Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$89.25

Service Code	NDC 00904693126
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$35.08
Max. Negotiated Rate	$80.33
Rate for Payer: Aetna Commercial	$75.86
Rate for Payer: Aetna Medicare	$44.62
Rate for Payer: Aetna New Business (MI Preferred)	$58.01
Rate for Payer: BCBS Complete	$35.70
Rate for Payer: Cash Price	$71.40
Rate for Payer: Cofinity Advantage	$62.48
Rate for Payer: Cofinity Commercial	$76.75
Rate for Payer: Encore Health Key Benefits Commercial	$71.40
Rate for Payer: Healthscope Commercial	$80.33
Rate for Payer: MI Amish Medical Board Commercial	$71.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$75.86
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.94
Rate for Payer: PHP Commercial	$75.86
Rate for Payer: Priority Health SBD	$56.23
Rate for Payer: UHC All Payor (Choice/PPO)	$58.01
Rate for Payer: UHC Core	$46.50
Rate for Payer: UHC Exchange	$35.08

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$833.28

Service Code	NDC 62559015710
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$524.97
Max. Negotiated Rate	$749.95
Rate for Payer: Aetna Commercial	$708.29
Rate for Payer: Aetna New Business (MI Preferred)	$541.63
Rate for Payer: Cash Price	$666.62
Rate for Payer: Cofinity Advantage	$583.30
Rate for Payer: Cofinity Commercial	$716.62
Rate for Payer: Encore Health Key Benefits Commercial	$666.62
Rate for Payer: Healthscope Commercial	$749.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$708.29
Rate for Payer: Opus (Opus Packaging Group) HMA	$624.96
Rate for Payer: PHP Commercial	$708.29
Rate for Payer: Priority Health SBD	$524.97

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	$434.34
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 Advantage	$773.63
Rate for Payer: Cofinity Commercial	$950.46
Rate for Payer: Encore Health Key Benefits Commercial	$884.15
Rate for Payer: Healthscope Commercial	$994.67
Rate for Payer: MI Amish Medical Board Commercial	$884.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$939.41
Rate for Payer: Opus (Opus Packaging Group) HMA	$828.89
Rate for Payer: PHP Commercial	$939.41
Rate for Payer: Priority Health SBD	$696.27
Rate for Payer: UHC All Payor (Choice/PPO)	$718.37
Rate for Payer: UHC Core	$575.80
Rate for Payer: UHC Exchange	$434.34

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.42

Service Code	NDC 51079030601
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.78
Rate for Payer: Aetna Commercial	$5.46
Rate for Payer: Aetna Medicare	$3.21
Rate for Payer: Aetna New Business (MI Preferred)	$4.17
Rate for Payer: BCBS Complete	$2.57
Rate for Payer: Cash Price	$5.14
Rate for Payer: Cofinity Advantage	$4.49
Rate for Payer: Cofinity Commercial	$5.52
Rate for Payer: Encore Health Key Benefits Commercial	$5.14
Rate for Payer: Healthscope Commercial	$5.78
Rate for Payer: MI Amish Medical Board Commercial	$5.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.46
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.82
Rate for Payer: PHP Commercial	$5.46
Rate for Payer: Priority Health SBD	$4.04
Rate for Payer: UHC All Payor (Choice/PPO)	$4.17
Rate for Payer: UHC Core	$3.34
Rate for Payer: UHC Exchange	$2.52

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$192.39

Service Code	NDC 51079030630
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$121.21
Max. Negotiated Rate	$173.15
Rate for Payer: Aetna Commercial	$163.53
Rate for Payer: Aetna New Business (MI Preferred)	$125.05
Rate for Payer: Cash Price	$153.91
Rate for Payer: Cofinity Advantage	$134.67
Rate for Payer: Cofinity Commercial	$165.46
Rate for Payer: Encore Health Key Benefits Commercial	$153.91
Rate for Payer: Healthscope Commercial	$173.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$163.53
Rate for Payer: Opus (Opus Packaging Group) HMA	$144.29
Rate for Payer: PHP Commercial	$163.53
Rate for Payer: Priority Health SBD	$121.21

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	$27.47
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 Advantage	$48.92
Rate for Payer: Cofinity Commercial	$60.11
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$62.90
Rate for Payer: MI Amish Medical Board Commercial	$55.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.41
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.42
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health SBD	$44.03
Rate for Payer: UHC All Payor (Choice/PPO)	$45.43
Rate for Payer: UHC Core	$36.41
Rate for Payer: UHC Exchange	$27.47

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$98.18

Service Code	NDC 45802086866
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$61.85
Max. Negotiated Rate	$88.36
Rate for Payer: Aetna Commercial	$83.45
Rate for Payer: Aetna New Business (MI Preferred)	$63.82
Rate for Payer: Cash Price	$78.54
Rate for Payer: Cofinity Advantage	$68.73
Rate for Payer: Cofinity Commercial	$84.43
Rate for Payer: Encore Health Key Benefits Commercial	$78.54
Rate for Payer: Healthscope Commercial	$88.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$83.45
Rate for Payer: Opus (Opus Packaging Group) HMA	$73.64
Rate for Payer: PHP Commercial	$83.45
Rate for Payer: Priority Health SBD	$61.85

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 Advantage	$773.63
Rate for Payer: Cofinity Commercial	$950.46
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: Opus (Opus Packaging Group) HMA	$828.89
Rate for Payer: PHP Commercial	$939.41
Rate for Payer: Priority Health SBD	$696.27

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$7.02

Service Code	NDC 45802086800
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$2.76
Max. Negotiated Rate	$6.32
Rate for Payer: Aetna Commercial	$5.97
Rate for Payer: Aetna Medicare	$3.51
Rate for Payer: Aetna New Business (MI Preferred)	$4.56
Rate for Payer: BCBS Complete	$2.81
Rate for Payer: Cash Price	$5.62
Rate for Payer: Cofinity Advantage	$4.91
Rate for Payer: Cofinity Commercial	$6.04
Rate for Payer: Encore Health Key Benefits Commercial	$5.62
Rate for Payer: Healthscope Commercial	$6.32
Rate for Payer: MI Amish Medical Board Commercial	$5.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$5.26
Rate for Payer: PHP Commercial	$5.97
Rate for Payer: Priority Health SBD	$4.42
Rate for Payer: UHC All Payor (Choice/PPO)	$4.56
Rate for Payer: UHC Core	$3.66
Rate for Payer: UHC Exchange	$2.76

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 Advantage	$7.74
Rate for Payer: Cofinity Commercial	$9.51
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: Opus (Opus Packaging Group) HMA	$8.29
Rate for Payer: PHP Commercial	$9.40
Rate for Payer: Priority Health SBD	$6.97

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.05

Service Code	NDC 60687043199
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$5.14
Rate for Payer: Aetna New Business (MI Preferred)	$3.93
Rate for Payer: Cash Price	$4.84
Rate for Payer: Cofinity Advantage	$4.24
Rate for Payer: Cofinity Commercial	$5.20
Rate for Payer: Encore Health Key Benefits Commercial	$4.84
Rate for Payer: Healthscope Commercial	$5.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.54
Rate for Payer: PHP Commercial	$5.14
Rate for Payer: Priority Health SBD	$3.81

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	$4.35
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 Advantage	$7.74
Rate for Payer: Cofinity Commercial	$9.51
Rate for Payer: Encore Health Key Benefits Commercial	$8.85
Rate for Payer: Healthscope Commercial	$9.95
Rate for Payer: MI Amish Medical Board Commercial	$8.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$8.29
Rate for Payer: PHP Commercial	$9.40
Rate for Payer: Priority Health SBD	$6.97
Rate for Payer: UHC All Payor (Choice/PPO)	$7.19
Rate for Payer: UHC Core	$5.76
Rate for Payer: UHC Exchange	$4.35

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	$27.47
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 Advantage	$48.92
Rate for Payer: Cofinity Commercial	$60.11
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$62.90
Rate for Payer: MI Amish Medical Board Commercial	$55.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.41
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.42
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health SBD	$44.03
Rate for Payer: UHC All Payor (Choice/PPO)	$45.43
Rate for Payer: UHC Core	$36.41
Rate for Payer: UHC Exchange	$27.47

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$572.64

Service Code	NDC 60687043192
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$360.76
Max. Negotiated Rate	$515.38
Rate for Payer: Aetna Commercial	$486.74
Rate for Payer: Aetna New Business (MI Preferred)	$372.22
Rate for Payer: Cash Price	$458.11
Rate for Payer: Cofinity Advantage	$400.85
Rate for Payer: Cofinity Commercial	$492.47
Rate for Payer: Encore Health Key Benefits Commercial	$458.11
Rate for Payer: Healthscope Commercial	$515.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$486.74
Rate for Payer: Opus (Opus Packaging Group) HMA	$429.48
Rate for Payer: PHP Commercial	$486.74
Rate for Payer: Priority Health SBD	$360.76

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 Advantage	$48.92
Rate for Payer: Cofinity Commercial	$60.11
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: Opus (Opus Packaging Group) HMA	$52.42
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health SBD	$44.03

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$89.25

Service Code	NDC 00904693126
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$56.23
Max. Negotiated Rate	$80.33
Rate for Payer: Aetna Commercial	$75.86
Rate for Payer: Aetna New Business (MI Preferred)	$58.01
Rate for Payer: Cash Price	$71.40
Rate for Payer: Cofinity Advantage	$62.48
Rate for Payer: Cofinity Commercial	$76.75
Rate for Payer: Encore Health Key Benefits Commercial	$71.40
Rate for Payer: Healthscope Commercial	$80.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$75.86
Rate for Payer: Opus (Opus Packaging Group) HMA	$66.94
Rate for Payer: PHP Commercial	$75.86
Rate for Payer: Priority Health SBD	$56.23

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.05

Service Code	NDC 60687043199
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$5.14
Rate for Payer: Aetna Medicare	$3.02
Rate for Payer: Aetna New Business (MI Preferred)	$3.93
Rate for Payer: BCBS Complete	$2.42
Rate for Payer: Cash Price	$4.84
Rate for Payer: Cofinity Advantage	$4.24
Rate for Payer: Cofinity Commercial	$5.20
Rate for Payer: Encore Health Key Benefits Commercial	$4.84
Rate for Payer: Healthscope Commercial	$5.45
Rate for Payer: MI Amish Medical Board Commercial	$4.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.54
Rate for Payer: PHP Commercial	$5.14
Rate for Payer: Priority Health SBD	$3.81
Rate for Payer: UHC All Payor (Choice/PPO)	$3.93
Rate for Payer: UHC Core	$3.15
Rate for Payer: UHC Exchange	$2.38

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.42

Service Code	NDC 51079030601
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$5.78
Rate for Payer: Aetna Commercial	$5.46
Rate for Payer: Aetna New Business (MI Preferred)	$4.17
Rate for Payer: Cash Price	$5.14
Rate for Payer: Cofinity Advantage	$4.49
Rate for Payer: Cofinity Commercial	$5.52
Rate for Payer: Encore Health Key Benefits Commercial	$5.14
Rate for Payer: Healthscope Commercial	$5.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.46
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.82
Rate for Payer: PHP Commercial	$5.46
Rate for Payer: Priority Health SBD	$4.04

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$8.34

Service Code	NDC 62559015717
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$7.51
Rate for Payer: Aetna Commercial	$7.09
Rate for Payer: Aetna Medicare	$4.17
Rate for Payer: Aetna New Business (MI Preferred)	$5.42
Rate for Payer: BCBS Complete	$3.34
Rate for Payer: Cash Price	$6.67
Rate for Payer: Cofinity Advantage	$5.84
Rate for Payer: Cofinity Commercial	$7.17
Rate for Payer: Encore Health Key Benefits Commercial	$6.67
Rate for Payer: Healthscope Commercial	$7.51
Rate for Payer: MI Amish Medical Board Commercial	$6.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.09
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.25
Rate for Payer: PHP Commercial	$7.09
Rate for Payer: Priority Health SBD	$5.25
Rate for Payer: UHC All Payor (Choice/PPO)	$5.42
Rate for Payer: UHC Core	$4.35
Rate for Payer: UHC Exchange	$3.28

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$833.28

Service Code	NDC 62559015710
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$327.48
Max. Negotiated Rate	$749.95
Rate for Payer: Aetna Commercial	$708.29
Rate for Payer: Aetna Medicare	$416.64
Rate for Payer: Aetna New Business (MI Preferred)	$541.63
Rate for Payer: BCBS Complete	$333.31
Rate for Payer: Cash Price	$666.62
Rate for Payer: Cofinity Advantage	$583.30
Rate for Payer: Cofinity Commercial	$716.62
Rate for Payer: Encore Health Key Benefits Commercial	$666.62
Rate for Payer: Healthscope Commercial	$749.95
Rate for Payer: MI Amish Medical Board Commercial	$666.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$708.29
Rate for Payer: Opus (Opus Packaging Group) HMA	$624.96
Rate for Payer: PHP Commercial	$708.29
Rate for Payer: Priority Health SBD	$524.97
Rate for Payer: UHC All Payor (Choice/PPO)	$541.63
Rate for Payer: UHC Core	$434.14
Rate for Payer: UHC Exchange	$327.48

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 Advantage	$48.92
Rate for Payer: Cofinity Commercial	$60.11
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: Opus (Opus Packaging Group) HMA	$52.42
Rate for Payer: PHP Commercial	$59.41
Rate for Payer: Priority Health SBD	$44.03

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS

Facility

$35.00

Service Code	NDC 24208031510
Hospital Charge Code	109275
Hospital Revenue Code	637
Min. Negotiated Rate	$13.76
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Commercial	$29.75
Rate for Payer: Aetna Medicare	$17.50
Rate for Payer: Aetna New Business (MI Preferred)	$22.75
Rate for Payer: BCBS Complete	$14.00
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cofinity Advantage	$24.50
Rate for Payer: Cofinity Commercial	$30.10
Rate for Payer: Encore Health Key Benefits Commercial	$28.00
Rate for Payer: Healthscope Commercial	$31.50
Rate for Payer: MI Amish Medical Board Commercial	$28.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$29.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$26.25
Rate for Payer: PHP Commercial	$29.75
Rate for Payer: Priority Health SBD	$22.05
Rate for Payer: UHC All Payor (Choice/PPO)	$22.75
Rate for Payer: UHC Core	$18.23
Rate for Payer: UHC Exchange	$13.76

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS

Facility

$35.46

Service Code	NDC 60758090810
Hospital Charge Code	109275
Hospital Revenue Code	637
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$31.91
Rate for Payer: Aetna Commercial	$30.14
Rate for Payer: Aetna Medicare	$17.73
Rate for Payer: Aetna New Business (MI Preferred)	$23.05
Rate for Payer: BCBS Complete	$14.18
Rate for Payer: Cash Price	$28.37
Rate for Payer: Cofinity Advantage	$24.82
Rate for Payer: Cofinity Commercial	$30.50
Rate for Payer: Encore Health Key Benefits Commercial	$28.37
Rate for Payer: Healthscope Commercial	$31.91
Rate for Payer: MI Amish Medical Board Commercial	$28.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$30.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$26.59
Rate for Payer: PHP Commercial	$30.14
Rate for Payer: Priority Health SBD	$22.34
Rate for Payer: UHC All Payor (Choice/PPO)	$23.05
Rate for Payer: UHC Core	$18.47
Rate for Payer: UHC Exchange	$13.94

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS

Facility

$35.46

Service Code	NDC 60758090810
Hospital Charge Code	109275
Hospital Revenue Code	637
Min. Negotiated Rate	$22.34
Max. Negotiated Rate	$31.91
Rate for Payer: Aetna Commercial	$30.14
Rate for Payer: Aetna New Business (MI Preferred)	$23.05
Rate for Payer: Cash Price	$28.37
Rate for Payer: Cofinity Advantage	$24.82
Rate for Payer: Cofinity Commercial	$30.50
Rate for Payer: Encore Health Key Benefits Commercial	$28.37
Rate for Payer: Healthscope Commercial	$31.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$30.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$26.59
Rate for Payer: PHP Commercial	$30.14
Rate for Payer: Priority Health SBD	$22.34

POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS

Facility

$35.00

Service Code	NDC 24208031510
Hospital Charge Code	109275
Hospital Revenue Code	637
Min. Negotiated Rate	$22.05
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Commercial	$29.75
Rate for Payer: Aetna New Business (MI Preferred)	$22.75
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cofinity Advantage	$24.50
Rate for Payer: Cofinity Commercial	$30.10
Rate for Payer: Encore Health Key Benefits Commercial	$28.00
Rate for Payer: Healthscope Commercial	$31.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$29.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$26.25
Rate for Payer: PHP Commercial	$29.75
Rate for Payer: Priority Health SBD	$22.05

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