Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

NOVASOURCE RENAL CONTINUOUS FEED

Facility

$5.69

Service Code	NDC 4390035111
Hospital Charge Code	168945
Hospital Revenue Code	637
Min. Negotiated Rate	$3.98
Max. Negotiated Rate	$5.69
Rate for Payer: Aetna Commercial	$5.12
Rate for Payer: ASR ASR	$5.52
Rate for Payer: BCBS Trust/PPO	$4.41
Rate for Payer: BCN Commercial	$4.41
Rate for Payer: Cash Price	$4.55
Rate for Payer: Cofinity Commercial	$5.35
Rate for Payer: Encore Health Key Benefits Commercial	$4.55
Rate for Payer: Healthscope Commercial	$5.69
Rate for Payer: Healthscope Whirlpool	$5.52
Rate for Payer: Mclaren Commercial	$5.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.84
Rate for Payer: Priority Health Cigna Priority Health	$3.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5.01

NOVASOURCE RENAL CYCLIC FEED

Facility

$5.69

Service Code	NDC 4390035111
Hospital Charge Code	200087
Hospital Revenue Code	637
Min. Negotiated Rate	$3.98
Max. Negotiated Rate	$5.69
Rate for Payer: Aetna Commercial	$5.12
Rate for Payer: ASR ASR	$5.52
Rate for Payer: BCBS Trust/PPO	$4.41
Rate for Payer: BCN Commercial	$4.41
Rate for Payer: Cash Price	$4.55
Rate for Payer: Cofinity Commercial	$5.35
Rate for Payer: Encore Health Key Benefits Commercial	$4.55
Rate for Payer: Healthscope Commercial	$5.69
Rate for Payer: Healthscope Whirlpool	$5.52
Rate for Payer: Mclaren Commercial	$5.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.84
Rate for Payer: Priority Health Cigna Priority Health	$3.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5.01

NOVASOURCE RENAL INTERMITTENT FEED

Facility

$5.69

Service Code	NDC 4390035111
Hospital Charge Code	200086
Hospital Revenue Code	637
Min. Negotiated Rate	$3.98
Max. Negotiated Rate	$5.69
Rate for Payer: Aetna Commercial	$5.12
Rate for Payer: ASR ASR	$5.52
Rate for Payer: BCBS Trust/PPO	$4.41
Rate for Payer: BCN Commercial	$4.41
Rate for Payer: Cash Price	$4.55
Rate for Payer: Cofinity Commercial	$5.35
Rate for Payer: Encore Health Key Benefits Commercial	$4.55
Rate for Payer: Healthscope Commercial	$5.69
Rate for Payer: Healthscope Whirlpool	$5.52
Rate for Payer: Mclaren Commercial	$5.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.84
Rate for Payer: Priority Health Cigna Priority Health	$3.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5.01

NURSING CASE MANAGEMENT

Professional

Both

$25.00

Service Code	HCPCS RN001
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$17.50
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50

NUTREN 1.5 BOLUS FEED

Facility

$4.75

Service Code	NDC 9871616220
Hospital Charge Code	180645
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

NUTREN 1.5 BOLUS FEED

Facility

$4.75

Service Code	NDC 9871606220
Hospital Charge Code	180645
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

NUTREN 1.5 CONTINUOUS FEED

Facility

$4.75

Service Code	NDC 9871616220
Hospital Charge Code	181405
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

NUTREN 1.5 CONTINUOUS FEED

Facility

$4.75

Service Code	NDC 9871606220
Hospital Charge Code	181405
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

NUTREN 1.5 CYCLIC FEED

Facility

$4.75

Service Code	NDC 9871606220
Hospital Charge Code	200083
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

NUTREN 1.5 CYCLIC FEED

Facility

$4.75

Service Code	NDC 9871616220
Hospital Charge Code	200083
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

NUTREN 1.5 INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 9871606220
Hospital Charge Code	200082
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

NUTREN 1.5 INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 9871616220
Hospital Charge Code	200082
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

NUTREN 2.0 BOLUS FEED

Facility

$4.75

Service Code	NDC 9871606230
Hospital Charge Code	150720
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

NUTREN 2.0 CONTINUOUS FEED

Facility

$4.75

Service Code	NDC 9871606230
Hospital Charge Code	168944
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

NUTREN 2.0 CYCLIC FEED

Facility

$4.75

Service Code	NDC 9871606230
Hospital Charge Code	200085
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

NUTREN 2.0 INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 9871606230
Hospital Charge Code	200084
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

NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM

Facility

$26.86

Service Code	NDC 45802-059-11
Hospital Charge Code	5749
Hospital Revenue Code	637
Min. Negotiated Rate	$18.80
Max. Negotiated Rate	$26.86
Rate for Payer: Aetna Commercial	$24.17
Rate for Payer: ASR ASR	$26.05
Rate for Payer: BCBS Trust/PPO	$20.82
Rate for Payer: BCN Commercial	$20.82
Rate for Payer: Cash Price	$21.49
Rate for Payer: Cofinity Commercial	$25.25
Rate for Payer: Encore Health Key Benefits Commercial	$21.49
Rate for Payer: Healthscope Commercial	$26.86
Rate for Payer: Healthscope Whirlpool	$26.05
Rate for Payer: Mclaren Commercial	$24.17
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.83
Rate for Payer: Priority Health Cigna Priority Health	$18.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$23.64

NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM

Facility

$17.82

Service Code	NDC 45802-059-35
Hospital Charge Code	5749
Hospital Revenue Code	637
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$17.82
Rate for Payer: Aetna Commercial	$16.04
Rate for Payer: ASR ASR	$17.29
Rate for Payer: BCBS Trust/PPO	$13.82
Rate for Payer: BCN Commercial	$13.82
Rate for Payer: Cash Price	$14.26
Rate for Payer: Cofinity Commercial	$16.75
Rate for Payer: Encore Health Key Benefits Commercial	$14.26
Rate for Payer: Healthscope Commercial	$17.82
Rate for Payer: Healthscope Whirlpool	$17.29
Rate for Payer: Mclaren Commercial	$16.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.15
Rate for Payer: Priority Health Cigna Priority Health	$12.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15.68

NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM

Facility

$65.10

Service Code	NDC 0713-0678-31
Hospital Charge Code	5749
Hospital Revenue Code	637
Min. Negotiated Rate	$45.57
Max. Negotiated Rate	$65.10
Rate for Payer: Aetna Commercial	$58.59
Rate for Payer: ASR ASR	$63.15
Rate for Payer: BCBS Trust/PPO	$50.47
Rate for Payer: BCN Commercial	$50.47
Rate for Payer: Cash Price	$52.08
Rate for Payer: Cofinity Commercial	$61.19
Rate for Payer: Encore Health Key Benefits Commercial	$52.08
Rate for Payer: Healthscope Commercial	$65.10
Rate for Payer: Healthscope Whirlpool	$63.15
Rate for Payer: Mclaren Commercial	$58.59
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$55.34
Rate for Payer: Priority Health Cigna Priority Health	$45.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$57.29

NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM

Facility

$42.52

Service Code	NDC 51672-1289-2
Hospital Charge Code	5749
Hospital Revenue Code	637
Min. Negotiated Rate	$29.76
Max. Negotiated Rate	$42.52
Rate for Payer: Aetna Commercial	$38.27
Rate for Payer: ASR ASR	$41.24
Rate for Payer: BCBS Trust/PPO	$32.97
Rate for Payer: BCN Commercial	$32.97
Rate for Payer: Cash Price	$34.02
Rate for Payer: Cofinity Commercial	$39.97
Rate for Payer: Encore Health Key Benefits Commercial	$34.02
Rate for Payer: Healthscope Commercial	$42.52
Rate for Payer: Healthscope Whirlpool	$41.24
Rate for Payer: Mclaren Commercial	$38.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$36.14
Rate for Payer: Priority Health Cigna Priority Health	$29.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.42

NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT

Facility

$68.25

Service Code	NDC 0168-0007-30
Hospital Charge Code	5750
Hospital Revenue Code	637
Min. Negotiated Rate	$47.78
Max. Negotiated Rate	$68.25
Rate for Payer: Aetna Commercial	$61.42
Rate for Payer: ASR ASR	$66.20
Rate for Payer: BCBS Trust/PPO	$52.91
Rate for Payer: BCN Commercial	$52.91
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cofinity Commercial	$64.16
Rate for Payer: Encore Health Key Benefits Commercial	$54.60
Rate for Payer: Healthscope Commercial	$68.25
Rate for Payer: Healthscope Whirlpool	$66.20
Rate for Payer: Mclaren Commercial	$61.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$58.01
Rate for Payer: Priority Health Cigna Priority Health	$47.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$60.06

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER

Facility

$66.77

Service Code	NDC 0574-2008-15
Hospital Charge Code	39136
Hospital Revenue Code	637
Min. Negotiated Rate	$46.74
Max. Negotiated Rate	$66.77
Rate for Payer: Aetna Commercial	$60.09
Rate for Payer: ASR ASR	$64.77
Rate for Payer: BCBS Trust/PPO	$51.77
Rate for Payer: BCN Commercial	$51.77
Rate for Payer: Cash Price	$53.41
Rate for Payer: Cofinity Commercial	$62.76
Rate for Payer: Encore Health Key Benefits Commercial	$53.42
Rate for Payer: Healthscope Commercial	$66.77
Rate for Payer: Healthscope Whirlpool	$64.77
Rate for Payer: Mclaren Commercial	$60.09
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$56.75
Rate for Payer: Priority Health Cigna Priority Health	$46.74
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$58.76

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER

Facility

$14.60

Service Code	NDC 0832-0465-15
Hospital Charge Code	39136
Hospital Revenue Code	637
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$14.60
Rate for Payer: Aetna Commercial	$13.14
Rate for Payer: ASR ASR	$14.16
Rate for Payer: BCBS Trust/PPO	$11.32
Rate for Payer: BCN Commercial	$11.32
Rate for Payer: Cash Price	$11.68
Rate for Payer: Cofinity Commercial	$13.72
Rate for Payer: Encore Health Key Benefits Commercial	$11.68
Rate for Payer: Healthscope Commercial	$14.60
Rate for Payer: Healthscope Whirlpool	$14.16
Rate for Payer: Mclaren Commercial	$13.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.41
Rate for Payer: Priority Health Cigna Priority Health	$10.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.85

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER

Facility

$24.09

Service Code	NDC 68308-152-15
Hospital Charge Code	39136
Hospital Revenue Code	637
Min. Negotiated Rate	$16.86
Max. Negotiated Rate	$24.09
Rate for Payer: Aetna Commercial	$21.68
Rate for Payer: ASR ASR	$23.37
Rate for Payer: BCBS Trust/PPO	$18.68
Rate for Payer: BCN Commercial	$18.68
Rate for Payer: Cash Price	$19.27
Rate for Payer: Cofinity Commercial	$22.64
Rate for Payer: Encore Health Key Benefits Commercial	$19.27
Rate for Payer: Healthscope Commercial	$24.09
Rate for Payer: Healthscope Whirlpool	$23.37
Rate for Payer: Mclaren Commercial	$21.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$20.48
Rate for Payer: Priority Health Cigna Priority Health	$16.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.20

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER

Facility

$51.78

Service Code	NDC 43386-530-01
Hospital Charge Code	39136
Hospital Revenue Code	637
Min. Negotiated Rate	$36.25
Max. Negotiated Rate	$51.78
Rate for Payer: Aetna Commercial	$46.60
Rate for Payer: ASR ASR	$50.23
Rate for Payer: BCBS Trust/PPO	$40.15
Rate for Payer: BCN Commercial	$40.15
Rate for Payer: Cash Price	$41.43
Rate for Payer: Cofinity Commercial	$48.67
Rate for Payer: Encore Health Key Benefits Commercial	$41.42
Rate for Payer: Healthscope Commercial	$51.78
Rate for Payer: Healthscope Whirlpool	$50.23
Rate for Payer: Mclaren Commercial	$46.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$44.01
Rate for Payer: Priority Health Cigna Priority Health	$36.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$45.57

Know your out-of-pocket cost for care.

All Charges