Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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

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	$14.00
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 Commercial	$24.50
Rate for Payer: Cofinity Commercial	$30.10
Rate for Payer: Cofinity Medicare Advantage	$24.50
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: PHP Commercial	$29.75
Rate for Payer: Priority Health Cigna Priority Health	$22.75
Rate for Payer: Priority Health SBD	$22.05

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	$14.18
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 Commercial	$24.82
Rate for Payer: Cofinity Commercial	$30.50
Rate for Payer: Cofinity Medicare Advantage	$24.82
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: PHP Commercial	$30.14
Rate for Payer: Priority Health Cigna Priority Health	$23.05
Rate for Payer: Priority Health SBD	$22.34

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 Commercial	$24.82
Rate for Payer: Cofinity Commercial	$30.50
Rate for Payer: Cofinity Medicare Advantage	$24.82
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: PHP Commercial	$30.14
Rate for Payer: Priority Health Cigna Priority Health	$23.05
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 Commercial	$24.50
Rate for Payer: Cofinity Commercial	$30.10
Rate for Payer: Cofinity Medicare Advantage	$24.50
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: PHP Commercial	$29.75
Rate for Payer: Priority Health Cigna Priority Health	$22.75
Rate for Payer: Priority Health SBD	$22.05

POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION

Facility

$23.40

Service Code	NDC 55150023410
Hospital Charge Code	6393
Hospital Revenue Code	250
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$21.06
Rate for Payer: Aetna Commercial	$19.89
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: Aetna New Business (MI Preferred)	$15.21
Rate for Payer: BCBS Complete	$9.36
Rate for Payer: Cash Price	$18.72
Rate for Payer: Cofinity Commercial	$16.38
Rate for Payer: Cofinity Commercial	$20.12
Rate for Payer: Cofinity Medicare Advantage	$16.38
Rate for Payer: Encore Health Key Benefits Commercial	$18.72
Rate for Payer: Healthscope Commercial	$21.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.89
Rate for Payer: PHP Commercial	$19.89
Rate for Payer: Priority Health Cigna Priority Health	$15.21
Rate for Payer: Priority Health SBD	$14.74

POLYMYXIN B SULFATE 500,000 UNIT SOLUTION FOR INJECTION

Facility

$23.40

Service Code	NDC 55150023410
Hospital Charge Code	6393
Hospital Revenue Code	250
Min. Negotiated Rate	$14.74
Max. Negotiated Rate	$21.06
Rate for Payer: Aetna Commercial	$19.89
Rate for Payer: Aetna New Business (MI Preferred)	$15.21
Rate for Payer: Cash Price	$18.72
Rate for Payer: Cofinity Commercial	$16.38
Rate for Payer: Cofinity Commercial	$20.12
Rate for Payer: Cofinity Medicare Advantage	$16.38
Rate for Payer: Encore Health Key Benefits Commercial	$18.72
Rate for Payer: Healthscope Commercial	$21.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.89
Rate for Payer: PHP Commercial	$19.89
Rate for Payer: Priority Health Cigna Priority Health	$15.21
Rate for Payer: Priority Health SBD	$14.74

POLYVINYL ALCOHOL 1.4 % EYE DROPS

Facility

$58.14

Service Code	NDC 00536132594
Hospital Charge Code	27994
Hospital Revenue Code	637
Min. Negotiated Rate	$36.63
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Cofinity Medicare Advantage	$40.70
Rate for Payer: Encore Health Key Benefits Commercial	$46.51
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$37.79
Rate for Payer: Priority Health SBD	$36.63

POLYVINYL ALCOHOL 1.4 % EYE DROPS

Facility

$58.14

Service Code	NDC 00536132594
Hospital Charge Code	27994
Hospital Revenue Code	637
Min. Negotiated Rate	$23.26
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna Medicare	$29.07
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: BCBS Complete	$23.26
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Cofinity Medicare Advantage	$40.70
Rate for Payer: Encore Health Key Benefits Commercial	$46.51
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$37.79
Rate for Payer: Priority Health SBD	$36.63

POLYVINYL ALCOHOL 1.4 % EYE DROPS

Facility

$92.34

Service Code	NDC 17478006012
Hospital Charge Code	27994
Hospital Revenue Code	637
Min. Negotiated Rate	$58.17
Max. Negotiated Rate	$83.11
Rate for Payer: Aetna Commercial	$78.49
Rate for Payer: Aetna New Business (MI Preferred)	$60.02
Rate for Payer: Cash Price	$73.87
Rate for Payer: Cofinity Commercial	$64.64
Rate for Payer: Cofinity Commercial	$79.41
Rate for Payer: Cofinity Medicare Advantage	$64.64
Rate for Payer: Encore Health Key Benefits Commercial	$73.87
Rate for Payer: Healthscope Commercial	$83.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$78.49
Rate for Payer: PHP Commercial	$78.49
Rate for Payer: Priority Health Cigna Priority Health	$60.02
Rate for Payer: Priority Health SBD	$58.17

POLYVINYL ALCOHOL 1.4 % EYE DROPS

Facility

$92.34

Service Code	NDC 17478006012
Hospital Charge Code	27994
Hospital Revenue Code	637
Min. Negotiated Rate	$36.94
Max. Negotiated Rate	$83.11
Rate for Payer: Aetna Commercial	$78.49
Rate for Payer: Aetna Medicare	$46.17
Rate for Payer: Aetna New Business (MI Preferred)	$60.02
Rate for Payer: BCBS Complete	$36.94
Rate for Payer: Cash Price	$73.87
Rate for Payer: Cofinity Commercial	$64.64
Rate for Payer: Cofinity Commercial	$79.41
Rate for Payer: Cofinity Medicare Advantage	$64.64
Rate for Payer: Encore Health Key Benefits Commercial	$73.87
Rate for Payer: Healthscope Commercial	$83.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$78.49
Rate for Payer: PHP Commercial	$78.49
Rate for Payer: Priority Health Cigna Priority Health	$60.02
Rate for Payer: Priority Health SBD	$58.17

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE

Facility

$3,337.77

Service Code	NDC 43598047060
Hospital Charge Code	169019
Hospital Revenue Code	637
Min. Negotiated Rate	$1,335.11
Max. Negotiated Rate	$3,003.99
Rate for Payer: Aetna Commercial	$2,837.10
Rate for Payer: Aetna Medicare	$1,668.88
Rate for Payer: Aetna New Business (MI Preferred)	$2,169.55
Rate for Payer: BCBS Complete	$1,335.11
Rate for Payer: Cash Price	$2,670.22
Rate for Payer: Cofinity Commercial	$2,336.44
Rate for Payer: Cofinity Commercial	$2,870.48
Rate for Payer: Cofinity Medicare Advantage	$2,336.44
Rate for Payer: Encore Health Key Benefits Commercial	$2,670.22
Rate for Payer: Healthscope Commercial	$3,003.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,837.10
Rate for Payer: PHP Commercial	$2,837.10
Rate for Payer: Priority Health Cigna Priority Health	$2,169.55
Rate for Payer: Priority Health SBD	$2,102.80

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE

Facility

$1,530.25

Service Code	NDC 70748025807
Hospital Charge Code	169019
Hospital Revenue Code	637
Min. Negotiated Rate	$612.10
Max. Negotiated Rate	$1,377.22
Rate for Payer: Aetna Commercial	$1,300.71
Rate for Payer: Aetna Medicare	$765.12
Rate for Payer: Aetna New Business (MI Preferred)	$994.66
Rate for Payer: BCBS Complete	$612.10
Rate for Payer: Cash Price	$1,224.20
Rate for Payer: Cofinity Commercial	$1,071.18
Rate for Payer: Cofinity Commercial	$1,316.02
Rate for Payer: Cofinity Medicare Advantage	$1,071.18
Rate for Payer: Encore Health Key Benefits Commercial	$1,224.20
Rate for Payer: Healthscope Commercial	$1,377.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,300.71
Rate for Payer: PHP Commercial	$1,300.71
Rate for Payer: Priority Health Cigna Priority Health	$994.66
Rate for Payer: Priority Health SBD	$964.06

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE

Facility

$1,530.25

Service Code	NDC 70748025807
Hospital Charge Code	169019
Hospital Revenue Code	637
Min. Negotiated Rate	$964.06
Max. Negotiated Rate	$1,377.22
Rate for Payer: Aetna Commercial	$1,300.71
Rate for Payer: Aetna New Business (MI Preferred)	$994.66
Rate for Payer: Cash Price	$1,224.20
Rate for Payer: Cofinity Commercial	$1,071.18
Rate for Payer: Cofinity Commercial	$1,316.02
Rate for Payer: Cofinity Medicare Advantage	$1,071.18
Rate for Payer: Encore Health Key Benefits Commercial	$1,224.20
Rate for Payer: Healthscope Commercial	$1,377.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,300.71
Rate for Payer: PHP Commercial	$1,300.71
Rate for Payer: Priority Health Cigna Priority Health	$994.66
Rate for Payer: Priority Health SBD	$964.06

POSACONAZOLE 100 MG TABLET,DELAYED RELEASE

Facility

$3,337.77

Service Code	NDC 43598047060
Hospital Charge Code	169019
Hospital Revenue Code	637
Min. Negotiated Rate	$2,102.80
Max. Negotiated Rate	$3,003.99
Rate for Payer: Aetna Commercial	$2,837.10
Rate for Payer: Aetna New Business (MI Preferred)	$2,169.55
Rate for Payer: Cash Price	$2,670.22
Rate for Payer: Cofinity Commercial	$2,336.44
Rate for Payer: Cofinity Commercial	$2,870.48
Rate for Payer: Cofinity Medicare Advantage	$2,336.44
Rate for Payer: Encore Health Key Benefits Commercial	$2,670.22
Rate for Payer: Healthscope Commercial	$3,003.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,837.10
Rate for Payer: PHP Commercial	$2,837.10
Rate for Payer: Priority Health Cigna Priority Health	$2,169.55
Rate for Payer: Priority Health SBD	$2,102.80

POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT PERINEORRHAPHY

Facility

$15,201.47

Service Code	CPT 57250
Hospital Revenue Code	360
Min. Negotiated Rate	$657.69
Max. Negotiated Rate	$15,201.47
Rate for Payer: Aetna Medicare	$5,030.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,045.79
Rate for Payer: Amish Plain Church Group Commercial	$6,045.79
Rate for Payer: BCBS Complete	$2,722.06
Rate for Payer: BCBS MAPPO	$4,836.63
Rate for Payer: BCBS Trust/PPO	$2,688.79
Rate for Payer: BCN Commercial	$2,688.79
Rate for Payer: BCN Medicare Advantage	$4,836.63
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,836.63
Rate for Payer: Mclaren Medicaid	$2,592.43
Rate for Payer: Mclaren Medicare	$4,836.63
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5,078.46
Rate for Payer: Meridian Medicaid	$2,722.06
Rate for Payer: MI Amish Medical Board Commercial	$5,562.12
Rate for Payer: Nomi Health Commercial	$10,156.92
Rate for Payer: PACE Medicare	$4,594.80
Rate for Payer: PACE SWMI	$4,836.63
Rate for Payer: PHP Medicare Advantage	$4,836.63
Rate for Payer: Priority Health Choice Medicaid	$2,592.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15,201.47
Rate for Payer: Priority Health Medicare	$4,836.63
Rate for Payer: Priority Health Narrow Network	$12,161.18
Rate for Payer: Railroad Medicare Medicare	$4,836.63
Rate for Payer: UHC All Payor (Choice/PPO)	$657.69
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$4,836.63
Rate for Payer: UHC Exchange	$5,811.00
Rate for Payer: UHC Medicare Advantage	$4,836.63
Rate for Payer: UHCCP Medicaid	$2,723.02
Rate for Payer: VA VA	$4,836.63

POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$1,620.64

Service Code	CPT 22842
Hospital Revenue Code	360
Min. Negotiated Rate	$826.57
Max. Negotiated Rate	$1,620.64
Rate for Payer: BCBS Trust/PPO	$1,620.64
Rate for Payer: BCN Commercial	$1,620.64
Rate for Payer: UHC All Payor (Choice/PPO)	$826.57
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Exchange	$940.00

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$40.50

Service Code	NDC 00409329415
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$36.45
Rate for Payer: Aetna Commercial	$34.42
Rate for Payer: Aetna Medicare	$20.25
Rate for Payer: Aetna New Business (MI Preferred)	$26.32
Rate for Payer: BCBS Complete	$16.20
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cofinity Commercial	$28.35
Rate for Payer: Cofinity Commercial	$34.83
Rate for Payer: Cofinity Medicare Advantage	$28.35
Rate for Payer: Encore Health Key Benefits Commercial	$32.40
Rate for Payer: Healthscope Commercial	$36.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$34.42
Rate for Payer: PHP Commercial	$34.42
Rate for Payer: Priority Health Cigna Priority Health	$26.32
Rate for Payer: Priority Health SBD	$25.52

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$40.50

Service Code	NDC 00409329451
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$25.52
Max. Negotiated Rate	$36.45
Rate for Payer: Aetna Commercial	$34.42
Rate for Payer: Aetna New Business (MI Preferred)	$26.32
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cofinity Commercial	$28.35
Rate for Payer: Cofinity Commercial	$34.83
Rate for Payer: Cofinity Medicare Advantage	$28.35
Rate for Payer: Encore Health Key Benefits Commercial	$32.40
Rate for Payer: Healthscope Commercial	$36.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$34.42
Rate for Payer: PHP Commercial	$34.42
Rate for Payer: Priority Health Cigna Priority Health	$26.32
Rate for Payer: Priority Health SBD	$25.52

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$40.50

Service Code	NDC 00409329461
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$25.52
Max. Negotiated Rate	$36.45
Rate for Payer: Aetna Commercial	$34.42
Rate for Payer: Aetna New Business (MI Preferred)	$26.32
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cofinity Commercial	$28.35
Rate for Payer: Cofinity Commercial	$34.83
Rate for Payer: Cofinity Medicare Advantage	$28.35
Rate for Payer: Encore Health Key Benefits Commercial	$32.40
Rate for Payer: Healthscope Commercial	$36.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$34.42
Rate for Payer: PHP Commercial	$34.42
Rate for Payer: Priority Health Cigna Priority Health	$26.32
Rate for Payer: Priority Health SBD	$25.52

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$40.50

Service Code	NDC 00409329461
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$36.45
Rate for Payer: Aetna Commercial	$34.42
Rate for Payer: Aetna Medicare	$20.25
Rate for Payer: Aetna New Business (MI Preferred)	$26.32
Rate for Payer: BCBS Complete	$16.20
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cofinity Commercial	$28.35
Rate for Payer: Cofinity Commercial	$34.83
Rate for Payer: Cofinity Medicare Advantage	$28.35
Rate for Payer: Encore Health Key Benefits Commercial	$32.40
Rate for Payer: Healthscope Commercial	$36.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$34.42
Rate for Payer: PHP Commercial	$34.42
Rate for Payer: Priority Health Cigna Priority Health	$26.32
Rate for Payer: Priority Health SBD	$25.52

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$40.50

Service Code	NDC 00409329415
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$25.52
Max. Negotiated Rate	$36.45
Rate for Payer: Aetna Commercial	$34.42
Rate for Payer: Aetna New Business (MI Preferred)	$26.32
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cofinity Commercial	$28.35
Rate for Payer: Cofinity Commercial	$34.83
Rate for Payer: Cofinity Medicare Advantage	$28.35
Rate for Payer: Encore Health Key Benefits Commercial	$32.40
Rate for Payer: Healthscope Commercial	$36.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$34.42
Rate for Payer: PHP Commercial	$34.42
Rate for Payer: Priority Health Cigna Priority Health	$26.32
Rate for Payer: Priority Health SBD	$25.52

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$40.50

Service Code	NDC 00409329425
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$25.52
Max. Negotiated Rate	$36.45
Rate for Payer: Aetna Commercial	$34.42
Rate for Payer: Aetna New Business (MI Preferred)	$26.32
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cofinity Commercial	$28.35
Rate for Payer: Cofinity Commercial	$34.83
Rate for Payer: Cofinity Medicare Advantage	$28.35
Rate for Payer: Encore Health Key Benefits Commercial	$32.40
Rate for Payer: Healthscope Commercial	$36.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$34.42
Rate for Payer: PHP Commercial	$34.42
Rate for Payer: Priority Health Cigna Priority Health	$26.32
Rate for Payer: Priority Health SBD	$25.52

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$40.50

Service Code	NDC 00409329451
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$36.45
Rate for Payer: Aetna Commercial	$34.42
Rate for Payer: Aetna Medicare	$20.25
Rate for Payer: Aetna New Business (MI Preferred)	$26.32
Rate for Payer: BCBS Complete	$16.20
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cofinity Commercial	$28.35
Rate for Payer: Cofinity Commercial	$34.83
Rate for Payer: Cofinity Medicare Advantage	$28.35
Rate for Payer: Encore Health Key Benefits Commercial	$32.40
Rate for Payer: Healthscope Commercial	$36.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$34.42
Rate for Payer: PHP Commercial	$34.42
Rate for Payer: Priority Health Cigna Priority Health	$26.32
Rate for Payer: Priority Health SBD	$25.52

POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$40.50

Service Code	NDC 00409329425
Hospital Charge Code	6420
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$36.45
Rate for Payer: Aetna Commercial	$34.42
Rate for Payer: Aetna Medicare	$20.25
Rate for Payer: Aetna New Business (MI Preferred)	$26.32
Rate for Payer: BCBS Complete	$16.20
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cofinity Commercial	$28.35
Rate for Payer: Cofinity Commercial	$34.83
Rate for Payer: Cofinity Medicare Advantage	$28.35
Rate for Payer: Encore Health Key Benefits Commercial	$32.40
Rate for Payer: Healthscope Commercial	$36.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$34.42
Rate for Payer: PHP Commercial	$34.42
Rate for Payer: Priority Health Cigna Priority Health	$26.32
Rate for Payer: Priority Health SBD	$25.52

Know your out-of-pocket cost for care.

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