity Medicare Advantage	$74.19
Rate for Payer: Encore Health Key Benefits Commercial	$63.59
Rate for Payer: Encore Health Key Benefits Commercial	$84.79
Rate for Payer: Encore Health Key Benefits Commercial	$66.24
Rate for Payer: Healthscope Commercial	$71.54
Rate for Payer: Healthscope Commercial	$74.52
Rate for Payer: Healthscope Commercial	$95.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$67.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$90.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$70.38
Rate for Payer: PHP Commercial	$70.38
Rate for Payer: PHP Commercial	$90.09
Rate for Payer: PHP Commercial	$67.57
Rate for Payer: Priority Health Cigna Priority Health	$68.89
Rate for Payer: Priority Health Cigna Priority Health	$53.82
Rate for Payer: Priority Health Cigna Priority Health	$51.67
Rate for Payer: Priority Health SBD	$52.16
Rate for Payer: Priority Health SBD	$66.77
Rate for Payer: Priority Health SBD	$50.08

PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION

Facility

$82.80

Service Code	HCPCS J3430
Hospital Charge Code	11023
Hospital Revenue Code	636
Min. Negotiated Rate	$7.07
Max. Negotiated Rate	$74.52
Rate for Payer: Aetna Commercial	$70.38
Rate for Payer: Aetna Commercial	$90.09
Rate for Payer: Aetna Commercial	$67.57
Rate for Payer: Aetna Medicare	$53.00
Rate for Payer: Aetna Medicare	$39.74
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: Aetna New Business (MI Preferred)	$51.67
Rate for Payer: Aetna New Business (MI Preferred)	$68.89
Rate for Payer: Aetna New Business (MI Preferred)	$53.82
Rate for Payer: BCBS Complete	$31.80
Rate for Payer: BCBS Complete	$42.40
Rate for Payer: BCBS Complete	$33.12
Rate for Payer: BCBS Trust/PPO	$7.07
Rate for Payer: BCBS Trust/PPO	$7.07
Rate for Payer: BCBS Trust/PPO	$7.07
Rate for Payer: BCN Commercial	$7.07
Rate for Payer: BCN Commercial	$7.07
Rate for Payer: BCN Commercial	$7.07
Rate for Payer: Cash Price	$63.59
Rate for Payer: Cash Price	$84.79
Rate for Payer: Cash Price	$66.24
Rate for Payer: Cash Price	$63.59
Rate for Payer: Cash Price	$84.79
Rate for Payer: Cash Price	$66.24
Rate for Payer: Cofinity Commercial	$55.64
Rate for Payer: Cofinity Commercial	$74.19
Rate for Payer: Cofinity Commercial	$91.15
Rate for Payer: Cofinity Commercial	$68.36
Rate for Payer: Cofinity Commercial	$57.96
Rate for Payer: Cofinity Commercial	$71.21
Rate for Payer: Cofinity Medicare Advantage	$57.96
Rate for Payer: Cofinity Medicare Advantage	$55.64
Rate for Payer: Cofinity Medicare Advantage	$74.19
Rate for Payer: Encore Health Key Benefits Commercial	$84.79
Rate for Payer: Encore Health Key Benefits Commercial	$63.59
Rate for Payer: Encore Health Key Benefits Commercial	$66.24
Rate for Payer: Healthscope Commercial	$71.54
Rate for Payer: Healthscope Commercial	$95.39
Rate for Payer: Healthscope Commercial	$74.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$67.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$90.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$70.38
Rate for Payer: PHP Commercial	$67.57
Rate for Payer: PHP Commercial	$70.38
Rate for Payer: PHP Commercial	$90.09
Rate for Payer: Priority Health Cigna Priority Health	$51.67
Rate for Payer: Priority Health Cigna Priority Health	$53.82
Rate for Payer: Priority Health Cigna Priority Health	$68.89
Rate for Payer: Priority Health SBD	$66.77
Rate for Payer: Priority Health SBD	$52.16
Rate for Payer: Priority Health SBD	$50.08

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION

Facility

$24.09

Service Code	HCPCS J3430
Hospital Charge Code	108266
Hospital Revenue Code	636
Min. Negotiated Rate	$7.07
Max. Negotiated Rate	$21.68
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: Aetna Commercial	$23.70
Rate for Payer: Aetna Medicare	$13.94
Rate for Payer: Aetna Medicare	$12.04
Rate for Payer: Aetna New Business (MI Preferred)	$15.66
Rate for Payer: Aetna New Business (MI Preferred)	$18.12
Rate for Payer: BCBS Complete	$11.15
Rate for Payer: BCBS Complete	$9.64
Rate for Payer: BCBS Trust/PPO	$7.07
Rate for Payer: BCBS Trust/PPO	$7.07
Rate for Payer: BCN Commercial	$7.07
Rate for Payer: BCN Commercial	$7.07
Rate for Payer: Cash Price	$22.30
Rate for Payer: Cash Price	$22.30
Rate for Payer: Cash Price	$19.27
Rate for Payer: Cash Price	$19.27
Rate for Payer: Cofinity Commercial	$16.86
Rate for Payer: Cofinity Commercial	$23.98
Rate for Payer: Cofinity Commercial	$19.52
Rate for Payer: Cofinity Commercial	$20.72
Rate for Payer: Cofinity Medicare Advantage	$19.52
Rate for Payer: Cofinity Medicare Advantage	$16.86
Rate for Payer: Encore Health Key Benefits Commercial	$19.27
Rate for Payer: Encore Health Key Benefits Commercial	$22.30
Rate for Payer: Healthscope Commercial	$21.68
Rate for Payer: Healthscope Commercial	$25.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.48
Rate for Payer: PHP Commercial	$23.70
Rate for Payer: PHP Commercial	$20.48
Rate for Payer: Priority Health Cigna Priority Health	$15.66
Rate for Payer: Priority Health Cigna Priority Health	$18.12
Rate for Payer: Priority Health SBD	$17.56
Rate for Payer: Priority Health SBD	$15.18

PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION

Facility

$24.09

Service Code	HCPCS J3430
Hospital Charge Code	108266
Hospital Revenue Code	636
Min. Negotiated Rate	$15.18
Max. Negotiated Rate	$21.68
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: Aetna Commercial	$23.70
Rate for Payer: Aetna New Business (MI Preferred)	$15.66
Rate for Payer: Aetna New Business (MI Preferred)	$18.12
Rate for Payer: Cash Price	$19.27
Rate for Payer: Cash Price	$22.30
Rate for Payer: Cofinity Commercial	$16.86
Rate for Payer: Cofinity Commercial	$19.52
Rate for Payer: Cofinity Commercial	$23.98
Rate for Payer: Cofinity Commercial	$20.72
Rate for Payer: Cofinity Medicare Advantage	$19.52
Rate for Payer: Cofinity Medicare Advantage	$16.86
Rate for Payer: Encore Health Key Benefits Commercial	$19.27
Rate for Payer: Encore Health Key Benefits Commercial	$22.30
Rate for Payer: Healthscope Commercial	$21.68
Rate for Payer: Healthscope Commercial	$25.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$23.70
Rate for Payer: PHP Commercial	$20.48
Rate for Payer: PHP Commercial	$23.70
Rate for Payer: Priority Health Cigna Priority Health	$18.12
Rate for Payer: Priority Health Cigna Priority Health	$15.66
Rate for Payer: Priority Health SBD	$17.56
Rate for Payer: Priority Health SBD	$15.18

PHYTONADIONE (VITAMIN K1) 5 MG TABLET

Facility

$4,114.66

Service Code	NDC 69238105103
Hospital Charge Code	11024
Hospital Revenue Code	637
Min. Negotiated Rate	$1,645.86
Max. Negotiated Rate	$3,703.19
Rate for Payer: Aetna Commercial	$3,497.46
Rate for Payer: Aetna Medicare	$2,057.33
Rate for Payer: Aetna New Business (MI Preferred)	$2,674.53
Rate for Payer: BCBS Complete	$1,645.86
Rate for Payer: Cash Price	$3,291.73
Rate for Payer: Cofinity Commercial	$2,880.26
Rate for Payer: Cofinity Commercial	$3,538.61
Rate for Payer: Cofinity Medicare Advantage	$2,880.26
Rate for Payer: Encore Health Key Benefits Commercial	$3,291.73
Rate for Payer: Healthscope Commercial	$3,703.19
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,497.46
Rate for Payer: PHP Commercial	$3,497.46
Rate for Payer: Priority Health Cigna Priority Health	$2,674.53
Rate for Payer: Priority Health SBD	$2,592.24

PHYTONADIONE (VITAMIN K1) 5 MG TABLET

Facility

$4,114.66

Service Code	NDC 69238105103
Hospital Charge Code	11024
Hospital Revenue Code	637
Min. Negotiated Rate	$2,592.24
Max. Negotiated Rate	$3,703.19
Rate for Payer: Aetna Commercial	$3,497.46
Rate for Payer: Aetna New Business (MI Preferred)	$2,674.53
Rate for Payer: Cash Price	$3,291.73
Rate for Payer: Cofinity Commercial	$2,880.26
Rate for Payer: Cofinity Commercial	$3,538.61
Rate for Payer: Cofinity Medicare Advantage	$2,880.26
Rate for Payer: Encore Health Key Benefits Commercial	$3,291.73
Rate for Payer: Healthscope Commercial	$3,703.19
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,497.46
Rate for Payer: PHP Commercial	$3,497.46
Rate for Payer: Priority Health Cigna Priority Health	$2,674.53
Rate for Payer: Priority Health SBD	$2,592.24

PILOCARPINE 1 % EYE DROPS

Facility

$304.61

Service Code	NDC 00998020315
Hospital Charge Code	6279
Hospital Revenue Code	637
Min. Negotiated Rate	$191.90
Max. Negotiated Rate	$274.15
Rate for Payer: Aetna Commercial	$258.92
Rate for Payer: Aetna New Business (MI Preferred)	$198.00
Rate for Payer: Cash Price	$243.69
Rate for Payer: Cofinity Commercial	$213.23
Rate for Payer: Cofinity Commercial	$261.96
Rate for Payer: Cofinity Medicare Advantage	$213.23
Rate for Payer: Encore Health Key Benefits Commercial	$243.69
Rate for Payer: Healthscope Commercial	$274.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$258.92
Rate for Payer: PHP Commercial	$258.92
Rate for Payer: Priority Health Cigna Priority Health	$198.00
Rate for Payer: Priority Health SBD	$191.90

PILOCARPINE 1 % EYE DROPS

Facility

$136.98

Service Code	NDC 61314020315
Hospital Charge Code	6279
Hospital Revenue Code	637
Min. Negotiated Rate	$54.79
Max. Negotiated Rate	$123.28
Rate for Payer: Aetna Commercial	$116.43
Rate for Payer: Aetna Medicare	$68.49
Rate for Payer: Aetna New Business (MI Preferred)	$89.04
Rate for Payer: BCBS Complete	$54.79
Rate for Payer: Cash Price	$109.58
Rate for Payer: Cofinity Commercial	$117.80
Rate for Payer: Cofinity Commercial	$95.89
Rate for Payer: Cofinity Medicare Advantage	$95.89
Rate for Payer: Encore Health Key Benefits Commercial	$109.58
Rate for Payer: Healthscope Commercial	$123.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$116.43
Rate for Payer: PHP Commercial	$116.43
Rate for Payer: Priority Health Cigna Priority Health	$89.04
Rate for Payer: Priority Health SBD	$86.30

PILOCARPINE 1 % EYE DROPS

Facility

$304.61

Service Code	NDC 00998020315
Hospital Charge Code	6279
Hospital Revenue Code	637
Min. Negotiated Rate	$121.84
Max. Negotiated Rate	$274.15
Rate for Payer: Aetna Commercial	$258.92
Rate for Payer: Aetna Medicare	$152.30
Rate for Payer: Aetna New Business (MI Preferred)	$198.00
Rate for Payer: BCBS Complete	$121.84
Rate for Payer: Cash Price	$243.69
Rate for Payer: Cofinity Commercial	$213.23
Rate for Payer: Cofinity Commercial	$261.96
Rate for Payer: Cofinity Medicare Advantage	$213.23
Rate for Payer: Encore Health Key Benefits Commercial	$243.69
Rate for Payer: Healthscope Commercial	$274.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$258.92
Rate for Payer: PHP Commercial	$258.92
Rate for Payer: Priority Health Cigna Priority Health	$198.00
Rate for Payer: Priority Health SBD	$191.90

PILOCARPINE 1 % EYE DROPS

Facility

$136.98

Service Code	NDC 61314020315
Hospital Charge Code	6279
Hospital Revenue Code	637
Min. Negotiated Rate	$86.30
Max. Negotiated Rate	$123.28
Rate for Payer: Aetna Commercial	$116.43
Rate for Payer: Aetna New Business (MI Preferred)	$89.04
Rate for Payer: Cash Price	$109.58
Rate for Payer: Cofinity Commercial	$117.80
Rate for Payer: Cofinity Commercial	$95.89
Rate for Payer: Cofinity Medicare Advantage	$95.89
Rate for Payer: Encore Health Key Benefits Commercial	$109.58
Rate for Payer: Healthscope Commercial	$123.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$116.43
Rate for Payer: PHP Commercial	$116.43
Rate for Payer: Priority Health Cigna Priority Health	$89.04
Rate for Payer: Priority Health SBD	$86.30

PILOCARPINE 2 % EYE DROPS

Facility

$136.19

Service Code	NDC 61314020415
Hospital Charge Code	6280
Hospital Revenue Code	637
Min. Negotiated Rate	$85.80
Max. Negotiated Rate	$122.57
Rate for Payer: Aetna Commercial	$115.76
Rate for Payer: Aetna New Business (MI Preferred)	$88.52
Rate for Payer: Cash Price	$108.95
Rate for Payer: Cofinity Commercial	$117.12
Rate for Payer: Cofinity Commercial	$95.33
Rate for Payer: Cofinity Medicare Advantage	$95.33
Rate for Payer: Encore Health Key Benefits Commercial	$108.95
Rate for Payer: Healthscope Commercial	$122.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$115.76
Rate for Payer: PHP Commercial	$115.76
Rate for Payer: Priority Health Cigna Priority Health	$88.52
Rate for Payer: Priority Health SBD	$85.80

PILOCARPINE 2 % EYE DROPS

Facility

$311.54

Service Code	NDC 00998020415
Hospital Charge Code	6280
Hospital Revenue Code	637
Min. Negotiated Rate	$196.27
Max. Negotiated Rate	$280.39
Rate for Payer: Aetna Commercial	$264.81
Rate for Payer: Aetna New Business (MI Preferred)	$202.50
Rate for Payer: Cash Price	$249.23
Rate for Payer: Cofinity Commercial	$218.08
Rate for Payer: Cofinity Commercial	$267.92
Rate for Payer: Cofinity Medicare Advantage	$218.08
Rate for Payer: Encore Health Key Benefits Commercial	$249.23
Rate for Payer: Healthscope Commercial	$280.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$264.81
Rate for Payer: PHP Commercial	$264.81
Rate for Payer: Priority Health Cigna Priority Health	$202.50
Rate for Payer: Priority Health SBD	$196.27

PILOCARPINE 2 % EYE DROPS

Facility

$311.54

Service Code	NDC 00998020415
Hospital Charge Code	6280
Hospital Revenue Code	637
Min. Negotiated Rate	$124.62
Max. Negotiated Rate	$280.39
Rate for Payer: Aetna Commercial	$264.81
Rate for Payer: Aetna Medicare	$155.77
Rate for Payer: Aetna New Business (MI Preferred)	$202.50
Rate for Payer: BCBS Complete	$124.62
Rate for Payer: Cash Price	$249.23
Rate for Payer: Cofinity Commercial	$218.08
Rate for Payer: Cofinity Commercial	$267.92
Rate for Payer: Cofinity Medicare Advantage	$218.08
Rate for Payer: Encore Health Key Benefits Commercial	$249.23
Rate for Payer: Healthscope Commercial	$280.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$264.81
Rate for Payer: PHP Commercial	$264.81
Rate for Payer: Priority Health Cigna Priority Health	$202.50
Rate for Payer: Priority Health SBD	$196.27

PILOCARPINE 2 % EYE DROPS

Facility

$209.95

Service Code	NDC 69238174608
Hospital Charge Code	6280
Hospital Revenue Code	637
Min. Negotiated Rate	$132.27
Max. Negotiated Rate	$188.96
Rate for Payer: Aetna Commercial	$178.46
Rate for Payer: Aetna New Business (MI Preferred)	$136.47
Rate for Payer: Cash Price	$167.96
Rate for Payer: Cofinity Commercial	$146.96
Rate for Payer: Cofinity Commercial	$180.56
Rate for Payer: Cofinity Medicare Advantage	$146.96
Rate for Payer: Encore Health Key Benefits Commercial	$167.96
Rate for Payer: Healthscope Commercial	$188.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$178.46
Rate for Payer: PHP Commercial	$178.46
Rate for Payer: Priority Health Cigna Priority Health	$136.47
Rate for Payer: Priority Health SBD	$132.27

PILOCARPINE 2 % EYE DROPS

Facility

$136.19

Service Code	NDC 61314020415
Hospital Charge Code	6280
Hospital Revenue Code	637
Min. Negotiated Rate	$54.48
Max. Negotiated Rate	$122.57
Rate for Payer: Aetna Commercial	$115.76
Rate for Payer: Aetna Medicare	$68.10
Rate for Payer: Aetna New Business (MI Preferred)	$88.52
Rate for Payer: BCBS Complete	$54.48
Rate for Payer: Cash Price	$108.95
Rate for Payer: Cofinity Commercial	$117.12
Rate for Payer: Cofinity Commercial	$95.33
Rate for Payer: Cofinity Medicare Advantage	$95.33
Rate for Payer: Encore Health Key Benefits Commercial	$108.95
Rate for Payer: Healthscope Commercial	$122.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$115.76
Rate for Payer: PHP Commercial	$115.76
Rate for Payer: Priority Health Cigna Priority Health	$88.52
Rate for Payer: Priority Health SBD	$85.80

Know your out-of-pocket cost for care.

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