Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HYDROXYZINE HCL 25 MG TABLET

Facility

$124.55

Service Code	NDC 23155-501-01
Hospital Charge Code	3774
Hospital Revenue Code	637
Min. Negotiated Rate	$78.47
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$105.87
Rate for Payer: Aetna New Business (MI Preferred)	$80.96
Rate for Payer: Cash Price	$99.64
Rate for Payer: Cofinity Commercial	$107.11
Rate for Payer: Cofinity Commercial	$87.18
Rate for Payer: Healthscope Commercial	$112.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$105.87
Rate for Payer: PHP Commercial	$105.87
Rate for Payer: Priority Health Cigna Priority Health	$87.18
Rate for Payer: Priority Health SBD	$78.47

HYDROXYZINE HCL 25 MG TABLET

Facility

$2.82

Service Code	NDC 68084-254-11
Hospital Charge Code	3774
Hospital Revenue Code	637
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna Commercial	$2.40
Rate for Payer: Aetna New Business (MI Preferred)	$1.83
Rate for Payer: Cash Price	$2.26
Rate for Payer: Cofinity Commercial	$1.97
Rate for Payer: Cofinity Commercial	$2.43
Rate for Payer: Healthscope Commercial	$2.54
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.40
Rate for Payer: PHP Commercial	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.97
Rate for Payer: Priority Health SBD	$1.78

HYDROXYZINE HCL 25 MG TABLET

Facility

$345.45

Service Code	NDC 0904-6617-61
Hospital Charge Code	3774
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	$297.09
Rate for Payer: Cofinity Commercial	$241.82
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

HYDROXYZINE HCL 25 MG TABLET

Facility

$220.90

Service Code	NDC 10702-011-01
Hospital Charge Code	3774
Hospital Revenue Code	637
Min. Negotiated Rate	$139.17
Max. Negotiated Rate	$198.81
Rate for Payer: Aetna Commercial	$187.76
Rate for Payer: Aetna New Business (MI Preferred)	$143.58
Rate for Payer: Cash Price	$176.72
Rate for Payer: Cofinity Commercial	$154.63
Rate for Payer: Cofinity Commercial	$189.97
Rate for Payer: Healthscope Commercial	$198.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$187.76
Rate for Payer: PHP Commercial	$187.76
Rate for Payer: Priority Health Cigna Priority Health	$154.63
Rate for Payer: Priority Health SBD	$139.17

HYDROXYZINE HCL 25 MG TABLET

Facility

$423.00

Service Code	NDC 63739-486-10
Hospital Charge Code	3774
Hospital Revenue Code	637
Min. Negotiated Rate	$266.49
Max. Negotiated Rate	$380.70
Rate for Payer: Aetna Commercial	$359.55
Rate for Payer: Aetna New Business (MI Preferred)	$274.95
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cofinity Commercial	$296.10
Rate for Payer: Cofinity Commercial	$363.78
Rate for Payer: Healthscope Commercial	$380.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$359.55
Rate for Payer: PHP Commercial	$359.55
Rate for Payer: Priority Health Cigna Priority Health	$296.10
Rate for Payer: Priority Health SBD	$266.49

HYDROXYZINE HCL 25 MG TABLET

Facility

$281.20

Service Code	NDC 68084-254-01
Hospital Charge Code	3774
Hospital Revenue Code	637
Min. Negotiated Rate	$177.16
Max. Negotiated Rate	$253.08
Rate for Payer: Aetna Commercial	$239.02
Rate for Payer: Aetna New Business (MI Preferred)	$182.78
Rate for Payer: Cash Price	$224.96
Rate for Payer: Cofinity Commercial	$196.84
Rate for Payer: Cofinity Commercial	$241.83
Rate for Payer: Healthscope Commercial	$253.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$239.02
Rate for Payer: PHP Commercial	$239.02
Rate for Payer: Priority Health Cigna Priority Health	$196.84
Rate for Payer: Priority Health SBD	$177.16

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET

Facility

$373.65

Service Code	NDC 43199-011-01
Hospital Charge Code	17023
Hospital Revenue Code	637
Min. Negotiated Rate	$235.40
Max. Negotiated Rate	$336.28
Rate for Payer: Aetna Commercial	$317.60
Rate for Payer: Aetna New Business (MI Preferred)	$242.87
Rate for Payer: Cash Price	$298.92
Rate for Payer: Cofinity Commercial	$261.56
Rate for Payer: Cofinity Commercial	$321.34
Rate for Payer: Healthscope Commercial	$336.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$317.60
Rate for Payer: PHP Commercial	$317.60
Rate for Payer: Priority Health Cigna Priority Health	$261.56
Rate for Payer: Priority Health SBD	$235.40

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET

Facility

$406.60

Service Code	NDC 42192-339-01
Hospital Charge Code	17023
Hospital Revenue Code	637
Min. Negotiated Rate	$256.16
Max. Negotiated Rate	$365.94
Rate for Payer: Aetna Commercial	$345.61
Rate for Payer: Aetna New Business (MI Preferred)	$264.29
Rate for Payer: Cash Price	$325.28
Rate for Payer: Cofinity Commercial	$284.62
Rate for Payer: Cofinity Commercial	$349.68
Rate for Payer: Healthscope Commercial	$365.94
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$345.61
Rate for Payer: PHP Commercial	$345.61
Rate for Payer: Priority Health Cigna Priority Health	$284.62
Rate for Payer: Priority Health SBD	$256.16

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET

Facility

$203.30

Service Code	NDC 70156-105-01
Hospital Charge Code	17023
Hospital Revenue Code	637
Min. Negotiated Rate	$128.08
Max. Negotiated Rate	$182.97
Rate for Payer: Aetna Commercial	$172.80
Rate for Payer: Aetna New Business (MI Preferred)	$132.14
Rate for Payer: Cash Price	$162.64
Rate for Payer: Cofinity Commercial	$142.31
Rate for Payer: Cofinity Commercial	$174.84
Rate for Payer: Healthscope Commercial	$182.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$172.80
Rate for Payer: PHP Commercial	$172.80
Rate for Payer: Priority Health Cigna Priority Health	$142.31
Rate for Payer: Priority Health SBD	$128.08

HYPERTENSION WITH MCC

Facility

$24,446.95

Service Code	MS-DRG 304
Min. Negotiated Rate	$8,329.19
Max. Negotiated Rate	$24,446.95
Rate for Payer: Aetna Medicare	$9,118.27
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,959.46
Rate for Payer: Amish Plain Church Group Commercial	$10,959.46
Rate for Payer: BCBS MAPPO	$8,767.57
Rate for Payer: BCBS Trust/PPO	$24,446.95
Rate for Payer: BCN Medicare Advantage	$8,767.57
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,767.57
Rate for Payer: Mclaren Medicare	$8,767.57
Rate for Payer: Meridian Wellcare - Medicare Advantage	$9,205.95
Rate for Payer: MI Amish Medical Board Commercial	$10,082.71
Rate for Payer: PACE Medicare	$8,329.19
Rate for Payer: PACE SWMI	$8,767.57
Rate for Payer: PHP Medicare Advantage	$8,767.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16,488.06
Rate for Payer: Priority Health Medicare	$8,767.57
Rate for Payer: Priority Health Narrow Network	$13,190.45
Rate for Payer: Railroad Medicare Medicare	$8,767.57
Rate for Payer: UHC All Payor (Choice/PPO)	$17,526.85
Rate for Payer: UHC Core	$10,754.64
Rate for Payer: UHC Dual Complete DSNP	$8,767.57
Rate for Payer: UHC Exchange	$11,518.73
Rate for Payer: UHC Medicare Advantage	$9,030.60
Rate for Payer: VA VA	$8,767.57

HYPERTENSION WITHOUT MCC

Facility

$12,718.65

Service Code	MS-DRG 305
Min. Negotiated Rate	$5,623.32
Max. Negotiated Rate	$12,718.65
Rate for Payer: Aetna Medicare	$6,156.05
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,399.10
Rate for Payer: Amish Plain Church Group Commercial	$7,399.10
Rate for Payer: BCBS MAPPO	$5,919.28
Rate for Payer: BCBS Trust/PPO	$12,718.65
Rate for Payer: BCN Medicare Advantage	$5,919.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,919.28
Rate for Payer: Mclaren Medicare	$5,919.28
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6,215.24
Rate for Payer: MI Amish Medical Board Commercial	$6,807.17
Rate for Payer: PACE Medicare	$5,623.32
Rate for Payer: PACE SWMI	$5,919.28
Rate for Payer: PHP Medicare Advantage	$5,919.28
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,812.66
Rate for Payer: Priority Health Medicare	$5,919.28
Rate for Payer: Priority Health Narrow Network	$8,650.13
Rate for Payer: Railroad Medicare Medicare	$5,919.28
Rate for Payer: UHC All Payor (Choice/PPO)	$11,493.89
Rate for Payer: UHC Core	$7,052.76
Rate for Payer: UHC Dual Complete DSNP	$5,919.28
Rate for Payer: UHC Exchange	$7,553.84
Rate for Payer: UHC Medicare Advantage	$6,096.86
Rate for Payer: VA VA	$5,919.28

HYPERTENSIVE ENCEPHALOPATHY WITH CC

Facility

$17,088.49

Service Code	MS-DRG 078
Min. Negotiated Rate	$7,425.42
Max. Negotiated Rate	$17,088.49
Rate for Payer: Aetna Medicare	$8,128.88
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,770.29
Rate for Payer: Amish Plain Church Group Commercial	$9,770.29
Rate for Payer: BCBS MAPPO	$7,816.23
Rate for Payer: BCBS Trust/PPO	$17,088.49
Rate for Payer: BCN Medicare Advantage	$7,816.23
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,816.23
Rate for Payer: Mclaren Medicare	$7,816.23
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,207.04
Rate for Payer: MI Amish Medical Board Commercial	$8,988.66
Rate for Payer: PACE Medicare	$7,425.42
Rate for Payer: PACE SWMI	$7,816.23
Rate for Payer: PHP Medicare Advantage	$7,816.23
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14,592.43
Rate for Payer: Priority Health Medicare	$7,816.23
Rate for Payer: Priority Health Narrow Network	$11,673.94
Rate for Payer: Railroad Medicare Medicare	$7,816.23
Rate for Payer: UHC All Payor (Choice/PPO)	$15,511.79
Rate for Payer: UHC Core	$9,518.18
Rate for Payer: UHC Dual Complete DSNP	$7,816.23
Rate for Payer: UHC Exchange	$10,194.42
Rate for Payer: UHC Medicare Advantage	$8,050.72
Rate for Payer: VA VA	$7,816.23

HYPERTENSIVE ENCEPHALOPATHY WITH MCC

Facility

$32,126.02

Service Code	MS-DRG 077
Min. Negotiated Rate	$10,805.22
Max. Negotiated Rate	$32,126.02
Rate for Payer: Aetna Medicare	$11,828.88
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,217.40
Rate for Payer: Amish Plain Church Group Commercial	$14,217.40
Rate for Payer: BCBS MAPPO	$11,373.92
Rate for Payer: BCBS Trust/PPO	$32,126.02
Rate for Payer: BCN Medicare Advantage	$11,373.92
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,373.92
Rate for Payer: Mclaren Medicare	$11,373.92
Rate for Payer: Meridian Wellcare - Medicare Advantage	$11,942.62
Rate for Payer: MI Amish Medical Board Commercial	$13,080.01
Rate for Payer: PACE Medicare	$10,805.22
Rate for Payer: PACE SWMI	$11,373.92
Rate for Payer: PHP Medicare Advantage	$11,373.92
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$21,681.29
Rate for Payer: Priority Health Medicare	$11,373.92
Rate for Payer: Priority Health Narrow Network	$17,345.03
Rate for Payer: Railroad Medicare Medicare	$11,373.92
Rate for Payer: UHC All Payor (Choice/PPO)	$23,047.27
Rate for Payer: UHC Core	$14,142.02
Rate for Payer: UHC Dual Complete DSNP	$11,373.92
Rate for Payer: UHC Exchange	$15,146.77
Rate for Payer: UHC Medicare Advantage	$11,715.14
Rate for Payer: VA VA	$11,373.92

HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC

Facility

$13,456.48

Service Code	MS-DRG 079
Min. Negotiated Rate	$5,536.44
Max. Negotiated Rate	$13,456.48
Rate for Payer: Aetna Medicare	$6,060.94
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,284.79
Rate for Payer: Amish Plain Church Group Commercial	$7,284.79
Rate for Payer: BCBS MAPPO	$5,827.83
Rate for Payer: BCBS Trust/PPO	$13,456.48
Rate for Payer: BCN Medicare Advantage	$5,827.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,827.83
Rate for Payer: Mclaren Medicare	$5,827.83
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6,119.22
Rate for Payer: MI Amish Medical Board Commercial	$6,702.00
Rate for Payer: PACE Medicare	$5,536.44
Rate for Payer: PACE SWMI	$5,827.83
Rate for Payer: PHP Medicare Advantage	$5,827.83
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,630.42
Rate for Payer: Priority Health Medicare	$5,827.83
Rate for Payer: Priority Health Narrow Network	$8,504.34
Rate for Payer: Railroad Medicare Medicare	$5,827.83
Rate for Payer: UHC All Payor (Choice/PPO)	$11,300.16
Rate for Payer: UHC Core	$6,933.89
Rate for Payer: UHC Dual Complete DSNP	$5,827.83
Rate for Payer: UHC Exchange	$7,426.52
Rate for Payer: UHC Medicare Advantage	$6,002.66
Rate for Payer: VA VA	$5,827.83

HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)

Facility

$4,155.00

Service Code	CPT 58555
Hospital Revenue Code	360
Min. Negotiated Rate	$148.33
Max. Negotiated Rate	$4,155.00
Rate for Payer: Aetna Medicare	$2,893.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,477.26
Rate for Payer: Amish Plain Church Group Commercial	$3,477.26
Rate for Payer: BCBS Complete	$1,597.87
Rate for Payer: BCBS MAPPO	$2,781.81
Rate for Payer: BCBS Trust/PPO	$939.15
Rate for Payer: BCN Medicare Advantage	$2,781.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,781.81
Rate for Payer: Mclaren Medicaid	$1,521.65
Rate for Payer: Mclaren Medicare	$2,781.81
Rate for Payer: Meridian Medicaid	$1,597.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,920.90
Rate for Payer: MI Amish Medical Board Commercial	$3,199.08
Rate for Payer: PACE Medicare	$2,642.72
Rate for Payer: PACE SWMI	$2,781.81
Rate for Payer: PHP Medicare Advantage	$2,781.81
Rate for Payer: Priority Health Choice Medicaid	$1,521.65
Rate for Payer: Priority Health Medicare	$2,781.81
Rate for Payer: Railroad Medicare Medicare	$2,781.81
Rate for Payer: UHC All Payor (Choice/PPO)	$163.16
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$2,781.81
Rate for Payer: UHC Exchange	$148.33
Rate for Payer: UHC Medicare Advantage	$2,865.26
Rate for Payer: VA VA	$2,781.81

HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)

Facility

$5,532.19

Service Code	CPT 58563
Hospital Revenue Code	360
Min. Negotiated Rate	$240.67
Max. Negotiated Rate	$5,532.19
Rate for Payer: Aetna Medicare	$4,602.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$5,532.19
Rate for Payer: Amish Plain Church Group Commercial	$5,532.19
Rate for Payer: BCBS Complete	$2,542.15
Rate for Payer: BCBS MAPPO	$4,425.75
Rate for Payer: BCBS Trust/PPO	$1,983.85
Rate for Payer: BCN Medicare Advantage	$4,425.75
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,425.75
Rate for Payer: Mclaren Medicaid	$2,420.89
Rate for Payer: Mclaren Medicare	$4,425.75
Rate for Payer: Meridian Medicaid	$2,542.15
Rate for Payer: Meridian Wellcare - Medicare Advantage	$4,647.04
Rate for Payer: MI Amish Medical Board Commercial	$5,089.61
Rate for Payer: PACE Medicare	$4,204.46
Rate for Payer: PACE SWMI	$4,425.75
Rate for Payer: PHP Medicare Advantage	$4,425.75
Rate for Payer: Priority Health Choice Medicaid	$2,420.89
Rate for Payer: Priority Health Medicare	$4,425.75
Rate for Payer: Railroad Medicare Medicare	$4,425.75
Rate for Payer: UHC All Payor (Choice/PPO)	$264.74
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$4,425.75
Rate for Payer: UHC Exchange	$240.67
Rate for Payer: UHC Medicare Advantage	$4,558.52
Rate for Payer: VA VA	$4,425.75

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY

Facility

$4,155.00

Service Code	CPT 58562
Hospital Revenue Code	360
Min. Negotiated Rate	$217.09
Max. Negotiated Rate	$4,155.00
Rate for Payer: Aetna Medicare	$2,893.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,477.26
Rate for Payer: Amish Plain Church Group Commercial	$3,477.26
Rate for Payer: BCBS Complete	$1,597.87
Rate for Payer: BCBS MAPPO	$2,781.81
Rate for Payer: BCBS Trust/PPO	$1,505.59
Rate for Payer: BCN Medicare Advantage	$2,781.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,781.81
Rate for Payer: Mclaren Medicaid	$1,521.65
Rate for Payer: Mclaren Medicare	$2,781.81
Rate for Payer: Meridian Medicaid	$1,597.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,920.90
Rate for Payer: MI Amish Medical Board Commercial	$3,199.08
Rate for Payer: PACE Medicare	$2,642.72
Rate for Payer: PACE SWMI	$2,781.81
Rate for Payer: PHP Medicare Advantage	$2,781.81
Rate for Payer: Priority Health Choice Medicaid	$1,521.65
Rate for Payer: Priority Health Medicare	$2,781.81
Rate for Payer: Railroad Medicare Medicare	$2,781.81
Rate for Payer: UHC All Payor (Choice/PPO)	$238.80
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$2,781.81
Rate for Payer: UHC Exchange	$217.09
Rate for Payer: UHC Medicare Advantage	$2,865.26
Rate for Payer: VA VA	$2,781.81

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA

Facility

$5,532.19

Service Code	CPT 58561
Hospital Revenue Code	360
Min. Negotiated Rate	$350.36
Max. Negotiated Rate	$5,532.19
Rate for Payer: Aetna Medicare	$4,602.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$5,532.19
Rate for Payer: Amish Plain Church Group Commercial	$5,532.19
Rate for Payer: BCBS Complete	$2,542.15
Rate for Payer: BCBS MAPPO	$4,425.75
Rate for Payer: BCBS Trust/PPO	$2,395.50
Rate for Payer: BCN Medicare Advantage	$4,425.75
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,425.75
Rate for Payer: Mclaren Medicaid	$2,420.89
Rate for Payer: Mclaren Medicare	$4,425.75
Rate for Payer: Meridian Medicaid	$2,542.15
Rate for Payer: Meridian Wellcare - Medicare Advantage	$4,647.04
Rate for Payer: MI Amish Medical Board Commercial	$5,089.61
Rate for Payer: PACE Medicare	$4,204.46
Rate for Payer: PACE SWMI	$4,425.75
Rate for Payer: PHP Medicare Advantage	$4,425.75
Rate for Payer: Priority Health Choice Medicaid	$2,420.89
Rate for Payer: Priority Health Medicare	$4,425.75
Rate for Payer: Railroad Medicare Medicare	$4,425.75
Rate for Payer: UHC All Payor (Choice/PPO)	$385.40
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$4,425.75
Rate for Payer: UHC Exchange	$350.36
Rate for Payer: UHC Medicare Advantage	$4,558.52
Rate for Payer: VA VA	$4,425.75

HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C

Facility

$4,155.00

Service Code	CPT 58558
Hospital Revenue Code	360
Min. Negotiated Rate	$226.59
Max. Negotiated Rate	$4,155.00
Rate for Payer: Aetna Medicare	$2,893.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,477.26
Rate for Payer: Amish Plain Church Group Commercial	$3,477.26
Rate for Payer: BCBS Complete	$1,597.87
Rate for Payer: BCBS MAPPO	$2,781.81
Rate for Payer: BCBS Trust/PPO	$1,799.23
Rate for Payer: BCN Medicare Advantage	$2,781.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,781.81
Rate for Payer: Mclaren Medicaid	$1,521.65
Rate for Payer: Mclaren Medicare	$2,781.81
Rate for Payer: Meridian Medicaid	$1,597.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,920.90
Rate for Payer: MI Amish Medical Board Commercial	$3,199.08
Rate for Payer: PACE Medicare	$2,642.72
Rate for Payer: PACE SWMI	$2,781.81
Rate for Payer: PHP Medicare Advantage	$2,781.81
Rate for Payer: Priority Health Choice Medicaid	$1,521.65
Rate for Payer: Priority Health Medicare	$2,781.81
Rate for Payer: Railroad Medicare Medicare	$2,781.81
Rate for Payer: UHC All Payor (Choice/PPO)	$249.25
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$2,781.81
Rate for Payer: UHC Exchange	$226.59
Rate for Payer: UHC Medicare Advantage	$2,865.26
Rate for Payer: VA VA	$2,781.81

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.57

Service Code	NDC 68094-494-59
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$2.31
Rate for Payer: Aetna Commercial	$2.18
Rate for Payer: Aetna New Business (MI Preferred)	$1.67
Rate for Payer: Cash Price	$2.06
Rate for Payer: Cofinity Commercial	$1.80
Rate for Payer: Cofinity Commercial	$2.21
Rate for Payer: Healthscope Commercial	$2.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.18
Rate for Payer: PHP Commercial	$2.18
Rate for Payer: Priority Health Cigna Priority Health	$1.80
Rate for Payer: Priority Health SBD	$1.62

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$3.48

Service Code	NDC 68094-494-61
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna Commercial	$2.96
Rate for Payer: Aetna New Business (MI Preferred)	$2.26
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cofinity Commercial	$2.99
Rate for Payer: Cofinity Commercial	$2.44
Rate for Payer: Healthscope Commercial	$3.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.96
Rate for Payer: PHP Commercial	$2.96
Rate for Payer: Priority Health Cigna Priority Health	$2.44
Rate for Payer: Priority Health SBD	$2.19

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.35

Service Code	NDC 9900-0019-41
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna Commercial	$2.00
Rate for Payer: Aetna New Business (MI Preferred)	$1.53
Rate for Payer: Cash Price	$1.88
Rate for Payer: Cofinity Commercial	$1.64
Rate for Payer: Cofinity Commercial	$2.02
Rate for Payer: Healthscope Commercial	$2.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.00
Rate for Payer: PHP Commercial	$2.00
Rate for Payer: Priority Health Cigna Priority Health	$1.64
Rate for Payer: Priority Health SBD	$1.48

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$4.70

Service Code	NDC 9900-0019-42
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.96
Max. Negotiated Rate	$4.23
Rate for Payer: Aetna Commercial	$4.00
Rate for Payer: Aetna New Business (MI Preferred)	$3.06
Rate for Payer: Cash Price	$3.76
Rate for Payer: Cofinity Commercial	$3.29
Rate for Payer: Cofinity Commercial	$4.04
Rate for Payer: Healthscope Commercial	$4.23
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.00
Rate for Payer: PHP Commercial	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.29
Rate for Payer: Priority Health SBD	$2.96

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$4.75

Service Code	NDC 0121-1836-05
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna Commercial	$4.04
Rate for Payer: Aetna New Business (MI Preferred)	$3.09
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$3.32
Rate for Payer: Cofinity Commercial	$4.08
Rate for Payer: Healthscope Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.04
Rate for Payer: PHP Commercial	$4.04
Rate for Payer: Priority Health Cigna Priority Health	$3.32
Rate for Payer: Priority Health SBD	$2.99

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$4.66

Service Code	NDC 0121-0914-00
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$4.19
Rate for Payer: Aetna Commercial	$3.96
Rate for Payer: Aetna New Business (MI Preferred)	$3.03
Rate for Payer: Cash Price	$3.73
Rate for Payer: Cofinity Commercial	$3.26
Rate for Payer: Cofinity Commercial	$4.01
Rate for Payer: Healthscope Commercial	$4.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.96
Rate for Payer: PHP Commercial	$3.96
Rate for Payer: Priority Health Cigna Priority Health	$3.26
Rate for Payer: Priority Health SBD	$2.94

Know your out-of-pocket cost for care.

All Charges