Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$4.47

Service Code	NDC 66993-068-51
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: BCBS Trust/PPO	$3.45
Rate for Payer: BCN Commercial	$3.45
Rate for Payer: Cash Price	$3.58
Rate for Payer: Cofinity Commercial	$3.84
Rate for Payer: Encore Health Key Benefits Commercial	$3.58
Rate for Payer: Healthscope Commercial	$4.02
Rate for Payer: Lakeland Regional Health Systems Commercial	$3.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.80
Rate for Payer: PHP Commercial	$3.80
Rate for Payer: Priority Health Cigna Priority Health	$3.13
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.89
Rate for Payer: Priority Health Narrow/Tiered Network	$2.73
Rate for Payer: UHC All Payor (Choice/PPO)	$3.93
Rate for Payer: UHC Core	$3.73
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$3.35

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$199.50

Service Code	NDC 51079-051-20
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$121.68
Max. Negotiated Rate	$179.55
Rate for Payer: Aetna Commercial	$169.58
Rate for Payer: BCBS Trust/PPO	$154.17
Rate for Payer: BCN Commercial	$154.17
Rate for Payer: Cash Price	$159.60
Rate for Payer: Cofinity Commercial	$171.57
Rate for Payer: Encore Health Key Benefits Commercial	$159.60
Rate for Payer: Healthscope Commercial	$179.55
Rate for Payer: Lakeland Regional Health Systems Commercial	$149.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$169.58
Rate for Payer: PHP Commercial	$169.58
Rate for Payer: Priority Health Cigna Priority Health	$139.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$173.56
Rate for Payer: Priority Health Narrow/Tiered Network	$121.68
Rate for Payer: UHC All Payor (Choice/PPO)	$175.56
Rate for Payer: UHC Core	$166.58
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$149.62

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$446.50

Service Code	NDC 66993-068-80
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$272.32
Max. Negotiated Rate	$401.85
Rate for Payer: Aetna Commercial	$379.52
Rate for Payer: BCBS Trust/PPO	$345.06
Rate for Payer: BCN Commercial	$345.06
Rate for Payer: Cash Price	$357.20
Rate for Payer: Cofinity Commercial	$383.99
Rate for Payer: Encore Health Key Benefits Commercial	$357.20
Rate for Payer: Healthscope Commercial	$401.85
Rate for Payer: Lakeland Regional Health Systems Commercial	$334.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$379.52
Rate for Payer: PHP Commercial	$379.52
Rate for Payer: Priority Health Cigna Priority Health	$312.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$388.46
Rate for Payer: Priority Health Narrow/Tiered Network	$272.32
Rate for Payer: UHC All Payor (Choice/PPO)	$392.92
Rate for Payer: UHC Core	$372.83
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$334.88

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$120.56

Service Code	NDC 65862-560-90
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$73.53
Max. Negotiated Rate	$108.50
Rate for Payer: Aetna Commercial	$102.48
Rate for Payer: BCBS Trust/PPO	$93.17
Rate for Payer: BCN Commercial	$93.17
Rate for Payer: Cash Price	$96.45
Rate for Payer: Cofinity Commercial	$103.68
Rate for Payer: Encore Health Key Benefits Commercial	$96.45
Rate for Payer: Healthscope Commercial	$108.50
Rate for Payer: Lakeland Regional Health Systems Commercial	$90.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$102.48
Rate for Payer: PHP Commercial	$102.48
Rate for Payer: Priority Health Cigna Priority Health	$84.39
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$104.89
Rate for Payer: Priority Health Narrow/Tiered Network	$73.53
Rate for Payer: UHC All Payor (Choice/PPO)	$106.09
Rate for Payer: UHC Core	$100.67
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$90.42

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$254.60

Service Code	NDC 63739-564-10
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$155.28
Max. Negotiated Rate	$229.14
Rate for Payer: Aetna Commercial	$216.41
Rate for Payer: BCBS Trust/PPO	$196.75
Rate for Payer: BCN Commercial	$196.75
Rate for Payer: Cash Price	$203.68
Rate for Payer: Cofinity Commercial	$218.96
Rate for Payer: Encore Health Key Benefits Commercial	$203.68
Rate for Payer: Healthscope Commercial	$229.14
Rate for Payer: Lakeland Regional Health Systems Commercial	$190.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$216.41
Rate for Payer: PHP Commercial	$216.41
Rate for Payer: Priority Health Cigna Priority Health	$178.22
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$221.50
Rate for Payer: Priority Health Narrow/Tiered Network	$155.28
Rate for Payer: UHC All Payor (Choice/PPO)	$224.05
Rate for Payer: UHC Core	$212.59
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$190.95

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$192.85

Service Code	NDC 0904-6474-61
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$117.62
Max. Negotiated Rate	$173.56
Rate for Payer: Aetna Commercial	$163.92
Rate for Payer: BCBS Trust/PPO	$149.03
Rate for Payer: BCN Commercial	$149.03
Rate for Payer: Cash Price	$154.28
Rate for Payer: Cofinity Commercial	$165.85
Rate for Payer: Encore Health Key Benefits Commercial	$154.28
Rate for Payer: Healthscope Commercial	$173.56
Rate for Payer: Lakeland Regional Health Systems Commercial	$144.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$163.92
Rate for Payer: PHP Commercial	$163.92
Rate for Payer: Priority Health Cigna Priority Health	$135.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$167.78
Rate for Payer: Priority Health Narrow/Tiered Network	$117.62
Rate for Payer: UHC All Payor (Choice/PPO)	$169.71
Rate for Payer: UHC Core	$161.03
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$144.64

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$2.00

Service Code	NDC 51079-051-01
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna Commercial	$1.70
Rate for Payer: BCBS Trust/PPO	$1.55
Rate for Payer: BCN Commercial	$1.55
Rate for Payer: Cash Price	$1.60
Rate for Payer: Cofinity Commercial	$1.72
Rate for Payer: Encore Health Key Benefits Commercial	$1.60
Rate for Payer: Healthscope Commercial	$1.80
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.70
Rate for Payer: PHP Commercial	$1.70
Rate for Payer: Priority Health Cigna Priority Health	$1.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1.74
Rate for Payer: Priority Health Narrow/Tiered Network	$1.22
Rate for Payer: UHC All Payor (Choice/PPO)	$1.76
Rate for Payer: UHC Core	$1.67
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.50

PAROXETINE 10 MG TABLET

Facility

$74.73

Service Code	NDC 0378-7001-93
Hospital Charge Code	16632
Hospital Revenue Code	637
Min. Negotiated Rate	$45.58
Max. Negotiated Rate	$67.26
Rate for Payer: Aetna Commercial	$63.52
Rate for Payer: BCBS Trust/PPO	$57.75
Rate for Payer: BCN Commercial	$57.75
Rate for Payer: Cash Price	$59.78
Rate for Payer: Cofinity Commercial	$64.27
Rate for Payer: Encore Health Key Benefits Commercial	$59.78
Rate for Payer: Healthscope Commercial	$67.26
Rate for Payer: Lakeland Regional Health Systems Commercial	$56.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$63.52
Rate for Payer: PHP Commercial	$63.52
Rate for Payer: Priority Health Cigna Priority Health	$52.31
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$65.02
Rate for Payer: Priority Health Narrow/Tiered Network	$45.58
Rate for Payer: UHC All Payor (Choice/PPO)	$65.76
Rate for Payer: UHC Core	$62.40
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$56.05

PAROXETINE 10 MG TABLET

Facility

$351.50

Service Code	NDC 0904-5676-61
Hospital Charge Code	16632
Hospital Revenue Code	637
Min. Negotiated Rate	$214.38
Max. Negotiated Rate	$316.35
Rate for Payer: Aetna Commercial	$298.78
Rate for Payer: BCBS Trust/PPO	$271.64
Rate for Payer: BCN Commercial	$271.64
Rate for Payer: Cash Price	$281.20
Rate for Payer: Cofinity Commercial	$302.29
Rate for Payer: Encore Health Key Benefits Commercial	$281.20
Rate for Payer: Healthscope Commercial	$316.35
Rate for Payer: Lakeland Regional Health Systems Commercial	$263.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$298.78
Rate for Payer: PHP Commercial	$298.78
Rate for Payer: Priority Health Cigna Priority Health	$246.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$305.80
Rate for Payer: Priority Health Narrow/Tiered Network	$214.38
Rate for Payer: UHC All Payor (Choice/PPO)	$309.32
Rate for Payer: UHC Core	$293.50
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$263.62

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS

Facility

$2,229.50

Service Code	CPT 28122
Hospital Revenue Code	360
Min. Negotiated Rate	$2,123.34
Max. Negotiated Rate	$2,229.50
Rate for Payer: BCBS Complete	$2,229.50
Rate for Payer: Mclaren Medicaid	$2,123.34
Rate for Payer: Meridian Medicaid	$2,229.50
Rate for Payer: Priority Health Choice Medicaid	$2,123.34

PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING

Facility

$2,153.41

Service Code	CPT 56700
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

PEDS ECHO LIMITED W/DEFINITY

Facility

$1,356.97

Service Code	HCPCS C8922
Hospital Charge Code	48000029
Hospital Revenue Code	480
Min. Negotiated Rate	$827.62
Max. Negotiated Rate	$1,221.27
Rate for Payer: Aetna Commercial	$1,153.42
Rate for Payer: BCBS Trust/PPO	$1,048.67
Rate for Payer: BCN Commercial	$1,048.67
Rate for Payer: Cash Price	$1,085.58
Rate for Payer: Cofinity Commercial	$1,166.99
Rate for Payer: Encore Health Key Benefits Commercial	$1,085.58
Rate for Payer: Healthscope Commercial	$1,221.27
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,017.73
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,153.42
Rate for Payer: PHP Commercial	$1,153.42
Rate for Payer: Priority Health Cigna Priority Health	$949.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,180.56
Rate for Payer: Priority Health Narrow/Tiered Network	$827.62
Rate for Payer: UHC All Payor (Choice/PPO)	$1,194.13
Rate for Payer: UHC Core	$1,133.07
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,017.73

PEDS ECHO LIMITED W/DEFINITY

Facility

$1,356.97

Service Code	HCPCS C8922
Hospital Charge Code	48000029
Hospital Revenue Code	480
Min. Negotiated Rate	$322.28
Max. Negotiated Rate	$1,221.27
Rate for Payer: Aetna Commercial	$1,153.42
Rate for Payer: Aetna Medicare	$352.81
Rate for Payer: Allen County Amish Medical Aid Commercial	$424.05
Rate for Payer: Amish Plain Church Group Commercial	$424.05
Rate for Payer: BCBS Complete	$551.50
Rate for Payer: BCBS MAPPO	$339.24
Rate for Payer: BCBS Trust/PPO	$1,055.04
Rate for Payer: BCN Commercial	$1,055.04
Rate for Payer: BCN Medicare Advantage	$339.24
Rate for Payer: Cash Price	$1,085.58
Rate for Payer: Cash Price	$1,085.58
Rate for Payer: Cofinity Commercial	$1,166.99
Rate for Payer: Encore Health Key Benefits Commercial	$1,085.58
Rate for Payer: Health Alliance Plan Medicare Advantage	$339.24
Rate for Payer: Healthscope Commercial	$1,221.27
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,017.73
Rate for Payer: Mclaren Medicaid	$525.24
Rate for Payer: Meridian Medicaid	$551.50
Rate for Payer: Meridian Wellcare - Medicare Advantage	$356.20
Rate for Payer: MI Amish Medical Board Commercial	$390.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,153.42
Rate for Payer: PACE Senior Care Partners	$322.28
Rate for Payer: PACE SWMI	$339.24
Rate for Payer: PHP Commercial	$1,153.42
Rate for Payer: PHP Medicare Advantage	$339.24
Rate for Payer: Priority Health Choice Medicaid	$525.24
Rate for Payer: Priority Health Cigna Priority Health	$949.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,180.56
Rate for Payer: Priority Health Medicare	$339.24
Rate for Payer: Priority Health Narrow/Tiered Network	$827.62
Rate for Payer: Railroad Medicare Medicare	$339.24
Rate for Payer: UHC All Payor (Choice/PPO)	$1,194.13
Rate for Payer: UHC Core	$1,133.07
Rate for Payer: UHC Dual Complete DSNP	$339.24
Rate for Payer: UHC Medicare Advantage	$349.42
Rate for Payer: VA VA	$339.24
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,017.73

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION

Facility

$56.00

Service Code	NDC 43386-090-19
Hospital Charge Code	10839
Hospital Revenue Code	637
Min. Negotiated Rate	$34.15
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna Commercial	$47.60
Rate for Payer: BCBS Trust/PPO	$43.28
Rate for Payer: BCN Commercial	$43.28
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cofinity Commercial	$48.16
Rate for Payer: Encore Health Key Benefits Commercial	$44.80
Rate for Payer: Healthscope Commercial	$50.40
Rate for Payer: Lakeland Regional Health Systems Commercial	$42.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$47.60
Rate for Payer: PHP Commercial	$47.60
Rate for Payer: Priority Health Cigna Priority Health	$39.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$48.72
Rate for Payer: Priority Health Narrow/Tiered Network	$34.15
Rate for Payer: UHC All Payor (Choice/PPO)	$49.28
Rate for Payer: UHC Core	$46.76
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$42.00

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS

Facility

$9.52

Service Code	NDC 57896-181-05
Hospital Charge Code	41412
Hospital Revenue Code	637
Min. Negotiated Rate	$5.81
Max. Negotiated Rate	$8.57
Rate for Payer: Aetna Commercial	$8.09
Rate for Payer: BCBS Trust/PPO	$7.36
Rate for Payer: BCN Commercial	$7.36
Rate for Payer: Cash Price	$7.62
Rate for Payer: Cofinity Commercial	$8.19
Rate for Payer: Encore Health Key Benefits Commercial	$7.62
Rate for Payer: Healthscope Commercial	$8.57
Rate for Payer: Lakeland Regional Health Systems Commercial	$7.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8.09
Rate for Payer: PHP Commercial	$8.09
Rate for Payer: Priority Health Cigna Priority Health	$6.66
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8.28
Rate for Payer: Priority Health Narrow/Tiered Network	$5.81
Rate for Payer: UHC All Payor (Choice/PPO)	$8.38
Rate for Payer: UHC Core	$7.95
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$7.14

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS

Facility

$29.04

Service Code	NDC 42002-20705
Hospital Charge Code	41412
Hospital Revenue Code	637
Min. Negotiated Rate	$17.71
Max. Negotiated Rate	$26.14
Rate for Payer: Aetna Commercial	$24.68
Rate for Payer: BCBS Trust/PPO	$22.44
Rate for Payer: BCN Commercial	$22.44
Rate for Payer: Cash Price	$23.23
Rate for Payer: Cofinity Commercial	$24.97
Rate for Payer: Encore Health Key Benefits Commercial	$23.23
Rate for Payer: Healthscope Commercial	$26.14
Rate for Payer: Lakeland Regional Health Systems Commercial	$21.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$24.68
Rate for Payer: PHP Commercial	$24.68
Rate for Payer: Priority Health Cigna Priority Health	$20.33
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$25.26
Rate for Payer: Priority Health Narrow/Tiered Network	$17.71
Rate for Payer: UHC All Payor (Choice/PPO)	$25.56
Rate for Payer: UHC Core	$24.25
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$21.78

PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS

Facility

$20.14

Service Code	NDC 0065-0429-21
Hospital Charge Code	35891
Hospital Revenue Code	637
Min. Negotiated Rate	$12.28
Max. Negotiated Rate	$18.13
Rate for Payer: Aetna Commercial	$17.12
Rate for Payer: BCBS Trust/PPO	$15.56
Rate for Payer: BCN Commercial	$15.56
Rate for Payer: Cash Price	$16.11
Rate for Payer: Cofinity Commercial	$17.32
Rate for Payer: Encore Health Key Benefits Commercial	$16.11
Rate for Payer: Healthscope Commercial	$18.13
Rate for Payer: Lakeland Regional Health Systems Commercial	$15.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.12
Rate for Payer: PHP Commercial	$17.12
Rate for Payer: Priority Health Cigna Priority Health	$14.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.52
Rate for Payer: Priority Health Narrow/Tiered Network	$12.28
Rate for Payer: UHC All Payor (Choice/PPO)	$17.72
Rate for Payer: UHC Core	$16.82
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$15.10

PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$9,392.27

Service Code	HCPCS J2506
Hospital Charge Code	32267
Hospital Revenue Code	636
Min. Negotiated Rate	$5,728.35
Max. Negotiated Rate	$8,453.04
Rate for Payer: Aetna Commercial	$7,983.43
Rate for Payer: BCBS Trust/PPO	$7,258.35
Rate for Payer: BCN Commercial	$7,258.35
Rate for Payer: Cash Price	$7,513.82
Rate for Payer: Cofinity Commercial	$8,077.35
Rate for Payer: Encore Health Key Benefits Commercial	$7,513.82
Rate for Payer: Healthscope Commercial	$8,453.04
Rate for Payer: Lakeland Regional Health Systems Commercial	$7,044.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7,983.43
Rate for Payer: PHP Commercial	$7,983.43
Rate for Payer: Priority Health Cigna Priority Health	$6,574.59
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,171.27
Rate for Payer: Priority Health Narrow/Tiered Network	$5,728.35
Rate for Payer: UHC All Payor (Choice/PPO)	$8,265.20
Rate for Payer: UHC Core	$7,842.55
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$7,044.20

PELVIC EXAMINATION UNDER ANESTHESIA (OTHER THAN LOCAL)

Facility

$2,153.41

Service Code	CPT 57410
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

PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE

Facility

$915.30

Service Code	HCPCS J0561
Hospital Charge Code	112201
Hospital Revenue Code	636
Min. Negotiated Rate	$558.24
Max. Negotiated Rate	$823.77
Rate for Payer: Aetna Commercial	$778.00
Rate for Payer: BCBS Trust/PPO	$707.34
Rate for Payer: BCN Commercial	$707.34
Rate for Payer: Cash Price	$732.24
Rate for Payer: Cofinity Commercial	$787.16
Rate for Payer: Encore Health Key Benefits Commercial	$732.24
Rate for Payer: Healthscope Commercial	$823.77
Rate for Payer: Lakeland Regional Health Systems Commercial	$686.48
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$778.00
Rate for Payer: PHP Commercial	$778.00
Rate for Payer: Priority Health Cigna Priority Health	$640.71
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$796.31
Rate for Payer: Priority Health Narrow/Tiered Network	$558.24
Rate for Payer: UHC All Payor (Choice/PPO)	$805.46
Rate for Payer: UHC Core	$764.28
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$686.48

PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION

Facility

$18.34

Service Code	HCPCS J2540
Hospital Charge Code	6086
Hospital Revenue Code	636
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$16.51
Rate for Payer: Aetna Commercial	$15.59
Rate for Payer: BCBS Trust/PPO	$14.17
Rate for Payer: BCN Commercial	$14.17
Rate for Payer: Cash Price	$14.67
Rate for Payer: Cofinity Commercial	$15.77
Rate for Payer: Encore Health Key Benefits Commercial	$14.67
Rate for Payer: Healthscope Commercial	$16.51
Rate for Payer: Lakeland Regional Health Systems Commercial	$13.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.59
Rate for Payer: PHP Commercial	$15.59
Rate for Payer: Priority Health Cigna Priority Health	$12.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15.96
Rate for Payer: Priority Health Narrow/Tiered Network	$11.19
Rate for Payer: UHC All Payor (Choice/PPO)	$16.14
Rate for Payer: UHC Core	$15.31
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$13.76

PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION

Facility

$211.50

Service Code	NDC 0093-4127-74
Hospital Charge Code	6091
Hospital Revenue Code	637
Min. Negotiated Rate	$128.99
Max. Negotiated Rate	$190.35
Rate for Payer: Aetna Commercial	$179.78
Rate for Payer: BCBS Trust/PPO	$163.45
Rate for Payer: BCN Commercial	$163.45
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cofinity Commercial	$181.89
Rate for Payer: Encore Health Key Benefits Commercial	$169.20
Rate for Payer: Healthscope Commercial	$190.35
Rate for Payer: Lakeland Regional Health Systems Commercial	$158.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$179.78
Rate for Payer: PHP Commercial	$179.78
Rate for Payer: Priority Health Cigna Priority Health	$148.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$184.00
Rate for Payer: Priority Health Narrow/Tiered Network	$128.99
Rate for Payer: UHC All Payor (Choice/PPO)	$186.12
Rate for Payer: UHC Core	$176.60
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$158.62

PENICILLIN V POTASSIUM 500 MG TABLET

Facility

$416.64

Service Code	NDC 0781-1655-01
Hospital Charge Code	6093
Hospital Revenue Code	637
Min. Negotiated Rate	$254.11
Max. Negotiated Rate	$374.98
Rate for Payer: Aetna Commercial	$354.14
Rate for Payer: BCBS Trust/PPO	$321.98
Rate for Payer: BCN Commercial	$321.98
Rate for Payer: Cash Price	$333.31
Rate for Payer: Cofinity Commercial	$358.31
Rate for Payer: Encore Health Key Benefits Commercial	$333.31
Rate for Payer: Healthscope Commercial	$374.98
Rate for Payer: Lakeland Regional Health Systems Commercial	$312.48
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$354.14
Rate for Payer: PHP Commercial	$354.14
Rate for Payer: Priority Health Cigna Priority Health	$291.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$362.48
Rate for Payer: Priority Health Narrow/Tiered Network	$254.11
Rate for Payer: UHC All Payor (Choice/PPO)	$366.64
Rate for Payer: UHC Core	$347.89
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$312.48

PENICILLIN V POTASSIUM 500 MG TABLET

Facility

$185.65

Service Code	NDC 65862-176-01
Hospital Charge Code	6093
Hospital Revenue Code	637
Min. Negotiated Rate	$113.23
Max. Negotiated Rate	$167.08
Rate for Payer: Aetna Commercial	$157.80
Rate for Payer: BCBS Trust/PPO	$143.47
Rate for Payer: BCN Commercial	$143.47
Rate for Payer: Cash Price	$148.52
Rate for Payer: Cofinity Commercial	$159.66
Rate for Payer: Encore Health Key Benefits Commercial	$148.52
Rate for Payer: Healthscope Commercial	$167.08
Rate for Payer: Lakeland Regional Health Systems Commercial	$139.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$157.80
Rate for Payer: PHP Commercial	$157.80
Rate for Payer: Priority Health Cigna Priority Health	$129.96
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$161.52
Rate for Payer: Priority Health Narrow/Tiered Network	$113.23
Rate for Payer: UHC All Payor (Choice/PPO)	$163.37
Rate for Payer: UHC Core	$155.02
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$139.24

PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE

Facility

$254.60

Service Code	NDC 60505-0033-6
Hospital Charge Code	10911
Hospital Revenue Code	637
Min. Negotiated Rate	$155.28
Max. Negotiated Rate	$229.14
Rate for Payer: Aetna Commercial	$216.41
Rate for Payer: BCBS Trust/PPO	$196.75
Rate for Payer: BCN Commercial	$196.75
Rate for Payer: Cash Price	$203.68
Rate for Payer: Cofinity Commercial	$218.96
Rate for Payer: Encore Health Key Benefits Commercial	$203.68
Rate for Payer: Healthscope Commercial	$229.14
Rate for Payer: Lakeland Regional Health Systems Commercial	$190.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$216.41
Rate for Payer: PHP Commercial	$216.41
Rate for Payer: Priority Health Cigna Priority Health	$178.22
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$221.50
Rate for Payer: Priority Health Narrow/Tiered Network	$155.28
Rate for Payer: UHC All Payor (Choice/PPO)	$224.05
Rate for Payer: UHC Core	$212.59
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$190.95

Know your out-of-pocket cost for care.

All Charges