Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

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	$1.72
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna Commercial	$2.40
Rate for Payer: BCBS Trust/PPO	$2.18
Rate for Payer: BCN Commercial	$2.18
Rate for Payer: Cash Price	$2.26
Rate for Payer: Cofinity Commercial	$2.43
Rate for Payer: Encore Health Key Benefits Commercial	$2.26
Rate for Payer: Healthscope Commercial	$2.54
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.12
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 HMO/PPO/Tiered Network	$2.45
Rate for Payer: Priority Health Narrow/Tiered Network	$1.72
Rate for Payer: UHC All Payor (Choice/PPO)	$2.48
Rate for Payer: UHC Core	$2.35
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.12

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	$210.69
Max. Negotiated Rate	$310.90
Rate for Payer: Aetna Commercial	$293.63
Rate for Payer: BCBS Trust/PPO	$266.96
Rate for Payer: BCN Commercial	$266.96
Rate for Payer: Cash Price	$276.36
Rate for Payer: Cofinity Commercial	$297.09
Rate for Payer: Encore Health Key Benefits Commercial	$276.36
Rate for Payer: Healthscope Commercial	$310.90
Rate for Payer: Lakeland Regional Health Systems Commercial	$259.09
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 HMO/PPO/Tiered Network	$300.54
Rate for Payer: Priority Health Narrow/Tiered Network	$210.69
Rate for Payer: UHC All Payor (Choice/PPO)	$304.00
Rate for Payer: UHC Core	$288.45
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$259.09

HYOSCYAMINE 0.125 MG DISINTEGRATING TABLET

Facility

$300.96

Service Code	NDC 43199-012-01
Hospital Charge Code	29822
Hospital Revenue Code	637
Min. Negotiated Rate	$183.56
Max. Negotiated Rate	$270.86
Rate for Payer: Aetna Commercial	$255.82
Rate for Payer: BCBS Trust/PPO	$232.58
Rate for Payer: BCN Commercial	$232.58
Rate for Payer: Cash Price	$240.77
Rate for Payer: Cofinity Commercial	$258.83
Rate for Payer: Encore Health Key Benefits Commercial	$240.77
Rate for Payer: Healthscope Commercial	$270.86
Rate for Payer: Lakeland Regional Health Systems Commercial	$225.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$255.82
Rate for Payer: PHP Commercial	$255.82
Rate for Payer: Priority Health Cigna Priority Health	$210.67
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$261.84
Rate for Payer: Priority Health Narrow/Tiered Network	$183.56
Rate for Payer: UHC All Payor (Choice/PPO)	$264.84
Rate for Payer: UHC Core	$251.30
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$225.72

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET

Facility

$251.45

Service Code	NDC 47781-011-01
Hospital Charge Code	17023
Hospital Revenue Code	637
Min. Negotiated Rate	$153.36
Max. Negotiated Rate	$226.30
Rate for Payer: Aetna Commercial	$213.73
Rate for Payer: BCBS Trust/PPO	$194.32
Rate for Payer: BCN Commercial	$194.32
Rate for Payer: Cash Price	$201.16
Rate for Payer: Cofinity Commercial	$216.25
Rate for Payer: Encore Health Key Benefits Commercial	$201.16
Rate for Payer: Healthscope Commercial	$226.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$188.59
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$213.73
Rate for Payer: PHP Commercial	$213.73
Rate for Payer: Priority Health Cigna Priority Health	$176.02
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$218.76
Rate for Payer: Priority Health Narrow/Tiered Network	$153.36
Rate for Payer: UHC All Payor (Choice/PPO)	$221.28
Rate for Payer: UHC Core	$209.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$188.59

HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)

Facility

$2,153.41

Service Code	CPT 58555
Hospital Revenue Code	360
Min. Negotiated Rate	$2,050.87
Max. Negotiated Rate	$2,153.41
Rate for Payer: BCBS Complete	$2,153.41
Rate for Payer: Mclaren Medicaid	$2,050.87
Rate for Payer: Meridian Medicaid	$2,153.41
Rate for Payer: Priority Health Choice Medicaid	$2,050.87

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

Facility

$3,425.99

Service Code	CPT 58563
Hospital Revenue Code	360
Min. Negotiated Rate	$3,262.85
Max. Negotiated Rate	$3,425.99
Rate for Payer: BCBS Complete	$3,425.99
Rate for Payer: Mclaren Medicaid	$3,262.85
Rate for Payer: Meridian Medicaid	$3,425.99
Rate for Payer: Priority Health Choice Medicaid	$3,262.85

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY

Facility

$2,153.41

Service Code	CPT 58562
Hospital Revenue Code	360
Min. Negotiated Rate	$2,050.87
Max. Negotiated Rate	$2,153.41
Rate for Payer: BCBS Complete	$2,153.41
Rate for Payer: Mclaren Medicaid	$2,050.87
Rate for Payer: Meridian Medicaid	$2,153.41
Rate for Payer: Priority Health Choice Medicaid	$2,050.87

HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA

Facility

$3,425.99

Service Code	CPT 58561
Hospital Revenue Code	360
Min. Negotiated Rate	$3,262.85
Max. Negotiated Rate	$3,425.99
Rate for Payer: BCBS Complete	$3,425.99
Rate for Payer: Mclaren Medicaid	$3,262.85
Rate for Payer: Meridian Medicaid	$3,425.99
Rate for Payer: Priority Health Choice Medicaid	$3,262.85

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

Facility

$2,153.41

Service Code	CPT 58558
Hospital Revenue Code	360
Min. Negotiated Rate	$2,050.87
Max. Negotiated Rate	$2,153.41
Rate for Payer: BCBS Complete	$2,153.41
Rate for Payer: Mclaren Medicaid	$2,050.87
Rate for Payer: Meridian Medicaid	$2,153.41
Rate for Payer: Priority Health Choice Medicaid	$2,050.87

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.91

Service Code	NDC 0121-0918-05
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.62
Rate for Payer: Aetna Commercial	$2.47
Rate for Payer: BCBS Trust/PPO	$2.25
Rate for Payer: BCN Commercial	$2.25
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cofinity Commercial	$2.50
Rate for Payer: Encore Health Key Benefits Commercial	$2.33
Rate for Payer: Healthscope Commercial	$2.62
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.47
Rate for Payer: PHP Commercial	$2.47
Rate for Payer: Priority Health Cigna Priority Health	$2.04
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.53
Rate for Payer: Priority Health Narrow/Tiered Network	$1.77
Rate for Payer: UHC All Payor (Choice/PPO)	$2.56
Rate for Payer: UHC Core	$2.43
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.18

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	$1.57
Max. Negotiated Rate	$2.31
Rate for Payer: Aetna Commercial	$2.18
Rate for Payer: BCBS Trust/PPO	$1.99
Rate for Payer: BCN Commercial	$1.99
Rate for Payer: Cash Price	$2.06
Rate for Payer: Cofinity Commercial	$2.21
Rate for Payer: Encore Health Key Benefits Commercial	$2.06
Rate for Payer: Healthscope Commercial	$2.31
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.93
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 HMO/PPO/Tiered Network	$2.24
Rate for Payer: Priority Health Narrow/Tiered Network	$1.57
Rate for Payer: UHC All Payor (Choice/PPO)	$2.26
Rate for Payer: UHC Core	$2.15
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.93

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$5.81

Service Code	NDC 68094-503-59
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$5.23
Rate for Payer: Aetna Commercial	$4.94
Rate for Payer: BCBS Trust/PPO	$4.49
Rate for Payer: BCN Commercial	$4.49
Rate for Payer: Cash Price	$4.65
Rate for Payer: Cofinity Commercial	$5.00
Rate for Payer: Encore Health Key Benefits Commercial	$4.65
Rate for Payer: Healthscope Commercial	$5.23
Rate for Payer: Lakeland Regional Health Systems Commercial	$4.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.94
Rate for Payer: PHP Commercial	$4.94
Rate for Payer: Priority Health Cigna Priority Health	$4.07
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5.05
Rate for Payer: Priority Health Narrow/Tiered Network	$3.54
Rate for Payer: UHC All Payor (Choice/PPO)	$5.11
Rate for Payer: UHC Core	$4.85
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$4.36

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$7.97

Service Code	NDC 68094-037-01
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$4.86
Max. Negotiated Rate	$7.17
Rate for Payer: Aetna Commercial	$6.77
Rate for Payer: BCBS Trust/PPO	$6.16
Rate for Payer: BCN Commercial	$6.16
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cofinity Commercial	$6.85
Rate for Payer: Encore Health Key Benefits Commercial	$6.38
Rate for Payer: Healthscope Commercial	$7.17
Rate for Payer: Lakeland Regional Health Systems Commercial	$5.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.77
Rate for Payer: PHP Commercial	$6.77
Rate for Payer: Priority Health Cigna Priority Health	$5.58
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$6.93
Rate for Payer: Priority Health Narrow/Tiered Network	$4.86
Rate for Payer: UHC All Payor (Choice/PPO)	$7.01
Rate for Payer: UHC Core	$6.65
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$5.98

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.55

Service Code	NDC 0121-0917-05
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.30
Rate for Payer: Aetna Commercial	$2.17
Rate for Payer: BCBS Trust/PPO	$1.97
Rate for Payer: BCN Commercial	$1.97
Rate for Payer: Cash Price	$2.04
Rate for Payer: Cofinity Commercial	$2.19
Rate for Payer: Encore Health Key Benefits Commercial	$2.04
Rate for Payer: Healthscope Commercial	$2.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.17
Rate for Payer: PHP Commercial	$2.17
Rate for Payer: Priority Health Cigna Priority Health	$1.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.22
Rate for Payer: Priority Health Narrow/Tiered Network	$1.56
Rate for Payer: UHC All Payor (Choice/PPO)	$2.24
Rate for Payer: UHC Core	$2.13
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.91

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.55

Service Code	NDC 0121-0917-00
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.30
Rate for Payer: Aetna Commercial	$2.17
Rate for Payer: BCBS Trust/PPO	$1.97
Rate for Payer: BCN Commercial	$1.97
Rate for Payer: Cash Price	$2.04
Rate for Payer: Cofinity Commercial	$2.19
Rate for Payer: Encore Health Key Benefits Commercial	$2.04
Rate for Payer: Healthscope Commercial	$2.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.17
Rate for Payer: PHP Commercial	$2.17
Rate for Payer: Priority Health Cigna Priority Health	$1.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.22
Rate for Payer: Priority Health Narrow/Tiered Network	$1.56
Rate for Payer: UHC All Payor (Choice/PPO)	$2.24
Rate for Payer: UHC Core	$2.13
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.91

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$8.44

Service Code	NDC 50580-601-21
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$5.15
Max. Negotiated Rate	$7.60
Rate for Payer: Aetna Commercial	$7.17
Rate for Payer: BCBS Trust/PPO	$6.52
Rate for Payer: BCN Commercial	$6.52
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cofinity Commercial	$7.26
Rate for Payer: Encore Health Key Benefits Commercial	$6.75
Rate for Payer: Healthscope Commercial	$7.60
Rate for Payer: Lakeland Regional Health Systems Commercial	$6.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7.17
Rate for Payer: PHP Commercial	$7.17
Rate for Payer: Priority Health Cigna Priority Health	$5.91
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$7.34
Rate for Payer: Priority Health Narrow/Tiered Network	$5.15
Rate for Payer: UHC All Payor (Choice/PPO)	$7.43
Rate for Payer: UHC Core	$7.05
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$6.33

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	$1.43
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna Commercial	$2.00
Rate for Payer: BCBS Trust/PPO	$1.82
Rate for Payer: BCN Commercial	$1.82
Rate for Payer: Cash Price	$1.88
Rate for Payer: Cofinity Commercial	$2.02
Rate for Payer: Encore Health Key Benefits Commercial	$1.88
Rate for Payer: Healthscope Commercial	$2.12
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.76
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 HMO/PPO/Tiered Network	$2.04
Rate for Payer: Priority Health Narrow/Tiered Network	$1.43
Rate for Payer: UHC All Payor (Choice/PPO)	$2.07
Rate for Payer: UHC Core	$1.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.76

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	$2.84
Max. Negotiated Rate	$4.19
Rate for Payer: Aetna Commercial	$3.96
Rate for Payer: BCBS Trust/PPO	$3.60
Rate for Payer: BCN Commercial	$3.60
Rate for Payer: Cash Price	$3.73
Rate for Payer: Cofinity Commercial	$4.01
Rate for Payer: Encore Health Key Benefits Commercial	$3.73
Rate for Payer: Healthscope Commercial	$4.19
Rate for Payer: Lakeland Regional Health Systems Commercial	$3.50
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 HMO/PPO/Tiered Network	$4.05
Rate for Payer: Priority Health Narrow/Tiered Network	$2.84
Rate for Payer: UHC All Payor (Choice/PPO)	$4.10
Rate for Payer: UHC Core	$3.89
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$3.50

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$3.63

Service Code	NDC 68094-600-59
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$3.27
Rate for Payer: Aetna Commercial	$3.09
Rate for Payer: BCBS Trust/PPO	$2.81
Rate for Payer: BCN Commercial	$2.81
Rate for Payer: Cash Price	$2.90
Rate for Payer: Cofinity Commercial	$3.12
Rate for Payer: Encore Health Key Benefits Commercial	$2.90
Rate for Payer: Healthscope Commercial	$3.27
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.09
Rate for Payer: PHP Commercial	$3.09
Rate for Payer: Priority Health Cigna Priority Health	$2.54
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.16
Rate for Payer: Priority Health Narrow/Tiered Network	$2.21
Rate for Payer: UHC All Payor (Choice/PPO)	$3.19
Rate for Payer: UHC Core	$3.03
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.72

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	$2.12
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna Commercial	$2.96
Rate for Payer: BCBS Trust/PPO	$2.69
Rate for Payer: BCN Commercial	$2.69
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cofinity Commercial	$2.99
Rate for Payer: Encore Health Key Benefits Commercial	$2.78
Rate for Payer: Healthscope Commercial	$3.13
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.61
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 HMO/PPO/Tiered Network	$3.03
Rate for Payer: Priority Health Narrow/Tiered Network	$2.12
Rate for Payer: UHC All Payor (Choice/PPO)	$3.06
Rate for Payer: UHC Core	$2.91
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.61

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$7.97

Service Code	NDC 68094-037-58
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$4.86
Max. Negotiated Rate	$7.17
Rate for Payer: Aetna Commercial	$6.77
Rate for Payer: BCBS Trust/PPO	$6.16
Rate for Payer: BCN Commercial	$6.16
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cofinity Commercial	$6.85
Rate for Payer: Encore Health Key Benefits Commercial	$6.38
Rate for Payer: Healthscope Commercial	$7.17
Rate for Payer: Lakeland Regional Health Systems Commercial	$5.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.77
Rate for Payer: PHP Commercial	$6.77
Rate for Payer: Priority Health Cigna Priority Health	$5.58
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$6.93
Rate for Payer: Priority Health Narrow/Tiered Network	$4.86
Rate for Payer: UHC All Payor (Choice/PPO)	$7.01
Rate for Payer: UHC Core	$6.65
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$5.98

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$4.66

Service Code	NDC 0121-0914-05
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$4.19
Rate for Payer: Aetna Commercial	$3.96
Rate for Payer: BCBS Trust/PPO	$3.60
Rate for Payer: BCN Commercial	$3.60
Rate for Payer: Cash Price	$3.73
Rate for Payer: Cofinity Commercial	$4.01
Rate for Payer: Encore Health Key Benefits Commercial	$3.73
Rate for Payer: Healthscope Commercial	$4.19
Rate for Payer: Lakeland Regional Health Systems Commercial	$3.50
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 HMO/PPO/Tiered Network	$4.05
Rate for Payer: Priority Health Narrow/Tiered Network	$2.84
Rate for Payer: UHC All Payor (Choice/PPO)	$4.10
Rate for Payer: UHC Core	$3.89
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$3.50

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.91

Service Code	NDC 0121-0918-40
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.62
Rate for Payer: Aetna Commercial	$2.47
Rate for Payer: BCBS Trust/PPO	$2.25
Rate for Payer: BCN Commercial	$2.25
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cofinity Commercial	$2.50
Rate for Payer: Encore Health Key Benefits Commercial	$2.33
Rate for Payer: Healthscope Commercial	$2.62
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.47
Rate for Payer: PHP Commercial	$2.47
Rate for Payer: Priority Health Cigna Priority Health	$2.04
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.53
Rate for Payer: Priority Health Narrow/Tiered Network	$1.77
Rate for Payer: UHC All Payor (Choice/PPO)	$2.56
Rate for Payer: UHC Core	$2.43
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.18

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$5.81

Service Code	NDC 68094-503-61
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$5.23
Rate for Payer: Aetna Commercial	$4.94
Rate for Payer: BCBS Trust/PPO	$4.49
Rate for Payer: BCN Commercial	$4.49
Rate for Payer: Cash Price	$4.65
Rate for Payer: Cofinity Commercial	$5.00
Rate for Payer: Encore Health Key Benefits Commercial	$4.65
Rate for Payer: Healthscope Commercial	$5.23
Rate for Payer: Lakeland Regional Health Systems Commercial	$4.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.94
Rate for Payer: PHP Commercial	$4.94
Rate for Payer: Priority Health Cigna Priority Health	$4.07
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5.05
Rate for Payer: Priority Health Narrow/Tiered Network	$3.54
Rate for Payer: UHC All Payor (Choice/PPO)	$5.11
Rate for Payer: UHC Core	$4.85
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$4.36

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	$2.90
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna Commercial	$4.04
Rate for Payer: BCBS Trust/PPO	$3.67
Rate for Payer: BCN Commercial	$3.67
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.08
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.28
Rate for Payer: Lakeland Regional Health Systems Commercial	$3.56
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 HMO/PPO/Tiered Network	$4.13
Rate for Payer: Priority Health Narrow/Tiered Network	$2.90
Rate for Payer: UHC All Payor (Choice/PPO)	$4.18
Rate for Payer: UHC Core	$3.97
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$3.56

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