Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

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	$241.82
Max. Negotiated Rate	$345.45
Rate for Payer: Aetna Commercial	$310.90
Rate for Payer: ASR ASR	$335.09
Rate for Payer: BCBS Trust/PPO	$267.83
Rate for Payer: BCN Commercial	$267.83
Rate for Payer: Cash Price	$276.36
Rate for Payer: Cofinity Commercial	$324.72
Rate for Payer: Encore Health Key Benefits Commercial	$276.36
Rate for Payer: Healthscope Commercial	$345.45
Rate for Payer: Healthscope Whirlpool	$335.09
Rate for Payer: Mclaren Commercial	$310.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$293.63
Rate for Payer: Priority Health Cigna Priority Health	$241.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$304.00

HYDROXYZINE HCL 25 MG TABLET

Facility

$2.81

Service Code	NDC 68084-254-11
Hospital Charge Code	3774
Hospital Revenue Code	637
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.81
Rate for Payer: Aetna Commercial	$2.53
Rate for Payer: ASR ASR	$2.73
Rate for Payer: BCBS Trust/PPO	$2.18
Rate for Payer: BCN Commercial	$2.18
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cofinity Commercial	$2.64
Rate for Payer: Encore Health Key Benefits Commercial	$2.25
Rate for Payer: Healthscope Commercial	$2.81
Rate for Payer: Healthscope Whirlpool	$2.73
Rate for Payer: Mclaren Commercial	$2.53
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.39
Rate for Payer: Priority Health Cigna Priority Health	$1.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.47

HYDROXYZINE PAMOATE 25 MG CAPSULE

Facility

$317.30

Service Code	NDC 0904-7065-61
Hospital Charge Code	3777
Hospital Revenue Code	637
Min. Negotiated Rate	$222.11
Max. Negotiated Rate	$317.30
Rate for Payer: Aetna Commercial	$285.57
Rate for Payer: ASR ASR	$307.78
Rate for Payer: BCBS Trust/PPO	$246.00
Rate for Payer: BCN Commercial	$246.00
Rate for Payer: Cash Price	$253.84
Rate for Payer: Cofinity Commercial	$298.26
Rate for Payer: Encore Health Key Benefits Commercial	$253.84
Rate for Payer: Healthscope Commercial	$317.30
Rate for Payer: Healthscope Whirlpool	$307.78
Rate for Payer: Mclaren Commercial	$285.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$269.70
Rate for Payer: Priority Health Cigna Priority Health	$222.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$279.22

HYDROXYZINE PAMOATE 25 MG CAPSULE

Facility

$399.50

Service Code	NDC 0069-5410-66
Hospital Charge Code	3777
Hospital Revenue Code	637
Min. Negotiated Rate	$279.65
Max. Negotiated Rate	$399.50
Rate for Payer: Aetna Commercial	$359.55
Rate for Payer: ASR ASR	$387.52
Rate for Payer: BCBS Trust/PPO	$309.73
Rate for Payer: BCN Commercial	$309.73
Rate for Payer: Cash Price	$319.60
Rate for Payer: Cofinity Commercial	$375.53
Rate for Payer: Encore Health Key Benefits Commercial	$319.60
Rate for Payer: Healthscope Commercial	$399.50
Rate for Payer: Healthscope Whirlpool	$387.52
Rate for Payer: Mclaren Commercial	$359.55
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$339.58
Rate for Payer: Priority Health Cigna Priority Health	$279.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$351.56

HYDROXYZINE PAMOATE 25 MG CAPSULE

Facility

$157.45

Service Code	NDC 0185-0674-01
Hospital Charge Code	3777
Hospital Revenue Code	637
Min. Negotiated Rate	$110.22
Max. Negotiated Rate	$157.45
Rate for Payer: Aetna Commercial	$141.70
Rate for Payer: ASR ASR	$152.73
Rate for Payer: BCBS Trust/PPO	$122.07
Rate for Payer: BCN Commercial	$122.07
Rate for Payer: Cash Price	$125.96
Rate for Payer: Cofinity Commercial	$148.00
Rate for Payer: Encore Health Key Benefits Commercial	$125.96
Rate for Payer: Healthscope Commercial	$157.45
Rate for Payer: Healthscope Whirlpool	$152.73
Rate for Payer: Mclaren Commercial	$141.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$133.83
Rate for Payer: Priority Health Cigna Priority Health	$110.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$138.56

HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE

Facility

$753.63

Service Code	HCPCS J7325
Hospital Charge Code	17381
Hospital Revenue Code	636
Min. Negotiated Rate	$527.54
Max. Negotiated Rate	$753.63
Rate for Payer: Aetna Commercial	$678.27
Rate for Payer: ASR ASR	$731.02
Rate for Payer: BCBS Trust/PPO	$584.29
Rate for Payer: BCN Commercial	$584.29
Rate for Payer: Cash Price	$602.90
Rate for Payer: Cofinity Commercial	$708.41
Rate for Payer: Encore Health Key Benefits Commercial	$602.90
Rate for Payer: Healthscope Commercial	$753.63
Rate for Payer: Healthscope Whirlpool	$731.02
Rate for Payer: Mclaren Commercial	$678.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$640.59
Rate for Payer: Priority Health Cigna Priority Health	$527.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$663.19

HYLAN G-F 20 48 MG/6 ML INTRA-ARTICULAR SYRINGE

Facility

$2,037.98

Service Code	HCPCS J7325
Hospital Charge Code	118765
Hospital Revenue Code	636
Min. Negotiated Rate	$1,426.59
Max. Negotiated Rate	$2,037.98
Rate for Payer: Aetna Commercial	$1,834.18
Rate for Payer: ASR ASR	$1,976.84
Rate for Payer: BCBS Trust/PPO	$1,580.05
Rate for Payer: BCN Commercial	$1,580.05
Rate for Payer: Cash Price	$1,630.39
Rate for Payer: Cofinity Commercial	$1,915.70
Rate for Payer: Encore Health Key Benefits Commercial	$1,630.38
Rate for Payer: Healthscope Commercial	$2,037.98
Rate for Payer: Healthscope Whirlpool	$1,976.84
Rate for Payer: Mclaren Commercial	$1,834.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,732.28
Rate for Payer: Priority Health Cigna Priority Health	$1,426.59
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,793.42

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET

Facility

$302.40

Service Code	NDC 43199-011-01
Hospital Charge Code	17023
Hospital Revenue Code	637
Min. Negotiated Rate	$211.68
Max. Negotiated Rate	$302.40
Rate for Payer: Aetna Commercial	$272.16
Rate for Payer: ASR ASR	$293.33
Rate for Payer: BCBS Trust/PPO	$234.45
Rate for Payer: BCN Commercial	$234.45
Rate for Payer: Cash Price	$241.92
Rate for Payer: Cofinity Commercial	$284.26
Rate for Payer: Encore Health Key Benefits Commercial	$241.92
Rate for Payer: Healthscope Commercial	$302.40
Rate for Payer: Healthscope Whirlpool	$293.33
Rate for Payer: Mclaren Commercial	$272.16
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$257.04
Rate for Payer: Priority Health Cigna Priority Health	$211.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$266.11

HYOSCYAMINE SULFATE 0.125 MG TABLET

Facility

$204.45

Service Code	NDC 47781-013-01
Hospital Charge Code	3783
Hospital Revenue Code	637
Min. Negotiated Rate	$143.12
Max. Negotiated Rate	$204.45
Rate for Payer: Aetna Commercial	$184.00
Rate for Payer: ASR ASR	$198.32
Rate for Payer: BCBS Trust/PPO	$158.51
Rate for Payer: BCN Commercial	$158.51
Rate for Payer: Cash Price	$163.56
Rate for Payer: Cofinity Commercial	$192.18
Rate for Payer: Encore Health Key Benefits Commercial	$163.56
Rate for Payer: Healthscope Commercial	$204.45
Rate for Payer: Healthscope Whirlpool	$198.32
Rate for Payer: Mclaren Commercial	$184.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$173.78
Rate for Payer: Priority Health Cigna Priority Health	$143.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$179.92

HYPERTENSION WITH MCC

Facility

$14,753.16

Service Code	MS-DRG 304
Min. Negotiated Rate	$10,838.39
Max. Negotiated Rate	$14,753.16
Rate for Payer: Aetna Medicare	$11,408.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,261.04
Rate for Payer: Amish Plain Church Group Commercial	$14,261.04
Rate for Payer: BCBS MAPPO	$11,408.83
Rate for Payer: BCN Medicare Advantage	$11,408.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,408.83
Rate for Payer: Humana Choice PPO Medicare	$11,408.83
Rate for Payer: Mclaren Medicare	$11,408.83
Rate for Payer: Meridian Wellcare - Medicare Advantage	$11,979.27
Rate for Payer: MI Amish Medical Board Commercial	$13,120.15
Rate for Payer: PACE Medicare	$10,838.39
Rate for Payer: PACE SWMI	$11,408.83
Rate for Payer: PHP Commercial	$12,549.71
Rate for Payer: PHP Medicare Advantage	$11,408.83
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14,753.16
Rate for Payer: Priority Health Medicare	$11,408.83
Rate for Payer: Priority Health Narrow Network	$11,802.53
Rate for Payer: Railroad Medicare Medicare	$11,408.83
Rate for Payer: UHC Medicare Advantage	$11,751.09
Rate for Payer: VA VA	$11,408.83

HYPERTENSION WITHOUT MCC

Facility

$10,075.45

Service Code	MS-DRG 305
Min. Negotiated Rate	$7,657.34
Max. Negotiated Rate	$10,075.45
Rate for Payer: Aetna Medicare	$8,060.36
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,075.45
Rate for Payer: Amish Plain Church Group Commercial	$10,075.45
Rate for Payer: BCBS MAPPO	$8,060.36
Rate for Payer: BCN Medicare Advantage	$8,060.36
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,060.36
Rate for Payer: Humana Choice PPO Medicare	$8,060.36
Rate for Payer: Mclaren Medicare	$8,060.36
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,463.38
Rate for Payer: MI Amish Medical Board Commercial	$9,269.41
Rate for Payer: PACE Medicare	$7,657.34
Rate for Payer: PACE SWMI	$8,060.36
Rate for Payer: PHP Commercial	$8,866.40
Rate for Payer: PHP Medicare Advantage	$8,060.36
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,674.94
Rate for Payer: Priority Health Medicare	$8,060.36
Rate for Payer: Priority Health Narrow Network	$7,739.95
Rate for Payer: Railroad Medicare Medicare	$8,060.36
Rate for Payer: UHC Medicare Advantage	$8,302.17
Rate for Payer: VA VA	$8,060.36

HYPERTENSIVE ENCEPHALOPATHY WITH CC

Facility

$13,057.00

Service Code	MS-DRG 078
Min. Negotiated Rate	$9,775.89
Max. Negotiated Rate	$13,057.00
Rate for Payer: Aetna Medicare	$10,290.41
Rate for Payer: Allen County Amish Medical Aid Commercial	$12,863.01
Rate for Payer: Amish Plain Church Group Commercial	$12,863.01
Rate for Payer: BCBS MAPPO	$10,290.41
Rate for Payer: BCN Medicare Advantage	$10,290.41
Rate for Payer: Health Alliance Plan Medicare Advantage	$10,290.41
Rate for Payer: Humana Choice PPO Medicare	$10,290.41
Rate for Payer: Mclaren Medicare	$10,290.41
Rate for Payer: Meridian Wellcare - Medicare Advantage	$10,804.93
Rate for Payer: MI Amish Medical Board Commercial	$11,833.97
Rate for Payer: PACE Medicare	$9,775.89
Rate for Payer: PACE SWMI	$10,290.41
Rate for Payer: PHP Commercial	$11,319.45
Rate for Payer: PHP Medicare Advantage	$10,290.41
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13,057.00
Rate for Payer: Priority Health Medicare	$10,290.41
Rate for Payer: Priority Health Narrow Network	$10,445.60
Rate for Payer: Railroad Medicare Medicare	$10,290.41
Rate for Payer: UHC Medicare Advantage	$10,599.12
Rate for Payer: VA VA	$10,290.41

HYPERTENSIVE ENCEPHALOPATHY WITH MCC

Facility

$19,399.96

Service Code	MS-DRG 077
Min. Negotiated Rate	$13,749.17
Max. Negotiated Rate	$19,399.96
Rate for Payer: Aetna Medicare	$14,472.81
Rate for Payer: Allen County Amish Medical Aid Commercial	$18,091.01
Rate for Payer: Amish Plain Church Group Commercial	$18,091.01
Rate for Payer: BCBS MAPPO	$14,472.81
Rate for Payer: BCN Medicare Advantage	$14,472.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$14,472.81
Rate for Payer: Humana Choice PPO Medicare	$14,472.81
Rate for Payer: Mclaren Medicare	$14,472.81
Rate for Payer: Meridian Wellcare - Medicare Advantage	$15,196.45
Rate for Payer: MI Amish Medical Board Commercial	$16,643.73
Rate for Payer: PACE Medicare	$13,749.17
Rate for Payer: PACE SWMI	$14,472.81
Rate for Payer: PHP Commercial	$15,920.09
Rate for Payer: PHP Medicare Advantage	$14,472.81
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19,399.96
Rate for Payer: Priority Health Medicare	$14,472.81
Rate for Payer: Priority Health Narrow Network	$15,519.97
Rate for Payer: Railroad Medicare Medicare	$14,472.81
Rate for Payer: UHC Medicare Advantage	$14,906.99
Rate for Payer: VA VA	$14,472.81

HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC

Facility

$9,941.06

Service Code	MS-DRG 079
Min. Negotiated Rate	$7,555.21
Max. Negotiated Rate	$9,941.06
Rate for Payer: Aetna Medicare	$7,952.85
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,941.06
Rate for Payer: Amish Plain Church Group Commercial	$9,941.06
Rate for Payer: BCBS MAPPO	$7,952.85
Rate for Payer: BCN Medicare Advantage	$7,952.85
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,952.85
Rate for Payer: Humana Choice PPO Medicare	$7,952.85
Rate for Payer: Mclaren Medicare	$7,952.85
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,350.49
Rate for Payer: MI Amish Medical Board Commercial	$9,145.78
Rate for Payer: PACE Medicare	$7,555.21
Rate for Payer: PACE SWMI	$7,952.85
Rate for Payer: PHP Commercial	$8,748.14
Rate for Payer: PHP Medicare Advantage	$7,952.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,511.87
Rate for Payer: Priority Health Medicare	$7,952.85
Rate for Payer: Priority Health Narrow Network	$7,609.50
Rate for Payer: Railroad Medicare Medicare	$7,952.85
Rate for Payer: UHC Medicare Advantage	$8,191.44
Rate for Payer: VA VA	$7,952.85

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

Facility

$5,526.50

Service Code	CPT 58563
Hospital Revenue Code	360
Min. Negotiated Rate	$2,418.40
Max. Negotiated Rate	$5,526.50
Rate for Payer: Aetna Medicare	$4,421.20
Rate for Payer: Allen County Amish Medical Aid Commercial	$5,526.50
Rate for Payer: Amish Plain Church Group Commercial	$5,526.50
Rate for Payer: BCBS Complete	$2,539.54
Rate for Payer: BCBS MAPPO	$4,421.20
Rate for Payer: BCN Medicare Advantage	$4,421.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,421.20
Rate for Payer: Humana Choice PPO Medicare	$4,421.20
Rate for Payer: Mclaren Medicaid	$2,418.40
Rate for Payer: Mclaren Medicare	$4,421.20
Rate for Payer: Meridian Medicaid	$2,539.54
Rate for Payer: Meridian Wellcare - Medicare Advantage	$4,642.26
Rate for Payer: MI Amish Medical Board Commercial	$5,084.38
Rate for Payer: PACE Medicare	$4,200.14
Rate for Payer: PACE SWMI	$4,421.20
Rate for Payer: PHP Commercial	$4,863.32
Rate for Payer: PHP Medicaid	$2,418.40
Rate for Payer: PHP Medicare Advantage	$4,421.20
Rate for Payer: Priority Health Choice Medicaid	$2,418.40
Rate for Payer: Priority Health Medicare	$4,421.20
Rate for Payer: Railroad Medicare Medicare	$4,421.20
Rate for Payer: UHC Medicare Advantage	$4,553.84
Rate for Payer: VA VA	$4,421.20

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.54

Service Code	NDC 0121-0917-05
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna Commercial	$2.29
Rate for Payer: ASR ASR	$2.46
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	$2.39
Rate for Payer: Encore Health Key Benefits Commercial	$2.03
Rate for Payer: Healthscope Commercial	$2.54
Rate for Payer: Healthscope Whirlpool	$2.46
Rate for Payer: Mclaren Commercial	$2.29
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.16
Rate for Payer: Priority Health Cigna Priority Health	$1.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.24

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	$2.44
Max. Negotiated Rate	$3.48
Rate for Payer: Aetna Commercial	$3.13
Rate for Payer: ASR ASR	$3.38
Rate for Payer: BCBS Trust/PPO	$2.70
Rate for Payer: BCN Commercial	$2.70
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cofinity Commercial	$3.27
Rate for Payer: Encore Health Key Benefits Commercial	$2.78
Rate for Payer: Healthscope Commercial	$3.48
Rate for Payer: Healthscope Whirlpool	$3.38
Rate for Payer: Mclaren Commercial	$3.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.96
Rate for Payer: Priority Health Cigna Priority Health	$2.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.06

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.54

Service Code	NDC 0121-0917-00
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.54
Rate for Payer: Aetna Commercial	$2.29
Rate for Payer: ASR ASR	$2.46
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	$2.39
Rate for Payer: Encore Health Key Benefits Commercial	$2.03
Rate for Payer: Healthscope Commercial	$2.54
Rate for Payer: Healthscope Whirlpool	$2.46
Rate for Payer: Mclaren Commercial	$2.29
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.16
Rate for Payer: Priority Health Cigna Priority Health	$1.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.24

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$3.62

Service Code	NDC 68094-600-59
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$3.62
Rate for Payer: Aetna Commercial	$3.26
Rate for Payer: ASR ASR	$3.51
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	$3.40
Rate for Payer: Encore Health Key Benefits Commercial	$2.90
Rate for Payer: Healthscope Commercial	$3.62
Rate for Payer: Healthscope Whirlpool	$3.51
Rate for Payer: Mclaren Commercial	$3.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.08
Rate for Payer: Priority Health Cigna Priority Health	$2.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.19

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$2.64

Service Code	NDC 68094-494-59
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$2.64
Rate for Payer: Aetna Commercial	$2.38
Rate for Payer: ASR ASR	$2.56
Rate for Payer: BCBS Trust/PPO	$2.05
Rate for Payer: BCN Commercial	$2.05
Rate for Payer: Cash Price	$2.11
Rate for Payer: Cofinity Commercial	$2.48
Rate for Payer: Encore Health Key Benefits Commercial	$2.11
Rate for Payer: Healthscope Commercial	$2.64
Rate for Payer: Healthscope Whirlpool	$2.56
Rate for Payer: Mclaren Commercial	$2.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.24
Rate for Payer: Priority Health Cigna Priority Health	$1.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.32

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	$3.26
Max. Negotiated Rate	$4.66
Rate for Payer: Aetna Commercial	$4.19
Rate for Payer: ASR ASR	$4.52
Rate for Payer: BCBS Trust/PPO	$3.61
Rate for Payer: BCN Commercial	$3.61
Rate for Payer: Cash Price	$3.72
Rate for Payer: Cofinity Commercial	$4.38
Rate for Payer: Encore Health Key Benefits Commercial	$3.73
Rate for Payer: Healthscope Commercial	$4.66
Rate for Payer: Healthscope Whirlpool	$4.52
Rate for Payer: Mclaren Commercial	$4.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.96
Rate for Payer: Priority Health Cigna Priority Health	$3.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.10

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	$3.32
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.68
Rate for Payer: BCN Commercial	$3.68
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.04
Rate for Payer: Priority Health Cigna Priority Health	$3.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$3.62

Service Code	NDC 68094-600-61
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$3.62
Rate for Payer: Aetna Commercial	$3.26
Rate for Payer: ASR ASR	$3.51
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	$3.40
Rate for Payer: Encore Health Key Benefits Commercial	$2.90
Rate for Payer: Healthscope Commercial	$3.62
Rate for Payer: Healthscope Whirlpool	$3.51
Rate for Payer: Mclaren Commercial	$3.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.08
Rate for Payer: Priority Health Cigna Priority Health	$2.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.19

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	$3.26
Max. Negotiated Rate	$4.66
Rate for Payer: Aetna Commercial	$4.19
Rate for Payer: ASR ASR	$4.52
Rate for Payer: BCBS Trust/PPO	$3.61
Rate for Payer: BCN Commercial	$3.61
Rate for Payer: Cash Price	$3.72
Rate for Payer: Cofinity Commercial	$4.38
Rate for Payer: Encore Health Key Benefits Commercial	$3.73
Rate for Payer: Healthscope Commercial	$4.66
Rate for Payer: Healthscope Whirlpool	$4.52
Rate for Payer: Mclaren Commercial	$4.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.96
Rate for Payer: Priority Health Cigna Priority Health	$3.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.10

IBUPROFEN 100 MG/5 ML ORAL SUSPENSION

Facility

$4.18

Service Code	NDC 0121-4774-40
Hospital Charge Code	10246
Hospital Revenue Code	637
Min. Negotiated Rate	$2.93
Max. Negotiated Rate	$4.18
Rate for Payer: Aetna Commercial	$3.76
Rate for Payer: ASR ASR	$4.05
Rate for Payer: BCBS Trust/PPO	$3.24
Rate for Payer: BCN Commercial	$3.24
Rate for Payer: Cash Price	$3.34
Rate for Payer: Cofinity Commercial	$3.93
Rate for Payer: Encore Health Key Benefits Commercial	$3.34
Rate for Payer: Healthscope Commercial	$4.18
Rate for Payer: Healthscope Whirlpool	$4.05
Rate for Payer: Mclaren Commercial	$3.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.55
Rate for Payer: Priority Health Cigna Priority Health	$2.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.68

Know your out-of-pocket cost for care.

All Charges