Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$15,398.84

Service Code	APR-DRG 8904
Min. Negotiated Rate	$14,665.56
Max. Negotiated Rate	$15,398.84
Rate for Payer: BCBS Complete	$15,398.84
Rate for Payer: Mclaren Medicaid	$14,665.56
Rate for Payer: Meridian Medicaid	$15,398.84
Rate for Payer: Priority Health Choice Medicaid	$14,665.56
Rate for Payer: UHC Medicaid	$14,665.56
Rate for Payer: UHCCP Medicaid	$14,665.56

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$7,294.67

Service Code	APR-DRG 8902
Min. Negotiated Rate	$6,947.30
Max. Negotiated Rate	$7,294.67
Rate for Payer: BCBS Complete	$7,294.67
Rate for Payer: Mclaren Medicaid	$6,947.30
Rate for Payer: Meridian Medicaid	$7,294.67
Rate for Payer: Priority Health Choice Medicaid	$6,947.30
Rate for Payer: UHC Medicaid	$6,947.30
Rate for Payer: UHCCP Medicaid	$6,947.30

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$4,942.42

Service Code	APR-DRG 8943
Min. Negotiated Rate	$4,707.07
Max. Negotiated Rate	$4,942.42
Rate for Payer: BCBS Complete	$4,942.42
Rate for Payer: Mclaren Medicaid	$4,707.07
Rate for Payer: Meridian Medicaid	$4,942.42
Rate for Payer: Priority Health Choice Medicaid	$4,707.07
Rate for Payer: UHC Medicaid	$4,707.07
Rate for Payer: UHCCP Medicaid	$4,707.07

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$4,173.62

Service Code	APR-DRG 8941
Min. Negotiated Rate	$3,974.88
Max. Negotiated Rate	$4,173.62
Rate for Payer: BCBS Complete	$4,173.62
Rate for Payer: Mclaren Medicaid	$3,974.88
Rate for Payer: Meridian Medicaid	$4,173.62
Rate for Payer: Priority Health Choice Medicaid	$3,974.88
Rate for Payer: UHC Medicaid	$3,974.88
Rate for Payer: UHCCP Medicaid	$3,974.88

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$7,729.80

Service Code	APR-DRG 8944
Min. Negotiated Rate	$7,361.72
Max. Negotiated Rate	$7,729.80
Rate for Payer: BCBS Complete	$7,729.80
Rate for Payer: Mclaren Medicaid	$7,361.72
Rate for Payer: Meridian Medicaid	$7,729.80
Rate for Payer: Priority Health Choice Medicaid	$7,361.72
Rate for Payer: UHC Medicaid	$7,361.72
Rate for Payer: UHCCP Medicaid	$7,361.72

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$4,457.98

Service Code	APR-DRG 8942
Min. Negotiated Rate	$4,245.70
Max. Negotiated Rate	$4,457.98
Rate for Payer: BCBS Complete	$4,457.98
Rate for Payer: Mclaren Medicaid	$4,245.70
Rate for Payer: Meridian Medicaid	$4,457.98
Rate for Payer: Priority Health Choice Medicaid	$4,245.70
Rate for Payer: UHC Medicaid	$4,245.70
Rate for Payer: UHCCP Medicaid	$4,245.70

HIV WITH OR WITHOUT OTHER RELATED CONDITION

Facility

$20,921.70

Service Code	MSDRG 977
Min. Negotiated Rate	$10,077.51
Max. Negotiated Rate	$20,921.70
Rate for Payer: Aetna Medicare	$11,032.23
Rate for Payer: Allen County Amish Medical Aid Commercial	$13,259.89
Rate for Payer: Amish Plain Church Group Commercial	$13,259.89
Rate for Payer: BCBS MAPPO	$10,607.91
Rate for Payer: BCBS Trust/PPO	$19,821.89
Rate for Payer: BCN Commercial	$19,821.89
Rate for Payer: BCN Medicare Advantage	$10,607.91
Rate for Payer: Health Alliance Plan Medicare Advantage	$10,607.91
Rate for Payer: Mclaren Medicare	$10,607.91
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$11,138.31
Rate for Payer: MI Amish Medical Board Commercial	$12,199.10
Rate for Payer: Molina Medicare/Medicaid	$11,668.70
Rate for Payer: Nomi Health Commercial	$16,352.04
Rate for Payer: PACE Medicare	$10,077.51
Rate for Payer: PACE SWMI	$10,607.91
Rate for Payer: PHP Medicare Advantage	$10,607.91
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$20,921.70
Rate for Payer: Priority Health Medicare	$10,607.91
Rate for Payer: Priority Health Tiered Network	$16,737.36
Rate for Payer: Railroad Medicare Medicare	$10,607.91
Rate for Payer: UHC All Payor (Choice/PPO)	$20,661.88
Rate for Payer: UHC Core	$17,286.26
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$10,607.91
Rate for Payer: UHC Exchange	$14,117.26
Rate for Payer: VA VA	$10,607.91

HONEY 100 % TOPICAL PASTE

Facility

$55.75

Service Code	NDC 09958003361
Hospital Charge Code	166117
Hospital Revenue Code	637
Min. Negotiated Rate	$21.91
Max. Negotiated Rate	$50.17
Rate for Payer: Aetna Commercial	$47.39
Rate for Payer: Aetna Medicare	$27.88
Rate for Payer: Aetna New Business (MI Preferred)	$36.24
Rate for Payer: BCBS Complete	$22.30
Rate for Payer: Cash Price	$44.60
Rate for Payer: Cofinity Advantage	$39.02
Rate for Payer: Cofinity Commercial	$47.95
Rate for Payer: Encore Health Key Benefits Commercial	$44.60
Rate for Payer: Healthscope Commercial	$50.17
Rate for Payer: MI Amish Medical Board Commercial	$44.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$41.81
Rate for Payer: PHP Commercial	$47.39
Rate for Payer: Priority Health SBD	$35.12
Rate for Payer: UHC All Payor (Choice/PPO)	$36.24
Rate for Payer: UHC Core	$29.05
Rate for Payer: UHC Exchange	$21.91

HONEY 100 % TOPICAL PASTE

Facility

$55.75

Service Code	NDC 09958003361
Hospital Charge Code	166117
Hospital Revenue Code	637
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$50.17
Rate for Payer: Aetna Commercial	$47.39
Rate for Payer: Aetna New Business (MI Preferred)	$36.24
Rate for Payer: Cash Price	$44.60
Rate for Payer: Cofinity Advantage	$39.02
Rate for Payer: Cofinity Commercial	$47.95
Rate for Payer: Encore Health Key Benefits Commercial	$44.60
Rate for Payer: Healthscope Commercial	$50.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$41.81
Rate for Payer: PHP Commercial	$47.39
Rate for Payer: Priority Health SBD	$35.12

HONEY 100 % TOPICAL PASTE

Facility

$55.75

Service Code	NDC 09958003360
Hospital Charge Code	166117
Hospital Revenue Code	637
Min. Negotiated Rate	$21.91
Max. Negotiated Rate	$50.17
Rate for Payer: Aetna Commercial	$47.39
Rate for Payer: Aetna Medicare	$27.88
Rate for Payer: Aetna New Business (MI Preferred)	$36.24
Rate for Payer: BCBS Complete	$22.30
Rate for Payer: Cash Price	$44.60
Rate for Payer: Cofinity Advantage	$39.02
Rate for Payer: Cofinity Commercial	$47.95
Rate for Payer: Encore Health Key Benefits Commercial	$44.60
Rate for Payer: Healthscope Commercial	$50.17
Rate for Payer: MI Amish Medical Board Commercial	$44.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$41.81
Rate for Payer: PHP Commercial	$47.39
Rate for Payer: Priority Health SBD	$35.12
Rate for Payer: UHC All Payor (Choice/PPO)	$36.24
Rate for Payer: UHC Core	$29.05
Rate for Payer: UHC Exchange	$21.91

HONEY 100 % TOPICAL PASTE

Facility

$55.75

Service Code	NDC 09958003360
Hospital Charge Code	166117
Hospital Revenue Code	637
Min. Negotiated Rate	$35.12
Max. Negotiated Rate	$50.17
Rate for Payer: Aetna Commercial	$47.39
Rate for Payer: Aetna New Business (MI Preferred)	$36.24
Rate for Payer: Cash Price	$44.60
Rate for Payer: Cofinity Advantage	$39.02
Rate for Payer: Cofinity Commercial	$47.95
Rate for Payer: Encore Health Key Benefits Commercial	$44.60
Rate for Payer: Healthscope Commercial	$50.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.39
Rate for Payer: Opus (Opus Packaging Group) HMA	$41.81
Rate for Payer: PHP Commercial	$47.39
Rate for Payer: Priority Health SBD	$35.12

HONEY 80 % TOPICAL GEL

Facility

$56.21

Service Code	NDC 09958003471
Hospital Charge Code	164073
Hospital Revenue Code	637
Min. Negotiated Rate	$22.09
Max. Negotiated Rate	$50.59
Rate for Payer: Aetna Commercial	$47.78
Rate for Payer: Aetna Medicare	$28.11
Rate for Payer: Aetna New Business (MI Preferred)	$36.54
Rate for Payer: BCBS Complete	$22.48
Rate for Payer: Cash Price	$44.97
Rate for Payer: Cofinity Advantage	$39.35
Rate for Payer: Cofinity Commercial	$48.34
Rate for Payer: Encore Health Key Benefits Commercial	$44.97
Rate for Payer: Healthscope Commercial	$50.59
Rate for Payer: MI Amish Medical Board Commercial	$44.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.78
Rate for Payer: Opus (Opus Packaging Group) HMA	$42.16
Rate for Payer: PHP Commercial	$47.78
Rate for Payer: Priority Health SBD	$35.41
Rate for Payer: UHC All Payor (Choice/PPO)	$36.54
Rate for Payer: UHC Core	$29.29
Rate for Payer: UHC Exchange	$22.09

HONEY 80 % TOPICAL GEL

Facility

$56.21

Service Code	NDC 09958003471
Hospital Charge Code	164073
Hospital Revenue Code	637
Min. Negotiated Rate	$35.41
Max. Negotiated Rate	$50.59
Rate for Payer: Aetna Commercial	$47.78
Rate for Payer: Aetna New Business (MI Preferred)	$36.54
Rate for Payer: Cash Price	$44.97
Rate for Payer: Cofinity Advantage	$39.35
Rate for Payer: Cofinity Commercial	$48.34
Rate for Payer: Encore Health Key Benefits Commercial	$44.97
Rate for Payer: Healthscope Commercial	$50.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.78
Rate for Payer: Opus (Opus Packaging Group) HMA	$42.16
Rate for Payer: PHP Commercial	$47.78
Rate for Payer: Priority Health SBD	$35.41

HOSPICE AND PALLIATIVE CARE

Facility

$969.45

Service Code	APR-DRG 8642
Min. Negotiated Rate	$923.29
Max. Negotiated Rate	$969.45
Rate for Payer: BCBS Complete	$969.45
Rate for Payer: Mclaren Medicaid	$923.29
Rate for Payer: Meridian Medicaid	$969.45
Rate for Payer: Priority Health Choice Medicaid	$923.29
Rate for Payer: UHC Medicaid	$923.29
Rate for Payer: UHCCP Medicaid	$923.29

HOSPICE AND PALLIATIVE CARE

Facility

$1,076.08

Service Code	APR-DRG 8643
Min. Negotiated Rate	$1,024.84
Max. Negotiated Rate	$1,076.08
Rate for Payer: BCBS Complete	$1,076.08
Rate for Payer: Mclaren Medicaid	$1,024.84
Rate for Payer: Meridian Medicaid	$1,076.08
Rate for Payer: Priority Health Choice Medicaid	$1,024.84
Rate for Payer: UHC Medicaid	$1,024.84
Rate for Payer: UHCCP Medicaid	$1,024.84

HOSPICE AND PALLIATIVE CARE

Facility

$941.36

Service Code	APR-DRG 8641
Min. Negotiated Rate	$896.53
Max. Negotiated Rate	$941.36
Rate for Payer: BCBS Complete	$941.36
Rate for Payer: Mclaren Medicaid	$896.53
Rate for Payer: Meridian Medicaid	$941.36
Rate for Payer: Priority Health Choice Medicaid	$896.53
Rate for Payer: UHC Medicaid	$896.53
Rate for Payer: UHCCP Medicaid	$896.53

HOSPICE AND PALLIATIVE CARE

Facility

$1,129.97

Service Code	APR-DRG 8644
Min. Negotiated Rate	$1,076.17
Max. Negotiated Rate	$1,129.97
Rate for Payer: BCBS Complete	$1,129.97
Rate for Payer: Mclaren Medicaid	$1,076.17
Rate for Payer: Meridian Medicaid	$1,129.97
Rate for Payer: Priority Health Choice Medicaid	$1,076.17
Rate for Payer: UHC Medicaid	$1,076.17
Rate for Payer: UHCCP Medicaid	$1,076.17

HUMAN PROTHROMBIN COMPLEX CONCENTRATE-LANS 1,000 UNIT IV SOLUTION

Facility

$5.82

Service Code	HCPCS J7165
Hospital Charge Code	204902
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$5.24
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: Aetna New Business (MI Preferred)	$3.78
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cofinity Advantage	$4.07
Rate for Payer: Cofinity Commercial	$5.01
Rate for Payer: Encore Health Key Benefits Commercial	$4.66
Rate for Payer: Healthscope Commercial	$5.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.37
Rate for Payer: PHP Commercial	$4.95
Rate for Payer: Priority Health SBD	$3.67

HUMAN PROTHROMBIN COMPLEX CONCENTRATE-LANS 1,000 UNIT IV SOLUTION

Facility

$5.82

Service Code	HCPCS J7165
Hospital Charge Code	204902
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$7.88
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: Aetna Medicare	$1.79
Rate for Payer: Aetna New Business (MI Preferred)	$3.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$2.15
Rate for Payer: Amish Plain Church Group Commercial	$2.15
Rate for Payer: BCBS Complete	$0.94
Rate for Payer: BCBS MAPPO	$1.72
Rate for Payer: BCBS Trust/PPO	$7.88
Rate for Payer: BCN Commercial	$7.88
Rate for Payer: BCN Medicare Advantage	$1.72
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cofinity Advantage	$4.07
Rate for Payer: Cofinity Commercial	$5.01
Rate for Payer: Encore Health Key Benefits Commercial	$4.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$1.72
Rate for Payer: Healthscope Commercial	$5.24
Rate for Payer: Mclaren Medicaid	$0.90
Rate for Payer: Mclaren Medicare	$1.72
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1.81
Rate for Payer: Meridian Medicaid	$1.81
Rate for Payer: MI Amish Medical Board Commercial	$1.98
Rate for Payer: Molina Medicare/Medicaid	$1.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.95
Rate for Payer: Nomi Health Commercial	$5.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.37
Rate for Payer: PACE Medicare	$1.63
Rate for Payer: PACE SWMI	$1.72
Rate for Payer: PHP Commercial	$4.95
Rate for Payer: PHP Medicare Advantage	$1.72
Rate for Payer: Priority Health Choice Medicaid	$0.90
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$4.87
Rate for Payer: Priority Health Medicare	$1.72
Rate for Payer: Priority Health SBD	$3.67
Rate for Payer: Priority Health Tiered Network	$3.90
Rate for Payer: Railroad Medicare Medicare	$1.72
Rate for Payer: UHC All Payor (Choice/PPO)	$2.82
Rate for Payer: UHC Core	$2.82
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$1.72
Rate for Payer: UHC Exchange	$2.82
Rate for Payer: UHC Medicaid	$0.90
Rate for Payer: UHCCP Medicaid	$0.90
Rate for Payer: VA VA	$1.72

HUMAN PROTHROMBIN COMPLEX CONCENTRATE-LANS 500 UNIT IV SOLUTION

Facility

$5.82

Service Code	HCPCS J7165
Hospital Charge Code	204903
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$7.88
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: Aetna Medicare	$1.79
Rate for Payer: Aetna New Business (MI Preferred)	$3.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$2.15
Rate for Payer: Amish Plain Church Group Commercial	$2.15
Rate for Payer: BCBS Complete	$0.94
Rate for Payer: BCBS MAPPO	$1.72
Rate for Payer: BCBS Trust/PPO	$7.88
Rate for Payer: BCN Commercial	$7.88
Rate for Payer: BCN Medicare Advantage	$1.72
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cofinity Advantage	$4.07
Rate for Payer: Cofinity Commercial	$5.01
Rate for Payer: Encore Health Key Benefits Commercial	$4.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$1.72
Rate for Payer: Healthscope Commercial	$5.24
Rate for Payer: Mclaren Medicaid	$0.90
Rate for Payer: Mclaren Medicare	$1.72
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1.81
Rate for Payer: Meridian Medicaid	$1.81
Rate for Payer: MI Amish Medical Board Commercial	$1.98
Rate for Payer: Molina Medicare/Medicaid	$1.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.95
Rate for Payer: Nomi Health Commercial	$5.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.37
Rate for Payer: PACE Medicare	$1.63
Rate for Payer: PACE SWMI	$1.72
Rate for Payer: PHP Commercial	$4.95
Rate for Payer: PHP Medicare Advantage	$1.72
Rate for Payer: Priority Health Choice Medicaid	$0.90
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$4.87
Rate for Payer: Priority Health Medicare	$1.72
Rate for Payer: Priority Health SBD	$3.67
Rate for Payer: Priority Health Tiered Network	$3.90
Rate for Payer: Railroad Medicare Medicare	$1.72
Rate for Payer: UHC All Payor (Choice/PPO)	$2.82
Rate for Payer: UHC Core	$2.82
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$1.72
Rate for Payer: UHC Exchange	$2.82
Rate for Payer: UHC Medicaid	$0.90
Rate for Payer: UHCCP Medicaid	$0.90
Rate for Payer: VA VA	$1.72

HUMAN PROTHROMBIN COMPLEX CONCENTRATE-LANS 500 UNIT IV SOLUTION

Facility

$5.82

Service Code	HCPCS J7165
Hospital Charge Code	204903
Hospital Revenue Code	636
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$5.24
Rate for Payer: Aetna Commercial	$4.95
Rate for Payer: Aetna New Business (MI Preferred)	$3.78
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cofinity Advantage	$4.07
Rate for Payer: Cofinity Commercial	$5.01
Rate for Payer: Encore Health Key Benefits Commercial	$4.66
Rate for Payer: Healthscope Commercial	$5.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.37
Rate for Payer: PHP Commercial	$4.95
Rate for Payer: Priority Health SBD	$3.67

HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION

Facility

$212.46

Service Code	HCPCS J3473
Hospital Charge Code	76338
Hospital Revenue Code	636
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$191.21
Rate for Payer: Aetna Commercial	$180.59
Rate for Payer: Aetna Medicare	$106.23
Rate for Payer: Aetna New Business (MI Preferred)	$138.10
Rate for Payer: BCBS Complete	$84.98
Rate for Payer: BCBS Trust/PPO	$0.89
Rate for Payer: BCN Commercial	$0.89
Rate for Payer: Cash Price	$169.97
Rate for Payer: Cash Price	$169.97
Rate for Payer: Cofinity Advantage	$148.72
Rate for Payer: Cofinity Commercial	$182.72
Rate for Payer: Encore Health Key Benefits Commercial	$169.97
Rate for Payer: Healthscope Commercial	$191.21
Rate for Payer: MI Amish Medical Board Commercial	$169.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$180.59
Rate for Payer: Opus (Opus Packaging Group) HMA	$159.34
Rate for Payer: PHP Commercial	$180.59
Rate for Payer: Priority Health SBD	$133.85
Rate for Payer: UHC All Payor (Choice/PPO)	$0.59
Rate for Payer: UHC Core	$0.59
Rate for Payer: UHC Exchange	$0.59

HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION

Facility

$212.46

Service Code	HCPCS J3473
Hospital Charge Code	76338
Hospital Revenue Code	636
Min. Negotiated Rate	$133.85
Max. Negotiated Rate	$191.21
Rate for Payer: Aetna Commercial	$180.59
Rate for Payer: Aetna New Business (MI Preferred)	$138.10
Rate for Payer: Cash Price	$169.97
Rate for Payer: Cofinity Advantage	$148.72
Rate for Payer: Cofinity Commercial	$182.72
Rate for Payer: Encore Health Key Benefits Commercial	$169.97
Rate for Payer: Healthscope Commercial	$191.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$180.59
Rate for Payer: Opus (Opus Packaging Group) HMA	$159.34
Rate for Payer: PHP Commercial	$180.59
Rate for Payer: Priority Health SBD	$133.85

HYDRALAZINE 100 MG TABLET

Facility

$188.00

Service Code	NDC 23155083501
Hospital Charge Code	3699
Hospital Revenue Code	637
Min. Negotiated Rate	$118.44
Max. Negotiated Rate	$169.20
Rate for Payer: Aetna Commercial	$159.80
Rate for Payer: Aetna New Business (MI Preferred)	$122.20
Rate for Payer: Cash Price	$150.40
Rate for Payer: Cofinity Advantage	$131.60
Rate for Payer: Cofinity Commercial	$161.68
Rate for Payer: Encore Health Key Benefits Commercial	$150.40
Rate for Payer: Healthscope Commercial	$169.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$159.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$141.00
Rate for Payer: PHP Commercial	$159.80
Rate for Payer: Priority Health SBD	$118.44

HYDRALAZINE 100 MG TABLET

Facility

$248.90

Service Code	NDC 00904745061
Hospital Charge Code	3699
Hospital Revenue Code	637
Min. Negotiated Rate	$156.81
Max. Negotiated Rate	$224.01
Rate for Payer: Aetna Commercial	$211.56
Rate for Payer: Aetna New Business (MI Preferred)	$161.78
Rate for Payer: Cash Price	$199.12
Rate for Payer: Cofinity Advantage	$174.23
Rate for Payer: Cofinity Commercial	$214.05
Rate for Payer: Encore Health Key Benefits Commercial	$199.12
Rate for Payer: Healthscope Commercial	$224.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$211.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$186.68
Rate for Payer: PHP Commercial	$211.56
Rate for Payer: Priority Health SBD	$156.81

Know your out-of-pocket cost for care.

All Charges