Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

INSULIN SUBCUTANEOUS BASAL PUMP - HUMAN (HUMULIN R)

Facility

$56.94

Service Code	NDC 0169-1833-11
Hospital Charge Code	180910
Hospital Revenue Code	637
Min. Negotiated Rate	$39.86
Max. Negotiated Rate	$56.94
Rate for Payer: Aetna Commercial	$51.25
Rate for Payer: ASR ASR	$55.23
Rate for Payer: BCBS Trust/PPO	$44.15
Rate for Payer: BCN Commercial	$44.15
Rate for Payer: Cash Price	$45.55
Rate for Payer: Cofinity Commercial	$53.52
Rate for Payer: Encore Health Key Benefits Commercial	$45.55
Rate for Payer: Healthscope Commercial	$56.94
Rate for Payer: Healthscope Whirlpool	$55.23
Rate for Payer: Mclaren Commercial	$51.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$48.40
Rate for Payer: Priority Health Cigna Priority Health	$39.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$50.11

INSULIN SUBCUTANEOUS BASAL PUMP - INSULIN GLULISINE (APIDRA)

Facility

$290.23

Service Code	HCPCS J1815
Hospital Charge Code	180908
Hospital Revenue Code	637
Min. Negotiated Rate	$203.16
Max. Negotiated Rate	$290.23
Rate for Payer: Aetna Commercial	$261.21
Rate for Payer: ASR ASR	$281.52
Rate for Payer: BCBS Trust/PPO	$225.02
Rate for Payer: BCN Commercial	$225.02
Rate for Payer: Cash Price	$232.18
Rate for Payer: Cofinity Commercial	$272.82
Rate for Payer: Encore Health Key Benefits Commercial	$232.18
Rate for Payer: Healthscope Commercial	$290.23
Rate for Payer: Healthscope Whirlpool	$281.52
Rate for Payer: Mclaren Commercial	$261.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$246.70
Rate for Payer: Priority Health Cigna Priority Health	$203.16
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$255.40

INSULIN SUBCUTANEOUS BASAL PUMP - LISPRO (HUMALOG)

Facility

$177.23

Service Code	NDC 0002-7510-01
Hospital Charge Code	180914
Hospital Revenue Code	637
Min. Negotiated Rate	$124.06
Max. Negotiated Rate	$177.23
Rate for Payer: Aetna Commercial	$159.51
Rate for Payer: ASR ASR	$171.91
Rate for Payer: BCBS Trust/PPO	$137.41
Rate for Payer: BCN Commercial	$137.41
Rate for Payer: Cash Price	$141.78
Rate for Payer: Cofinity Commercial	$166.60
Rate for Payer: Encore Health Key Benefits Commercial	$141.78
Rate for Payer: Healthscope Commercial	$177.23
Rate for Payer: Healthscope Whirlpool	$171.91
Rate for Payer: Mclaren Commercial	$159.51
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$150.65
Rate for Payer: Priority Health Cigna Priority Health	$124.06
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$155.96

INSULIN SUBCUTANEOUS BASAL PUMP - REGULAR HUMAN (U-500)

Facility

$5,065.60

Service Code	NDC 0002-8501-01
Hospital Charge Code	180916
Hospital Revenue Code	637
Min. Negotiated Rate	$3,545.92
Max. Negotiated Rate	$5,065.60
Rate for Payer: Aetna Commercial	$4,559.04
Rate for Payer: ASR ASR	$4,913.63
Rate for Payer: BCBS Trust/PPO	$3,927.36
Rate for Payer: BCN Commercial	$3,927.36
Rate for Payer: Cash Price	$4,052.48
Rate for Payer: Cofinity Commercial	$4,761.66
Rate for Payer: Encore Health Key Benefits Commercial	$4,052.48
Rate for Payer: Healthscope Commercial	$5,065.60
Rate for Payer: Healthscope Whirlpool	$4,913.63
Rate for Payer: Mclaren Commercial	$4,559.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,305.76
Rate for Payer: Priority Health Cigna Priority Health	$3,545.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,457.73

INSULIN SUBCUTANEOUS BOLUS PUMP - HUMAN (HUMULIN R)

Facility

$56.94

Service Code	NDC 0169-1833-11
Hospital Charge Code	180911
Hospital Revenue Code	637
Min. Negotiated Rate	$39.86
Max. Negotiated Rate	$56.94
Rate for Payer: Aetna Commercial	$51.25
Rate for Payer: ASR ASR	$55.23
Rate for Payer: BCBS Trust/PPO	$44.15
Rate for Payer: BCN Commercial	$44.15
Rate for Payer: Cash Price	$45.55
Rate for Payer: Cofinity Commercial	$53.52
Rate for Payer: Encore Health Key Benefits Commercial	$45.55
Rate for Payer: Healthscope Commercial	$56.94
Rate for Payer: Healthscope Whirlpool	$55.23
Rate for Payer: Mclaren Commercial	$51.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$48.40
Rate for Payer: Priority Health Cigna Priority Health	$39.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$50.11

INSULIN SUBCUTANEOUS CONTINUOUS BASAL PUMP - ASPARTATE (NOVOLOG)

Facility

$248.94

Service Code	NDC 0169-7501-11
Hospital Charge Code	180912
Hospital Revenue Code	637
Min. Negotiated Rate	$174.26
Max. Negotiated Rate	$248.94
Rate for Payer: Aetna Commercial	$224.05
Rate for Payer: ASR ASR	$241.47
Rate for Payer: BCBS Trust/PPO	$193.00
Rate for Payer: BCN Commercial	$193.00
Rate for Payer: Cash Price	$199.15
Rate for Payer: Cofinity Commercial	$234.00
Rate for Payer: Encore Health Key Benefits Commercial	$199.15
Rate for Payer: Healthscope Commercial	$248.94
Rate for Payer: Healthscope Whirlpool	$241.47
Rate for Payer: Mclaren Commercial	$224.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$211.60
Rate for Payer: Priority Health Cigna Priority Health	$174.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$219.07

INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION

Facility

$19.46

Service Code	NDC 0002-0213-01
Hospital Charge Code	10289
Hospital Revenue Code	637
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$19.46
Rate for Payer: Aetna Commercial	$17.51
Rate for Payer: ASR ASR	$18.88
Rate for Payer: BCBS Trust/PPO	$15.09
Rate for Payer: BCN Commercial	$15.09
Rate for Payer: Cash Price	$15.57
Rate for Payer: Cofinity Commercial	$18.29
Rate for Payer: Encore Health Key Benefits Commercial	$15.57
Rate for Payer: Healthscope Commercial	$19.46
Rate for Payer: Healthscope Whirlpool	$18.88
Rate for Payer: Mclaren Commercial	$17.51
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.54
Rate for Payer: Priority Health Cigna Priority Health	$13.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.12

INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION

Facility

$76.26

Service Code	NDC 0002-8215-17
Hospital Charge Code	10289
Hospital Revenue Code	637
Min. Negotiated Rate	$53.38
Max. Negotiated Rate	$76.26
Rate for Payer: Aetna Commercial	$68.63
Rate for Payer: ASR ASR	$73.97
Rate for Payer: BCBS Trust/PPO	$59.12
Rate for Payer: BCN Commercial	$59.12
Rate for Payer: Cash Price	$61.00
Rate for Payer: Cofinity Commercial	$71.68
Rate for Payer: Encore Health Key Benefits Commercial	$61.01
Rate for Payer: Healthscope Commercial	$76.26
Rate for Payer: Healthscope Whirlpool	$73.97
Rate for Payer: Mclaren Commercial	$68.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$64.82
Rate for Payer: Priority Health Cigna Priority Health	$53.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$67.11

INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR PEN INJECTOR

Facility

$3,496.74

Service Code	HCPCS Q3027
Hospital Charge Code	159694
Hospital Revenue Code	636
Min. Negotiated Rate	$2,447.72
Max. Negotiated Rate	$3,496.74
Rate for Payer: Aetna Commercial	$3,147.07
Rate for Payer: ASR ASR	$3,391.84
Rate for Payer: BCBS Trust/PPO	$2,711.02
Rate for Payer: BCN Commercial	$2,711.02
Rate for Payer: Cash Price	$2,797.40
Rate for Payer: Cofinity Commercial	$3,286.94
Rate for Payer: Encore Health Key Benefits Commercial	$2,797.39
Rate for Payer: Healthscope Commercial	$3,496.74
Rate for Payer: Healthscope Whirlpool	$3,391.84
Rate for Payer: Mclaren Commercial	$3,147.07
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,972.23
Rate for Payer: Priority Health Cigna Priority Health	$2,447.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,077.13

INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE

Facility

$5,993.30

Service Code	HCPCS Q3027
Hospital Charge Code	161584
Hospital Revenue Code	636
Min. Negotiated Rate	$4,195.31
Max. Negotiated Rate	$5,993.30
Rate for Payer: Aetna Commercial	$5,393.97
Rate for Payer: ASR ASR	$5,813.50
Rate for Payer: BCBS Trust/PPO	$4,646.61
Rate for Payer: BCN Commercial	$4,646.61
Rate for Payer: Cash Price	$4,794.64
Rate for Payer: Cofinity Commercial	$5,633.70
Rate for Payer: Encore Health Key Benefits Commercial	$4,794.64
Rate for Payer: Healthscope Commercial	$5,993.30
Rate for Payer: Healthscope Whirlpool	$5,813.50
Rate for Payer: Mclaren Commercial	$5,393.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5,094.30
Rate for Payer: Priority Health Cigna Priority Health	$4,195.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,274.10

INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE KIT

Facility

$5,238.48

Service Code	HCPCS Q3027
Hospital Charge Code	36417
Hospital Revenue Code	636
Min. Negotiated Rate	$3,666.94
Max. Negotiated Rate	$5,238.48
Rate for Payer: Aetna Commercial	$4,714.63
Rate for Payer: ASR ASR	$5,081.33
Rate for Payer: BCBS Trust/PPO	$4,061.39
Rate for Payer: BCN Commercial	$4,061.39
Rate for Payer: Cash Price	$4,190.78
Rate for Payer: Cofinity Commercial	$4,924.17
Rate for Payer: Encore Health Key Benefits Commercial	$4,190.78
Rate for Payer: Healthscope Commercial	$5,238.48
Rate for Payer: Healthscope Whirlpool	$5,081.33
Rate for Payer: Mclaren Commercial	$4,714.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,452.71
Rate for Payer: Priority Health Cigna Priority Health	$3,666.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,609.86

INTERSTITIAL LUNG DISEASE WITH CC

Facility

$12,807.90

Service Code	MS-DRG 197
Min. Negotiated Rate	$9,619.85
Max. Negotiated Rate	$12,807.90
Rate for Payer: Aetna Medicare	$10,126.16
Rate for Payer: Allen County Amish Medical Aid Commercial	$12,657.70
Rate for Payer: Amish Plain Church Group Commercial	$12,657.70
Rate for Payer: BCBS MAPPO	$10,126.16
Rate for Payer: BCN Medicare Advantage	$10,126.16
Rate for Payer: Health Alliance Plan Medicare Advantage	$10,126.16
Rate for Payer: Humana Choice PPO Medicare	$10,126.16
Rate for Payer: Mclaren Medicare	$10,126.16
Rate for Payer: Meridian Wellcare - Medicare Advantage	$10,632.47
Rate for Payer: MI Amish Medical Board Commercial	$11,645.08
Rate for Payer: PACE Medicare	$9,619.85
Rate for Payer: PACE SWMI	$10,126.16
Rate for Payer: PHP Commercial	$11,138.78
Rate for Payer: PHP Medicare Advantage	$10,126.16
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12,807.90
Rate for Payer: Priority Health Medicare	$10,126.16
Rate for Payer: Priority Health Narrow Network	$10,246.32
Rate for Payer: Railroad Medicare Medicare	$10,126.16
Rate for Payer: UHC Medicare Advantage	$10,429.94
Rate for Payer: VA VA	$10,126.16

INTERSTITIAL LUNG DISEASE WITH MCC

Facility

$24,336.94

Service Code	MS-DRG 196
Min. Negotiated Rate	$16,841.74
Max. Negotiated Rate	$24,336.94
Rate for Payer: Aetna Medicare	$17,728.15
Rate for Payer: Allen County Amish Medical Aid Commercial	$22,160.19
Rate for Payer: Amish Plain Church Group Commercial	$22,160.19
Rate for Payer: BCBS MAPPO	$17,728.15
Rate for Payer: BCN Medicare Advantage	$17,728.15
Rate for Payer: Health Alliance Plan Medicare Advantage	$17,728.15
Rate for Payer: Humana Choice PPO Medicare	$17,728.15
Rate for Payer: Mclaren Medicare	$17,728.15
Rate for Payer: Meridian Wellcare - Medicare Advantage	$18,614.56
Rate for Payer: MI Amish Medical Board Commercial	$20,387.37
Rate for Payer: PACE Medicare	$16,841.74
Rate for Payer: PACE SWMI	$17,728.15
Rate for Payer: PHP Commercial	$19,500.96
Rate for Payer: PHP Medicare Advantage	$17,728.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24,336.94
Rate for Payer: Priority Health Medicare	$17,728.15
Rate for Payer: Priority Health Narrow Network	$19,469.55
Rate for Payer: Railroad Medicare Medicare	$17,728.15
Rate for Payer: UHC Medicare Advantage	$18,259.99
Rate for Payer: VA VA	$17,728.15

INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC

Facility

$10,336.86

Service Code	MS-DRG 198
Min. Negotiated Rate	$7,856.02
Max. Negotiated Rate	$10,336.86
Rate for Payer: Aetna Medicare	$8,269.49
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,336.86
Rate for Payer: Amish Plain Church Group Commercial	$10,336.86
Rate for Payer: BCBS MAPPO	$8,269.49
Rate for Payer: BCN Medicare Advantage	$8,269.49
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,269.49
Rate for Payer: Humana Choice PPO Medicare	$8,269.49
Rate for Payer: Mclaren Medicare	$8,269.49
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,682.96
Rate for Payer: MI Amish Medical Board Commercial	$9,509.91
Rate for Payer: PACE Medicare	$7,856.02
Rate for Payer: PACE SWMI	$8,269.49
Rate for Payer: PHP Commercial	$9,096.44
Rate for Payer: PHP Medicare Advantage	$8,269.49
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,992.09
Rate for Payer: Priority Health Medicare	$8,269.49
Rate for Payer: Priority Health Narrow Network	$7,993.67
Rate for Payer: Railroad Medicare Medicare	$8,269.49
Rate for Payer: UHC Medicare Advantage	$8,517.57
Rate for Payer: VA VA	$8,269.49

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS

Facility

$13,050.58

Service Code	MS-DRG 065
Min. Negotiated Rate	$9,771.87
Max. Negotiated Rate	$13,050.58
Rate for Payer: Aetna Medicare	$10,286.18
Rate for Payer: Allen County Amish Medical Aid Commercial	$12,857.72
Rate for Payer: Amish Plain Church Group Commercial	$12,857.72
Rate for Payer: BCBS MAPPO	$10,286.18
Rate for Payer: BCN Medicare Advantage	$10,286.18
Rate for Payer: Health Alliance Plan Medicare Advantage	$10,286.18
Rate for Payer: Humana Choice PPO Medicare	$10,286.18
Rate for Payer: Mclaren Medicare	$10,286.18
Rate for Payer: Meridian Wellcare - Medicare Advantage	$10,800.49
Rate for Payer: MI Amish Medical Board Commercial	$11,829.11
Rate for Payer: PACE Medicare	$9,771.87
Rate for Payer: PACE SWMI	$10,286.18
Rate for Payer: PHP Commercial	$11,314.80
Rate for Payer: PHP Medicare Advantage	$10,286.18
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13,050.58
Rate for Payer: Priority Health Medicare	$10,286.18
Rate for Payer: Priority Health Narrow Network	$10,440.46
Rate for Payer: Railroad Medicare Medicare	$10,286.18
Rate for Payer: UHC Medicare Advantage	$10,594.77
Rate for Payer: VA VA	$10,286.18

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC

Facility

$25,718.52

Service Code	MS-DRG 064
Min. Negotiated Rate	$17,707.17
Max. Negotiated Rate	$25,718.52
Rate for Payer: Aetna Medicare	$18,639.13
Rate for Payer: Allen County Amish Medical Aid Commercial	$23,298.91
Rate for Payer: Amish Plain Church Group Commercial	$23,298.91
Rate for Payer: BCBS MAPPO	$18,639.13
Rate for Payer: BCN Medicare Advantage	$18,639.13
Rate for Payer: Health Alliance Plan Medicare Advantage	$18,639.13
Rate for Payer: Humana Choice PPO Medicare	$18,639.13
Rate for Payer: Mclaren Medicare	$18,639.13
Rate for Payer: Meridian Wellcare - Medicare Advantage	$19,571.09
Rate for Payer: MI Amish Medical Board Commercial	$21,435.00
Rate for Payer: PACE Medicare	$17,707.17
Rate for Payer: PACE SWMI	$18,639.13
Rate for Payer: PHP Commercial	$20,503.04
Rate for Payer: PHP Medicare Advantage	$18,639.13
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$25,718.52
Rate for Payer: Priority Health Medicare	$18,639.13
Rate for Payer: Priority Health Narrow Network	$20,574.82
Rate for Payer: Railroad Medicare Medicare	$18,639.13
Rate for Payer: UHC Medicare Advantage	$19,198.30
Rate for Payer: VA VA	$18,639.13

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC

Facility

$9,376.99

Service Code	MS-DRG 066
Min. Negotiated Rate	$7,062.00
Max. Negotiated Rate	$9,376.99
Rate for Payer: Aetna Medicare	$7,501.59
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,376.99
Rate for Payer: Amish Plain Church Group Commercial	$9,376.99
Rate for Payer: BCBS MAPPO	$7,501.59
Rate for Payer: BCN Medicare Advantage	$7,501.59
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,501.59
Rate for Payer: Humana Choice PPO Medicare	$7,501.59
Rate for Payer: Mclaren Medicare	$7,501.59
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7,876.67
Rate for Payer: MI Amish Medical Board Commercial	$8,626.83
Rate for Payer: PACE Medicare	$7,126.51
Rate for Payer: PACE SWMI	$7,501.59
Rate for Payer: PHP Commercial	$8,251.75
Rate for Payer: PHP Medicare Advantage	$7,501.59
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,827.50
Rate for Payer: Priority Health Medicare	$7,501.59
Rate for Payer: Priority Health Narrow Network	$7,062.00
Rate for Payer: Railroad Medicare Medicare	$7,501.59
Rate for Payer: UHC Medicare Advantage	$7,726.64
Rate for Payer: VA VA	$7,501.59

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC

Facility

$78,855.58

Service Code	MS-DRG 021
Min. Negotiated Rate	$50,992.64
Max. Negotiated Rate	$78,855.58
Rate for Payer: Aetna Medicare	$53,676.46
Rate for Payer: Allen County Amish Medical Aid Commercial	$67,095.58
Rate for Payer: Amish Plain Church Group Commercial	$67,095.58
Rate for Payer: BCBS MAPPO	$53,676.46
Rate for Payer: BCN Medicare Advantage	$53,676.46
Rate for Payer: Health Alliance Plan Medicare Advantage	$53,676.46
Rate for Payer: Humana Choice PPO Medicare	$53,676.46
Rate for Payer: Mclaren Medicare	$53,676.46
Rate for Payer: Meridian Wellcare - Medicare Advantage	$56,360.28
Rate for Payer: MI Amish Medical Board Commercial	$61,727.93
Rate for Payer: PACE Medicare	$50,992.64
Rate for Payer: PACE SWMI	$53,676.46
Rate for Payer: PHP Commercial	$59,044.11
Rate for Payer: PHP Medicare Advantage	$53,676.46
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$78,855.58
Rate for Payer: Priority Health Medicare	$53,676.46
Rate for Payer: Priority Health Narrow Network	$63,084.46
Rate for Payer: Railroad Medicare Medicare	$53,676.46
Rate for Payer: UHC Medicare Advantage	$55,286.75
Rate for Payer: VA VA	$53,676.46

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC

Facility

$108,528.82

Service Code	MS-DRG 020
Min. Negotiated Rate	$69,580.19
Max. Negotiated Rate	$108,528.82
Rate for Payer: Aetna Medicare	$73,242.31
Rate for Payer: Allen County Amish Medical Aid Commercial	$91,552.89
Rate for Payer: Amish Plain Church Group Commercial	$91,552.89
Rate for Payer: BCBS MAPPO	$73,242.31
Rate for Payer: BCN Medicare Advantage	$73,242.31
Rate for Payer: Health Alliance Plan Medicare Advantage	$73,242.31
Rate for Payer: Humana Choice PPO Medicare	$73,242.31
Rate for Payer: Mclaren Medicare	$73,242.31
Rate for Payer: Meridian Wellcare - Medicare Advantage	$76,904.43
Rate for Payer: MI Amish Medical Board Commercial	$84,228.66
Rate for Payer: PACE Medicare	$69,580.19
Rate for Payer: PACE SWMI	$73,242.31
Rate for Payer: PHP Commercial	$80,566.54
Rate for Payer: PHP Medicare Advantage	$73,242.31
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$108,528.82
Rate for Payer: Priority Health Medicare	$73,242.31
Rate for Payer: Priority Health Narrow Network	$86,823.06
Rate for Payer: Railroad Medicare Medicare	$73,242.31
Rate for Payer: UHC Medicare Advantage	$75,439.58
Rate for Payer: VA VA	$73,242.31

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC

Facility

$44,640.83

Service Code	MS-DRG 022
Min. Negotiated Rate	$33,147.46
Max. Negotiated Rate	$44,640.83
Rate for Payer: Aetna Medicare	$34,892.06
Rate for Payer: Allen County Amish Medical Aid Commercial	$43,615.08
Rate for Payer: Amish Plain Church Group Commercial	$43,615.08
Rate for Payer: BCBS MAPPO	$34,892.06
Rate for Payer: BCN Medicare Advantage	$34,892.06
Rate for Payer: Health Alliance Plan Medicare Advantage	$34,892.06
Rate for Payer: Humana Choice PPO Medicare	$34,892.06
Rate for Payer: Mclaren Medicare	$34,892.06
Rate for Payer: Meridian Wellcare - Medicare Advantage	$36,636.66
Rate for Payer: MI Amish Medical Board Commercial	$40,125.87
Rate for Payer: PACE Medicare	$33,147.46
Rate for Payer: PACE SWMI	$34,892.06
Rate for Payer: PHP Commercial	$38,381.27
Rate for Payer: PHP Medicare Advantage	$34,892.06
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44,640.83
Rate for Payer: Priority Health Medicare	$34,892.06
Rate for Payer: Priority Health Narrow Network	$35,712.66
Rate for Payer: Railroad Medicare Medicare	$34,892.06
Rate for Payer: UHC Medicare Advantage	$35,938.82
Rate for Payer: VA VA	$34,892.06

INTRAOCULAR PROCEDURES WITH CC/MCC

Facility

$23,507.47

Service Code	MS-DRG 116
Min. Negotiated Rate	$16,322.15
Max. Negotiated Rate	$23,507.47
Rate for Payer: Aetna Medicare	$17,181.21
Rate for Payer: Allen County Amish Medical Aid Commercial	$21,476.51
Rate for Payer: Amish Plain Church Group Commercial	$21,476.51
Rate for Payer: BCBS MAPPO	$17,181.21
Rate for Payer: BCN Medicare Advantage	$17,181.21
Rate for Payer: Health Alliance Plan Medicare Advantage	$17,181.21
Rate for Payer: Humana Choice PPO Medicare	$17,181.21
Rate for Payer: Mclaren Medicare	$17,181.21
Rate for Payer: Meridian Wellcare - Medicare Advantage	$18,040.27
Rate for Payer: MI Amish Medical Board Commercial	$19,758.39
Rate for Payer: PACE Medicare	$16,322.15
Rate for Payer: PACE SWMI	$17,181.21
Rate for Payer: PHP Commercial	$18,899.33
Rate for Payer: PHP Medicare Advantage	$17,181.21
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$23,507.47
Rate for Payer: Priority Health Medicare	$17,181.21
Rate for Payer: Priority Health Narrow Network	$18,805.98
Rate for Payer: Railroad Medicare Medicare	$17,181.21
Rate for Payer: UHC Medicare Advantage	$17,696.65
Rate for Payer: VA VA	$17,181.21

INTRAOCULAR PROCEDURES WITHOUT CC/MCC

Facility

$15,387.46

Service Code	MS-DRG 117
Min. Negotiated Rate	$11,235.71
Max. Negotiated Rate	$15,387.46
Rate for Payer: Aetna Medicare	$11,827.06
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,783.82
Rate for Payer: Amish Plain Church Group Commercial	$14,783.82
Rate for Payer: BCBS MAPPO	$11,827.06
Rate for Payer: BCN Medicare Advantage	$11,827.06
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,827.06
Rate for Payer: Humana Choice PPO Medicare	$11,827.06
Rate for Payer: Mclaren Medicare	$11,827.06
Rate for Payer: Meridian Wellcare - Medicare Advantage	$12,418.41
Rate for Payer: MI Amish Medical Board Commercial	$13,601.12
Rate for Payer: PACE Medicare	$11,235.71
Rate for Payer: PACE SWMI	$11,827.06
Rate for Payer: PHP Commercial	$13,009.77
Rate for Payer: PHP Medicare Advantage	$11,827.06
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15,387.46
Rate for Payer: Priority Health Medicare	$11,827.06
Rate for Payer: Priority Health Narrow Network	$12,309.97
Rate for Payer: Railroad Medicare Medicare	$11,827.06
Rate for Payer: UHC Medicare Advantage	$12,181.87
Rate for Payer: VA VA	$11,827.06

IODIXANOL 320 MG IODINE/ML INTRAVENOUS SOLUTION

Facility

$50.00

Service Code	HCPCS Q9967
Hospital Charge Code	17595
Hospital Revenue Code	636
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$45.00
Rate for Payer: Aetna Commercial	$90.00
Rate for Payer: ASR ASR	$97.00
Rate for Payer: ASR ASR	$48.50
Rate for Payer: BCBS Trust/PPO	$77.53
Rate for Payer: BCBS Trust/PPO	$38.76
Rate for Payer: BCN Commercial	$38.76
Rate for Payer: BCN Commercial	$77.53
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cofinity Commercial	$94.00
Rate for Payer: Cofinity Commercial	$47.00
Rate for Payer: Encore Health Key Benefits Commercial	$80.00
Rate for Payer: Encore Health Key Benefits Commercial	$40.00
Rate for Payer: Healthscope Commercial	$100.00
Rate for Payer: Healthscope Commercial	$50.00
Rate for Payer: Healthscope Whirlpool	$48.50
Rate for Payer: Healthscope Whirlpool	$97.00
Rate for Payer: Mclaren Commercial	$90.00
Rate for Payer: Mclaren Commercial	$45.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$42.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$85.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00
Rate for Payer: Priority Health Cigna Priority Health	$35.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$88.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$44.00

IODOFORM 1/2" X 5 YARD BANDAGE

Facility

$14.96

Service Code	NDC 8080783200
Hospital Charge Code	110335
Hospital Revenue Code	637
Min. Negotiated Rate	$10.47
Max. Negotiated Rate	$14.96
Rate for Payer: Aetna Commercial	$13.46
Rate for Payer: ASR ASR	$14.51
Rate for Payer: BCBS Trust/PPO	$11.60
Rate for Payer: BCN Commercial	$11.60
Rate for Payer: Cash Price	$11.97
Rate for Payer: Cofinity Commercial	$14.06
Rate for Payer: Encore Health Key Benefits Commercial	$11.97
Rate for Payer: Healthscope Commercial	$14.96
Rate for Payer: Healthscope Whirlpool	$14.51
Rate for Payer: Mclaren Commercial	$13.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.72
Rate for Payer: Priority Health Cigna Priority Health	$10.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.16

IODOFORM 1/4" X 5 YARD BANDAGE

Facility

$11.76

Service Code	NDC 80196-733-03
Hospital Charge Code	110336
Hospital Revenue Code	637
Min. Negotiated Rate	$8.23
Max. Negotiated Rate	$11.76
Rate for Payer: Aetna Commercial	$10.58
Rate for Payer: ASR ASR	$11.41
Rate for Payer: BCBS Trust/PPO	$9.12
Rate for Payer: BCN Commercial	$9.12
Rate for Payer: Cash Price	$9.41
Rate for Payer: Cofinity Commercial	$11.05
Rate for Payer: Encore Health Key Benefits Commercial	$9.41
Rate for Payer: Healthscope Commercial	$11.76
Rate for Payer: Healthscope Whirlpool	$11.41
Rate for Payer: Mclaren Commercial	$10.58
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.00
Rate for Payer: Priority Health Cigna Priority Health	$8.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.35

Know your out-of-pocket cost for care.

All Charges