Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE

Facility

$788.90

Service Code	NDC 00406833062
Hospital Charge Code	20921
Hospital Revenue Code	637
Min. Negotiated Rate	$497.01
Max. Negotiated Rate	$710.01
Rate for Payer: Aetna Commercial	$670.57
Rate for Payer: Aetna New Business (MI Preferred)	$512.78
Rate for Payer: Cash Price	$631.12
Rate for Payer: Cofinity Commercial	$552.23
Rate for Payer: Cofinity Commercial	$678.45
Rate for Payer: Cofinity Medicare Advantage	$552.23
Rate for Payer: Encore Health Key Benefits Commercial	$631.12
Rate for Payer: Healthscope Commercial	$710.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$670.57
Rate for Payer: PHP Commercial	$670.57
Rate for Payer: Priority Health Cigna Priority Health	$512.78
Rate for Payer: Priority Health SBD	$497.01

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE

Facility

$7.89

Service Code	NDC 00406833023
Hospital Charge Code	20921
Hospital Revenue Code	637
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$7.10
Rate for Payer: Aetna Commercial	$6.71
Rate for Payer: Aetna Medicare	$3.94
Rate for Payer: Aetna New Business (MI Preferred)	$5.13
Rate for Payer: BCBS Complete	$3.16
Rate for Payer: Cash Price	$6.31
Rate for Payer: Cofinity Commercial	$5.52
Rate for Payer: Cofinity Commercial	$6.79
Rate for Payer: Cofinity Medicare Advantage	$5.52
Rate for Payer: Encore Health Key Benefits Commercial	$6.31
Rate for Payer: Healthscope Commercial	$7.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.71
Rate for Payer: PHP Commercial	$6.71
Rate for Payer: Priority Health Cigna Priority Health	$5.13
Rate for Payer: Priority Health SBD	$4.97

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE

Facility

$717.50

Service Code	NDC 00904655861
Hospital Charge Code	20921
Hospital Revenue Code	637
Min. Negotiated Rate	$452.02
Max. Negotiated Rate	$645.75
Rate for Payer: Aetna Commercial	$609.88
Rate for Payer: Aetna New Business (MI Preferred)	$466.38
Rate for Payer: Cash Price	$574.00
Rate for Payer: Cofinity Commercial	$502.25
Rate for Payer: Cofinity Commercial	$617.05
Rate for Payer: Cofinity Medicare Advantage	$502.25
Rate for Payer: Encore Health Key Benefits Commercial	$574.00
Rate for Payer: Healthscope Commercial	$645.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$609.88
Rate for Payer: PHP Commercial	$609.88
Rate for Payer: Priority Health Cigna Priority Health	$466.38
Rate for Payer: Priority Health SBD	$452.02

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE

Facility

$717.50

Service Code	NDC 00904655861
Hospital Charge Code	20921
Hospital Revenue Code	637
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$645.75
Rate for Payer: Aetna Commercial	$609.88
Rate for Payer: Aetna Medicare	$358.75
Rate for Payer: Aetna New Business (MI Preferred)	$466.38
Rate for Payer: BCBS Complete	$287.00
Rate for Payer: Cash Price	$574.00
Rate for Payer: Cofinity Commercial	$502.25
Rate for Payer: Cofinity Commercial	$617.05
Rate for Payer: Cofinity Medicare Advantage	$502.25
Rate for Payer: Encore Health Key Benefits Commercial	$574.00
Rate for Payer: Healthscope Commercial	$645.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$609.88
Rate for Payer: PHP Commercial	$609.88
Rate for Payer: Priority Health Cigna Priority Health	$466.38
Rate for Payer: Priority Health SBD	$452.02

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE

Facility

$788.90

Service Code	NDC 00406833062
Hospital Charge Code	20921
Hospital Revenue Code	637
Min. Negotiated Rate	$315.56
Max. Negotiated Rate	$710.01
Rate for Payer: Aetna Commercial	$670.57
Rate for Payer: Aetna Medicare	$394.45
Rate for Payer: Aetna New Business (MI Preferred)	$512.78
Rate for Payer: BCBS Complete	$315.56
Rate for Payer: Cash Price	$631.12
Rate for Payer: Cofinity Commercial	$552.23
Rate for Payer: Cofinity Commercial	$678.45
Rate for Payer: Cofinity Medicare Advantage	$552.23
Rate for Payer: Encore Health Key Benefits Commercial	$631.12
Rate for Payer: Healthscope Commercial	$710.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$670.57
Rate for Payer: PHP Commercial	$670.57
Rate for Payer: Priority Health Cigna Priority Health	$512.78
Rate for Payer: Priority Health SBD	$497.01

MORPHINE ER 30 MG TABLET,EXTENDED RELEASE

Facility

$7.89

Service Code	NDC 00406833023
Hospital Charge Code	20921
Hospital Revenue Code	637
Min. Negotiated Rate	$4.97
Max. Negotiated Rate	$7.10
Rate for Payer: Aetna Commercial	$6.71
Rate for Payer: Aetna New Business (MI Preferred)	$5.13
Rate for Payer: Cash Price	$6.31
Rate for Payer: Cofinity Commercial	$5.52
Rate for Payer: Cofinity Commercial	$6.79
Rate for Payer: Cofinity Medicare Advantage	$5.52
Rate for Payer: Encore Health Key Benefits Commercial	$6.31
Rate for Payer: Healthscope Commercial	$7.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.71
Rate for Payer: PHP Commercial	$6.71
Rate for Payer: Priority Health Cigna Priority Health	$5.13
Rate for Payer: Priority Health SBD	$4.97

MORPHINE ER 60 MG TABLET,EXTENDED RELEASE

Facility

$901.29

Service Code	NDC 00228431111
Hospital Charge Code	20922
Hospital Revenue Code	637
Min. Negotiated Rate	$360.52
Max. Negotiated Rate	$811.16
Rate for Payer: Aetna Commercial	$766.10
Rate for Payer: Aetna Medicare	$450.64
Rate for Payer: Aetna New Business (MI Preferred)	$585.84
Rate for Payer: BCBS Complete	$360.52
Rate for Payer: Cash Price	$721.03
Rate for Payer: Cofinity Commercial	$630.90
Rate for Payer: Cofinity Commercial	$775.11
Rate for Payer: Cofinity Medicare Advantage	$630.90
Rate for Payer: Encore Health Key Benefits Commercial	$721.03
Rate for Payer: Healthscope Commercial	$811.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$766.10
Rate for Payer: PHP Commercial	$766.10
Rate for Payer: Priority Health Cigna Priority Health	$585.84
Rate for Payer: Priority Health SBD	$567.81

MORPHINE ER 60 MG TABLET,EXTENDED RELEASE

Facility

$1,049.88

Service Code	NDC 00406838062
Hospital Charge Code	20922
Hospital Revenue Code	637
Min. Negotiated Rate	$419.95
Max. Negotiated Rate	$944.89
Rate for Payer: Aetna Commercial	$892.40
Rate for Payer: Aetna Medicare	$524.94
Rate for Payer: Aetna New Business (MI Preferred)	$682.42
Rate for Payer: BCBS Complete	$419.95
Rate for Payer: Cash Price	$839.90
Rate for Payer: Cofinity Commercial	$734.92
Rate for Payer: Cofinity Commercial	$902.90
Rate for Payer: Cofinity Medicare Advantage	$734.92
Rate for Payer: Encore Health Key Benefits Commercial	$839.90
Rate for Payer: Healthscope Commercial	$944.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$892.40
Rate for Payer: PHP Commercial	$892.40
Rate for Payer: Priority Health Cigna Priority Health	$682.42
Rate for Payer: Priority Health SBD	$661.42

MORPHINE ER 60 MG TABLET,EXTENDED RELEASE

Facility

$1,049.88

Service Code	NDC 00406838062
Hospital Charge Code	20922
Hospital Revenue Code	637
Min. Negotiated Rate	$661.42
Max. Negotiated Rate	$944.89
Rate for Payer: Aetna Commercial	$892.40
Rate for Payer: Aetna New Business (MI Preferred)	$682.42
Rate for Payer: Cash Price	$839.90
Rate for Payer: Cofinity Commercial	$734.92
Rate for Payer: Cofinity Commercial	$902.90
Rate for Payer: Cofinity Medicare Advantage	$734.92
Rate for Payer: Encore Health Key Benefits Commercial	$839.90
Rate for Payer: Healthscope Commercial	$944.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$892.40
Rate for Payer: PHP Commercial	$892.40
Rate for Payer: Priority Health Cigna Priority Health	$682.42
Rate for Payer: Priority Health SBD	$661.42

MORPHINE ER 60 MG TABLET,EXTENDED RELEASE

Facility

$10.50

Service Code	NDC 00406838023
Hospital Charge Code	20922
Hospital Revenue Code	637
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$9.45
Rate for Payer: Aetna Commercial	$8.93
Rate for Payer: Aetna Medicare	$5.25
Rate for Payer: Aetna New Business (MI Preferred)	$6.83
Rate for Payer: BCBS Complete	$4.20
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cofinity Commercial	$7.35
Rate for Payer: Cofinity Commercial	$9.03
Rate for Payer: Cofinity Medicare Advantage	$7.35
Rate for Payer: Encore Health Key Benefits Commercial	$8.40
Rate for Payer: Healthscope Commercial	$9.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.93
Rate for Payer: PHP Commercial	$8.93
Rate for Payer: Priority Health Cigna Priority Health	$6.83
Rate for Payer: Priority Health SBD	$6.62

MORPHINE ER 60 MG TABLET,EXTENDED RELEASE

Facility

$10.50

Service Code	NDC 00406838023
Hospital Charge Code	20922
Hospital Revenue Code	637
Min. Negotiated Rate	$6.62
Max. Negotiated Rate	$9.45
Rate for Payer: Aetna Commercial	$8.93
Rate for Payer: Aetna New Business (MI Preferred)	$6.83
Rate for Payer: Cash Price	$8.40
Rate for Payer: Cofinity Commercial	$7.35
Rate for Payer: Cofinity Commercial	$9.03
Rate for Payer: Cofinity Medicare Advantage	$7.35
Rate for Payer: Encore Health Key Benefits Commercial	$8.40
Rate for Payer: Healthscope Commercial	$9.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.93
Rate for Payer: PHP Commercial	$8.93
Rate for Payer: Priority Health Cigna Priority Health	$6.83
Rate for Payer: Priority Health SBD	$6.62

MORPHINE ER 60 MG TABLET,EXTENDED RELEASE

Facility

$901.29

Service Code	NDC 00228431111
Hospital Charge Code	20922
Hospital Revenue Code	637
Min. Negotiated Rate	$567.81
Max. Negotiated Rate	$811.16
Rate for Payer: Aetna Commercial	$766.10
Rate for Payer: Aetna New Business (MI Preferred)	$585.84
Rate for Payer: Cash Price	$721.03
Rate for Payer: Cofinity Commercial	$630.90
Rate for Payer: Cofinity Commercial	$775.11
Rate for Payer: Cofinity Medicare Advantage	$630.90
Rate for Payer: Encore Health Key Benefits Commercial	$721.03
Rate for Payer: Healthscope Commercial	$811.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$766.10
Rate for Payer: PHP Commercial	$766.10
Rate for Payer: Priority Health Cigna Priority Health	$585.84
Rate for Payer: Priority Health SBD	$567.81

MORPHINE INHALATION (VARIABLE DOSE)

Facility

$11.68

Service Code	HCPCS J2270
Hospital Charge Code	300139
Hospital Revenue Code	636
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$10.51
Rate for Payer: Aetna Commercial	$9.93
Rate for Payer: Aetna Medicare	$5.84
Rate for Payer: Aetna New Business (MI Preferred)	$7.59
Rate for Payer: BCBS Complete	$4.67
Rate for Payer: Cash Price	$9.34
Rate for Payer: Cofinity Commercial	$10.04
Rate for Payer: Cofinity Commercial	$8.18
Rate for Payer: Cofinity Medicare Advantage	$8.18
Rate for Payer: Encore Health Key Benefits Commercial	$9.34
Rate for Payer: Healthscope Commercial	$10.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.93
Rate for Payer: PHP Commercial	$9.93
Rate for Payer: Priority Health Cigna Priority Health	$7.59
Rate for Payer: Priority Health SBD	$7.36

MORPHINE INHALATION (VARIABLE DOSE)

Facility

$11.68

Service Code	HCPCS J2270
Hospital Charge Code	300139
Hospital Revenue Code	636
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$10.51
Rate for Payer: Aetna Commercial	$9.93
Rate for Payer: Aetna New Business (MI Preferred)	$7.59
Rate for Payer: Cash Price	$9.34
Rate for Payer: Cofinity Commercial	$10.04
Rate for Payer: Cofinity Commercial	$8.18
Rate for Payer: Cofinity Medicare Advantage	$8.18
Rate for Payer: Encore Health Key Benefits Commercial	$9.34
Rate for Payer: Healthscope Commercial	$10.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.93
Rate for Payer: PHP Commercial	$9.93
Rate for Payer: Priority Health Cigna Priority Health	$7.59
Rate for Payer: Priority Health SBD	$7.36

MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION

Facility

$39.95

Service Code	HCPCS J2274
Hospital Charge Code	29464
Hospital Revenue Code	636
Min. Negotiated Rate	$15.98
Max. Negotiated Rate	$35.95
Rate for Payer: Aetna Commercial	$33.96
Rate for Payer: Aetna Commercial	$114.37
Rate for Payer: Aetna Medicare	$67.28
Rate for Payer: Aetna Medicare	$19.98
Rate for Payer: Aetna New Business (MI Preferred)	$25.97
Rate for Payer: Aetna New Business (MI Preferred)	$87.46
Rate for Payer: BCBS Complete	$15.98
Rate for Payer: BCBS Complete	$53.82
Rate for Payer: Cash Price	$31.96
Rate for Payer: Cash Price	$107.64
Rate for Payer: Cofinity Commercial	$34.36
Rate for Payer: Cofinity Commercial	$115.71
Rate for Payer: Cofinity Commercial	$94.19
Rate for Payer: Cofinity Commercial	$27.96
Rate for Payer: Cofinity Medicare Advantage	$94.19
Rate for Payer: Cofinity Medicare Advantage	$27.96
Rate for Payer: Encore Health Key Benefits Commercial	$107.64
Rate for Payer: Encore Health Key Benefits Commercial	$31.96
Rate for Payer: Healthscope Commercial	$35.95
Rate for Payer: Healthscope Commercial	$121.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$114.37
Rate for Payer: PHP Commercial	$33.96
Rate for Payer: PHP Commercial	$114.37
Rate for Payer: Priority Health Cigna Priority Health	$87.46
Rate for Payer: Priority Health Cigna Priority Health	$25.97
Rate for Payer: Priority Health SBD	$84.77
Rate for Payer: Priority Health SBD	$25.17

MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION

Facility

$134.55

Service Code	HCPCS J2274
Hospital Charge Code	29464
Hospital Revenue Code	636
Min. Negotiated Rate	$84.77
Max. Negotiated Rate	$121.09
Rate for Payer: Aetna Commercial	$114.37
Rate for Payer: Aetna Commercial	$33.96
Rate for Payer: Aetna New Business (MI Preferred)	$87.46
Rate for Payer: Aetna New Business (MI Preferred)	$25.97
Rate for Payer: Cash Price	$107.64
Rate for Payer: Cash Price	$31.96
Rate for Payer: Cofinity Commercial	$115.71
Rate for Payer: Cofinity Commercial	$27.96
Rate for Payer: Cofinity Commercial	$34.36
Rate for Payer: Cofinity Commercial	$94.19
Rate for Payer: Cofinity Medicare Advantage	$27.96
Rate for Payer: Cofinity Medicare Advantage	$94.19
Rate for Payer: Encore Health Key Benefits Commercial	$107.64
Rate for Payer: Encore Health Key Benefits Commercial	$31.96
Rate for Payer: Healthscope Commercial	$121.09
Rate for Payer: Healthscope Commercial	$35.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$114.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.96
Rate for Payer: PHP Commercial	$114.37
Rate for Payer: PHP Commercial	$33.96
Rate for Payer: Priority Health Cigna Priority Health	$25.97
Rate for Payer: Priority Health Cigna Priority Health	$87.46
Rate for Payer: Priority Health SBD	$25.17
Rate for Payer: Priority Health SBD	$84.77

MORPHINE (PF) 25 MG/ML INJECTION SOLUTION

Facility

$1,041.92

Service Code	NDC 00641604001
Hospital Charge Code	27392
Hospital Revenue Code	250
Min. Negotiated Rate	$416.77
Max. Negotiated Rate	$937.73
Rate for Payer: Aetna Commercial	$885.63
Rate for Payer: Aetna Medicare	$520.96
Rate for Payer: Aetna New Business (MI Preferred)	$677.25
Rate for Payer: BCBS Complete	$416.77
Rate for Payer: Cash Price	$833.54
Rate for Payer: Cofinity Commercial	$729.34
Rate for Payer: Cofinity Commercial	$896.05
Rate for Payer: Cofinity Medicare Advantage	$729.34
Rate for Payer: Encore Health Key Benefits Commercial	$833.54
Rate for Payer: Healthscope Commercial	$937.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$885.63
Rate for Payer: PHP Commercial	$885.63
Rate for Payer: Priority Health Cigna Priority Health	$677.25
Rate for Payer: Priority Health SBD	$656.41

MORPHINE (PF) 25 MG/ML INJECTION SOLUTION

Facility

$1,057.41

Service Code	NDC 66794016202
Hospital Charge Code	27392
Hospital Revenue Code	250
Min. Negotiated Rate	$422.96
Max. Negotiated Rate	$951.67
Rate for Payer: Aetna Commercial	$898.80
Rate for Payer: Aetna Medicare	$528.71
Rate for Payer: Aetna New Business (MI Preferred)	$687.32
Rate for Payer: BCBS Complete	$422.96
Rate for Payer: Cash Price	$845.93
Rate for Payer: Cofinity Commercial	$740.19
Rate for Payer: Cofinity Commercial	$909.37
Rate for Payer: Cofinity Medicare Advantage	$740.19
Rate for Payer: Encore Health Key Benefits Commercial	$845.93
Rate for Payer: Healthscope Commercial	$951.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$898.80
Rate for Payer: PHP Commercial	$898.80
Rate for Payer: Priority Health Cigna Priority Health	$687.32
Rate for Payer: Priority Health SBD	$666.17

MORPHINE (PF) 25 MG/ML INJECTION SOLUTION

Facility

$1,057.41

Service Code	NDC 66794016202
Hospital Charge Code	27392
Hospital Revenue Code	250
Min. Negotiated Rate	$666.17
Max. Negotiated Rate	$951.67
Rate for Payer: Aetna Commercial	$898.80
Rate for Payer: Aetna New Business (MI Preferred)	$687.32
Rate for Payer: Cash Price	$845.93
Rate for Payer: Cofinity Commercial	$740.19
Rate for Payer: Cofinity Commercial	$909.37
Rate for Payer: Cofinity Medicare Advantage	$740.19
Rate for Payer: Encore Health Key Benefits Commercial	$845.93
Rate for Payer: Healthscope Commercial	$951.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$898.80
Rate for Payer: PHP Commercial	$898.80
Rate for Payer: Priority Health Cigna Priority Health	$687.32
Rate for Payer: Priority Health SBD	$666.17

MORPHINE (PF) 25 MG/ML INJECTION SOLUTION

Facility

$1,041.92

Service Code	NDC 00641604001
Hospital Charge Code	27392
Hospital Revenue Code	250
Min. Negotiated Rate	$656.41
Max. Negotiated Rate	$937.73
Rate for Payer: Aetna Commercial	$885.63
Rate for Payer: Aetna New Business (MI Preferred)	$677.25
Rate for Payer: Cash Price	$833.54
Rate for Payer: Cofinity Commercial	$729.34
Rate for Payer: Cofinity Commercial	$896.05
Rate for Payer: Cofinity Medicare Advantage	$729.34
Rate for Payer: Encore Health Key Benefits Commercial	$833.54
Rate for Payer: Healthscope Commercial	$937.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$885.63
Rate for Payer: PHP Commercial	$885.63
Rate for Payer: Priority Health Cigna Priority Health	$677.25
Rate for Payer: Priority Health SBD	$656.41

MORPHINE VARIABLE DOSE

Facility

$11.68

Service Code	HCPCS J2270
Hospital Charge Code	150710
Hospital Revenue Code	636
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$10.51
Rate for Payer: Aetna Commercial	$9.93
Rate for Payer: Aetna Medicare	$5.84
Rate for Payer: Aetna New Business (MI Preferred)	$7.59
Rate for Payer: BCBS Complete	$4.67
Rate for Payer: Cash Price	$9.34
Rate for Payer: Cofinity Commercial	$10.04
Rate for Payer: Cofinity Commercial	$8.18
Rate for Payer: Cofinity Medicare Advantage	$8.18
Rate for Payer: Encore Health Key Benefits Commercial	$9.34
Rate for Payer: Healthscope Commercial	$10.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.93
Rate for Payer: PHP Commercial	$9.93
Rate for Payer: Priority Health Cigna Priority Health	$7.59
Rate for Payer: Priority Health SBD	$7.36

MORPHINE VARIABLE DOSE

Facility

$11.68

Service Code	HCPCS J2270
Hospital Charge Code	150710
Hospital Revenue Code	636
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$10.51
Rate for Payer: Aetna Commercial	$9.93
Rate for Payer: Aetna New Business (MI Preferred)	$7.59
Rate for Payer: Cash Price	$9.34
Rate for Payer: Cofinity Commercial	$10.04
Rate for Payer: Cofinity Commercial	$8.18
Rate for Payer: Cofinity Medicare Advantage	$8.18
Rate for Payer: Encore Health Key Benefits Commercial	$9.34
Rate for Payer: Healthscope Commercial	$10.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.93
Rate for Payer: PHP Commercial	$9.93
Rate for Payer: Priority Health Cigna Priority Health	$7.59
Rate for Payer: Priority Health SBD	$7.36

MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK

Facility

$190.24

Service Code	HCPCS J2280
Hospital Charge Code	31906
Hospital Revenue Code	636
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$171.22
Rate for Payer: Aetna Commercial	$161.70
Rate for Payer: Aetna New Business (MI Preferred)	$123.66
Rate for Payer: Cash Price	$152.19
Rate for Payer: Cofinity Commercial	$163.61
Rate for Payer: Cofinity Commercial	$133.17
Rate for Payer: Cofinity Medicare Advantage	$133.17
Rate for Payer: Encore Health Key Benefits Commercial	$152.19
Rate for Payer: Healthscope Commercial	$171.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.70
Rate for Payer: PHP Commercial	$161.70
Rate for Payer: Priority Health Cigna Priority Health	$123.66
Rate for Payer: Priority Health SBD	$119.85

MOXIFLOXACIN 400 MG/250 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK

Facility

$190.24

Service Code	HCPCS J2280
Hospital Charge Code	31906
Hospital Revenue Code	636
Min. Negotiated Rate	$76.10
Max. Negotiated Rate	$171.22
Rate for Payer: Aetna Commercial	$161.70
Rate for Payer: Aetna Medicare	$95.12
Rate for Payer: Aetna New Business (MI Preferred)	$123.66
Rate for Payer: BCBS Complete	$76.10
Rate for Payer: Cash Price	$152.19
Rate for Payer: Cofinity Commercial	$133.17
Rate for Payer: Cofinity Commercial	$163.61
Rate for Payer: Cofinity Medicare Advantage	$133.17
Rate for Payer: Encore Health Key Benefits Commercial	$152.19
Rate for Payer: Healthscope Commercial	$171.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.70
Rate for Payer: PHP Commercial	$161.70
Rate for Payer: Priority Health Cigna Priority Health	$123.66
Rate for Payer: Priority Health SBD	$119.85

MS-DRG 42.00: ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY

Facility

$10,951.64

Service Code	MSDRG 770
Min. Negotiated Rate	$8,323.24
Max. Negotiated Rate	$10,951.64
Rate for Payer: Aetna Medicare	$9,111.76
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,951.64
Rate for Payer: Amish Plain Church Group Commercial	$10,951.64
Rate for Payer: BCBS MAPPO	$8,761.31
Rate for Payer: BCN Medicare Advantage	$8,761.31
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,761.31
Rate for Payer: Mclaren Medicare	$8,761.31
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$9,199.38
Rate for Payer: MI Amish Medical Board Commercial	$10,075.51
Rate for Payer: PACE Medicare	$8,323.24
Rate for Payer: PACE SWMI	$8,761.31
Rate for Payer: PHP Medicare Advantage	$8,761.31
Rate for Payer: Priority Health Medicare	$8,761.31
Rate for Payer: Railroad Medicare Medicare	$8,761.31
Rate for Payer: UHC Dual Complete DSNP	$8,761.31
Rate for Payer: UHC Medicare Advantage	$8,761.31
Rate for Payer: VA VA	$8,761.31

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