Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

POLATUZUMAB VEDOTIN-PIIQ 30 MG INTRAVENOUS SOLUTION

Facility

$17,906.89

Service Code	HCPCS J9309
Hospital Charge Code	195050
Hospital Revenue Code	636
Min. Negotiated Rate	$73.26
Max. Negotiated Rate	$16,116.20
Rate for Payer: Aetna Commercial	$15,220.86
Rate for Payer: Aetna Medicare	$142.14
Rate for Payer: Aetna New Business (MI Preferred)	$11,639.48
Rate for Payer: Allen County Amish Medical Aid Commercial	$170.84
Rate for Payer: Amish Plain Church Group Commercial	$170.84
Rate for Payer: BCBS Complete	$76.92
Rate for Payer: BCBS MAPPO	$136.67
Rate for Payer: BCN Medicare Advantage	$136.67
Rate for Payer: Cash Price	$14,325.51
Rate for Payer: Cash Price	$14,325.51
Rate for Payer: Cofinity Commercial	$12,534.82
Rate for Payer: Cofinity Commercial	$15,399.93
Rate for Payer: Cofinity Medicare Advantage	$12,534.82
Rate for Payer: Encore Health Key Benefits Commercial	$14,325.51
Rate for Payer: Health Alliance Plan Medicare Advantage	$136.67
Rate for Payer: Healthscope Commercial	$16,116.20
Rate for Payer: Mclaren Medicaid	$73.26
Rate for Payer: Mclaren Medicare	$136.67
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$143.50
Rate for Payer: Meridian Medicaid	$76.92
Rate for Payer: MI Amish Medical Board Commercial	$157.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15,220.86
Rate for Payer: PACE Medicare	$129.84
Rate for Payer: PACE SWMI	$136.67
Rate for Payer: PHP Commercial	$15,220.86
Rate for Payer: PHP Medicare Advantage	$136.67
Rate for Payer: Priority Health Choice Medicaid	$73.26
Rate for Payer: Priority Health Cigna Priority Health	$11,639.48
Rate for Payer: Priority Health Medicare	$136.67
Rate for Payer: Priority Health SBD	$11,281.34
Rate for Payer: Railroad Medicare Medicare	$136.67
Rate for Payer: UHC All Payor (Choice/PPO)	$384.71
Rate for Payer: UHC Dual Complete DSNP	$136.67
Rate for Payer: UHC Medicare Advantage	$136.67
Rate for Payer: UHCCP Medicaid	$76.95
Rate for Payer: VA VA	$136.67

POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION

Facility

$89.00

Service Code	NDC 46783022152
Hospital Charge Code	155488
Hospital Revenue Code	250
Min. Negotiated Rate	$56.07
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna Commercial	$75.65
Rate for Payer: Aetna New Business (MI Preferred)	$57.85
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cofinity Commercial	$62.30
Rate for Payer: Cofinity Commercial	$76.54
Rate for Payer: Cofinity Medicare Advantage	$62.30
Rate for Payer: Encore Health Key Benefits Commercial	$71.20
Rate for Payer: Healthscope Commercial	$80.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$75.65
Rate for Payer: PHP Commercial	$75.65
Rate for Payer: Priority Health Cigna Priority Health	$57.85
Rate for Payer: Priority Health SBD	$56.07

POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION

Facility

$89.00

Service Code	NDC 46783022152
Hospital Charge Code	155488
Hospital Revenue Code	250
Min. Negotiated Rate	$35.60
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna Commercial	$75.65
Rate for Payer: Aetna Medicare	$44.50
Rate for Payer: Aetna New Business (MI Preferred)	$57.85
Rate for Payer: BCBS Complete	$35.60
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cofinity Commercial	$62.30
Rate for Payer: Cofinity Commercial	$76.54
Rate for Payer: Cofinity Medicare Advantage	$62.30
Rate for Payer: Encore Health Key Benefits Commercial	$71.20
Rate for Payer: Healthscope Commercial	$80.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$75.65
Rate for Payer: PHP Commercial	$75.65
Rate for Payer: Priority Health Cigna Priority Health	$57.85
Rate for Payer: Priority Health SBD	$56.07

POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER

Facility

$18.75

Service Code	NDC 45802086801
Hospital Charge Code	24984
Hospital Revenue Code	637
Min. Negotiated Rate	$11.81
Max. Negotiated Rate	$16.88
Rate for Payer: Aetna Commercial	$15.94
Rate for Payer: Aetna New Business (MI Preferred)	$12.19
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cofinity Commercial	$16.12
Rate for Payer: Cofinity Commercial	$13.12
Rate for Payer: Cofinity Medicare Advantage	$13.12
Rate for Payer: Encore Health Key Benefits Commercial	$15.00
Rate for Payer: Healthscope Commercial	$16.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.94
Rate for Payer: PHP Commercial	$15.94
Rate for Payer: Priority Health Cigna Priority Health	$12.19
Rate for Payer: Priority Health SBD	$11.81

POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER

Facility

$11.25

Service Code	NDC 09629513543
Hospital Charge Code	24984
Hospital Revenue Code	637
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$10.12
Rate for Payer: Aetna Commercial	$9.56
Rate for Payer: Aetna Medicare	$5.62
Rate for Payer: Aetna New Business (MI Preferred)	$7.31
Rate for Payer: BCBS Complete	$4.50
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cofinity Commercial	$7.88
Rate for Payer: Cofinity Commercial	$9.68
Rate for Payer: Cofinity Medicare Advantage	$7.88
Rate for Payer: Encore Health Key Benefits Commercial	$9.00
Rate for Payer: Healthscope Commercial	$10.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.56
Rate for Payer: PHP Commercial	$9.56
Rate for Payer: Priority Health Cigna Priority Health	$7.31
Rate for Payer: Priority Health SBD	$7.09

POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER

Facility

$18.75

Service Code	NDC 45802086801
Hospital Charge Code	24984
Hospital Revenue Code	637
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$16.88
Rate for Payer: Aetna Commercial	$15.94
Rate for Payer: Aetna Medicare	$9.38
Rate for Payer: Aetna New Business (MI Preferred)	$12.19
Rate for Payer: BCBS Complete	$7.50
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cofinity Commercial	$13.12
Rate for Payer: Cofinity Commercial	$16.12
Rate for Payer: Cofinity Medicare Advantage	$13.12
Rate for Payer: Encore Health Key Benefits Commercial	$15.00
Rate for Payer: Healthscope Commercial	$16.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.94
Rate for Payer: PHP Commercial	$15.94
Rate for Payer: Priority Health Cigna Priority Health	$12.19
Rate for Payer: Priority Health SBD	$11.81

POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER

Facility

$25.83

Service Code	NDC 41100082076
Hospital Charge Code	24984
Hospital Revenue Code	637
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$23.25
Rate for Payer: Aetna Commercial	$21.96
Rate for Payer: Aetna Medicare	$12.91
Rate for Payer: Aetna New Business (MI Preferred)	$16.79
Rate for Payer: BCBS Complete	$10.33
Rate for Payer: Cash Price	$20.66
Rate for Payer: Cofinity Commercial	$18.08
Rate for Payer: Cofinity Commercial	$22.21
Rate for Payer: Cofinity Medicare Advantage	$18.08
Rate for Payer: Encore Health Key Benefits Commercial	$20.66
Rate for Payer: Healthscope Commercial	$23.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.96
Rate for Payer: PHP Commercial	$21.96
Rate for Payer: Priority Health Cigna Priority Health	$16.79
Rate for Payer: Priority Health SBD	$16.27

POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER

Facility

$11.25

Service Code	NDC 09629513543
Hospital Charge Code	24984
Hospital Revenue Code	637
Min. Negotiated Rate	$7.09
Max. Negotiated Rate	$10.12
Rate for Payer: Aetna Commercial	$9.56
Rate for Payer: Aetna New Business (MI Preferred)	$7.31
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cofinity Commercial	$7.88
Rate for Payer: Cofinity Commercial	$9.68
Rate for Payer: Cofinity Medicare Advantage	$7.88
Rate for Payer: Encore Health Key Benefits Commercial	$9.00
Rate for Payer: Healthscope Commercial	$10.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.56
Rate for Payer: PHP Commercial	$9.56
Rate for Payer: Priority Health Cigna Priority Health	$7.31
Rate for Payer: Priority Health SBD	$7.09

POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER

Facility

$25.83

Service Code	NDC 41100082076
Hospital Charge Code	24984
Hospital Revenue Code	637
Min. Negotiated Rate	$16.27
Max. Negotiated Rate	$23.25
Rate for Payer: Aetna Commercial	$21.96
Rate for Payer: Aetna New Business (MI Preferred)	$16.79
Rate for Payer: Cash Price	$20.66
Rate for Payer: Cofinity Commercial	$18.08
Rate for Payer: Cofinity Commercial	$22.21
Rate for Payer: Cofinity Medicare Advantage	$18.08
Rate for Payer: Encore Health Key Benefits Commercial	$20.66
Rate for Payer: Healthscope Commercial	$23.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.96
Rate for Payer: PHP Commercial	$21.96
Rate for Payer: Priority Health Cigna Priority Health	$16.79
Rate for Payer: Priority Health SBD	$16.27

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$11.06

Service Code	NDC 69784018001
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$9.95
Rate for Payer: Aetna Commercial	$9.40
Rate for Payer: Aetna Medicare	$5.53
Rate for Payer: Aetna New Business (MI Preferred)	$7.19
Rate for Payer: BCBS Complete	$4.42
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cofinity Commercial	$7.74
Rate for Payer: Cofinity Commercial	$9.51
Rate for Payer: Cofinity Medicare Advantage	$7.74
Rate for Payer: Encore Health Key Benefits Commercial	$8.85
Rate for Payer: Healthscope Commercial	$9.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.40
Rate for Payer: PHP Commercial	$9.40
Rate for Payer: Priority Health Cigna Priority Health	$7.19
Rate for Payer: Priority Health SBD	$6.97

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$69.89

Service Code	NDC 68084043098
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$27.96
Max. Negotiated Rate	$62.90
Rate for Payer: Aetna Commercial	$59.41
Rate for Payer: Aetna Medicare	$34.95
Rate for Payer: Aetna New Business (MI Preferred)	$45.43
Rate for Payer: BCBS Complete	$27.96
Rate for Payer: Cash Price	$55.91
Rate for Payer: Cofinity Commercial	$48.92
Rate for Payer: Cofinity Commercial	$60.11
Rate for Payer: Cofinity Medicare Advantage	$48.92
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$62.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.41
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health Cigna Priority Health	$45.43
Rate for Payer: Priority Health SBD	$44.03

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$1,105.19

Service Code	NDC 69784018010
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$696.27
Max. Negotiated Rate	$994.67
Rate for Payer: Aetna Commercial	$939.41
Rate for Payer: Aetna New Business (MI Preferred)	$718.37
Rate for Payer: Cash Price	$884.15
Rate for Payer: Cofinity Commercial	$773.63
Rate for Payer: Cofinity Commercial	$950.46
Rate for Payer: Cofinity Medicare Advantage	$773.63
Rate for Payer: Encore Health Key Benefits Commercial	$884.15
Rate for Payer: Healthscope Commercial	$994.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$939.41
Rate for Payer: PHP Commercial	$939.41
Rate for Payer: Priority Health Cigna Priority Health	$718.37
Rate for Payer: Priority Health SBD	$696.27

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$554.88

Service Code	NDC 60687043192
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$221.95
Max. Negotiated Rate	$499.39
Rate for Payer: Aetna Commercial	$471.65
Rate for Payer: Aetna Medicare	$277.44
Rate for Payer: Aetna New Business (MI Preferred)	$360.67
Rate for Payer: BCBS Complete	$221.95
Rate for Payer: Cash Price	$443.90
Rate for Payer: Cofinity Commercial	$388.42
Rate for Payer: Cofinity Commercial	$477.20
Rate for Payer: Cofinity Medicare Advantage	$388.42
Rate for Payer: Encore Health Key Benefits Commercial	$443.90
Rate for Payer: Healthscope Commercial	$499.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$471.65
Rate for Payer: PHP Commercial	$471.65
Rate for Payer: Priority Health Cigna Priority Health	$360.67
Rate for Payer: Priority Health SBD	$349.57

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$5.76

Service Code	NDC 60687043199
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$5.18
Rate for Payer: Aetna Commercial	$4.90
Rate for Payer: Aetna Medicare	$2.88
Rate for Payer: Aetna New Business (MI Preferred)	$3.74
Rate for Payer: BCBS Complete	$2.30
Rate for Payer: Cash Price	$4.61
Rate for Payer: Cofinity Commercial	$4.03
Rate for Payer: Cofinity Commercial	$4.95
Rate for Payer: Cofinity Medicare Advantage	$4.03
Rate for Payer: Encore Health Key Benefits Commercial	$4.61
Rate for Payer: Healthscope Commercial	$5.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.90
Rate for Payer: PHP Commercial	$4.90
Rate for Payer: Priority Health Cigna Priority Health	$3.74
Rate for Payer: Priority Health SBD	$3.63

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$11.06

Service Code	NDC 69784018001
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$9.95
Rate for Payer: Aetna Commercial	$9.40
Rate for Payer: Aetna New Business (MI Preferred)	$7.19
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cofinity Commercial	$7.74
Rate for Payer: Cofinity Commercial	$9.51
Rate for Payer: Cofinity Medicare Advantage	$7.74
Rate for Payer: Encore Health Key Benefits Commercial	$8.85
Rate for Payer: Healthscope Commercial	$9.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.40
Rate for Payer: PHP Commercial	$9.40
Rate for Payer: Priority Health Cigna Priority Health	$7.19
Rate for Payer: Priority Health SBD	$6.97

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.84

Service Code	NDC 51079030601
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$6.16
Rate for Payer: Aetna Commercial	$5.81
Rate for Payer: Aetna Medicare	$3.42
Rate for Payer: Aetna New Business (MI Preferred)	$4.45
Rate for Payer: BCBS Complete	$2.74
Rate for Payer: Cash Price	$5.47
Rate for Payer: Cofinity Commercial	$4.79
Rate for Payer: Cofinity Commercial	$5.88
Rate for Payer: Cofinity Medicare Advantage	$4.79
Rate for Payer: Encore Health Key Benefits Commercial	$5.47
Rate for Payer: Healthscope Commercial	$6.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.81
Rate for Payer: PHP Commercial	$5.81
Rate for Payer: Priority Health Cigna Priority Health	$4.45
Rate for Payer: Priority Health SBD	$4.31

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$205.20

Service Code	NDC 51079030630
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$129.28
Max. Negotiated Rate	$184.68
Rate for Payer: Aetna Commercial	$174.42
Rate for Payer: Aetna New Business (MI Preferred)	$133.38
Rate for Payer: Cash Price	$164.16
Rate for Payer: Cofinity Commercial	$143.64
Rate for Payer: Cofinity Commercial	$176.47
Rate for Payer: Cofinity Medicare Advantage	$143.64
Rate for Payer: Encore Health Key Benefits Commercial	$164.16
Rate for Payer: Healthscope Commercial	$184.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$174.42
Rate for Payer: PHP Commercial	$174.42
Rate for Payer: Priority Health Cigna Priority Health	$133.38
Rate for Payer: Priority Health SBD	$129.28

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$1,105.19

Service Code	NDC 69784018010
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$442.08
Max. Negotiated Rate	$994.67
Rate for Payer: Aetna Commercial	$939.41
Rate for Payer: Aetna Medicare	$552.60
Rate for Payer: Aetna New Business (MI Preferred)	$718.37
Rate for Payer: BCBS Complete	$442.08
Rate for Payer: Cash Price	$884.15
Rate for Payer: Cofinity Commercial	$773.63
Rate for Payer: Cofinity Commercial	$950.46
Rate for Payer: Cofinity Medicare Advantage	$773.63
Rate for Payer: Encore Health Key Benefits Commercial	$884.15
Rate for Payer: Healthscope Commercial	$994.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$939.41
Rate for Payer: PHP Commercial	$939.41
Rate for Payer: Priority Health Cigna Priority Health	$718.37
Rate for Payer: Priority Health SBD	$696.27

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$69.89

Service Code	NDC 68084043099
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$27.96
Max. Negotiated Rate	$62.90
Rate for Payer: Aetna Commercial	$59.41
Rate for Payer: Aetna Medicare	$34.95
Rate for Payer: Aetna New Business (MI Preferred)	$45.43
Rate for Payer: BCBS Complete	$27.96
Rate for Payer: Cash Price	$55.91
Rate for Payer: Cofinity Commercial	$48.92
Rate for Payer: Cofinity Commercial	$60.11
Rate for Payer: Cofinity Medicare Advantage	$48.92
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$62.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.41
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health Cigna Priority Health	$45.43
Rate for Payer: Priority Health SBD	$44.03

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$69.89

Service Code	NDC 68084043099
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$44.03
Max. Negotiated Rate	$62.90
Rate for Payer: Aetna Commercial	$59.41
Rate for Payer: Aetna New Business (MI Preferred)	$45.43
Rate for Payer: Cash Price	$55.91
Rate for Payer: Cofinity Commercial	$48.92
Rate for Payer: Cofinity Commercial	$60.11
Rate for Payer: Cofinity Medicare Advantage	$48.92
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$62.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.41
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health Cigna Priority Health	$45.43
Rate for Payer: Priority Health SBD	$44.03

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$103.22

Service Code	NDC 45802086866
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$65.03
Max. Negotiated Rate	$92.90
Rate for Payer: Aetna Commercial	$87.74
Rate for Payer: Aetna New Business (MI Preferred)	$67.09
Rate for Payer: Cash Price	$82.58
Rate for Payer: Cofinity Commercial	$72.25
Rate for Payer: Cofinity Commercial	$88.77
Rate for Payer: Cofinity Medicare Advantage	$72.25
Rate for Payer: Encore Health Key Benefits Commercial	$82.58
Rate for Payer: Healthscope Commercial	$92.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$87.74
Rate for Payer: PHP Commercial	$87.74
Rate for Payer: Priority Health Cigna Priority Health	$67.09
Rate for Payer: Priority Health SBD	$65.03

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$69.89

Service Code	NDC 68084043098
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$44.03
Max. Negotiated Rate	$62.90
Rate for Payer: Aetna Commercial	$59.41
Rate for Payer: Aetna New Business (MI Preferred)	$45.43
Rate for Payer: Cash Price	$55.91
Rate for Payer: Cofinity Commercial	$48.92
Rate for Payer: Cofinity Commercial	$60.11
Rate for Payer: Cofinity Medicare Advantage	$48.92
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$62.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.41
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health Cigna Priority Health	$45.43
Rate for Payer: Priority Health SBD	$44.03

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.84

Service Code	NDC 51079030601
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$6.16
Rate for Payer: Aetna Commercial	$5.81
Rate for Payer: Aetna New Business (MI Preferred)	$4.45
Rate for Payer: Cash Price	$5.47
Rate for Payer: Cofinity Commercial	$4.79
Rate for Payer: Cofinity Commercial	$5.88
Rate for Payer: Cofinity Medicare Advantage	$4.79
Rate for Payer: Encore Health Key Benefits Commercial	$5.47
Rate for Payer: Healthscope Commercial	$6.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.81
Rate for Payer: PHP Commercial	$5.81
Rate for Payer: Priority Health Cigna Priority Health	$4.45
Rate for Payer: Priority Health SBD	$4.31

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$7.38

Service Code	NDC 45802086800
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$6.64
Rate for Payer: Aetna Commercial	$6.27
Rate for Payer: Aetna Medicare	$3.69
Rate for Payer: Aetna New Business (MI Preferred)	$4.80
Rate for Payer: BCBS Complete	$2.95
Rate for Payer: Cash Price	$5.90
Rate for Payer: Cofinity Commercial	$5.17
Rate for Payer: Cofinity Commercial	$6.35
Rate for Payer: Cofinity Medicare Advantage	$5.17
Rate for Payer: Encore Health Key Benefits Commercial	$5.90
Rate for Payer: Healthscope Commercial	$6.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.27
Rate for Payer: PHP Commercial	$6.27
Rate for Payer: Priority Health Cigna Priority Health	$4.80
Rate for Payer: Priority Health SBD	$4.65

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$93.82

Service Code	NDC 00904693126
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$59.11
Max. Negotiated Rate	$84.44
Rate for Payer: Aetna Commercial	$79.75
Rate for Payer: Aetna New Business (MI Preferred)	$60.98
Rate for Payer: Cash Price	$75.06
Rate for Payer: Cofinity Commercial	$65.67
Rate for Payer: Cofinity Commercial	$80.69
Rate for Payer: Cofinity Medicare Advantage	$65.67
Rate for Payer: Encore Health Key Benefits Commercial	$75.06
Rate for Payer: Healthscope Commercial	$84.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$79.75
Rate for Payer: PHP Commercial	$79.75
Rate for Payer: Priority Health Cigna Priority Health	$60.98
Rate for Payer: Priority Health SBD	$59.11

Know your out-of-pocket cost for care.

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