Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

LACTATED RINGERS EYE BOLUS

Facility

$69.92

Service Code	HCPCS J7120
Hospital Charge Code	300324
Hospital Revenue Code	636
Min. Negotiated Rate	$48.94
Max. Negotiated Rate	$69.92
Rate for Payer: Aetna Commercial	$62.93
Rate for Payer: ASR ASR	$67.82
Rate for Payer: BCBS Trust/PPO	$54.21
Rate for Payer: BCN Commercial	$54.21
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Commercial	$65.72
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$69.92
Rate for Payer: Healthscope Whirlpool	$67.82
Rate for Payer: Mclaren Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$48.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.53

LACTATED RINGERS INTRAVENOUS SOLUTION

Facility

$67.18

Service Code	HCPCS J7120
Hospital Charge Code	4318
Hospital Revenue Code	636
Min. Negotiated Rate	$47.03
Max. Negotiated Rate	$67.18
Rate for Payer: Aetna Commercial	$60.46
Rate for Payer: Aetna Commercial	$62.93
Rate for Payer: ASR ASR	$67.82
Rate for Payer: ASR ASR	$65.16
Rate for Payer: BCBS Trust/PPO	$54.21
Rate for Payer: BCBS Trust/PPO	$52.08
Rate for Payer: BCN Commercial	$52.08
Rate for Payer: BCN Commercial	$54.21
Rate for Payer: Cash Price	$53.75
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Commercial	$63.15
Rate for Payer: Cofinity Commercial	$65.72
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Encore Health Key Benefits Commercial	$53.74
Rate for Payer: Healthscope Commercial	$67.18
Rate for Payer: Healthscope Commercial	$69.92
Rate for Payer: Healthscope Whirlpool	$67.82
Rate for Payer: Healthscope Whirlpool	$65.16
Rate for Payer: Mclaren Commercial	$60.46
Rate for Payer: Mclaren Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$48.94
Rate for Payer: Priority Health Cigna Priority Health	$47.03
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.53

LACTATED RINGERS IV BOLUS

Facility

$69.92

Service Code	HCPCS J7120
Hospital Charge Code	400296
Hospital Revenue Code	636
Min. Negotiated Rate	$48.94
Max. Negotiated Rate	$69.92
Rate for Payer: Aetna Commercial	$62.93
Rate for Payer: ASR ASR	$67.82
Rate for Payer: BCBS Trust/PPO	$54.21
Rate for Payer: BCN Commercial	$54.21
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Commercial	$65.72
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$69.92
Rate for Payer: Healthscope Whirlpool	$67.82
Rate for Payer: Mclaren Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$48.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.53

LACTATED RINGERS IV -DKA

Facility

$67.18

Service Code	HCPCS J7120
Hospital Charge Code	301462
Hospital Revenue Code	636
Min. Negotiated Rate	$47.03
Max. Negotiated Rate	$67.18
Rate for Payer: Aetna Commercial	$60.46
Rate for Payer: Aetna Commercial	$62.93
Rate for Payer: ASR ASR	$65.16
Rate for Payer: ASR ASR	$67.82
Rate for Payer: BCBS Trust/PPO	$52.08
Rate for Payer: BCBS Trust/PPO	$54.21
Rate for Payer: BCN Commercial	$52.08
Rate for Payer: BCN Commercial	$54.21
Rate for Payer: Cash Price	$53.75
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Commercial	$65.72
Rate for Payer: Cofinity Commercial	$63.15
Rate for Payer: Encore Health Key Benefits Commercial	$53.74
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$69.92
Rate for Payer: Healthscope Commercial	$67.18
Rate for Payer: Healthscope Whirlpool	$65.16
Rate for Payer: Healthscope Whirlpool	$67.82
Rate for Payer: Mclaren Commercial	$62.93
Rate for Payer: Mclaren Commercial	$60.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.10
Rate for Payer: Priority Health Cigna Priority Health	$47.03
Rate for Payer: Priority Health Cigna Priority Health	$48.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.53

LACTATED RINGERS IV INFUSION/BOLUS (CODE)

Facility

$67.18

Service Code	HCPCS J7120
Hospital Charge Code	163717
Hospital Revenue Code	636
Min. Negotiated Rate	$47.03
Max. Negotiated Rate	$67.18
Rate for Payer: Aetna Commercial	$60.46
Rate for Payer: Aetna Commercial	$62.93
Rate for Payer: ASR ASR	$65.16
Rate for Payer: ASR ASR	$67.82
Rate for Payer: BCBS Trust/PPO	$54.21
Rate for Payer: BCBS Trust/PPO	$52.08
Rate for Payer: BCN Commercial	$54.21
Rate for Payer: BCN Commercial	$52.08
Rate for Payer: Cash Price	$53.75
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Commercial	$65.72
Rate for Payer: Cofinity Commercial	$63.15
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Encore Health Key Benefits Commercial	$53.74
Rate for Payer: Healthscope Commercial	$67.18
Rate for Payer: Healthscope Commercial	$69.92
Rate for Payer: Healthscope Whirlpool	$65.16
Rate for Payer: Healthscope Whirlpool	$67.82
Rate for Payer: Mclaren Commercial	$62.93
Rate for Payer: Mclaren Commercial	$60.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.10
Rate for Payer: Priority Health Cigna Priority Health	$47.03
Rate for Payer: Priority Health Cigna Priority Health	$48.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.53

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION

Facility

$4.18

Service Code	NDC 0121-1154-00
Hospital Charge Code	150919
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

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION

Facility

$2.59

Service Code	NDC 50383-779-33
Hospital Charge Code	150919
Hospital Revenue Code	637
Min. Negotiated Rate	$1.81
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna Commercial	$2.33
Rate for Payer: ASR ASR	$2.51
Rate for Payer: BCBS Trust/PPO	$2.01
Rate for Payer: BCN Commercial	$2.01
Rate for Payer: Cash Price	$2.07
Rate for Payer: Cofinity Commercial	$2.43
Rate for Payer: Encore Health Key Benefits Commercial	$2.07
Rate for Payer: Healthscope Commercial	$2.59
Rate for Payer: Healthscope Whirlpool	$2.51
Rate for Payer: Mclaren Commercial	$2.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.20
Rate for Payer: Priority Health Cigna Priority Health	$1.81
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.28

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION

Facility

$4.61

Service Code	NDC 50383-779-30
Hospital Charge Code	150919
Hospital Revenue Code	637
Min. Negotiated Rate	$3.23
Max. Negotiated Rate	$4.61
Rate for Payer: Aetna Commercial	$4.15
Rate for Payer: ASR ASR	$4.47
Rate for Payer: BCBS Trust/PPO	$3.57
Rate for Payer: BCN Commercial	$3.57
Rate for Payer: Cash Price	$3.69
Rate for Payer: Cofinity Commercial	$4.33
Rate for Payer: Encore Health Key Benefits Commercial	$3.69
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.47
Rate for Payer: Mclaren Commercial	$4.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.92
Rate for Payer: Priority Health Cigna Priority Health	$3.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.06

LACTULOSE 20 GRAM/30 ML ORAL SOLUTION

Facility

$4.18

Service Code	NDC 0121-1154-30
Hospital Charge Code	150919
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

LAMOTRIGINE 200 MG TABLET

Facility

$183.30

Service Code	NDC 51672-4133-4
Hospital Charge Code	13983
Hospital Revenue Code	637
Min. Negotiated Rate	$128.31
Max. Negotiated Rate	$183.30
Rate for Payer: Aetna Commercial	$164.97
Rate for Payer: ASR ASR	$177.80
Rate for Payer: BCBS Trust/PPO	$142.11
Rate for Payer: BCN Commercial	$142.11
Rate for Payer: Cash Price	$146.64
Rate for Payer: Cofinity Commercial	$172.30
Rate for Payer: Encore Health Key Benefits Commercial	$146.64
Rate for Payer: Healthscope Commercial	$183.30
Rate for Payer: Healthscope Whirlpool	$177.80
Rate for Payer: Mclaren Commercial	$164.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$155.80
Rate for Payer: Priority Health Cigna Priority Health	$128.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$161.30

LAMOTRIGINE 200 MG TABLET

Facility

$87.42

Service Code	NDC 65862-230-60
Hospital Charge Code	13983
Hospital Revenue Code	637
Min. Negotiated Rate	$61.19
Max. Negotiated Rate	$87.42
Rate for Payer: Aetna Commercial	$78.68
Rate for Payer: ASR ASR	$84.80
Rate for Payer: BCBS Trust/PPO	$67.78
Rate for Payer: BCN Commercial	$67.78
Rate for Payer: Cash Price	$69.94
Rate for Payer: Cofinity Commercial	$82.17
Rate for Payer: Encore Health Key Benefits Commercial	$69.94
Rate for Payer: Healthscope Commercial	$87.42
Rate for Payer: Healthscope Whirlpool	$84.80
Rate for Payer: Mclaren Commercial	$78.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$74.31
Rate for Payer: Priority Health Cigna Priority Health	$61.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$76.93

LAMOTRIGINE 25 MG TABLET

Facility

$338.40

Service Code	NDC 63739-670-10
Hospital Charge Code	13981
Hospital Revenue Code	637
Min. Negotiated Rate	$236.88
Max. Negotiated Rate	$338.40
Rate for Payer: Aetna Commercial	$304.56
Rate for Payer: ASR ASR	$328.25
Rate for Payer: BCBS Trust/PPO	$262.36
Rate for Payer: BCN Commercial	$262.36
Rate for Payer: Cash Price	$270.72
Rate for Payer: Cofinity Commercial	$318.10
Rate for Payer: Encore Health Key Benefits Commercial	$270.72
Rate for Payer: Healthscope Commercial	$338.40
Rate for Payer: Healthscope Whirlpool	$328.25
Rate for Payer: Mclaren Commercial	$304.56
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$287.64
Rate for Payer: Priority Health Cigna Priority Health	$236.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$297.79

LAMOTRIGINE 25 MG TABLET

Facility

$317.25

Service Code	NDC 0904-7007-61
Hospital Charge Code	13981
Hospital Revenue Code	637
Min. Negotiated Rate	$222.08
Max. Negotiated Rate	$317.25
Rate for Payer: Aetna Commercial	$285.52
Rate for Payer: ASR ASR	$307.73
Rate for Payer: BCBS Trust/PPO	$245.96
Rate for Payer: BCN Commercial	$245.96
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cofinity Commercial	$298.22
Rate for Payer: Encore Health Key Benefits Commercial	$253.80
Rate for Payer: Healthscope Commercial	$317.25
Rate for Payer: Healthscope Whirlpool	$307.73
Rate for Payer: Mclaren Commercial	$285.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$269.66
Rate for Payer: Priority Health Cigna Priority Health	$222.08
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$279.18

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC

Facility

$20,989.55

Service Code	MS-DRG 418
Min. Negotiated Rate	$14,744.91
Max. Negotiated Rate	$20,989.55
Rate for Payer: Aetna Medicare	$15,520.96
Rate for Payer: Allen County Amish Medical Aid Commercial	$19,401.20
Rate for Payer: Amish Plain Church Group Commercial	$19,401.20
Rate for Payer: BCBS MAPPO	$15,520.96
Rate for Payer: BCN Medicare Advantage	$15,520.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$15,520.96
Rate for Payer: Humana Choice PPO Medicare	$15,520.96
Rate for Payer: Mclaren Medicare	$15,520.96
Rate for Payer: Meridian Wellcare - Medicare Advantage	$16,297.01
Rate for Payer: MI Amish Medical Board Commercial	$17,849.10
Rate for Payer: PACE Medicare	$14,744.91
Rate for Payer: PACE SWMI	$15,520.96
Rate for Payer: PHP Commercial	$17,073.06
Rate for Payer: PHP Medicare Advantage	$15,520.96
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$20,989.55
Rate for Payer: Priority Health Medicare	$15,520.96
Rate for Payer: Priority Health Narrow Network	$16,791.64
Rate for Payer: Railroad Medicare Medicare	$15,520.96
Rate for Payer: UHC Medicare Advantage	$15,986.59
Rate for Payer: VA VA	$15,520.96

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC

Facility

$29,760.55

Service Code	MS-DRG 417
Min. Negotiated Rate	$20,239.14
Max. Negotiated Rate	$29,760.55
Rate for Payer: Aetna Medicare	$21,304.36
Rate for Payer: Allen County Amish Medical Aid Commercial	$26,630.45
Rate for Payer: Amish Plain Church Group Commercial	$26,630.45
Rate for Payer: BCBS MAPPO	$21,304.36
Rate for Payer: BCN Medicare Advantage	$21,304.36
Rate for Payer: Health Alliance Plan Medicare Advantage	$21,304.36
Rate for Payer: Humana Choice PPO Medicare	$21,304.36
Rate for Payer: Mclaren Medicare	$21,304.36
Rate for Payer: Meridian Wellcare - Medicare Advantage	$22,369.58
Rate for Payer: MI Amish Medical Board Commercial	$24,500.01
Rate for Payer: PACE Medicare	$20,239.14
Rate for Payer: PACE SWMI	$21,304.36
Rate for Payer: PHP Commercial	$23,434.80
Rate for Payer: PHP Medicare Advantage	$21,304.36
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$29,760.55
Rate for Payer: Priority Health Medicare	$21,304.36
Rate for Payer: Priority Health Narrow Network	$23,808.44
Rate for Payer: Railroad Medicare Medicare	$21,304.36
Rate for Payer: UHC Medicare Advantage	$21,943.49
Rate for Payer: VA VA	$21,304.36

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$16,861.49

Service Code	MS-DRG 419
Min. Negotiated Rate	$12,159.06
Max. Negotiated Rate	$16,861.49
Rate for Payer: Aetna Medicare	$12,799.01
Rate for Payer: Allen County Amish Medical Aid Commercial	$15,998.76
Rate for Payer: Amish Plain Church Group Commercial	$15,998.76
Rate for Payer: BCBS MAPPO	$12,799.01
Rate for Payer: BCN Medicare Advantage	$12,799.01
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,799.01
Rate for Payer: Humana Choice PPO Medicare	$12,799.01
Rate for Payer: Mclaren Medicare	$12,799.01
Rate for Payer: Meridian Wellcare - Medicare Advantage	$13,438.96
Rate for Payer: MI Amish Medical Board Commercial	$14,718.86
Rate for Payer: PACE Medicare	$12,159.06
Rate for Payer: PACE SWMI	$12,799.01
Rate for Payer: PHP Commercial	$14,078.91
Rate for Payer: PHP Medicare Advantage	$12,799.01
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16,861.49
Rate for Payer: Priority Health Medicare	$12,799.01
Rate for Payer: Priority Health Narrow Network	$13,489.19
Rate for Payer: Railroad Medicare Medicare	$12,799.01
Rate for Payer: UHC Medicare Advantage	$13,182.98
Rate for Payer: VA VA	$12,799.01

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL;

Facility

$1,885.82

Service Code	CPT 31530
Hospital Revenue Code	361
Min. Negotiated Rate	$825.24
Max. Negotiated Rate	$1,885.82
Rate for Payer: Aetna Medicare	$1,508.66
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,885.82
Rate for Payer: Amish Plain Church Group Commercial	$1,885.82
Rate for Payer: BCBS Complete	$866.57
Rate for Payer: BCBS MAPPO	$1,508.66
Rate for Payer: BCN Medicare Advantage	$1,508.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,508.66
Rate for Payer: Humana Choice PPO Medicare	$1,508.66
Rate for Payer: Mclaren Medicaid	$825.24
Rate for Payer: Mclaren Medicare	$1,508.66
Rate for Payer: Meridian Medicaid	$866.57
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,584.09
Rate for Payer: MI Amish Medical Board Commercial	$1,734.96
Rate for Payer: PACE Medicare	$1,433.23
Rate for Payer: PACE SWMI	$1,508.66
Rate for Payer: PHP Commercial	$1,659.53
Rate for Payer: PHP Medicaid	$825.24
Rate for Payer: PHP Medicare Advantage	$1,508.66
Rate for Payer: Priority Health Choice Medicaid	$825.24
Rate for Payer: Priority Health Medicare	$1,508.66
Rate for Payer: Railroad Medicare Medicare	$1,508.66
Rate for Payer: UHC Medicare Advantage	$1,553.92
Rate for Payer: VA VA	$1,508.66

LATANOPROST 0.005 % EYE DROPS

Facility

$25.92

Service Code	NDC 61314-547-01
Hospital Charge Code	18621
Hospital Revenue Code	637
Min. Negotiated Rate	$18.14
Max. Negotiated Rate	$25.92
Rate for Payer: Aetna Commercial	$23.33
Rate for Payer: ASR ASR	$25.14
Rate for Payer: BCBS Trust/PPO	$20.10
Rate for Payer: BCN Commercial	$20.10
Rate for Payer: Cash Price	$20.74
Rate for Payer: Cofinity Commercial	$24.36
Rate for Payer: Encore Health Key Benefits Commercial	$20.74
Rate for Payer: Healthscope Commercial	$25.92
Rate for Payer: Healthscope Whirlpool	$25.14
Rate for Payer: Mclaren Commercial	$23.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.03
Rate for Payer: Priority Health Cigna Priority Health	$18.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.81

LATANOPROST 0.005 % EYE DROPS

Facility

$50.75

Service Code	NDC 17478-625-12
Hospital Charge Code	18621
Hospital Revenue Code	637
Min. Negotiated Rate	$35.52
Max. Negotiated Rate	$50.75
Rate for Payer: Aetna Commercial	$45.68
Rate for Payer: ASR ASR	$49.23
Rate for Payer: BCBS Trust/PPO	$39.35
Rate for Payer: BCN Commercial	$39.35
Rate for Payer: Cash Price	$40.60
Rate for Payer: Cofinity Commercial	$47.70
Rate for Payer: Encore Health Key Benefits Commercial	$40.60
Rate for Payer: Healthscope Commercial	$50.75
Rate for Payer: Healthscope Whirlpool	$49.23
Rate for Payer: Mclaren Commercial	$45.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$43.14
Rate for Payer: Priority Health Cigna Priority Health	$35.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$44.66

LATANOPROST 0.005 % EYE DROPS

Facility

$43.60

Service Code	NDC 61314-547-03
Hospital Charge Code	18621
Hospital Revenue Code	637
Min. Negotiated Rate	$30.52
Max. Negotiated Rate	$43.60
Rate for Payer: Aetna Commercial	$39.24
Rate for Payer: ASR ASR	$42.29
Rate for Payer: BCBS Trust/PPO	$33.80
Rate for Payer: BCN Commercial	$33.80
Rate for Payer: Cash Price	$34.88
Rate for Payer: Cofinity Commercial	$40.98
Rate for Payer: Encore Health Key Benefits Commercial	$34.88
Rate for Payer: Healthscope Commercial	$43.60
Rate for Payer: Healthscope Whirlpool	$42.29
Rate for Payer: Mclaren Commercial	$39.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$37.06
Rate for Payer: Priority Health Cigna Priority Health	$30.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$38.37

LATANOPROST 0.005 % EYE DROPS

Facility

$50.75

Service Code	NDC 0517-0830-01
Hospital Charge Code	18621
Hospital Revenue Code	637
Min. Negotiated Rate	$35.52
Max. Negotiated Rate	$50.75
Rate for Payer: Aetna Commercial	$45.68
Rate for Payer: ASR ASR	$49.23
Rate for Payer: BCBS Trust/PPO	$39.35
Rate for Payer: BCN Commercial	$39.35
Rate for Payer: Cash Price	$40.60
Rate for Payer: Cofinity Commercial	$47.70
Rate for Payer: Encore Health Key Benefits Commercial	$40.60
Rate for Payer: Healthscope Commercial	$50.75
Rate for Payer: Healthscope Whirlpool	$49.23
Rate for Payer: Mclaren Commercial	$45.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$43.14
Rate for Payer: Priority Health Cigna Priority Health	$35.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$44.66

LATANOPROST 0.005 % EYE DROPS

Facility

$19.22

Service Code	NDC 70069-421-01
Hospital Charge Code	18621
Hospital Revenue Code	637
Min. Negotiated Rate	$13.45
Max. Negotiated Rate	$19.22
Rate for Payer: Aetna Commercial	$17.30
Rate for Payer: ASR ASR	$18.64
Rate for Payer: BCBS Trust/PPO	$14.90
Rate for Payer: BCN Commercial	$14.90
Rate for Payer: Cash Price	$15.37
Rate for Payer: Cofinity Commercial	$18.07
Rate for Payer: Encore Health Key Benefits Commercial	$15.38
Rate for Payer: Healthscope Commercial	$19.22
Rate for Payer: Healthscope Whirlpool	$18.64
Rate for Payer: Mclaren Commercial	$17.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.34
Rate for Payer: Priority Health Cigna Priority Health	$13.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$16.91

LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT

Facility

$17,707.64

Service Code	HCPCS J1950
Hospital Charge Code	21044
Hospital Revenue Code	636
Min. Negotiated Rate	$12,395.35
Max. Negotiated Rate	$17,707.64
Rate for Payer: Aetna Commercial	$15,936.88
Rate for Payer: ASR ASR	$17,176.41
Rate for Payer: BCBS Trust/PPO	$13,728.73
Rate for Payer: BCN Commercial	$13,728.73
Rate for Payer: Cash Price	$14,166.12
Rate for Payer: Cofinity Commercial	$16,645.18
Rate for Payer: Encore Health Key Benefits Commercial	$14,166.11
Rate for Payer: Healthscope Commercial	$17,707.64
Rate for Payer: Healthscope Whirlpool	$17,176.41
Rate for Payer: Mclaren Commercial	$15,936.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15,051.49
Rate for Payer: Priority Health Cigna Priority Health	$12,395.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15,582.72

LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT

Facility

$14,827.83

Service Code	HCPCS J9217
Hospital Charge Code	21045
Hospital Revenue Code	636
Min. Negotiated Rate	$10,379.48
Max. Negotiated Rate	$14,827.83
Rate for Payer: Aetna Commercial	$13,345.05
Rate for Payer: ASR ASR	$14,383.00
Rate for Payer: BCBS Trust/PPO	$11,496.02
Rate for Payer: BCN Commercial	$11,496.02
Rate for Payer: Cash Price	$11,862.26
Rate for Payer: Cofinity Commercial	$13,938.16
Rate for Payer: Encore Health Key Benefits Commercial	$11,862.26
Rate for Payer: Healthscope Commercial	$14,827.83
Rate for Payer: Healthscope Whirlpool	$14,383.00
Rate for Payer: Mclaren Commercial	$13,345.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12,603.66
Rate for Payer: Priority Health Cigna Priority Health	$10,379.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13,048.49

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT

Facility

$29,656.17

Service Code	HCPCS J9217
Hospital Charge Code	152942
Hospital Revenue Code	636
Min. Negotiated Rate	$20,759.32
Max. Negotiated Rate	$29,656.17
Rate for Payer: Aetna Commercial	$26,690.55
Rate for Payer: ASR ASR	$28,766.48
Rate for Payer: BCBS Trust/PPO	$22,992.43
Rate for Payer: BCN Commercial	$22,992.43
Rate for Payer: Cash Price	$23,724.94
Rate for Payer: Cofinity Commercial	$27,876.80
Rate for Payer: Encore Health Key Benefits Commercial	$23,724.94
Rate for Payer: Healthscope Commercial	$29,656.17
Rate for Payer: Healthscope Whirlpool	$28,766.48
Rate for Payer: Mclaren Commercial	$26,690.55
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$25,207.74
Rate for Payer: Priority Health Cigna Priority Health	$20,759.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$26,097.43

Know your out-of-pocket cost for care.

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