Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SOTALOL 80 MG TABLET

Facility

$117.50

Service Code	NDC 60505-0080-0
Hospital Charge Code	11421
Hospital Revenue Code	637
Min. Negotiated Rate	$74.02
Max. Negotiated Rate	$105.75
Rate for Payer: Aetna Commercial	$99.88
Rate for Payer: Aetna New Business (MI Preferred)	$76.38
Rate for Payer: Cash Price	$94.00
Rate for Payer: Cofinity Commercial	$101.05
Rate for Payer: Cofinity Commercial	$82.25
Rate for Payer: Healthscope Commercial	$105.75
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$99.88
Rate for Payer: PHP Commercial	$99.88
Rate for Payer: Priority Health Cigna Priority Health	$82.25
Rate for Payer: Priority Health SBD	$74.02

SOTALOL 80 MG TABLET

Facility

$4.63

Service Code	NDC 0245-0012-89
Hospital Charge Code	11421
Hospital Revenue Code	637
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.17
Rate for Payer: Aetna Commercial	$3.94
Rate for Payer: Aetna New Business (MI Preferred)	$3.01
Rate for Payer: Cash Price	$3.70
Rate for Payer: Cofinity Commercial	$3.24
Rate for Payer: Cofinity Commercial	$3.98
Rate for Payer: Healthscope Commercial	$4.17
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.94
Rate for Payer: PHP Commercial	$3.94
Rate for Payer: Priority Health Cigna Priority Health	$3.24
Rate for Payer: Priority Health SBD	$2.92

SOTALOL 80 MG TABLET

Facility

$500.64

Service Code	NDC 68084-654-01
Hospital Charge Code	11421
Hospital Revenue Code	637
Min. Negotiated Rate	$315.40
Max. Negotiated Rate	$450.58
Rate for Payer: Aetna Commercial	$425.54
Rate for Payer: Aetna New Business (MI Preferred)	$325.42
Rate for Payer: Cash Price	$400.51
Rate for Payer: Cofinity Commercial	$350.45
Rate for Payer: Cofinity Commercial	$430.55
Rate for Payer: Healthscope Commercial	$450.58
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$425.54
Rate for Payer: PHP Commercial	$425.54
Rate for Payer: Priority Health Cigna Priority Health	$350.45
Rate for Payer: Priority Health SBD	$315.40

SOTALOL 80 MG TABLET

Facility

$462.24

Service Code	NDC 0245-0012-01
Hospital Charge Code	11421
Hospital Revenue Code	637
Min. Negotiated Rate	$291.21
Max. Negotiated Rate	$416.02
Rate for Payer: Aetna Commercial	$392.90
Rate for Payer: Aetna New Business (MI Preferred)	$300.46
Rate for Payer: Cash Price	$369.79
Rate for Payer: Cofinity Commercial	$323.57
Rate for Payer: Cofinity Commercial	$397.53
Rate for Payer: Healthscope Commercial	$416.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$392.90
Rate for Payer: PHP Commercial	$392.90
Rate for Payer: Priority Health Cigna Priority Health	$323.57
Rate for Payer: Priority Health SBD	$291.21

SPINAL DISORDERS AND INJURIES WITH CC/MCC

Facility

$29,661.40

Service Code	MS-DRG 052
Min. Negotiated Rate	$13,771.78
Max. Negotiated Rate	$29,661.40
Rate for Payer: Aetna Medicare	$15,076.47
Rate for Payer: Allen County Amish Medical Aid Commercial	$18,120.76
Rate for Payer: Amish Plain Church Group Commercial	$18,120.76
Rate for Payer: BCBS MAPPO	$14,496.61
Rate for Payer: BCBS Trust/PPO	$26,533.06
Rate for Payer: BCN Medicare Advantage	$14,496.61
Rate for Payer: Health Alliance Plan Medicare Advantage	$14,496.61
Rate for Payer: Mclaren Medicare	$14,496.61
Rate for Payer: Meridian Wellcare - Medicare Advantage	$15,221.44
Rate for Payer: MI Amish Medical Board Commercial	$16,671.10
Rate for Payer: PACE Medicare	$13,771.78
Rate for Payer: PACE SWMI	$14,496.61
Rate for Payer: PHP Medicare Advantage	$14,496.61
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27,903.42
Rate for Payer: Priority Health Medicare	$14,496.61
Rate for Payer: Priority Health Narrow Network	$22,322.74
Rate for Payer: Railroad Medicare Medicare	$14,496.61
Rate for Payer: UHC All Payor (Choice/PPO)	$29,661.40
Rate for Payer: UHC Core	$18,200.52
Rate for Payer: UHC Dual Complete DSNP	$14,496.61
Rate for Payer: UHC Exchange	$19,493.61
Rate for Payer: UHC Medicare Advantage	$14,931.51
Rate for Payer: VA VA	$14,496.61

SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC

Facility

$19,139.46

Service Code	MS-DRG 053
Min. Negotiated Rate	$7,198.96
Max. Negotiated Rate	$19,139.46
Rate for Payer: Aetna Medicare	$7,880.96
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,472.31
Rate for Payer: Amish Plain Church Group Commercial	$9,472.31
Rate for Payer: BCBS MAPPO	$7,577.85
Rate for Payer: BCBS Trust/PPO	$19,139.46
Rate for Payer: BCN Medicare Advantage	$7,577.85
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,577.85
Rate for Payer: Mclaren Medicare	$7,577.85
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7,956.74
Rate for Payer: MI Amish Medical Board Commercial	$8,714.53
Rate for Payer: PACE Medicare	$7,198.96
Rate for Payer: PACE SWMI	$7,577.85
Rate for Payer: PHP Medicare Advantage	$7,577.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14,117.45
Rate for Payer: Priority Health Medicare	$7,577.85
Rate for Payer: Priority Health Narrow Network	$11,293.96
Rate for Payer: Railroad Medicare Medicare	$7,577.85
Rate for Payer: UHC All Payor (Choice/PPO)	$15,006.89
Rate for Payer: UHC Core	$9,208.37
Rate for Payer: UHC Dual Complete DSNP	$7,577.85
Rate for Payer: UHC Exchange	$9,862.60
Rate for Payer: UHC Medicare Advantage	$7,805.19
Rate for Payer: VA VA	$7,577.85

SPINAL FUSION EXCEPT CERVICAL WITH MCC

Facility

$101,169.10

Service Code	MS-DRG 459
Min. Negotiated Rate	$45,844.32
Max. Negotiated Rate	$101,169.10
Rate for Payer: Aetna Medicare	$50,187.47
Rate for Payer: Allen County Amish Medical Aid Commercial	$60,321.48
Rate for Payer: Amish Plain Church Group Commercial	$60,321.48
Rate for Payer: BCBS MAPPO	$48,257.18
Rate for Payer: BCBS Trust/PPO	$83,510.08
Rate for Payer: BCN Medicare Advantage	$48,257.18
Rate for Payer: Health Alliance Plan Medicare Advantage	$48,257.18
Rate for Payer: Mclaren Medicare	$48,257.18
Rate for Payer: Meridian Wellcare - Medicare Advantage	$50,670.04
Rate for Payer: MI Amish Medical Board Commercial	$55,495.76
Rate for Payer: PACE Medicare	$45,844.32
Rate for Payer: PACE SWMI	$48,257.18
Rate for Payer: PHP Medicare Advantage	$48,257.18
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$95,172.97
Rate for Payer: Priority Health Medicare	$48,257.18
Rate for Payer: Priority Health Narrow Network	$76,138.38
Rate for Payer: Railroad Medicare Medicare	$48,257.18
Rate for Payer: UHC All Payor (Choice/PPO)	$101,169.10
Rate for Payer: UHC Core	$62,078.33
Rate for Payer: UHC Dual Complete DSNP	$48,257.18
Rate for Payer: UHC Exchange	$66,488.81
Rate for Payer: UHC Medicare Advantage	$49,704.90
Rate for Payer: VA VA	$48,257.18

SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$55,797.61

Service Code	MS-DRG 460
Min. Negotiated Rate	$25,494.35
Max. Negotiated Rate	$55,797.61
Rate for Payer: Aetna Medicare	$27,909.61
Rate for Payer: Allen County Amish Medical Aid Commercial	$33,545.20
Rate for Payer: Amish Plain Church Group Commercial	$33,545.20
Rate for Payer: BCBS MAPPO	$26,836.16
Rate for Payer: BCBS Trust/PPO	$53,630.47
Rate for Payer: BCN Medicare Advantage	$26,836.16
Rate for Payer: Health Alliance Plan Medicare Advantage	$26,836.16
Rate for Payer: Mclaren Medicare	$26,836.16
Rate for Payer: Meridian Wellcare - Medicare Advantage	$28,177.97
Rate for Payer: MI Amish Medical Board Commercial	$30,861.58
Rate for Payer: PACE Medicare	$25,494.35
Rate for Payer: PACE SWMI	$26,836.16
Rate for Payer: PHP Medicare Advantage	$26,836.16
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$52,490.57
Rate for Payer: Priority Health Medicare	$26,836.16
Rate for Payer: Priority Health Narrow Network	$41,992.46
Rate for Payer: Railroad Medicare Medicare	$26,836.16
Rate for Payer: UHC All Payor (Choice/PPO)	$55,797.61
Rate for Payer: UHC Core	$34,237.94
Rate for Payer: UHC Dual Complete DSNP	$26,836.16
Rate for Payer: UHC Exchange	$36,670.45
Rate for Payer: UHC Medicare Advantage	$27,641.24
Rate for Payer: VA VA	$26,836.16

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC

Facility

$96,597.64

Service Code	MS-DRG 457
Min. Negotiated Rate	$42,033.48
Max. Negotiated Rate	$96,597.64
Rate for Payer: Aetna Medicare	$46,015.60
Rate for Payer: Allen County Amish Medical Aid Commercial	$55,307.21
Rate for Payer: Amish Plain Church Group Commercial	$55,307.21
Rate for Payer: BCBS MAPPO	$44,245.77
Rate for Payer: BCBS Trust/PPO	$96,597.64
Rate for Payer: BCN Medicare Advantage	$44,245.77
Rate for Payer: Health Alliance Plan Medicare Advantage	$44,245.77
Rate for Payer: Mclaren Medicare	$44,245.77
Rate for Payer: Meridian Wellcare - Medicare Advantage	$46,458.06
Rate for Payer: MI Amish Medical Board Commercial	$50,882.64
Rate for Payer: PACE Medicare	$42,033.48
Rate for Payer: PACE SWMI	$44,245.77
Rate for Payer: PHP Medicare Advantage	$44,245.77
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$87,180.07
Rate for Payer: Priority Health Medicare	$44,245.77
Rate for Payer: Priority Health Narrow Network	$69,744.06
Rate for Payer: Railroad Medicare Medicare	$44,245.77
Rate for Payer: UHC All Payor (Choice/PPO)	$92,672.63
Rate for Payer: UHC Core	$56,864.81
Rate for Payer: UHC Dual Complete DSNP	$44,245.77
Rate for Payer: UHC Exchange	$60,904.88
Rate for Payer: UHC Medicare Advantage	$45,573.14
Rate for Payer: VA VA	$44,245.77

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC

Facility

$128,582.07

Service Code	MS-DRG 456
Min. Negotiated Rate	$58,139.54
Max. Negotiated Rate	$128,582.07
Rate for Payer: Aetna Medicare	$63,647.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$76,499.40
Rate for Payer: Amish Plain Church Group Commercial	$76,499.40
Rate for Payer: BCBS MAPPO	$61,199.52
Rate for Payer: BCBS Trust/PPO	$117,425.75
Rate for Payer: BCN Medicare Advantage	$61,199.52
Rate for Payer: Health Alliance Plan Medicare Advantage	$61,199.52
Rate for Payer: Mclaren Medicare	$61,199.52
Rate for Payer: Meridian Wellcare - Medicare Advantage	$64,259.50
Rate for Payer: MI Amish Medical Board Commercial	$70,379.45
Rate for Payer: PACE Medicare	$58,139.54
Rate for Payer: PACE SWMI	$61,199.52
Rate for Payer: PHP Medicare Advantage	$61,199.52
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$120,961.22
Rate for Payer: Priority Health Medicare	$61,199.52
Rate for Payer: Priority Health Narrow Network	$96,768.98
Rate for Payer: Railroad Medicare Medicare	$61,199.52
Rate for Payer: UHC All Payor (Choice/PPO)	$128,582.07
Rate for Payer: UHC Core	$78,899.18
Rate for Payer: UHC Dual Complete DSNP	$61,199.52
Rate for Payer: UHC Exchange	$84,504.74
Rate for Payer: UHC Medicare Advantage	$63,035.51
Rate for Payer: VA VA	$61,199.52

SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC

Facility

$91,353.83

Service Code	MS-DRG 458
Min. Negotiated Rate	$31,467.85
Max. Negotiated Rate	$91,353.83
Rate for Payer: Aetna Medicare	$34,449.01
Rate for Payer: Allen County Amish Medical Aid Commercial	$41,405.06
Rate for Payer: Amish Plain Church Group Commercial	$41,405.06
Rate for Payer: BCBS MAPPO	$33,124.05
Rate for Payer: BCBS Trust/PPO	$91,353.83
Rate for Payer: BCN Medicare Advantage	$33,124.05
Rate for Payer: Health Alliance Plan Medicare Advantage	$33,124.05
Rate for Payer: Mclaren Medicare	$33,124.05
Rate for Payer: Meridian Wellcare - Medicare Advantage	$34,780.25
Rate for Payer: MI Amish Medical Board Commercial	$38,092.66
Rate for Payer: PACE Medicare	$31,467.85
Rate for Payer: PACE SWMI	$33,124.05
Rate for Payer: PHP Medicare Advantage	$33,124.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$65,019.49
Rate for Payer: Priority Health Medicare	$33,124.05
Rate for Payer: Priority Health Narrow Network	$52,015.59
Rate for Payer: Railroad Medicare Medicare	$33,124.05
Rate for Payer: UHC All Payor (Choice/PPO)	$69,115.87
Rate for Payer: UHC Core	$42,410.16
Rate for Payer: UHC Dual Complete DSNP	$33,124.05
Rate for Payer: UHC Exchange	$45,423.28
Rate for Payer: UHC Medicare Advantage	$34,117.77
Rate for Payer: VA VA	$33,124.05

SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS

Facility

$56,250.17

Service Code	MS-DRG 029
Min. Negotiated Rate	$23,922.82
Max. Negotiated Rate	$56,250.17
Rate for Payer: Aetna Medicare	$26,189.20
Rate for Payer: Allen County Amish Medical Aid Commercial	$31,477.40
Rate for Payer: Amish Plain Church Group Commercial	$31,477.40
Rate for Payer: BCBS MAPPO	$25,181.92
Rate for Payer: BCBS Trust/PPO	$56,250.17
Rate for Payer: BCN Medicare Advantage	$25,181.92
Rate for Payer: Health Alliance Plan Medicare Advantage	$25,181.92
Rate for Payer: Mclaren Medicare	$25,181.92
Rate for Payer: Meridian Wellcare - Medicare Advantage	$26,441.02
Rate for Payer: MI Amish Medical Board Commercial	$28,959.21
Rate for Payer: PACE Medicare	$23,922.82
Rate for Payer: PACE SWMI	$25,181.92
Rate for Payer: PHP Medicare Advantage	$25,181.92
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$49,194.40
Rate for Payer: Priority Health Medicare	$25,181.92
Rate for Payer: Priority Health Narrow Network	$39,355.52
Rate for Payer: Railroad Medicare Medicare	$25,181.92
Rate for Payer: UHC All Payor (Choice/PPO)	$52,293.76
Rate for Payer: UHC Core	$32,087.95
Rate for Payer: UHC Dual Complete DSNP	$25,181.92
Rate for Payer: UHC Exchange	$34,367.71
Rate for Payer: UHC Medicare Advantage	$25,937.38
Rate for Payer: VA VA	$25,181.92

SPINAL PROCEDURES WITH MCC

Facility

$91,922.13

Service Code	MS-DRG 028
Min. Negotiated Rate	$41,696.89
Max. Negotiated Rate	$91,922.13
Rate for Payer: Aetna Medicare	$45,647.12
Rate for Payer: Allen County Amish Medical Aid Commercial	$54,864.32
Rate for Payer: Amish Plain Church Group Commercial	$54,864.32
Rate for Payer: BCBS MAPPO	$43,891.46
Rate for Payer: BCBS Trust/PPO	$85,391.96
Rate for Payer: BCN Medicare Advantage	$43,891.46
Rate for Payer: Health Alliance Plan Medicare Advantage	$43,891.46
Rate for Payer: Mclaren Medicare	$43,891.46
Rate for Payer: Meridian Wellcare - Medicare Advantage	$46,086.03
Rate for Payer: MI Amish Medical Board Commercial	$50,475.18
Rate for Payer: PACE Medicare	$41,696.89
Rate for Payer: PACE SWMI	$43,891.46
Rate for Payer: PHP Medicare Advantage	$43,891.46
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$86,474.05
Rate for Payer: Priority Health Medicare	$43,891.46
Rate for Payer: Priority Health Narrow Network	$69,179.24
Rate for Payer: Railroad Medicare Medicare	$43,891.46
Rate for Payer: UHC All Payor (Choice/PPO)	$91,922.13
Rate for Payer: UHC Core	$56,404.30
Rate for Payer: UHC Dual Complete DSNP	$43,891.46
Rate for Payer: UHC Exchange	$60,411.65
Rate for Payer: UHC Medicare Advantage	$45,208.20
Rate for Payer: VA VA	$43,891.46

SPINAL PROCEDURES WITHOUT CC/MCC

Facility

$41,179.71

Service Code	MS-DRG 030
Min. Negotiated Rate	$16,334.01
Max. Negotiated Rate	$41,179.71
Rate for Payer: Aetna Medicare	$17,881.44
Rate for Payer: Allen County Amish Medical Aid Commercial	$21,492.11
Rate for Payer: Amish Plain Church Group Commercial	$21,492.11
Rate for Payer: BCBS MAPPO	$17,193.69
Rate for Payer: BCBS Trust/PPO	$41,179.71
Rate for Payer: BCN Medicare Advantage	$17,193.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$17,193.69
Rate for Payer: Mclaren Medicare	$17,193.69
Rate for Payer: Meridian Wellcare - Medicare Advantage	$18,053.37
Rate for Payer: MI Amish Medical Board Commercial	$19,772.74
Rate for Payer: PACE Medicare	$16,334.01
Rate for Payer: PACE SWMI	$17,193.69
Rate for Payer: PHP Medicare Advantage	$17,193.69
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$33,277.46
Rate for Payer: Priority Health Medicare	$17,193.69
Rate for Payer: Priority Health Narrow Network	$26,621.97
Rate for Payer: Railroad Medicare Medicare	$17,193.69
Rate for Payer: UHC All Payor (Choice/PPO)	$35,374.03
Rate for Payer: UHC Core	$21,705.84
Rate for Payer: UHC Dual Complete DSNP	$17,193.69
Rate for Payer: UHC Exchange	$23,247.98
Rate for Payer: UHC Medicare Advantage	$17,709.50
Rate for Payer: VA VA	$17,193.69

SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC;

Facility

$1,932.06

Service Code	CPT 62270
Hospital Revenue Code	361
Min. Negotiated Rate	$62.21
Max. Negotiated Rate	$1,932.06
Rate for Payer: Aetna Medicare	$639.94
Rate for Payer: Allen County Amish Medical Aid Commercial	$769.16
Rate for Payer: Amish Plain Church Group Commercial	$769.16
Rate for Payer: BCBS Complete	$353.45
Rate for Payer: BCBS MAPPO	$615.33
Rate for Payer: BCBS Trust/PPO	$530.21
Rate for Payer: BCN Medicare Advantage	$615.33
Rate for Payer: Health Alliance Plan Medicare Advantage	$615.33
Rate for Payer: Mclaren Medicaid	$336.59
Rate for Payer: Mclaren Medicare	$615.33
Rate for Payer: Meridian Medicaid	$353.45
Rate for Payer: Meridian Wellcare - Medicare Advantage	$646.10
Rate for Payer: MI Amish Medical Board Commercial	$707.63
Rate for Payer: PACE Medicare	$584.56
Rate for Payer: PACE SWMI	$615.33
Rate for Payer: PHP Medicare Advantage	$615.33
Rate for Payer: Priority Health Choice Medicaid	$336.59
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,932.06
Rate for Payer: Priority Health Medicare	$615.33
Rate for Payer: Priority Health Narrow Network	$1,545.65
Rate for Payer: Railroad Medicare Medicare	$615.33
Rate for Payer: UHC All Payor (Choice/PPO)	$68.43
Rate for Payer: UHC Core	$1,463.00
Rate for Payer: UHC Dual Complete DSNP	$615.33
Rate for Payer: UHC Exchange	$62.21
Rate for Payer: UHC Medicare Advantage	$633.79
Rate for Payer: VA VA	$615.33

SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY NEEDLE OR CATHETER);

Facility

$1,932.06

Service Code	CPT 62272
Hospital Revenue Code	361
Min. Negotiated Rate	$90.05
Max. Negotiated Rate	$1,932.06
Rate for Payer: Aetna Medicare	$639.94
Rate for Payer: Allen County Amish Medical Aid Commercial	$769.16
Rate for Payer: Amish Plain Church Group Commercial	$769.16
Rate for Payer: BCBS Complete	$353.45
Rate for Payer: BCBS MAPPO	$615.33
Rate for Payer: BCBS Trust/PPO	$237.92
Rate for Payer: BCN Medicare Advantage	$615.33
Rate for Payer: Health Alliance Plan Medicare Advantage	$615.33
Rate for Payer: Mclaren Medicaid	$336.59
Rate for Payer: Mclaren Medicare	$615.33
Rate for Payer: Meridian Medicaid	$353.45
Rate for Payer: Meridian Wellcare - Medicare Advantage	$646.10
Rate for Payer: MI Amish Medical Board Commercial	$707.63
Rate for Payer: PACE Medicare	$584.56
Rate for Payer: PACE SWMI	$615.33
Rate for Payer: PHP Medicare Advantage	$615.33
Rate for Payer: Priority Health Choice Medicaid	$336.59
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,932.06
Rate for Payer: Priority Health Medicare	$615.33
Rate for Payer: Priority Health Narrow Network	$1,545.65
Rate for Payer: Railroad Medicare Medicare	$615.33
Rate for Payer: UHC All Payor (Choice/PPO)	$99.06
Rate for Payer: UHC Core	$1,463.00
Rate for Payer: UHC Dual Complete DSNP	$615.33
Rate for Payer: UHC Exchange	$90.05
Rate for Payer: UHC Medicare Advantage	$633.79
Rate for Payer: VA VA	$615.33

SPIRONOLACTONE 25 MG TABLET

Facility

$3.46

Service Code	NDC 60687-465-11
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.11
Rate for Payer: Aetna Commercial	$2.94
Rate for Payer: Aetna New Business (MI Preferred)	$2.25
Rate for Payer: Cash Price	$2.77
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Healthscope Commercial	$3.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.94
Rate for Payer: PHP Commercial	$2.94
Rate for Payer: Priority Health Cigna Priority Health	$2.42
Rate for Payer: Priority Health SBD	$2.18

SPIRONOLACTONE 25 MG TABLET

Facility

$274.95

Service Code	NDC 53746-511-01
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$173.22
Max. Negotiated Rate	$247.46
Rate for Payer: Aetna Commercial	$233.71
Rate for Payer: Aetna New Business (MI Preferred)	$178.72
Rate for Payer: Cash Price	$219.96
Rate for Payer: Cofinity Commercial	$192.46
Rate for Payer: Cofinity Commercial	$236.46
Rate for Payer: Healthscope Commercial	$247.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$233.71
Rate for Payer: PHP Commercial	$233.71
Rate for Payer: Priority Health Cigna Priority Health	$192.46
Rate for Payer: Priority Health SBD	$173.22

SPIRONOLACTONE 25 MG TABLET

Facility

$383.05

Service Code	NDC 51079-103-20
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$241.32
Max. Negotiated Rate	$344.74
Rate for Payer: Aetna Commercial	$325.59
Rate for Payer: Aetna New Business (MI Preferred)	$248.98
Rate for Payer: Cash Price	$306.44
Rate for Payer: Cofinity Commercial	$268.14
Rate for Payer: Cofinity Commercial	$329.42
Rate for Payer: Healthscope Commercial	$344.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$325.59
Rate for Payer: PHP Commercial	$325.59
Rate for Payer: Priority Health Cigna Priority Health	$268.14
Rate for Payer: Priority Health SBD	$241.32

SPIRONOLACTONE 25 MG TABLET

Facility

$303.15

Service Code	NDC 63739-544-10
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$190.98
Max. Negotiated Rate	$272.84
Rate for Payer: Aetna Commercial	$257.68
Rate for Payer: Aetna New Business (MI Preferred)	$197.05
Rate for Payer: Cash Price	$242.52
Rate for Payer: Cofinity Commercial	$212.20
Rate for Payer: Cofinity Commercial	$260.71
Rate for Payer: Healthscope Commercial	$272.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$257.68
Rate for Payer: PHP Commercial	$257.68
Rate for Payer: Priority Health Cigna Priority Health	$212.20
Rate for Payer: Priority Health SBD	$190.98

SPIRONOLACTONE 25 MG TABLET

Facility

$3.84

Service Code	NDC 51079-103-01
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$3.46
Rate for Payer: Aetna Commercial	$3.26
Rate for Payer: Aetna New Business (MI Preferred)	$2.50
Rate for Payer: Cash Price	$3.07
Rate for Payer: Cofinity Commercial	$2.69
Rate for Payer: Cofinity Commercial	$3.30
Rate for Payer: Healthscope Commercial	$3.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.26
Rate for Payer: PHP Commercial	$3.26
Rate for Payer: Priority Health Cigna Priority Health	$2.69
Rate for Payer: Priority Health SBD	$2.42

SPIRONOLACTONE 25 MG TABLET

Facility

$159.80

Service Code	NDC 68382-660-01
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$100.67
Max. Negotiated Rate	$143.82
Rate for Payer: Aetna Commercial	$135.83
Rate for Payer: Aetna New Business (MI Preferred)	$103.87
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cofinity Commercial	$111.86
Rate for Payer: Cofinity Commercial	$137.43
Rate for Payer: Healthscope Commercial	$143.82
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$135.83
Rate for Payer: PHP Commercial	$135.83
Rate for Payer: Priority Health Cigna Priority Health	$111.86
Rate for Payer: Priority Health SBD	$100.67

SPIRONOLACTONE 25 MG TABLET

Facility

$345.45

Service Code	NDC 60687-465-01
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$217.63
Max. Negotiated Rate	$310.90
Rate for Payer: Aetna Commercial	$293.63
Rate for Payer: Aetna New Business (MI Preferred)	$224.54
Rate for Payer: Cash Price	$276.36
Rate for Payer: Cofinity Commercial	$241.82
Rate for Payer: Cofinity Commercial	$297.09
Rate for Payer: Healthscope Commercial	$310.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$293.63
Rate for Payer: PHP Commercial	$293.63
Rate for Payer: Priority Health Cigna Priority Health	$241.82
Rate for Payer: Priority Health SBD	$217.63

SPIRONOLACTONE 50 MG TABLET

Facility

$296.40

Service Code	NDC 63739-545-10
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$186.73
Max. Negotiated Rate	$266.76
Rate for Payer: Aetna Commercial	$251.94
Rate for Payer: Aetna New Business (MI Preferred)	$192.66
Rate for Payer: Cash Price	$237.12
Rate for Payer: Cofinity Commercial	$207.48
Rate for Payer: Cofinity Commercial	$254.90
Rate for Payer: Healthscope Commercial	$266.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$251.94
Rate for Payer: PHP Commercial	$251.94
Rate for Payer: Priority Health Cigna Priority Health	$207.48
Rate for Payer: Priority Health SBD	$186.73

SPIRONOLACTONE 50 MG TABLET

Facility

$262.20

Service Code	NDC 53746-514-01
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$165.19
Max. Negotiated Rate	$235.98
Rate for Payer: Aetna Commercial	$222.87
Rate for Payer: Aetna New Business (MI Preferred)	$170.43
Rate for Payer: Cash Price	$209.76
Rate for Payer: Cofinity Commercial	$183.54
Rate for Payer: Cofinity Commercial	$225.49
Rate for Payer: Healthscope Commercial	$235.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$222.87
Rate for Payer: PHP Commercial	$222.87
Rate for Payer: Priority Health Cigna Priority Health	$183.54
Rate for Payer: Priority Health SBD	$165.19

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