Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$19.10

Service Code	NDC 0143-9300-01
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$13.37
Max. Negotiated Rate	$19.10
Rate for Payer: Aetna Commercial	$17.19
Rate for Payer: ASR ASR	$18.53
Rate for Payer: BCBS Trust/PPO	$14.81
Rate for Payer: BCN Commercial	$14.81
Rate for Payer: Cash Price	$15.28
Rate for Payer: Cofinity Commercial	$17.95
Rate for Payer: Encore Health Key Benefits Commercial	$15.28
Rate for Payer: Healthscope Commercial	$19.10
Rate for Payer: Healthscope Whirlpool	$18.53
Rate for Payer: Mclaren Commercial	$17.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.24
Rate for Payer: Priority Health Cigna Priority Health	$13.37
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$16.81

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION

Facility

$22.06

Service Code	NDC 55150-202-00
Hospital Charge Code	26226
Hospital Revenue Code	250
Min. Negotiated Rate	$15.44
Max. Negotiated Rate	$22.06
Rate for Payer: Aetna Commercial	$19.85
Rate for Payer: ASR ASR	$21.40
Rate for Payer: BCBS Trust/PPO	$17.10
Rate for Payer: BCN Commercial	$17.10
Rate for Payer: Cash Price	$17.64
Rate for Payer: Cofinity Commercial	$20.74
Rate for Payer: Encore Health Key Benefits Commercial	$17.65
Rate for Payer: Healthscope Commercial	$22.06
Rate for Payer: Healthscope Whirlpool	$21.40
Rate for Payer: Mclaren Commercial	$19.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.75
Rate for Payer: Priority Health Cigna Priority Health	$15.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$19.41

PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION FOR DRIP

Facility

$19.42

Service Code	NDC 0781-3232-95
Hospital Charge Code	301183
Hospital Revenue Code	250
Min. Negotiated Rate	$13.59
Max. Negotiated Rate	$19.42
Rate for Payer: Aetna Commercial	$17.48
Rate for Payer: ASR ASR	$18.84
Rate for Payer: BCBS Trust/PPO	$15.06
Rate for Payer: BCN Commercial	$15.06
Rate for Payer: Cash Price	$15.54
Rate for Payer: Cofinity Commercial	$18.25
Rate for Payer: Encore Health Key Benefits Commercial	$15.54
Rate for Payer: Healthscope Commercial	$19.42
Rate for Payer: Healthscope Whirlpool	$18.84
Rate for Payer: Mclaren Commercial	$17.48
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.51
Rate for Payer: Priority Health Cigna Priority Health	$13.59
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.09

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$4,482.85

Service Code	NDC 0008-0841-81
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$3,138.00
Max. Negotiated Rate	$4,482.85
Rate for Payer: Aetna Commercial	$4,034.56
Rate for Payer: ASR ASR	$4,348.36
Rate for Payer: BCBS Trust/PPO	$3,475.55
Rate for Payer: BCN Commercial	$3,475.55
Rate for Payer: Cash Price	$3,586.28
Rate for Payer: Cofinity Commercial	$4,213.88
Rate for Payer: Encore Health Key Benefits Commercial	$3,586.28
Rate for Payer: Healthscope Commercial	$4,482.85
Rate for Payer: Healthscope Whirlpool	$4,348.36
Rate for Payer: Mclaren Commercial	$4,034.56
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,810.42
Rate for Payer: Priority Health Cigna Priority Health	$3,138.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,944.91

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$192.85

Service Code	NDC 0904-6474-61
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$192.85
Rate for Payer: Aetna Commercial	$173.56
Rate for Payer: ASR ASR	$187.06
Rate for Payer: BCBS Trust/PPO	$149.52
Rate for Payer: BCN Commercial	$149.52
Rate for Payer: Cash Price	$154.28
Rate for Payer: Cofinity Commercial	$181.28
Rate for Payer: Encore Health Key Benefits Commercial	$154.28
Rate for Payer: Healthscope Commercial	$192.85
Rate for Payer: Healthscope Whirlpool	$187.06
Rate for Payer: Mclaren Commercial	$173.56
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$163.92
Rate for Payer: Priority Health Cigna Priority Health	$135.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$169.71

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$265.08

Service Code	NDC 0904-6870-45
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$185.56
Max. Negotiated Rate	$265.08
Rate for Payer: Aetna Commercial	$238.57
Rate for Payer: ASR ASR	$257.13
Rate for Payer: BCBS Trust/PPO	$205.52
Rate for Payer: BCN Commercial	$205.52
Rate for Payer: Cash Price	$212.06
Rate for Payer: Cofinity Commercial	$249.18
Rate for Payer: Encore Health Key Benefits Commercial	$212.06
Rate for Payer: Healthscope Commercial	$265.08
Rate for Payer: Healthscope Whirlpool	$257.13
Rate for Payer: Mclaren Commercial	$238.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$225.32
Rate for Payer: Priority Health Cigna Priority Health	$185.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$233.27

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$149.22

Service Code	NDC 50268-639-15
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$104.45
Max. Negotiated Rate	$149.22
Rate for Payer: Aetna Commercial	$134.30
Rate for Payer: ASR ASR	$144.74
Rate for Payer: BCBS Trust/PPO	$115.69
Rate for Payer: BCN Commercial	$115.69
Rate for Payer: Cash Price	$119.38
Rate for Payer: Cofinity Commercial	$140.27
Rate for Payer: Encore Health Key Benefits Commercial	$119.38
Rate for Payer: Healthscope Commercial	$149.22
Rate for Payer: Healthscope Whirlpool	$144.74
Rate for Payer: Mclaren Commercial	$134.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$126.84
Rate for Payer: Priority Health Cigna Priority Health	$104.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$131.31

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$4.46

Service Code	NDC 66993-068-51
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$4.46
Rate for Payer: Aetna Commercial	$4.01
Rate for Payer: ASR ASR	$4.33
Rate for Payer: BCBS Trust/PPO	$3.46
Rate for Payer: BCN Commercial	$3.46
Rate for Payer: Cash Price	$3.57
Rate for Payer: Cofinity Commercial	$4.19
Rate for Payer: Encore Health Key Benefits Commercial	$3.57
Rate for Payer: Healthscope Commercial	$4.46
Rate for Payer: Healthscope Whirlpool	$4.33
Rate for Payer: Mclaren Commercial	$4.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.79
Rate for Payer: Priority Health Cigna Priority Health	$3.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.92

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$446.50

Service Code	NDC 66993-068-80
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$312.55
Max. Negotiated Rate	$446.50
Rate for Payer: Aetna Commercial	$401.85
Rate for Payer: ASR ASR	$433.10
Rate for Payer: BCBS Trust/PPO	$346.17
Rate for Payer: BCN Commercial	$346.17
Rate for Payer: Cash Price	$357.20
Rate for Payer: Cofinity Commercial	$419.71
Rate for Payer: Encore Health Key Benefits Commercial	$357.20
Rate for Payer: Healthscope Commercial	$446.50
Rate for Payer: Healthscope Whirlpool	$433.10
Rate for Payer: Mclaren Commercial	$401.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$379.52
Rate for Payer: Priority Health Cigna Priority Health	$312.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$392.92

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$2.00

Service Code	NDC 51079-051-01
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.80
Rate for Payer: ASR ASR	$1.94
Rate for Payer: BCBS Trust/PPO	$1.55
Rate for Payer: BCN Commercial	$1.55
Rate for Payer: Cash Price	$1.60
Rate for Payer: Cofinity Commercial	$1.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.60
Rate for Payer: Healthscope Commercial	$2.00
Rate for Payer: Healthscope Whirlpool	$1.94
Rate for Payer: Mclaren Commercial	$1.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.70
Rate for Payer: Priority Health Cigna Priority Health	$1.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.76

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$2.98

Service Code	NDC 50268-639-11
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna Commercial	$2.68
Rate for Payer: ASR ASR	$2.89
Rate for Payer: BCBS Trust/PPO	$2.31
Rate for Payer: BCN Commercial	$2.31
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cofinity Commercial	$2.80
Rate for Payer: Encore Health Key Benefits Commercial	$2.38
Rate for Payer: Healthscope Commercial	$2.98
Rate for Payer: Healthscope Whirlpool	$2.89
Rate for Payer: Mclaren Commercial	$2.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.53
Rate for Payer: Priority Health Cigna Priority Health	$2.09
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.62

PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE

Facility

$254.60

Service Code	NDC 63739-564-10
Hospital Charge Code	26225
Hospital Revenue Code	637
Min. Negotiated Rate	$178.22
Max. Negotiated Rate	$254.60
Rate for Payer: Aetna Commercial	$229.14
Rate for Payer: ASR ASR	$246.96
Rate for Payer: BCBS Trust/PPO	$197.39
Rate for Payer: BCN Commercial	$197.39
Rate for Payer: Cash Price	$203.68
Rate for Payer: Cofinity Commercial	$239.32
Rate for Payer: Encore Health Key Benefits Commercial	$203.68
Rate for Payer: Healthscope Commercial	$254.60
Rate for Payer: Healthscope Whirlpool	$246.96
Rate for Payer: Mclaren Commercial	$229.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$216.41
Rate for Payer: Priority Health Cigna Priority Health	$178.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$224.05

PAROXETINE 10 MG TABLET

Facility

$442.70

Service Code	NDC 68084-044-01
Hospital Charge Code	16632
Hospital Revenue Code	637
Min. Negotiated Rate	$309.89
Max. Negotiated Rate	$442.70
Rate for Payer: Aetna Commercial	$398.43
Rate for Payer: ASR ASR	$429.42
Rate for Payer: BCBS Trust/PPO	$343.23
Rate for Payer: BCN Commercial	$343.23
Rate for Payer: Cash Price	$354.16
Rate for Payer: Cofinity Commercial	$416.14
Rate for Payer: Encore Health Key Benefits Commercial	$354.16
Rate for Payer: Healthscope Commercial	$442.70
Rate for Payer: Healthscope Whirlpool	$429.42
Rate for Payer: Mclaren Commercial	$398.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$376.30
Rate for Payer: Priority Health Cigna Priority Health	$309.89
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$389.58

PAROXETINE 10 MG TABLET

Facility

$74.73

Service Code	NDC 0378-7001-93
Hospital Charge Code	16632
Hospital Revenue Code	637
Min. Negotiated Rate	$52.31
Max. Negotiated Rate	$74.73
Rate for Payer: Aetna Commercial	$67.26
Rate for Payer: ASR ASR	$72.49
Rate for Payer: BCBS Trust/PPO	$57.94
Rate for Payer: BCN Commercial	$57.94
Rate for Payer: Cash Price	$59.78
Rate for Payer: Cofinity Commercial	$70.25
Rate for Payer: Encore Health Key Benefits Commercial	$59.78
Rate for Payer: Healthscope Commercial	$74.73
Rate for Payer: Healthscope Whirlpool	$72.49
Rate for Payer: Mclaren Commercial	$67.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$63.52
Rate for Payer: Priority Health Cigna Priority Health	$52.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$65.76

PAROXETINE 10 MG TABLET

Facility

$442.70

Service Code	NDC 68084-044-11
Hospital Charge Code	16632
Hospital Revenue Code	637
Min. Negotiated Rate	$309.89
Max. Negotiated Rate	$442.70
Rate for Payer: Aetna Commercial	$398.43
Rate for Payer: ASR ASR	$429.42
Rate for Payer: BCBS Trust/PPO	$343.23
Rate for Payer: BCN Commercial	$343.23
Rate for Payer: Cash Price	$354.16
Rate for Payer: Cofinity Commercial	$416.14
Rate for Payer: Encore Health Key Benefits Commercial	$354.16
Rate for Payer: Healthscope Commercial	$442.70
Rate for Payer: Healthscope Whirlpool	$429.42
Rate for Payer: Mclaren Commercial	$398.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$376.30
Rate for Payer: Priority Health Cigna Priority Health	$309.89
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$389.58

PAROXETINE 20 MG TABLET

Facility

$392.45

Service Code	NDC 0904-5677-61
Hospital Charge Code	10855
Hospital Revenue Code	637
Min. Negotiated Rate	$274.72
Max. Negotiated Rate	$392.45
Rate for Payer: Aetna Commercial	$353.20
Rate for Payer: ASR ASR	$380.68
Rate for Payer: BCBS Trust/PPO	$304.27
Rate for Payer: BCN Commercial	$304.27
Rate for Payer: Cash Price	$313.96
Rate for Payer: Cofinity Commercial	$368.90
Rate for Payer: Encore Health Key Benefits Commercial	$313.96
Rate for Payer: Healthscope Commercial	$392.45
Rate for Payer: Healthscope Whirlpool	$380.68
Rate for Payer: Mclaren Commercial	$353.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$333.58
Rate for Payer: Priority Health Cigna Priority Health	$274.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$345.36

PAROXETINE 20 MG TABLET

Facility

$408.90

Service Code	NDC 63739-963-10
Hospital Charge Code	10855
Hospital Revenue Code	637
Min. Negotiated Rate	$286.23
Max. Negotiated Rate	$408.90
Rate for Payer: Aetna Commercial	$368.01
Rate for Payer: ASR ASR	$396.63
Rate for Payer: BCBS Trust/PPO	$317.02
Rate for Payer: BCN Commercial	$317.02
Rate for Payer: Cash Price	$327.12
Rate for Payer: Cofinity Commercial	$384.37
Rate for Payer: Encore Health Key Benefits Commercial	$327.12
Rate for Payer: Healthscope Commercial	$408.90
Rate for Payer: Healthscope Whirlpool	$396.63
Rate for Payer: Mclaren Commercial	$368.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$347.56
Rate for Payer: Priority Health Cigna Priority Health	$286.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$359.83

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$14,004.59

Service Code	MS-DRG 543
Min. Negotiated Rate	$10,369.48
Max. Negotiated Rate	$14,004.59
Rate for Payer: Aetna Medicare	$10,915.24
Rate for Payer: Allen County Amish Medical Aid Commercial	$13,644.05
Rate for Payer: Amish Plain Church Group Commercial	$13,644.05
Rate for Payer: BCBS MAPPO	$10,915.24
Rate for Payer: BCN Medicare Advantage	$10,915.24
Rate for Payer: Health Alliance Plan Medicare Advantage	$10,915.24
Rate for Payer: Humana Choice PPO Medicare	$10,915.24
Rate for Payer: Mclaren Medicare	$10,915.24
Rate for Payer: Meridian Wellcare - Medicare Advantage	$11,461.00
Rate for Payer: MI Amish Medical Board Commercial	$12,552.53
Rate for Payer: PACE Medicare	$10,369.48
Rate for Payer: PACE SWMI	$10,915.24
Rate for Payer: PHP Commercial	$12,006.76
Rate for Payer: PHP Medicare Advantage	$10,915.24
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$14,004.59
Rate for Payer: Priority Health Medicare	$10,915.24
Rate for Payer: Priority Health Narrow Network	$11,203.67
Rate for Payer: Railroad Medicare Medicare	$10,915.24
Rate for Payer: UHC Medicare Advantage	$11,242.70
Rate for Payer: VA VA	$10,915.24

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$23,416.31

Service Code	MS-DRG 542
Min. Negotiated Rate	$16,265.04
Max. Negotiated Rate	$23,416.31
Rate for Payer: Aetna Medicare	$17,121.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$21,401.38
Rate for Payer: Amish Plain Church Group Commercial	$21,401.38
Rate for Payer: BCBS MAPPO	$17,121.10
Rate for Payer: BCN Medicare Advantage	$17,121.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$17,121.10
Rate for Payer: Humana Choice PPO Medicare	$17,121.10
Rate for Payer: Mclaren Medicare	$17,121.10
Rate for Payer: Meridian Wellcare - Medicare Advantage	$17,977.16
Rate for Payer: MI Amish Medical Board Commercial	$19,689.26
Rate for Payer: PACE Medicare	$16,265.04
Rate for Payer: PACE SWMI	$17,121.10
Rate for Payer: PHP Commercial	$18,833.21
Rate for Payer: PHP Medicare Advantage	$17,121.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$23,416.31
Rate for Payer: Priority Health Medicare	$17,121.10
Rate for Payer: Priority Health Narrow Network	$18,733.05
Rate for Payer: Railroad Medicare Medicare	$17,121.10
Rate for Payer: UHC Medicare Advantage	$17,634.73
Rate for Payer: VA VA	$17,121.10

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$10,223.61

Service Code	MS-DRG 544
Min. Negotiated Rate	$7,769.95
Max. Negotiated Rate	$10,223.61
Rate for Payer: Aetna Medicare	$8,178.89
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,223.61
Rate for Payer: Amish Plain Church Group Commercial	$10,223.61
Rate for Payer: BCBS MAPPO	$8,178.89
Rate for Payer: BCN Medicare Advantage	$8,178.89
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,178.89
Rate for Payer: Humana Choice PPO Medicare	$8,178.89
Rate for Payer: Mclaren Medicare	$8,178.89
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,587.83
Rate for Payer: MI Amish Medical Board Commercial	$9,405.72
Rate for Payer: PACE Medicare	$7,769.95
Rate for Payer: PACE SWMI	$8,178.89
Rate for Payer: PHP Commercial	$8,996.78
Rate for Payer: PHP Medicare Advantage	$8,178.89
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,854.70
Rate for Payer: Priority Health Medicare	$8,178.89
Rate for Payer: Priority Health Narrow Network	$7,883.76
Rate for Payer: Railroad Medicare Medicare	$8,178.89
Rate for Payer: UHC Medicare Advantage	$8,424.26
Rate for Payer: VA VA	$8,178.89

PEDS ECHO LIMITED W/DEFINITY

Facility

$1,356.97

Service Code	HCPCS C8922
Hospital Charge Code	48000029
Hospital Revenue Code	480
Min. Negotiated Rate	$389.31
Max. Negotiated Rate	$1,356.97
Rate for Payer: Aetna Commercial	$1,221.27
Rate for Payer: Aetna Medicare	$711.71
Rate for Payer: Allen County Amish Medical Aid Commercial	$889.64
Rate for Payer: Amish Plain Church Group Commercial	$889.64
Rate for Payer: ASR ASR	$1,316.26
Rate for Payer: BCBS Complete	$408.81
Rate for Payer: BCBS MAPPO	$711.71
Rate for Payer: BCBS Trust/PPO	$1,052.06
Rate for Payer: BCN Commercial	$1,052.06
Rate for Payer: BCN Medicare Advantage	$711.71
Rate for Payer: Cash Price	$1,085.58
Rate for Payer: Cash Price	$1,085.58
Rate for Payer: Cofinity Commercial	$1,275.55
Rate for Payer: Encore Health Key Benefits Commercial	$1,085.58
Rate for Payer: Health Alliance Plan Medicare Advantage	$711.71
Rate for Payer: Healthscope Commercial	$1,356.97
Rate for Payer: Healthscope Whirlpool	$1,316.26
Rate for Payer: Humana Choice PPO Medicare	$711.71
Rate for Payer: Mclaren Commercial	$1,221.27
Rate for Payer: Mclaren Medicaid	$389.31
Rate for Payer: Mclaren Medicare	$711.71
Rate for Payer: Meridian Medicaid	$408.81
Rate for Payer: Meridian Wellcare - Medicare Advantage	$747.30
Rate for Payer: MI Amish Medical Board Commercial	$818.47
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,153.42
Rate for Payer: PACE Medicare	$676.12
Rate for Payer: PACE SWMI	$711.71
Rate for Payer: PHP Commercial	$782.88
Rate for Payer: PHP Medicaid	$389.31
Rate for Payer: PHP Medicare Advantage	$711.71
Rate for Payer: Priority Health Choice Medicaid	$389.31
Rate for Payer: Priority Health Cigna Priority Health	$949.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,234.84
Rate for Payer: Priority Health Medicare	$711.71
Rate for Payer: Priority Health Narrow Network	$963.45
Rate for Payer: Railroad Medicare Medicare	$711.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,194.13
Rate for Payer: UHC Medicare Advantage	$733.06
Rate for Payer: VA VA	$711.71

PEDS ECHO LIMITED W/DEFINITY

Facility

$1,356.97

Service Code	HCPCS C8922
Hospital Charge Code	48000029
Hospital Revenue Code	480
Min. Negotiated Rate	$949.88
Max. Negotiated Rate	$1,356.97
Rate for Payer: Aetna Commercial	$1,221.27
Rate for Payer: ASR ASR	$1,316.26
Rate for Payer: BCBS Trust/PPO	$1,052.06
Rate for Payer: BCN Commercial	$1,052.06
Rate for Payer: Cash Price	$1,085.58
Rate for Payer: Cofinity Commercial	$1,275.55
Rate for Payer: Encore Health Key Benefits Commercial	$1,085.58
Rate for Payer: Healthscope Commercial	$1,356.97
Rate for Payer: Healthscope Whirlpool	$1,316.26
Rate for Payer: Mclaren Commercial	$1,221.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,153.42
Rate for Payer: Priority Health Cigna Priority Health	$949.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,194.13

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION

Facility

$56.00

Service Code	NDC 43386-090-19
Hospital Charge Code	10839
Hospital Revenue Code	637
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$50.40
Rate for Payer: ASR ASR	$54.32
Rate for Payer: BCBS Trust/PPO	$43.42
Rate for Payer: BCN Commercial	$43.42
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cofinity Commercial	$52.64
Rate for Payer: Encore Health Key Benefits Commercial	$44.80
Rate for Payer: Healthscope Commercial	$56.00
Rate for Payer: Healthscope Whirlpool	$54.32
Rate for Payer: Mclaren Commercial	$50.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$47.60
Rate for Payer: Priority Health Cigna Priority Health	$39.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$49.28

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION

Facility

$70.00

Service Code	NDC 52268-100-01
Hospital Charge Code	10839
Hospital Revenue Code	637
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: ASR ASR	$67.90
Rate for Payer: BCBS Trust/PPO	$54.27
Rate for Payer: BCN Commercial	$54.27
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$65.80
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$70.00
Rate for Payer: Healthscope Whirlpool	$67.90
Rate for Payer: Mclaren Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.60

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS

Facility

$9.52

Service Code	NDC 57896-181-05
Hospital Charge Code	41412
Hospital Revenue Code	637
Min. Negotiated Rate	$6.66
Max. Negotiated Rate	$9.52
Rate for Payer: Aetna Commercial	$8.57
Rate for Payer: ASR ASR	$9.23
Rate for Payer: BCBS Trust/PPO	$7.38
Rate for Payer: BCN Commercial	$7.38
Rate for Payer: Cash Price	$7.61
Rate for Payer: Cofinity Commercial	$8.95
Rate for Payer: Encore Health Key Benefits Commercial	$7.62
Rate for Payer: Healthscope Commercial	$9.52
Rate for Payer: Healthscope Whirlpool	$9.23
Rate for Payer: Mclaren Commercial	$8.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8.09
Rate for Payer: Priority Health Cigna Priority Health	$6.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.38

Know your out-of-pocket cost for care.

All Charges