Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

GLIMEPIRIDE 2 MG TABLET

Facility

$404.70

Service Code	NDC 68084-326-01
Hospital Charge Code	16356
Hospital Revenue Code	637
Min. Negotiated Rate	$283.29
Max. Negotiated Rate	$404.70
Rate for Payer: Aetna Commercial	$364.23
Rate for Payer: ASR ASR	$392.56
Rate for Payer: BCBS Trust/PPO	$313.76
Rate for Payer: BCN Commercial	$313.76
Rate for Payer: Cash Price	$323.76
Rate for Payer: Cofinity Commercial	$380.42
Rate for Payer: Encore Health Key Benefits Commercial	$323.76
Rate for Payer: Healthscope Commercial	$404.70
Rate for Payer: Healthscope Whirlpool	$392.56
Rate for Payer: Mclaren Commercial	$364.23
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$344.00
Rate for Payer: Priority Health Cigna Priority Health	$283.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$356.14

GLIPIZIDE 5 MG TABLET

Facility

$206.15

Service Code	NDC 51079-810-20
Hospital Charge Code	10117
Hospital Revenue Code	637
Min. Negotiated Rate	$144.30
Max. Negotiated Rate	$206.15
Rate for Payer: Aetna Commercial	$185.54
Rate for Payer: ASR ASR	$199.97
Rate for Payer: BCBS Trust/PPO	$159.83
Rate for Payer: BCN Commercial	$159.83
Rate for Payer: Cash Price	$164.92
Rate for Payer: Cofinity Commercial	$193.78
Rate for Payer: Encore Health Key Benefits Commercial	$164.92
Rate for Payer: Healthscope Commercial	$206.15
Rate for Payer: Healthscope Whirlpool	$199.97
Rate for Payer: Mclaren Commercial	$185.54
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$175.23
Rate for Payer: Priority Health Cigna Priority Health	$144.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$181.41

GLIPIZIDE 5 MG TABLET

Facility

$227.05

Service Code	NDC 0904-6637-61
Hospital Charge Code	10117
Hospital Revenue Code	637
Min. Negotiated Rate	$158.94
Max. Negotiated Rate	$227.05
Rate for Payer: Aetna Commercial	$204.34
Rate for Payer: ASR ASR	$220.24
Rate for Payer: BCBS Trust/PPO	$176.03
Rate for Payer: BCN Commercial	$176.03
Rate for Payer: Cash Price	$181.64
Rate for Payer: Cofinity Commercial	$213.43
Rate for Payer: Encore Health Key Benefits Commercial	$181.64
Rate for Payer: Healthscope Commercial	$227.05
Rate for Payer: Healthscope Whirlpool	$220.24
Rate for Payer: Mclaren Commercial	$204.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$192.99
Rate for Payer: Priority Health Cigna Priority Health	$158.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$199.80

GLIPIZIDE 5 MG TABLET

Facility

$2.06

Service Code	NDC 51079-810-01
Hospital Charge Code	10117
Hospital Revenue Code	637
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna Commercial	$1.85
Rate for Payer: ASR ASR	$2.00
Rate for Payer: BCBS Trust/PPO	$1.60
Rate for Payer: BCN Commercial	$1.60
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cofinity Commercial	$1.94
Rate for Payer: Encore Health Key Benefits Commercial	$1.65
Rate for Payer: Healthscope Commercial	$2.06
Rate for Payer: Healthscope Whirlpool	$2.00
Rate for Payer: Mclaren Commercial	$1.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.75
Rate for Payer: Priority Health Cigna Priority Health	$1.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.81

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR

Facility

$2.59

Service Code	NDC 68084-111-11
Hospital Charge Code	37649
Hospital Revenue Code	637
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna Commercial	$2.33
Rate for Payer: ASR ASR	$2.51
Rate for Payer: BCBS Trust/PPO	$2.01
Rate for Payer: BCN Commercial	$2.01
Rate for Payer: Cash Price	$2.07
Rate for Payer: Cofinity Commercial	$2.43
Rate for Payer: Encore Health Key Benefits Commercial	$2.07
Rate for Payer: Healthscope Commercial	$2.59
Rate for Payer: Healthscope Whirlpool	$2.51
Rate for Payer: Mclaren Commercial	$2.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.20
Rate for Payer: Priority Health Cigna Priority Health	$1.81
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.28

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR

Facility

$213.85

Service Code	NDC 59651-269-01
Hospital Charge Code	37649
Hospital Revenue Code	637
Min. Negotiated Rate	$149.70
Max. Negotiated Rate	$213.85
Rate for Payer: Aetna Commercial	$192.46
Rate for Payer: ASR ASR	$207.43
Rate for Payer: BCBS Trust/PPO	$165.80
Rate for Payer: BCN Commercial	$165.80
Rate for Payer: Cash Price	$171.08
Rate for Payer: Cofinity Commercial	$201.02
Rate for Payer: Encore Health Key Benefits Commercial	$171.08
Rate for Payer: Healthscope Commercial	$213.85
Rate for Payer: Healthscope Whirlpool	$207.43
Rate for Payer: Mclaren Commercial	$192.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$181.77
Rate for Payer: Priority Health Cigna Priority Health	$149.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$188.19

GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR

Facility

$256.50

Service Code	NDC 0591-0844-01
Hospital Charge Code	37649
Hospital Revenue Code	637
Min. Negotiated Rate	$179.55
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: ASR ASR	$248.80
Rate for Payer: BCBS Trust/PPO	$198.86
Rate for Payer: BCN Commercial	$198.86
Rate for Payer: Cash Price	$205.20
Rate for Payer: Cofinity Commercial	$241.11
Rate for Payer: Encore Health Key Benefits Commercial	$205.20
Rate for Payer: Healthscope Commercial	$256.50
Rate for Payer: Healthscope Whirlpool	$248.80
Rate for Payer: Mclaren Commercial	$230.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$218.02
Rate for Payer: Priority Health Cigna Priority Health	$179.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$225.72

GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION

Facility

$458.88

Service Code	HCPCS J1611
Hospital Charge Code	168350
Hospital Revenue Code	636
Min. Negotiated Rate	$321.22
Max. Negotiated Rate	$458.88
Rate for Payer: Aetna Commercial	$412.99
Rate for Payer: Aetna Commercial	$413.01
Rate for Payer: ASR ASR	$445.13
Rate for Payer: ASR ASR	$445.11
Rate for Payer: BCBS Trust/PPO	$355.79
Rate for Payer: BCBS Trust/PPO	$355.77
Rate for Payer: BCN Commercial	$355.77
Rate for Payer: BCN Commercial	$355.79
Rate for Payer: Cash Price	$367.10
Rate for Payer: Cash Price	$367.12
Rate for Payer: Cofinity Commercial	$431.37
Rate for Payer: Cofinity Commercial	$431.35
Rate for Payer: Encore Health Key Benefits Commercial	$367.12
Rate for Payer: Encore Health Key Benefits Commercial	$367.10
Rate for Payer: Healthscope Commercial	$458.90
Rate for Payer: Healthscope Commercial	$458.88
Rate for Payer: Healthscope Whirlpool	$445.13
Rate for Payer: Healthscope Whirlpool	$445.11
Rate for Payer: Mclaren Commercial	$412.99
Rate for Payer: Mclaren Commercial	$413.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$390.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$390.06
Rate for Payer: Priority Health Cigna Priority Health	$321.23
Rate for Payer: Priority Health Cigna Priority Health	$321.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$403.81
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$403.83

GLYBURIDE 5 MG TABLET

Facility

$82.25

Service Code	NDC 23155-058-01
Hospital Charge Code	3489
Hospital Revenue Code	637
Min. Negotiated Rate	$57.58
Max. Negotiated Rate	$82.25
Rate for Payer: Aetna Commercial	$74.02
Rate for Payer: ASR ASR	$79.78
Rate for Payer: BCBS Trust/PPO	$63.77
Rate for Payer: BCN Commercial	$63.77
Rate for Payer: Cash Price	$65.80
Rate for Payer: Cofinity Commercial	$77.32
Rate for Payer: Encore Health Key Benefits Commercial	$65.80
Rate for Payer: Healthscope Commercial	$82.25
Rate for Payer: Healthscope Whirlpool	$79.78
Rate for Payer: Mclaren Commercial	$74.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$69.91
Rate for Payer: Priority Health Cigna Priority Health	$57.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$72.38

GLYBURIDE 5 MG TABLET

Facility

$277.30

Service Code	NDC 63739-119-10
Hospital Charge Code	3489
Hospital Revenue Code	637
Min. Negotiated Rate	$194.11
Max. Negotiated Rate	$277.30
Rate for Payer: Aetna Commercial	$249.57
Rate for Payer: ASR ASR	$268.98
Rate for Payer: BCBS Trust/PPO	$214.99
Rate for Payer: BCN Commercial	$214.99
Rate for Payer: Cash Price	$221.84
Rate for Payer: Cofinity Commercial	$260.66
Rate for Payer: Encore Health Key Benefits Commercial	$221.84
Rate for Payer: Healthscope Commercial	$277.30
Rate for Payer: Healthscope Whirlpool	$268.98
Rate for Payer: Mclaren Commercial	$249.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$235.70
Rate for Payer: Priority Health Cigna Priority Health	$194.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$244.02

GLYCERIN (ADULT) RECTAL SUPPOSITORY

Facility

$42.30

Service Code	NDC 58980-410-12
Hospital Charge Code	15053
Hospital Revenue Code	637
Min. Negotiated Rate	$29.61
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna Commercial	$38.07
Rate for Payer: ASR ASR	$41.03
Rate for Payer: BCBS Trust/PPO	$32.80
Rate for Payer: BCN Commercial	$32.80
Rate for Payer: Cash Price	$33.84
Rate for Payer: Cofinity Commercial	$39.76
Rate for Payer: Encore Health Key Benefits Commercial	$33.84
Rate for Payer: Healthscope Commercial	$42.30
Rate for Payer: Healthscope Whirlpool	$41.03
Rate for Payer: Mclaren Commercial	$38.07
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$35.96
Rate for Payer: Priority Health Cigna Priority Health	$29.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.22

GLYCERIN (ADULT) RECTAL SUPPOSITORY

Facility

$33.28

Service Code	NDC 0132-0079-12
Hospital Charge Code	15053
Hospital Revenue Code	637
Min. Negotiated Rate	$23.30
Max. Negotiated Rate	$33.28
Rate for Payer: Aetna Commercial	$29.95
Rate for Payer: ASR ASR	$32.28
Rate for Payer: BCBS Trust/PPO	$25.80
Rate for Payer: BCN Commercial	$25.80
Rate for Payer: Cash Price	$26.62
Rate for Payer: Cofinity Commercial	$31.28
Rate for Payer: Encore Health Key Benefits Commercial	$26.62
Rate for Payer: Healthscope Commercial	$33.28
Rate for Payer: Healthscope Whirlpool	$32.28
Rate for Payer: Mclaren Commercial	$29.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$28.29
Rate for Payer: Priority Health Cigna Priority Health	$23.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$29.29

GLYCERIN (CHILD) RECTAL SUPPOSITORY

Facility

$41.04

Service Code	NDC 58980-409-12
Hospital Charge Code	3492
Hospital Revenue Code	637
Min. Negotiated Rate	$28.73
Max. Negotiated Rate	$41.04
Rate for Payer: Aetna Commercial	$36.94
Rate for Payer: ASR ASR	$39.81
Rate for Payer: BCBS Trust/PPO	$31.82
Rate for Payer: BCN Commercial	$31.82
Rate for Payer: Cash Price	$32.83
Rate for Payer: Cofinity Commercial	$38.58
Rate for Payer: Encore Health Key Benefits Commercial	$32.83
Rate for Payer: Healthscope Commercial	$41.04
Rate for Payer: Healthscope Whirlpool	$39.81
Rate for Payer: Mclaren Commercial	$36.94
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.88
Rate for Payer: Priority Health Cigna Priority Health	$28.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.12

GLYCERIN (CHILD) RECTAL SUPPOSITORY

Facility

$37.51

Service Code	NDC 0132-0081-12
Hospital Charge Code	3492
Hospital Revenue Code	637
Min. Negotiated Rate	$26.26
Max. Negotiated Rate	$37.51
Rate for Payer: Aetna Commercial	$33.76
Rate for Payer: ASR ASR	$36.38
Rate for Payer: BCBS Trust/PPO	$29.08
Rate for Payer: BCN Commercial	$29.08
Rate for Payer: Cash Price	$30.00
Rate for Payer: Cofinity Commercial	$35.26
Rate for Payer: Encore Health Key Benefits Commercial	$30.01
Rate for Payer: Healthscope Commercial	$37.51
Rate for Payer: Healthscope Whirlpool	$36.38
Rate for Payer: Mclaren Commercial	$33.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$31.88
Rate for Payer: Priority Health Cigna Priority Health	$26.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$33.01

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION

Facility

$73.69

Service Code	HCPCS J1596
Hospital Charge Code	3497
Hospital Revenue Code	636
Min. Negotiated Rate	$51.58
Max. Negotiated Rate	$73.69
Rate for Payer: Aetna Commercial	$66.32
Rate for Payer: Aetna Commercial	$11.85
Rate for Payer: Aetna Commercial	$10.81
Rate for Payer: Aetna Commercial	$13.88
Rate for Payer: Aetna Commercial	$14.54
Rate for Payer: ASR ASR	$11.65
Rate for Payer: ASR ASR	$15.68
Rate for Payer: ASR ASR	$12.77
Rate for Payer: ASR ASR	$14.96
Rate for Payer: ASR ASR	$71.48
Rate for Payer: BCBS Trust/PPO	$12.53
Rate for Payer: BCBS Trust/PPO	$9.31
Rate for Payer: BCBS Trust/PPO	$11.96
Rate for Payer: BCBS Trust/PPO	$57.13
Rate for Payer: BCBS Trust/PPO	$10.21
Rate for Payer: BCN Commercial	$11.96
Rate for Payer: BCN Commercial	$10.21
Rate for Payer: BCN Commercial	$57.13
Rate for Payer: BCN Commercial	$9.31
Rate for Payer: BCN Commercial	$12.53
Rate for Payer: Cash Price	$58.95
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cash Price	$10.53
Rate for Payer: Cash Price	$12.92
Rate for Payer: Cash Price	$12.34
Rate for Payer: Cofinity Commercial	$14.49
Rate for Payer: Cofinity Commercial	$11.29
Rate for Payer: Cofinity Commercial	$12.38
Rate for Payer: Cofinity Commercial	$15.19
Rate for Payer: Cofinity Commercial	$69.27
Rate for Payer: Encore Health Key Benefits Commercial	$10.54
Rate for Payer: Encore Health Key Benefits Commercial	$58.95
Rate for Payer: Encore Health Key Benefits Commercial	$9.61
Rate for Payer: Encore Health Key Benefits Commercial	$12.34
Rate for Payer: Encore Health Key Benefits Commercial	$12.93
Rate for Payer: Healthscope Commercial	$73.69
Rate for Payer: Healthscope Commercial	$13.17
Rate for Payer: Healthscope Commercial	$16.16
Rate for Payer: Healthscope Commercial	$12.01
Rate for Payer: Healthscope Commercial	$15.42
Rate for Payer: Healthscope Whirlpool	$14.96
Rate for Payer: Healthscope Whirlpool	$71.48
Rate for Payer: Healthscope Whirlpool	$15.68
Rate for Payer: Healthscope Whirlpool	$11.65
Rate for Payer: Healthscope Whirlpool	$12.77
Rate for Payer: Mclaren Commercial	$13.88
Rate for Payer: Mclaren Commercial	$10.81
Rate for Payer: Mclaren Commercial	$11.85
Rate for Payer: Mclaren Commercial	$14.54
Rate for Payer: Mclaren Commercial	$66.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.11
Rate for Payer: Priority Health Cigna Priority Health	$11.31
Rate for Payer: Priority Health Cigna Priority Health	$8.41
Rate for Payer: Priority Health Cigna Priority Health	$10.79
Rate for Payer: Priority Health Cigna Priority Health	$9.22
Rate for Payer: Priority Health Cigna Priority Health	$51.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$14.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$11.59
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$64.85

GLYCOPYRROLATE 0.2 MG/ML ORAL SOLN (CUSTOM)

Facility

$442.67

Service Code	NDC 0900-0002-30
Hospital Charge Code	158482
Hospital Revenue Code	250
Min. Negotiated Rate	$309.87
Max. Negotiated Rate	$442.67
Rate for Payer: Aetna Commercial	$398.40
Rate for Payer: ASR ASR	$429.39
Rate for Payer: BCBS Trust/PPO	$343.20
Rate for Payer: BCN Commercial	$343.20
Rate for Payer: Cash Price	$354.13
Rate for Payer: Cofinity Commercial	$416.11
Rate for Payer: Encore Health Key Benefits Commercial	$354.14
Rate for Payer: Healthscope Commercial	$442.67
Rate for Payer: Healthscope Whirlpool	$429.39
Rate for Payer: Mclaren Commercial	$398.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$376.27
Rate for Payer: Priority Health Cigna Priority Health	$309.87
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$389.55

GOLIMUMAB 100 MG/ML SUBCUTANEOUS PEN INJECTOR

Facility

$17,105.09

Service Code	NDC 57894-071-02
Hospital Charge Code	167382
Hospital Revenue Code	250
Min. Negotiated Rate	$11,973.56
Max. Negotiated Rate	$17,105.09
Rate for Payer: Aetna Commercial	$15,394.58
Rate for Payer: ASR ASR	$16,591.94
Rate for Payer: BCBS Trust/PPO	$13,261.58
Rate for Payer: BCN Commercial	$13,261.58
Rate for Payer: Cash Price	$13,684.07
Rate for Payer: Cofinity Commercial	$16,078.78
Rate for Payer: Encore Health Key Benefits Commercial	$13,684.07
Rate for Payer: Healthscope Commercial	$17,105.09
Rate for Payer: Healthscope Whirlpool	$16,591.94
Rate for Payer: Mclaren Commercial	$15,394.58
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14,539.33
Rate for Payer: Priority Health Cigna Priority Health	$11,973.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15,052.48

GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION

Facility

$6,234.37

Service Code	HCPCS J1602
Hospital Charge Code	167346
Hospital Revenue Code	636
Min. Negotiated Rate	$4,364.06
Max. Negotiated Rate	$6,234.37
Rate for Payer: Aetna Commercial	$5,610.93
Rate for Payer: ASR ASR	$6,047.34
Rate for Payer: BCBS Trust/PPO	$4,833.51
Rate for Payer: BCN Commercial	$4,833.51
Rate for Payer: Cash Price	$4,987.49
Rate for Payer: Cofinity Commercial	$5,860.31
Rate for Payer: Encore Health Key Benefits Commercial	$4,987.50
Rate for Payer: Healthscope Commercial	$6,234.37
Rate for Payer: Healthscope Whirlpool	$6,047.34
Rate for Payer: Mclaren Commercial	$5,610.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5,299.21
Rate for Payer: Priority Health Cigna Priority Health	$4,364.06
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,486.25

GOLIMUMAB 50 MG/0.5 ML SUBCUTANEOUS SYRINGE

Facility

$14,130.27

Service Code	NDC 57894-070-01
Hospital Charge Code	97696
Hospital Revenue Code	250
Min. Negotiated Rate	$9,891.19
Max. Negotiated Rate	$14,130.27
Rate for Payer: Aetna Commercial	$12,717.24
Rate for Payer: ASR ASR	$13,706.36
Rate for Payer: BCBS Trust/PPO	$10,955.20
Rate for Payer: BCN Commercial	$10,955.20
Rate for Payer: Cash Price	$11,304.22
Rate for Payer: Cofinity Commercial	$13,282.45
Rate for Payer: Encore Health Key Benefits Commercial	$11,304.22
Rate for Payer: Healthscope Commercial	$14,130.27
Rate for Payer: Healthscope Whirlpool	$13,706.36
Rate for Payer: Mclaren Commercial	$12,717.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12,010.73
Rate for Payer: Priority Health Cigna Priority Health	$9,891.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12,434.64

GUAIFENESIN 100 MG/5 ML ORAL LIQUID

Facility

$2.66

Service Code	NDC 50383-063-05
Hospital Charge Code	3542
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$2.66
Rate for Payer: Aetna Commercial	$2.39
Rate for Payer: ASR ASR	$2.58
Rate for Payer: BCBS Trust/PPO	$2.06
Rate for Payer: BCN Commercial	$2.06
Rate for Payer: Cash Price	$2.13
Rate for Payer: Cofinity Commercial	$2.50
Rate for Payer: Encore Health Key Benefits Commercial	$2.13
Rate for Payer: Healthscope Commercial	$2.66
Rate for Payer: Healthscope Whirlpool	$2.58
Rate for Payer: Mclaren Commercial	$2.39
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.26
Rate for Payer: Priority Health Cigna Priority Health	$1.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.34

GUAIFENESIN 100 MG/5 ML ORAL LIQUID

Facility

$4.90

Service Code	NDC 0121-1744-05
Hospital Charge Code	3542
Hospital Revenue Code	637
Min. Negotiated Rate	$3.43
Max. Negotiated Rate	$4.90
Rate for Payer: Aetna Commercial	$4.41
Rate for Payer: ASR ASR	$4.75
Rate for Payer: BCBS Trust/PPO	$3.80
Rate for Payer: BCN Commercial	$3.80
Rate for Payer: Cash Price	$3.92
Rate for Payer: Cofinity Commercial	$4.61
Rate for Payer: Encore Health Key Benefits Commercial	$3.92
Rate for Payer: Healthscope Commercial	$4.90
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.41
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.16
Rate for Payer: Priority Health Cigna Priority Health	$3.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.31

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR

Facility

$368.16

Service Code	NDC 68084-572-01
Hospital Charge Code	170771
Hospital Revenue Code	637
Min. Negotiated Rate	$257.71
Max. Negotiated Rate	$368.16
Rate for Payer: Aetna Commercial	$331.34
Rate for Payer: ASR ASR	$357.12
Rate for Payer: BCBS Trust/PPO	$285.43
Rate for Payer: BCN Commercial	$285.43
Rate for Payer: Cash Price	$294.53
Rate for Payer: Cofinity Commercial	$346.07
Rate for Payer: Encore Health Key Benefits Commercial	$294.53
Rate for Payer: Healthscope Commercial	$368.16
Rate for Payer: Healthscope Whirlpool	$357.12
Rate for Payer: Mclaren Commercial	$331.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$312.94
Rate for Payer: Priority Health Cigna Priority Health	$257.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$323.98

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR

Facility

$63.65

Service Code	NDC 63824-008-32
Hospital Charge Code	170771
Hospital Revenue Code	637
Min. Negotiated Rate	$44.56
Max. Negotiated Rate	$63.65
Rate for Payer: Aetna Commercial	$57.28
Rate for Payer: ASR ASR	$61.74
Rate for Payer: BCBS Trust/PPO	$49.35
Rate for Payer: BCN Commercial	$49.35
Rate for Payer: Cash Price	$50.92
Rate for Payer: Cofinity Commercial	$59.83
Rate for Payer: Encore Health Key Benefits Commercial	$50.92
Rate for Payer: Healthscope Commercial	$63.65
Rate for Payer: Healthscope Whirlpool	$61.74
Rate for Payer: Mclaren Commercial	$57.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$54.10
Rate for Payer: Priority Health Cigna Priority Health	$44.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$56.01

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR

Facility

$3.68

Service Code	NDC 68084-572-11
Hospital Charge Code	170771
Hospital Revenue Code	637
Min. Negotiated Rate	$2.58
Max. Negotiated Rate	$3.68
Rate for Payer: Aetna Commercial	$3.31
Rate for Payer: ASR ASR	$3.57
Rate for Payer: BCBS Trust/PPO	$2.85
Rate for Payer: BCN Commercial	$2.85
Rate for Payer: Cash Price	$2.95
Rate for Payer: Cofinity Commercial	$3.46
Rate for Payer: Encore Health Key Benefits Commercial	$2.94
Rate for Payer: Healthscope Commercial	$3.68
Rate for Payer: Healthscope Whirlpool	$3.57
Rate for Payer: Mclaren Commercial	$3.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.13
Rate for Payer: Priority Health Cigna Priority Health	$2.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.24

GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR

Facility

$269.80

Service Code	NDC 63824-008-15
Hospital Charge Code	170771
Hospital Revenue Code	637
Min. Negotiated Rate	$188.86
Max. Negotiated Rate	$269.80
Rate for Payer: Aetna Commercial	$242.82
Rate for Payer: ASR ASR	$261.71
Rate for Payer: BCBS Trust/PPO	$209.18
Rate for Payer: BCN Commercial	$209.18
Rate for Payer: Cash Price	$215.84
Rate for Payer: Cofinity Commercial	$253.61
Rate for Payer: Encore Health Key Benefits Commercial	$215.84
Rate for Payer: Healthscope Commercial	$269.80
Rate for Payer: Healthscope Whirlpool	$261.71
Rate for Payer: Mclaren Commercial	$242.82
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$229.33
Rate for Payer: Priority Health Cigna Priority Health	$188.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$237.42

Know your out-of-pocket cost for care.

All Charges