Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

IODOFORM 1" X 5 YARD BANDAGE

Facility

$17.92

Service Code	NDC 8080783300
Hospital Charge Code	110337
Hospital Revenue Code	637
Min. Negotiated Rate	$12.54
Max. Negotiated Rate	$17.92
Rate for Payer: Aetna Commercial	$16.13
Rate for Payer: ASR ASR	$17.38
Rate for Payer: BCBS Trust/PPO	$13.89
Rate for Payer: BCN Commercial	$13.89
Rate for Payer: Cash Price	$14.34
Rate for Payer: Cofinity Commercial	$16.84
Rate for Payer: Encore Health Key Benefits Commercial	$14.34
Rate for Payer: Healthscope Commercial	$17.92
Rate for Payer: Healthscope Whirlpool	$17.38
Rate for Payer: Mclaren Commercial	$16.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.23
Rate for Payer: Priority Health Cigna Priority Health	$12.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15.77

IODOFORM 2" X 5 YARD BANDAGE

Facility

$13.88

Service Code	NDC 8080783400
Hospital Charge Code	110338
Hospital Revenue Code	637
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$13.88
Rate for Payer: Aetna Commercial	$12.49
Rate for Payer: ASR ASR	$13.46
Rate for Payer: BCBS Trust/PPO	$10.76
Rate for Payer: BCN Commercial	$10.76
Rate for Payer: Cash Price	$11.10
Rate for Payer: Cofinity Commercial	$13.05
Rate for Payer: Encore Health Key Benefits Commercial	$11.10
Rate for Payer: Healthscope Commercial	$13.88
Rate for Payer: Healthscope Whirlpool	$13.46
Rate for Payer: Mclaren Commercial	$12.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.80
Rate for Payer: Priority Health Cigna Priority Health	$9.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.21

IOPAMIDOL 300 MG IODINE/ML (61 %) INTRAVENOUS SOLUTION

Facility

$42.00

Service Code	HCPCS Q9967
Hospital Charge Code	27737
Hospital Revenue Code	636
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: ASR ASR	$40.74
Rate for Payer: BCBS Trust/PPO	$32.56
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$35.70
Rate for Payer: Priority Health Cigna Priority Health	$29.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION

Facility

$700.00

Service Code	HCPCS Q9967
Hospital Charge Code	10328
Hospital Revenue Code	636
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$630.00
Rate for Payer: Aetna Commercial	$252.00
Rate for Payer: Aetna Commercial	$126.00
Rate for Payer: ASR ASR	$271.60
Rate for Payer: ASR ASR	$679.00
Rate for Payer: ASR ASR	$135.80
Rate for Payer: BCBS Trust/PPO	$217.08
Rate for Payer: BCBS Trust/PPO	$108.54
Rate for Payer: BCBS Trust/PPO	$542.71
Rate for Payer: BCN Commercial	$542.71
Rate for Payer: BCN Commercial	$217.08
Rate for Payer: BCN Commercial	$108.54
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Cash Price	$224.00
Rate for Payer: Cofinity Commercial	$131.60
Rate for Payer: Cofinity Commercial	$658.00
Rate for Payer: Cofinity Commercial	$263.20
Rate for Payer: Encore Health Key Benefits Commercial	$112.00
Rate for Payer: Encore Health Key Benefits Commercial	$224.00
Rate for Payer: Encore Health Key Benefits Commercial	$560.00
Rate for Payer: Healthscope Commercial	$700.00
Rate for Payer: Healthscope Commercial	$280.00
Rate for Payer: Healthscope Commercial	$140.00
Rate for Payer: Healthscope Whirlpool	$271.60
Rate for Payer: Healthscope Whirlpool	$135.80
Rate for Payer: Healthscope Whirlpool	$679.00
Rate for Payer: Mclaren Commercial	$630.00
Rate for Payer: Mclaren Commercial	$126.00
Rate for Payer: Mclaren Commercial	$252.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$238.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$595.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$119.00
Rate for Payer: Priority Health Cigna Priority Health	$98.00
Rate for Payer: Priority Health Cigna Priority Health	$196.00
Rate for Payer: Priority Health Cigna Priority Health	$490.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$246.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$123.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$616.00

IPL CHEEKS FIRST

Professional

Both

$125.00

Service Code	HCPCS 00126
Hospital Revenue Code	960
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$87.50
Rate for Payer: BCBS Complete	$50.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Priority Health Cigna Priority Health	$87.50

IPL CHEST FIRST

Professional

Both

$300.00

Service Code	HCPCS 00128
Hospital Revenue Code	960
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$210.00
Rate for Payer: BCBS Complete	$120.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Priority Health Cigna Priority Health	$210.00

IPL CHEST SECOND

Professional

Both

$200.00

Service Code	HCPCS 00129
Hospital Revenue Code	960
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$140.00
Rate for Payer: BCBS Complete	$80.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Priority Health Cigna Priority Health	$140.00

IPL FACE FIRST

Professional

Both

$225.00

Service Code	HCPCS 00130
Hospital Revenue Code	960
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$157.50
Rate for Payer: BCBS Complete	$90.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Priority Health Cigna Priority Health	$157.50

IPL FACE, NECK, CHEST FIRST

Professional

Both

$400.00

Service Code	HCPCS 00132
Hospital Revenue Code	960
Min. Negotiated Rate	$160.00
Max. Negotiated Rate	$280.00
Rate for Payer: BCBS Complete	$160.00
Rate for Payer: Cash Price	$320.00
Rate for Payer: Priority Health Cigna Priority Health	$280.00

IPL FACE, NECK, CHEST SECOND

Professional

Both

$275.00

Service Code	HCPCS 00133
Hospital Revenue Code	960
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$192.50
Rate for Payer: BCBS Complete	$110.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Priority Health Cigna Priority Health	$192.50

IPL FACE & NECK FIRST

Professional

Both

$250.00

Service Code	HCPCS 00134
Hospital Revenue Code	960
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$175.00
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Priority Health Cigna Priority Health	$175.00

IPL FACE & NECK SECOND

Professional

Both

$175.00

Service Code	HCPCS 00135
Hospital Revenue Code	960
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$122.50
Rate for Payer: BCBS Complete	$70.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Priority Health Cigna Priority Health	$122.50

IPL FACE SECOND

Professional

Both

$100.00

Service Code	HCPCS 00131
Hospital Revenue Code	960
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$70.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00

IPL HANDS & ARMS FIRST

Professional

Both

$350.00

Service Code	HCPCS 00136
Hospital Revenue Code	960
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$245.00
Rate for Payer: BCBS Complete	$140.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Priority Health Cigna Priority Health	$245.00

IPL HANDS & ARMS SECOND

Professional

Both

$225.00

Service Code	HCPCS 00137
Hospital Revenue Code	960
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$157.50
Rate for Payer: BCBS Complete	$90.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Priority Health Cigna Priority Health	$157.50

IPL NECK

Professional

Both

$100.00

Service Code	HCPCS 00138
Hospital Revenue Code	960
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$70.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00

IPL NOSE & CHEEKS FIRST

Professional

Both

$150.00

Service Code	HCPCS 00127
Hospital Revenue Code	960
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$105.00
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Priority Health Cigna Priority Health	$105.00

IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN

Facility

$2.91

Service Code	HCPCS J7620
Hospital Charge Code	30510
Hospital Revenue Code	250
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$2.91
Rate for Payer: Aetna Commercial	$2.62
Rate for Payer: Aetna Commercial	$2.38
Rate for Payer: Aetna Commercial	$2.98
Rate for Payer: Aetna Commercial	$3.98
Rate for Payer: ASR ASR	$2.82
Rate for Payer: ASR ASR	$3.21
Rate for Payer: ASR ASR	$2.57
Rate for Payer: ASR ASR	$4.29
Rate for Payer: BCBS Trust/PPO	$2.26
Rate for Payer: BCBS Trust/PPO	$2.05
Rate for Payer: BCBS Trust/PPO	$2.57
Rate for Payer: BCBS Trust/PPO	$3.43
Rate for Payer: BCN Commercial	$2.26
Rate for Payer: BCN Commercial	$2.57
Rate for Payer: BCN Commercial	$2.05
Rate for Payer: BCN Commercial	$3.43
Rate for Payer: Cash Price	$2.12
Rate for Payer: Cash Price	$2.33
Rate for Payer: Cash Price	$3.53
Rate for Payer: Cash Price	$2.64
Rate for Payer: Cofinity Commercial	$2.49
Rate for Payer: Cofinity Commercial	$2.74
Rate for Payer: Cofinity Commercial	$4.15
Rate for Payer: Cofinity Commercial	$3.11
Rate for Payer: Encore Health Key Benefits Commercial	$2.33
Rate for Payer: Encore Health Key Benefits Commercial	$2.12
Rate for Payer: Encore Health Key Benefits Commercial	$2.65
Rate for Payer: Encore Health Key Benefits Commercial	$3.54
Rate for Payer: Healthscope Commercial	$2.65
Rate for Payer: Healthscope Commercial	$3.31
Rate for Payer: Healthscope Commercial	$4.42
Rate for Payer: Healthscope Commercial	$2.91
Rate for Payer: Healthscope Whirlpool	$2.57
Rate for Payer: Healthscope Whirlpool	$4.29
Rate for Payer: Healthscope Whirlpool	$2.82
Rate for Payer: Healthscope Whirlpool	$3.21
Rate for Payer: Mclaren Commercial	$2.98
Rate for Payer: Mclaren Commercial	$3.98
Rate for Payer: Mclaren Commercial	$2.62
Rate for Payer: Mclaren Commercial	$2.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.47
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.76
Rate for Payer: Priority Health Cigna Priority Health	$2.32
Rate for Payer: Priority Health Cigna Priority Health	$2.04
Rate for Payer: Priority Health Cigna Priority Health	$1.86
Rate for Payer: Priority Health Cigna Priority Health	$3.09
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.89

IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION

Facility

$1,592.82

Service Code	NDC 0597-0024-02
Hospital Charge Code	172696
Hospital Revenue Code	637
Min. Negotiated Rate	$1,114.97
Max. Negotiated Rate	$1,592.82
Rate for Payer: Aetna Commercial	$1,433.54
Rate for Payer: ASR ASR	$1,545.04
Rate for Payer: BCBS Trust/PPO	$1,234.91
Rate for Payer: BCN Commercial	$1,234.91
Rate for Payer: Cash Price	$1,274.26
Rate for Payer: Cofinity Commercial	$1,497.25
Rate for Payer: Encore Health Key Benefits Commercial	$1,274.26
Rate for Payer: Healthscope Commercial	$1,592.82
Rate for Payer: Healthscope Whirlpool	$1,545.04
Rate for Payer: Mclaren Commercial	$1,433.54
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,353.90
Rate for Payer: Priority Health Cigna Priority Health	$1,114.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,401.68

IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION

Facility

$3.47

Service Code	HCPCS J7644
Hospital Charge Code	12580
Hospital Revenue Code	250
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.47
Rate for Payer: Aetna Commercial	$3.12
Rate for Payer: Aetna Commercial	$4.12
Rate for Payer: Aetna Commercial	$5.13
Rate for Payer: ASR ASR	$4.44
Rate for Payer: ASR ASR	$3.37
Rate for Payer: ASR ASR	$5.53
Rate for Payer: BCBS Trust/PPO	$4.42
Rate for Payer: BCBS Trust/PPO	$3.55
Rate for Payer: BCBS Trust/PPO	$2.69
Rate for Payer: BCN Commercial	$2.69
Rate for Payer: BCN Commercial	$4.42
Rate for Payer: BCN Commercial	$3.55
Rate for Payer: Cash Price	$2.77
Rate for Payer: Cash Price	$4.56
Rate for Payer: Cash Price	$3.67
Rate for Payer: Cofinity Commercial	$4.31
Rate for Payer: Cofinity Commercial	$3.26
Rate for Payer: Cofinity Commercial	$5.36
Rate for Payer: Encore Health Key Benefits Commercial	$3.66
Rate for Payer: Encore Health Key Benefits Commercial	$4.56
Rate for Payer: Encore Health Key Benefits Commercial	$2.78
Rate for Payer: Healthscope Commercial	$4.58
Rate for Payer: Healthscope Commercial	$3.47
Rate for Payer: Healthscope Commercial	$5.70
Rate for Payer: Healthscope Whirlpool	$5.53
Rate for Payer: Healthscope Whirlpool	$4.44
Rate for Payer: Healthscope Whirlpool	$3.37
Rate for Payer: Mclaren Commercial	$5.13
Rate for Payer: Mclaren Commercial	$4.12
Rate for Payer: Mclaren Commercial	$3.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.89
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.84
Rate for Payer: Priority Health Cigna Priority Health	$2.43
Rate for Payer: Priority Health Cigna Priority Health	$3.21
Rate for Payer: Priority Health Cigna Priority Health	$3.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.03
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5.02

IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER

Facility

$1,624.40

Service Code	NDC 0597-0087-17
Hospital Charge Code	41142
Hospital Revenue Code	637
Min. Negotiated Rate	$1,137.08
Max. Negotiated Rate	$1,624.40
Rate for Payer: Aetna Commercial	$1,461.96
Rate for Payer: ASR ASR	$1,575.67
Rate for Payer: BCBS Trust/PPO	$1,259.40
Rate for Payer: BCN Commercial	$1,259.40
Rate for Payer: Cash Price	$1,299.52
Rate for Payer: Cofinity Commercial	$1,526.94
Rate for Payer: Encore Health Key Benefits Commercial	$1,299.52
Rate for Payer: Healthscope Commercial	$1,624.40
Rate for Payer: Healthscope Whirlpool	$1,575.67
Rate for Payer: Mclaren Commercial	$1,461.96
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,380.74
Rate for Payer: Priority Health Cigna Priority Health	$1,137.08
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,429.47

IRBESARTAN 150 MG TABLET

Facility

$790.21

Service Code	NDC 0024-5851-30
Hospital Charge Code	21848
Hospital Revenue Code	637
Min. Negotiated Rate	$553.15
Max. Negotiated Rate	$790.21
Rate for Payer: Aetna Commercial	$711.19
Rate for Payer: ASR ASR	$766.50
Rate for Payer: BCBS Trust/PPO	$612.65
Rate for Payer: BCN Commercial	$612.65
Rate for Payer: Cash Price	$632.17
Rate for Payer: Cofinity Commercial	$742.80
Rate for Payer: Encore Health Key Benefits Commercial	$632.17
Rate for Payer: Healthscope Commercial	$790.21
Rate for Payer: Healthscope Whirlpool	$766.50
Rate for Payer: Mclaren Commercial	$711.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$671.68
Rate for Payer: Priority Health Cigna Priority Health	$553.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$695.38

IRBESARTAN 150 MG TABLET

Facility

$79.67

Service Code	NDC 43547-375-03
Hospital Charge Code	21848
Hospital Revenue Code	637
Min. Negotiated Rate	$55.77
Max. Negotiated Rate	$79.67
Rate for Payer: Aetna Commercial	$71.70
Rate for Payer: ASR ASR	$77.28
Rate for Payer: BCBS Trust/PPO	$61.77
Rate for Payer: BCN Commercial	$61.77
Rate for Payer: Cash Price	$63.73
Rate for Payer: Cofinity Commercial	$74.89
Rate for Payer: Encore Health Key Benefits Commercial	$63.74
Rate for Payer: Healthscope Commercial	$79.67
Rate for Payer: Healthscope Whirlpool	$77.28
Rate for Payer: Mclaren Commercial	$71.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$67.72
Rate for Payer: Priority Health Cigna Priority Health	$55.77
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$70.11

IRBESARTAN 150 MG TABLET

Facility

$67.68

Service Code	NDC 43547-278-03
Hospital Charge Code	21848
Hospital Revenue Code	637
Min. Negotiated Rate	$47.38
Max. Negotiated Rate	$67.68
Rate for Payer: Aetna Commercial	$60.91
Rate for Payer: ASR ASR	$65.65
Rate for Payer: BCBS Trust/PPO	$52.47
Rate for Payer: BCN Commercial	$52.47
Rate for Payer: Cash Price	$54.14
Rate for Payer: Cofinity Commercial	$63.62
Rate for Payer: Encore Health Key Benefits Commercial	$54.14
Rate for Payer: Healthscope Commercial	$67.68
Rate for Payer: Healthscope Whirlpool	$65.65
Rate for Payer: Mclaren Commercial	$60.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.53
Rate for Payer: Priority Health Cigna Priority Health	$47.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.56

IRON DEXTRAN 50 MG/ML INJECTION SOLUTION

Facility

$146.88

Service Code	HCPCS J1750
Hospital Charge Code	186569
Hospital Revenue Code	636
Min. Negotiated Rate	$102.82
Max. Negotiated Rate	$146.88
Rate for Payer: Aetna Commercial	$132.19
Rate for Payer: ASR ASR	$142.47
Rate for Payer: BCBS Trust/PPO	$113.88
Rate for Payer: BCN Commercial	$113.88
Rate for Payer: Cash Price	$117.50
Rate for Payer: Cofinity Commercial	$138.07
Rate for Payer: Encore Health Key Benefits Commercial	$117.50
Rate for Payer: Healthscope Commercial	$146.88
Rate for Payer: Healthscope Whirlpool	$142.47
Rate for Payer: Mclaren Commercial	$132.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$124.85
Rate for Payer: Priority Health Cigna Priority Health	$102.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$129.25

Know your out-of-pocket cost for care.

All Charges