Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET

Facility

$241.83

Service Code	NDC 0456-4300-01
Hospital Charge Code	14825
Hospital Revenue Code	637
Min. Negotiated Rate	$169.28
Max. Negotiated Rate	$241.83
Rate for Payer: Aetna Commercial	$217.65
Rate for Payer: ASR ASR	$234.58
Rate for Payer: BCBS Trust/PPO	$187.49
Rate for Payer: BCN Commercial	$187.49
Rate for Payer: Cash Price	$193.47
Rate for Payer: Cofinity Commercial	$227.32
Rate for Payer: Encore Health Key Benefits Commercial	$193.46
Rate for Payer: Healthscope Commercial	$241.83
Rate for Payer: Healthscope Whirlpool	$234.58
Rate for Payer: Mclaren Commercial	$217.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$205.56
Rate for Payer: Priority Health Cigna Priority Health	$169.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$212.81

FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET

Facility

$190.40

Service Code	NDC 70700-268-99
Hospital Charge Code	14825
Hospital Revenue Code	637
Min. Negotiated Rate	$133.28
Max. Negotiated Rate	$190.40
Rate for Payer: Aetna Commercial	$171.36
Rate for Payer: ASR ASR	$184.69
Rate for Payer: BCBS Trust/PPO	$147.62
Rate for Payer: BCN Commercial	$147.62
Rate for Payer: Cash Price	$152.32
Rate for Payer: Cofinity Commercial	$178.98
Rate for Payer: Encore Health Key Benefits Commercial	$152.32
Rate for Payer: Healthscope Commercial	$190.40
Rate for Payer: Healthscope Whirlpool	$184.69
Rate for Payer: Mclaren Commercial	$171.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$161.84
Rate for Payer: Priority Health Cigna Priority Health	$133.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$167.55

FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET

Facility

$190.40

Service Code	NDC 70700-268-94
Hospital Charge Code	14825
Hospital Revenue Code	637
Min. Negotiated Rate	$133.28
Max. Negotiated Rate	$190.40
Rate for Payer: Aetna Commercial	$171.36
Rate for Payer: ASR ASR	$184.69
Rate for Payer: BCBS Trust/PPO	$147.62
Rate for Payer: BCN Commercial	$147.62
Rate for Payer: Cash Price	$152.32
Rate for Payer: Cofinity Commercial	$178.98
Rate for Payer: Encore Health Key Benefits Commercial	$152.32
Rate for Payer: Healthscope Commercial	$190.40
Rate for Payer: Healthscope Whirlpool	$184.69
Rate for Payer: Mclaren Commercial	$171.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$161.84
Rate for Payer: Priority Health Cigna Priority Health	$133.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$167.55

FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET

Facility

$203.94

Service Code	NDC 67877-749-57
Hospital Charge Code	14825
Hospital Revenue Code	637
Min. Negotiated Rate	$142.76
Max. Negotiated Rate	$203.94
Rate for Payer: Aetna Commercial	$183.55
Rate for Payer: ASR ASR	$197.82
Rate for Payer: BCBS Trust/PPO	$158.11
Rate for Payer: BCN Commercial	$158.11
Rate for Payer: Cash Price	$163.16
Rate for Payer: Cofinity Commercial	$191.70
Rate for Payer: Encore Health Key Benefits Commercial	$163.15
Rate for Payer: Healthscope Commercial	$203.94
Rate for Payer: Healthscope Whirlpool	$197.82
Rate for Payer: Mclaren Commercial	$183.55
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$173.35
Rate for Payer: Priority Health Cigna Priority Health	$142.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$179.47

FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET

Facility

$206.46

Service Code	NDC 82036-4274-8
Hospital Charge Code	14825
Hospital Revenue Code	637
Min. Negotiated Rate	$144.52
Max. Negotiated Rate	$206.46
Rate for Payer: Aetna Commercial	$185.81
Rate for Payer: ASR ASR	$200.27
Rate for Payer: BCBS Trust/PPO	$160.07
Rate for Payer: BCN Commercial	$160.07
Rate for Payer: Cash Price	$165.17
Rate for Payer: Cofinity Commercial	$194.07
Rate for Payer: Encore Health Key Benefits Commercial	$165.17
Rate for Payer: Healthscope Commercial	$206.46
Rate for Payer: Healthscope Whirlpool	$200.27
Rate for Payer: Mclaren Commercial	$185.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$175.49
Rate for Payer: Priority Health Cigna Priority Health	$144.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$181.68

FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET

Facility

$206.46

Service Code	NDC 82036-4274-1
Hospital Charge Code	14825
Hospital Revenue Code	637
Min. Negotiated Rate	$144.52
Max. Negotiated Rate	$206.46
Rate for Payer: Aetna Commercial	$185.81
Rate for Payer: ASR ASR	$200.27
Rate for Payer: BCBS Trust/PPO	$160.07
Rate for Payer: BCN Commercial	$160.07
Rate for Payer: Cash Price	$165.17
Rate for Payer: Cofinity Commercial	$194.07
Rate for Payer: Encore Health Key Benefits Commercial	$165.17
Rate for Payer: Healthscope Commercial	$206.46
Rate for Payer: Healthscope Whirlpool	$200.27
Rate for Payer: Mclaren Commercial	$185.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$175.49
Rate for Payer: Priority Health Cigna Priority Health	$144.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$181.68

FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET

Facility

$206.46

Service Code	NDC 69097-579-67
Hospital Charge Code	14825
Hospital Revenue Code	637
Min. Negotiated Rate	$144.52
Max. Negotiated Rate	$206.46
Rate for Payer: Aetna Commercial	$185.81
Rate for Payer: ASR ASR	$200.27
Rate for Payer: BCBS Trust/PPO	$160.07
Rate for Payer: BCN Commercial	$160.07
Rate for Payer: Cash Price	$165.17
Rate for Payer: Cofinity Commercial	$194.07
Rate for Payer: Encore Health Key Benefits Commercial	$165.17
Rate for Payer: Healthscope Commercial	$206.46
Rate for Payer: Healthscope Whirlpool	$200.27
Rate for Payer: Mclaren Commercial	$185.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$175.49
Rate for Payer: Priority Health Cigna Priority Health	$144.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$181.68

FOSINOPRIL 10 MG TABLET

Facility

$209.38

Service Code	NDC 69097-856-05
Hospital Charge Code	10094
Hospital Revenue Code	637
Min. Negotiated Rate	$146.57
Max. Negotiated Rate	$209.38
Rate for Payer: Aetna Commercial	$188.44
Rate for Payer: ASR ASR	$203.10
Rate for Payer: BCBS Trust/PPO	$162.33
Rate for Payer: BCN Commercial	$162.33
Rate for Payer: Cash Price	$167.51
Rate for Payer: Cofinity Commercial	$196.82
Rate for Payer: Encore Health Key Benefits Commercial	$167.50
Rate for Payer: Healthscope Commercial	$209.38
Rate for Payer: Healthscope Whirlpool	$203.10
Rate for Payer: Mclaren Commercial	$188.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$177.97
Rate for Payer: Priority Health Cigna Priority Health	$146.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$184.25

FRACTURES OF FEMUR WITH MCC

Facility

$20,947.18

Service Code	MS-DRG 533
Min. Negotiated Rate	$14,718.36
Max. Negotiated Rate	$20,947.18
Rate for Payer: Aetna Medicare	$15,493.01
Rate for Payer: Allen County Amish Medical Aid Commercial	$19,366.26
Rate for Payer: Amish Plain Church Group Commercial	$19,366.26
Rate for Payer: BCBS MAPPO	$15,493.01
Rate for Payer: BCN Medicare Advantage	$15,493.01
Rate for Payer: Health Alliance Plan Medicare Advantage	$15,493.01
Rate for Payer: Humana Choice PPO Medicare	$15,493.01
Rate for Payer: Mclaren Medicare	$15,493.01
Rate for Payer: Meridian Wellcare - Medicare Advantage	$16,267.66
Rate for Payer: MI Amish Medical Board Commercial	$17,816.96
Rate for Payer: PACE Medicare	$14,718.36
Rate for Payer: PACE SWMI	$15,493.01
Rate for Payer: PHP Commercial	$17,042.31
Rate for Payer: PHP Medicare Advantage	$15,493.01
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$20,947.18
Rate for Payer: Priority Health Medicare	$15,493.01
Rate for Payer: Priority Health Narrow Network	$16,757.74
Rate for Payer: Railroad Medicare Medicare	$15,493.01
Rate for Payer: UHC Medicare Advantage	$15,957.80
Rate for Payer: VA VA	$15,493.01

FRACTURES OF FEMUR WITHOUT MCC

Facility

$10,673.39

Service Code	MS-DRG 534
Min. Negotiated Rate	$8,111.77
Max. Negotiated Rate	$10,673.39
Rate for Payer: Aetna Medicare	$8,538.71
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,673.39
Rate for Payer: Amish Plain Church Group Commercial	$10,673.39
Rate for Payer: BCBS MAPPO	$8,538.71
Rate for Payer: BCN Medicare Advantage	$8,538.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,538.71
Rate for Payer: Humana Choice PPO Medicare	$8,538.71
Rate for Payer: Mclaren Medicare	$8,538.71
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,965.65
Rate for Payer: MI Amish Medical Board Commercial	$9,819.52
Rate for Payer: PACE Medicare	$8,111.77
Rate for Payer: PACE SWMI	$8,538.71
Rate for Payer: PHP Commercial	$9,392.58
Rate for Payer: PHP Medicare Advantage	$8,538.71
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,400.40
Rate for Payer: Priority Health Medicare	$8,538.71
Rate for Payer: Priority Health Narrow Network	$8,320.32
Rate for Payer: Railroad Medicare Medicare	$8,538.71
Rate for Payer: UHC Medicare Advantage	$8,794.87
Rate for Payer: VA VA	$8,538.71

FRACTURES OF HIP AND PELVIS WITH MCC

Facility

$16,649.63

Service Code	MS-DRG 535
Min. Negotiated Rate	$12,026.34
Max. Negotiated Rate	$16,649.63
Rate for Payer: Aetna Medicare	$12,659.31
Rate for Payer: Allen County Amish Medical Aid Commercial	$15,824.14
Rate for Payer: Amish Plain Church Group Commercial	$15,824.14
Rate for Payer: BCBS MAPPO	$12,659.31
Rate for Payer: BCN Medicare Advantage	$12,659.31
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,659.31
Rate for Payer: Humana Choice PPO Medicare	$12,659.31
Rate for Payer: Mclaren Medicare	$12,659.31
Rate for Payer: Meridian Wellcare - Medicare Advantage	$13,292.28
Rate for Payer: MI Amish Medical Board Commercial	$14,558.21
Rate for Payer: PACE Medicare	$12,026.34
Rate for Payer: PACE SWMI	$12,659.31
Rate for Payer: PHP Commercial	$13,925.24
Rate for Payer: PHP Medicare Advantage	$12,659.31
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16,649.63
Rate for Payer: Priority Health Medicare	$12,659.31
Rate for Payer: Priority Health Narrow Network	$13,319.70
Rate for Payer: Railroad Medicare Medicare	$12,659.31
Rate for Payer: UHC Medicare Advantage	$13,039.09
Rate for Payer: VA VA	$12,659.31

FRACTURES OF HIP AND PELVIS WITHOUT MCC

Facility

$10,431.05

Service Code	MS-DRG 536
Min. Negotiated Rate	$7,927.60
Max. Negotiated Rate	$10,431.05
Rate for Payer: Aetna Medicare	$8,344.84
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,431.05
Rate for Payer: Amish Plain Church Group Commercial	$10,431.05
Rate for Payer: BCBS MAPPO	$8,344.84
Rate for Payer: BCN Medicare Advantage	$8,344.84
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,344.84
Rate for Payer: Humana Choice PPO Medicare	$8,344.84
Rate for Payer: Mclaren Medicare	$8,344.84
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,762.08
Rate for Payer: MI Amish Medical Board Commercial	$9,596.57
Rate for Payer: PACE Medicare	$7,927.60
Rate for Payer: PACE SWMI	$8,344.84
Rate for Payer: PHP Commercial	$9,179.32
Rate for Payer: PHP Medicare Advantage	$8,344.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,106.36
Rate for Payer: Priority Health Medicare	$8,344.84
Rate for Payer: Priority Health Narrow Network	$8,085.09
Rate for Payer: Railroad Medicare Medicare	$8,344.84
Rate for Payer: UHC Medicare Advantage	$8,595.19
Rate for Payer: VA VA	$8,344.84

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC

Facility

$19,525.79

Service Code	MS-DRG 562
Min. Negotiated Rate	$13,828.00
Max. Negotiated Rate	$19,525.79
Rate for Payer: Aetna Medicare	$14,555.79
Rate for Payer: Allen County Amish Medical Aid Commercial	$18,194.74
Rate for Payer: Amish Plain Church Group Commercial	$18,194.74
Rate for Payer: BCBS MAPPO	$14,555.79
Rate for Payer: BCN Medicare Advantage	$14,555.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$14,555.79
Rate for Payer: Humana Choice PPO Medicare	$14,555.79
Rate for Payer: Mclaren Medicare	$14,555.79
Rate for Payer: Meridian Wellcare - Medicare Advantage	$15,283.58
Rate for Payer: MI Amish Medical Board Commercial	$16,739.16
Rate for Payer: PACE Medicare	$13,828.00
Rate for Payer: PACE SWMI	$14,555.79
Rate for Payer: PHP Commercial	$16,011.37
Rate for Payer: PHP Medicare Advantage	$14,555.79
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19,525.79
Rate for Payer: Priority Health Medicare	$14,555.79
Rate for Payer: Priority Health Narrow Network	$15,620.63
Rate for Payer: Railroad Medicare Medicare	$14,555.79
Rate for Payer: UHC Medicare Advantage	$14,992.46
Rate for Payer: VA VA	$14,555.79

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC

Facility

$11,579.31

Service Code	MS-DRG 563
Min. Negotiated Rate	$8,800.28
Max. Negotiated Rate	$11,579.31
Rate for Payer: Aetna Medicare	$9,263.45
Rate for Payer: Allen County Amish Medical Aid Commercial	$11,579.31
Rate for Payer: Amish Plain Church Group Commercial	$11,579.31
Rate for Payer: BCBS MAPPO	$9,263.45
Rate for Payer: BCN Medicare Advantage	$9,263.45
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,263.45
Rate for Payer: Humana Choice PPO Medicare	$9,263.45
Rate for Payer: Mclaren Medicare	$9,263.45
Rate for Payer: Meridian Wellcare - Medicare Advantage	$9,726.62
Rate for Payer: MI Amish Medical Board Commercial	$10,652.97
Rate for Payer: PACE Medicare	$8,800.28
Rate for Payer: PACE SWMI	$9,263.45
Rate for Payer: PHP Commercial	$10,189.80
Rate for Payer: PHP Medicare Advantage	$9,263.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11,499.50
Rate for Payer: Priority Health Medicare	$9,263.45
Rate for Payer: Priority Health Narrow Network	$9,199.60
Rate for Payer: Railroad Medicare Medicare	$9,263.45
Rate for Payer: UHC Medicare Advantage	$9,541.35
Rate for Payer: VA VA	$9,263.45

FRAXEL ARMS - BILATERAL

Professional

Both

$1,000.00

Service Code	HCPCS 00166
Hospital Revenue Code	960
Min. Negotiated Rate	$400.00
Max. Negotiated Rate	$700.00
Rate for Payer: BCBS Complete	$400.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Priority Health Cigna Priority Health	$700.00

FRAXEL CHEST

Professional

Both

$800.00

Service Code	HCPCS 00155
Hospital Revenue Code	960
Min. Negotiated Rate	$320.00
Max. Negotiated Rate	$560.00
Rate for Payer: BCBS Complete	$320.00
Rate for Payer: Cash Price	$640.00
Rate for Payer: Priority Health Cigna Priority Health	$560.00

FRAXEL FACE & NECK

Professional

Both

$1,000.00

Service Code	HCPCS 00162
Hospital Revenue Code	960
Min. Negotiated Rate	$400.00
Max. Negotiated Rate	$700.00
Rate for Payer: BCBS Complete	$400.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Priority Health Cigna Priority Health	$700.00

FRAXEL FULL FACE

Professional

Both

$600.00

Service Code	HCPCS 00152
Hospital Revenue Code	960
Min. Negotiated Rate	$240.00
Max. Negotiated Rate	$420.00
Rate for Payer: BCBS Complete	$240.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Priority Health Cigna Priority Health	$420.00

FRAXEL HANDS

Professional

Both

$350.00

Service Code	HCPCS 00154
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

FRAXEL LARGE SCAR

Professional

Both

$800.00

Service Code	HCPCS 00161
Hospital Revenue Code	960
Min. Negotiated Rate	$320.00
Max. Negotiated Rate	$560.00
Rate for Payer: BCBS Complete	$320.00
Rate for Payer: Cash Price	$640.00
Rate for Payer: Priority Health Cigna Priority Health	$560.00

FRAXEL MEDIUM SCAR

Professional

Both

$300.00

Service Code	HCPCS 00160
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

FRAXEL NECK

Professional

Both

$400.00

Service Code	HCPCS 00153
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

FRAXEL NECK & CHEST

Professional

Both

$1,200.00

Service Code	HCPCS 00163
Hospital Revenue Code	960
Min. Negotiated Rate	$480.00
Max. Negotiated Rate	$840.00
Rate for Payer: BCBS Complete	$480.00
Rate for Payer: Cash Price	$960.00
Rate for Payer: Priority Health Cigna Priority Health	$840.00

FRAXEL PARTIAL TREATMENT - BILATERAL EYES

Professional

Both

$300.00

Service Code	HCPCS 00157
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

FRAXEL PARTIAL TREATMENT - PERI-ORAL

Professional

Both

$500.00

Service Code	HCPCS 00156
Hospital Revenue Code	960
Min. Negotiated Rate	$200.00
Max. Negotiated Rate	$350.00
Rate for Payer: BCBS Complete	$200.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Priority Health Cigna Priority Health	$350.00

Know your out-of-pocket cost for care.

All Charges