Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

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

Facility

$11.07

Service Code	NDC 96295-13764
Hospital Charge Code	41412
Hospital Revenue Code	637
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$11.07
Rate for Payer: Aetna Commercial	$9.96
Rate for Payer: ASR ASR	$10.74
Rate for Payer: BCBS Trust/PPO	$8.58
Rate for Payer: BCN Commercial	$8.58
Rate for Payer: Cash Price	$8.86
Rate for Payer: Cofinity Commercial	$10.41
Rate for Payer: Encore Health Key Benefits Commercial	$8.86
Rate for Payer: Healthscope Commercial	$11.07
Rate for Payer: Healthscope Whirlpool	$10.74
Rate for Payer: Mclaren Commercial	$9.96
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$9.41
Rate for Payer: Priority Health Cigna Priority Health	$7.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.74

PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$9,031.02

Service Code	HCPCS J2506
Hospital Charge Code	32267
Hospital Revenue Code	636
Min. Negotiated Rate	$6,321.71
Max. Negotiated Rate	$9,031.02
Rate for Payer: Aetna Commercial	$8,127.92
Rate for Payer: ASR ASR	$8,760.09
Rate for Payer: BCBS Trust/PPO	$7,001.75
Rate for Payer: BCN Commercial	$7,001.75
Rate for Payer: Cash Price	$7,224.82
Rate for Payer: Cofinity Commercial	$8,489.16
Rate for Payer: Encore Health Key Benefits Commercial	$7,224.82
Rate for Payer: Healthscope Commercial	$9,031.02
Rate for Payer: Healthscope Whirlpool	$8,760.09
Rate for Payer: Mclaren Commercial	$8,127.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7,676.37
Rate for Payer: Priority Health Cigna Priority Health	$6,321.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7,947.30

PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$9,951.21

Service Code	HCPCS Q5120
Hospital Charge Code	192102
Hospital Revenue Code	636
Min. Negotiated Rate	$6,965.85
Max. Negotiated Rate	$9,951.21
Rate for Payer: Aetna Commercial	$8,956.09
Rate for Payer: ASR ASR	$9,652.67
Rate for Payer: BCBS Trust/PPO	$7,715.17
Rate for Payer: BCN Commercial	$7,715.17
Rate for Payer: Cash Price	$7,960.97
Rate for Payer: Cofinity Commercial	$9,354.14
Rate for Payer: Encore Health Key Benefits Commercial	$7,960.97
Rate for Payer: Healthscope Commercial	$9,951.21
Rate for Payer: Healthscope Whirlpool	$9,652.67
Rate for Payer: Mclaren Commercial	$8,956.09
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8,458.53
Rate for Payer: Priority Health Cigna Priority Health	$6,965.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8,757.06

PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$5,616.00

Service Code	HCPCS Q5108
Hospital Charge Code	187520
Hospital Revenue Code	636
Min. Negotiated Rate	$3,931.20
Max. Negotiated Rate	$5,616.00
Rate for Payer: Aetna Commercial	$5,054.40
Rate for Payer: ASR ASR	$5,447.52
Rate for Payer: BCBS Trust/PPO	$4,354.08
Rate for Payer: BCN Commercial	$4,354.08
Rate for Payer: Cash Price	$4,492.80
Rate for Payer: Cofinity Commercial	$5,279.04
Rate for Payer: Encore Health Key Benefits Commercial	$4,492.80
Rate for Payer: Healthscope Commercial	$5,616.00
Rate for Payer: Healthscope Whirlpool	$5,447.52
Rate for Payer: Mclaren Commercial	$5,054.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,773.60
Rate for Payer: Priority Health Cigna Priority Health	$3,931.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,942.08

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$27,909.02

Service Code	MS-DRG 734
Min. Negotiated Rate	$19,079.32
Max. Negotiated Rate	$27,909.02
Rate for Payer: Aetna Medicare	$20,083.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$25,104.38
Rate for Payer: Amish Plain Church Group Commercial	$25,104.38
Rate for Payer: BCBS MAPPO	$20,083.50
Rate for Payer: BCN Medicare Advantage	$20,083.50
Rate for Payer: Health Alliance Plan Medicare Advantage	$20,083.50
Rate for Payer: Humana Choice PPO Medicare	$20,083.50
Rate for Payer: Mclaren Medicare	$20,083.50
Rate for Payer: Meridian Wellcare - Medicare Advantage	$21,087.68
Rate for Payer: MI Amish Medical Board Commercial	$23,096.02
Rate for Payer: PACE Medicare	$19,079.32
Rate for Payer: PACE SWMI	$20,083.50
Rate for Payer: PHP Commercial	$22,091.85
Rate for Payer: PHP Medicare Advantage	$20,083.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27,909.02
Rate for Payer: Priority Health Medicare	$20,083.50
Rate for Payer: Priority Health Narrow Network	$22,327.22
Rate for Payer: Railroad Medicare Medicare	$20,083.50
Rate for Payer: UHC Medicare Advantage	$20,686.00
Rate for Payer: VA VA	$20,083.50

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$16,180.97

Service Code	MS-DRG 735
Min. Negotiated Rate	$11,732.78
Max. Negotiated Rate	$16,180.97
Rate for Payer: Aetna Medicare	$12,350.29
Rate for Payer: Allen County Amish Medical Aid Commercial	$15,437.86
Rate for Payer: Amish Plain Church Group Commercial	$15,437.86
Rate for Payer: BCBS MAPPO	$12,350.29
Rate for Payer: BCN Medicare Advantage	$12,350.29
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,350.29
Rate for Payer: Humana Choice PPO Medicare	$12,350.29
Rate for Payer: Mclaren Medicare	$12,350.29
Rate for Payer: Meridian Wellcare - Medicare Advantage	$12,967.80
Rate for Payer: MI Amish Medical Board Commercial	$14,202.83
Rate for Payer: PACE Medicare	$11,732.78
Rate for Payer: PACE SWMI	$12,350.29
Rate for Payer: PHP Commercial	$13,585.32
Rate for Payer: PHP Medicare Advantage	$12,350.29
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16,180.97
Rate for Payer: Priority Health Medicare	$12,350.29
Rate for Payer: Priority Health Narrow Network	$12,944.78
Rate for Payer: Railroad Medicare Medicare	$12,350.29
Rate for Payer: UHC Medicare Advantage	$12,720.80
Rate for Payer: VA VA	$12,350.29

PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE

Facility

$915.30

Service Code	HCPCS J0561
Hospital Charge Code	112201
Hospital Revenue Code	636
Min. Negotiated Rate	$640.71
Max. Negotiated Rate	$915.30
Rate for Payer: Aetna Commercial	$823.77
Rate for Payer: ASR ASR	$887.84
Rate for Payer: BCBS Trust/PPO	$709.63
Rate for Payer: BCN Commercial	$709.63
Rate for Payer: Cash Price	$732.24
Rate for Payer: Cofinity Commercial	$860.38
Rate for Payer: Encore Health Key Benefits Commercial	$732.24
Rate for Payer: Healthscope Commercial	$915.30
Rate for Payer: Healthscope Whirlpool	$887.84
Rate for Payer: Mclaren Commercial	$823.77
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$778.00
Rate for Payer: Priority Health Cigna Priority Health	$640.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$805.46

PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE

Facility

$729.60

Service Code	HCPCS J0558
Hospital Charge Code	10903
Hospital Revenue Code	636
Min. Negotiated Rate	$510.72
Max. Negotiated Rate	$729.60
Rate for Payer: Aetna Commercial	$656.64
Rate for Payer: ASR ASR	$707.71
Rate for Payer: BCBS Trust/PPO	$565.66
Rate for Payer: BCN Commercial	$565.66
Rate for Payer: Cash Price	$583.68
Rate for Payer: Cofinity Commercial	$685.82
Rate for Payer: Encore Health Key Benefits Commercial	$583.68
Rate for Payer: Healthscope Commercial	$729.60
Rate for Payer: Healthscope Whirlpool	$707.71
Rate for Payer: Mclaren Commercial	$656.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$620.16
Rate for Payer: Priority Health Cigna Priority Health	$510.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$642.05

PENICILLIN V POTASSIUM 250 MG TABLET

Facility

$244.32

Service Code	NDC 0781-1205-01
Hospital Charge Code	6092
Hospital Revenue Code	637
Min. Negotiated Rate	$171.02
Max. Negotiated Rate	$244.32
Rate for Payer: Aetna Commercial	$219.89
Rate for Payer: ASR ASR	$236.99
Rate for Payer: BCBS Trust/PPO	$189.42
Rate for Payer: BCN Commercial	$189.42
Rate for Payer: Cash Price	$195.46
Rate for Payer: Cofinity Commercial	$229.66
Rate for Payer: Encore Health Key Benefits Commercial	$195.46
Rate for Payer: Healthscope Commercial	$244.32
Rate for Payer: Healthscope Whirlpool	$236.99
Rate for Payer: Mclaren Commercial	$219.89
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$207.67
Rate for Payer: Priority Health Cigna Priority Health	$171.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$215.00

PENICILLIN V POTASSIUM 250 MG TABLET

Facility

$148.05

Service Code	NDC 65862-175-01
Hospital Charge Code	6092
Hospital Revenue Code	637
Min. Negotiated Rate	$103.64
Max. Negotiated Rate	$148.05
Rate for Payer: Aetna Commercial	$133.24
Rate for Payer: ASR ASR	$143.61
Rate for Payer: BCBS Trust/PPO	$114.78
Rate for Payer: BCN Commercial	$114.78
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$139.17
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$148.05
Rate for Payer: Healthscope Whirlpool	$143.61
Rate for Payer: Mclaren Commercial	$133.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$103.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$130.28

PENICILLIN V POTASSIUM 250 MG TABLET

Facility

$176.25

Service Code	NDC 57237-040-01
Hospital Charge Code	6092
Hospital Revenue Code	637
Min. Negotiated Rate	$123.38
Max. Negotiated Rate	$176.25
Rate for Payer: Aetna Commercial	$158.62
Rate for Payer: ASR ASR	$170.96
Rate for Payer: BCBS Trust/PPO	$136.65
Rate for Payer: BCN Commercial	$136.65
Rate for Payer: Cash Price	$141.00
Rate for Payer: Cofinity Commercial	$165.68
Rate for Payer: Encore Health Key Benefits Commercial	$141.00
Rate for Payer: Healthscope Commercial	$176.25
Rate for Payer: Healthscope Whirlpool	$170.96
Rate for Payer: Mclaren Commercial	$158.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$149.81
Rate for Payer: Priority Health Cigna Priority Health	$123.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$155.10

PENIS PROCEDURES WITH CC/MCC

Facility

$27,220.80

Service Code	MS-DRG 709
Min. Negotiated Rate	$19,056.80
Max. Negotiated Rate	$27,220.80
Rate for Payer: Aetna Medicare	$20,059.79
Rate for Payer: Allen County Amish Medical Aid Commercial	$25,074.74
Rate for Payer: Amish Plain Church Group Commercial	$25,074.74
Rate for Payer: BCBS MAPPO	$20,059.79
Rate for Payer: BCN Medicare Advantage	$20,059.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$20,059.79
Rate for Payer: Humana Choice PPO Medicare	$20,059.79
Rate for Payer: Mclaren Medicare	$20,059.79
Rate for Payer: Meridian Wellcare - Medicare Advantage	$21,062.78
Rate for Payer: MI Amish Medical Board Commercial	$23,068.76
Rate for Payer: PACE Medicare	$19,056.80
Rate for Payer: PACE SWMI	$20,059.79
Rate for Payer: PHP Commercial	$22,065.77
Rate for Payer: PHP Medicare Advantage	$20,059.79
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27,220.80
Rate for Payer: Priority Health Medicare	$20,059.79
Rate for Payer: Priority Health Narrow Network	$21,776.64
Rate for Payer: Railroad Medicare Medicare	$20,059.79
Rate for Payer: UHC Medicare Advantage	$20,661.58
Rate for Payer: VA VA	$20,059.79

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$15,848.41

Service Code	MS-DRG 710
Min. Negotiated Rate	$12,031.17
Max. Negotiated Rate	$15,848.41
Rate for Payer: Aetna Medicare	$12,664.39
Rate for Payer: Allen County Amish Medical Aid Commercial	$15,830.49
Rate for Payer: Amish Plain Church Group Commercial	$15,830.49
Rate for Payer: BCBS MAPPO	$12,664.39
Rate for Payer: BCN Medicare Advantage	$12,664.39
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,664.39
Rate for Payer: Humana Choice PPO Medicare	$12,664.39
Rate for Payer: Mclaren Medicare	$12,664.39
Rate for Payer: Meridian Wellcare - Medicare Advantage	$13,297.61
Rate for Payer: MI Amish Medical Board Commercial	$14,564.05
Rate for Payer: PACE Medicare	$12,031.17
Rate for Payer: PACE SWMI	$12,664.39
Rate for Payer: PHP Commercial	$13,930.83
Rate for Payer: PHP Medicare Advantage	$12,664.39
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15,848.41
Rate for Payer: Priority Health Medicare	$12,664.39
Rate for Payer: Priority Health Narrow Network	$12,678.73
Rate for Payer: Railroad Medicare Medicare	$12,664.39
Rate for Payer: UHC Medicare Advantage	$13,044.32
Rate for Payer: VA VA	$12,664.39

PEN NEEDLE, DIABETIC, SAFETY 30 GAUGE X 1/3" (8MM)

Facility

$146.15

Service Code	NDC 169185275
Hospital Charge Code	117156
Hospital Revenue Code	637
Min. Negotiated Rate	$102.30
Max. Negotiated Rate	$146.15
Rate for Payer: Aetna Commercial	$131.54
Rate for Payer: ASR ASR	$141.77
Rate for Payer: BCBS Trust/PPO	$113.31
Rate for Payer: BCN Commercial	$113.31
Rate for Payer: Cash Price	$116.92
Rate for Payer: Cofinity Commercial	$137.38
Rate for Payer: Encore Health Key Benefits Commercial	$116.92
Rate for Payer: Healthscope Commercial	$146.15
Rate for Payer: Healthscope Whirlpool	$141.77
Rate for Payer: Mclaren Commercial	$131.54
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$124.23
Rate for Payer: Priority Health Cigna Priority Health	$102.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$128.61

PEPTAMEN AF BOLUS FEED

Facility

$14.80

Service Code	NDC 9871666370
Hospital Charge Code	150863
Hospital Revenue Code	637
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$14.80
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: ASR ASR	$14.36
Rate for Payer: BCBS Trust/PPO	$11.47
Rate for Payer: BCN Commercial	$11.47
Rate for Payer: Cash Price	$11.84
Rate for Payer: Cofinity Commercial	$13.91
Rate for Payer: Encore Health Key Benefits Commercial	$11.84
Rate for Payer: Healthscope Commercial	$14.80
Rate for Payer: Healthscope Whirlpool	$14.36
Rate for Payer: Mclaren Commercial	$13.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.58
Rate for Payer: Priority Health Cigna Priority Health	$10.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.02

PEPTAMEN AF BOLUS FEED

Facility

$14.80

Service Code	NDC 9871666360
Hospital Charge Code	150863
Hospital Revenue Code	637
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$14.80
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: ASR ASR	$14.36
Rate for Payer: BCBS Trust/PPO	$11.47
Rate for Payer: BCN Commercial	$11.47
Rate for Payer: Cash Price	$11.84
Rate for Payer: Cofinity Commercial	$13.91
Rate for Payer: Encore Health Key Benefits Commercial	$11.84
Rate for Payer: Healthscope Commercial	$14.80
Rate for Payer: Healthscope Whirlpool	$14.36
Rate for Payer: Mclaren Commercial	$13.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.58
Rate for Payer: Priority Health Cigna Priority Health	$10.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.02

PEPTAMEN AF CONTINUOUS FEED

Facility

$14.80

Service Code	NDC 9871666370
Hospital Charge Code	168955
Hospital Revenue Code	637
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$14.80
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: ASR ASR	$14.36
Rate for Payer: BCBS Trust/PPO	$11.47
Rate for Payer: BCN Commercial	$11.47
Rate for Payer: Cash Price	$11.84
Rate for Payer: Cofinity Commercial	$13.91
Rate for Payer: Encore Health Key Benefits Commercial	$11.84
Rate for Payer: Healthscope Commercial	$14.80
Rate for Payer: Healthscope Whirlpool	$14.36
Rate for Payer: Mclaren Commercial	$13.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.58
Rate for Payer: Priority Health Cigna Priority Health	$10.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.02

PEPTAMEN AF CONTINUOUS FEED

Facility

$14.80

Service Code	NDC 9871666360
Hospital Charge Code	168955
Hospital Revenue Code	637
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$14.80
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: ASR ASR	$14.36
Rate for Payer: BCBS Trust/PPO	$11.47
Rate for Payer: BCN Commercial	$11.47
Rate for Payer: Cash Price	$11.84
Rate for Payer: Cofinity Commercial	$13.91
Rate for Payer: Encore Health Key Benefits Commercial	$11.84
Rate for Payer: Healthscope Commercial	$14.80
Rate for Payer: Healthscope Whirlpool	$14.36
Rate for Payer: Mclaren Commercial	$13.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.58
Rate for Payer: Priority Health Cigna Priority Health	$10.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.02

PEPTAMEN AF CYCLIC FEED

Facility

$14.80

Service Code	NDC 9871666360
Hospital Charge Code	200079
Hospital Revenue Code	637
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$14.80
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: ASR ASR	$14.36
Rate for Payer: BCBS Trust/PPO	$11.47
Rate for Payer: BCN Commercial	$11.47
Rate for Payer: Cash Price	$11.84
Rate for Payer: Cofinity Commercial	$13.91
Rate for Payer: Encore Health Key Benefits Commercial	$11.84
Rate for Payer: Healthscope Commercial	$14.80
Rate for Payer: Healthscope Whirlpool	$14.36
Rate for Payer: Mclaren Commercial	$13.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.58
Rate for Payer: Priority Health Cigna Priority Health	$10.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.02

PEPTAMEN AF CYCLIC FEED

Facility

$14.80

Service Code	NDC 9871666370
Hospital Charge Code	200079
Hospital Revenue Code	637
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$14.80
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: ASR ASR	$14.36
Rate for Payer: BCBS Trust/PPO	$11.47
Rate for Payer: BCN Commercial	$11.47
Rate for Payer: Cash Price	$11.84
Rate for Payer: Cofinity Commercial	$13.91
Rate for Payer: Encore Health Key Benefits Commercial	$11.84
Rate for Payer: Healthscope Commercial	$14.80
Rate for Payer: Healthscope Whirlpool	$14.36
Rate for Payer: Mclaren Commercial	$13.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.58
Rate for Payer: Priority Health Cigna Priority Health	$10.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.02

PEPTAMEN AF INTERMITTENT FEED

Facility

$14.80

Service Code	NDC 9871666360
Hospital Charge Code	200078
Hospital Revenue Code	637
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$14.80
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: ASR ASR	$14.36
Rate for Payer: BCBS Trust/PPO	$11.47
Rate for Payer: BCN Commercial	$11.47
Rate for Payer: Cash Price	$11.84
Rate for Payer: Cofinity Commercial	$13.91
Rate for Payer: Encore Health Key Benefits Commercial	$11.84
Rate for Payer: Healthscope Commercial	$14.80
Rate for Payer: Healthscope Whirlpool	$14.36
Rate for Payer: Mclaren Commercial	$13.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.58
Rate for Payer: Priority Health Cigna Priority Health	$10.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.02

PEPTAMEN AF INTERMITTENT FEED

Facility

$14.80

Service Code	NDC 9871666370
Hospital Charge Code	200078
Hospital Revenue Code	637
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$14.80
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: ASR ASR	$14.36
Rate for Payer: BCBS Trust/PPO	$11.47
Rate for Payer: BCN Commercial	$11.47
Rate for Payer: Cash Price	$11.84
Rate for Payer: Cofinity Commercial	$13.91
Rate for Payer: Encore Health Key Benefits Commercial	$11.84
Rate for Payer: Healthscope Commercial	$14.80
Rate for Payer: Healthscope Whirlpool	$14.36
Rate for Payer: Mclaren Commercial	$13.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.58
Rate for Payer: Priority Health Cigna Priority Health	$10.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.02

PEPTAMEN INTENSE VHP BOLUS FEED

Facility

$15.72

Service Code	NDC 4390043271
Hospital Charge Code	300293
Hospital Revenue Code	637
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.72
Rate for Payer: Aetna Commercial	$14.15
Rate for Payer: ASR ASR	$15.25
Rate for Payer: BCBS Trust/PPO	$12.19
Rate for Payer: BCN Commercial	$12.19
Rate for Payer: Cash Price	$12.58
Rate for Payer: Cofinity Commercial	$14.78
Rate for Payer: Encore Health Key Benefits Commercial	$12.58
Rate for Payer: Healthscope Commercial	$15.72
Rate for Payer: Healthscope Whirlpool	$15.25
Rate for Payer: Mclaren Commercial	$14.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.36
Rate for Payer: Priority Health Cigna Priority Health	$11.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.83

PEPTAMEN INTENSE VHP CONTINUOUS FEED

Facility

$15.72

Service Code	NDC 4390043271
Hospital Charge Code	181406
Hospital Revenue Code	637
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.72
Rate for Payer: Aetna Commercial	$14.15
Rate for Payer: ASR ASR	$15.25
Rate for Payer: BCBS Trust/PPO	$12.19
Rate for Payer: BCN Commercial	$12.19
Rate for Payer: Cash Price	$12.58
Rate for Payer: Cofinity Commercial	$14.78
Rate for Payer: Encore Health Key Benefits Commercial	$12.58
Rate for Payer: Healthscope Commercial	$15.72
Rate for Payer: Healthscope Whirlpool	$15.25
Rate for Payer: Mclaren Commercial	$14.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.36
Rate for Payer: Priority Health Cigna Priority Health	$11.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.83

PEPTAMEN INTENSE VHP CONTINUOUS FEED

Facility

$15.72

Service Code	NDC 4390073049
Hospital Charge Code	181406
Hospital Revenue Code	637
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.72
Rate for Payer: Aetna Commercial	$14.15
Rate for Payer: ASR ASR	$15.25
Rate for Payer: BCBS Trust/PPO	$12.19
Rate for Payer: BCN Commercial	$12.19
Rate for Payer: Cash Price	$12.58
Rate for Payer: Cofinity Commercial	$14.78
Rate for Payer: Encore Health Key Benefits Commercial	$12.58
Rate for Payer: Healthscope Commercial	$15.72
Rate for Payer: Healthscope Whirlpool	$15.25
Rate for Payer: Mclaren Commercial	$14.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.36
Rate for Payer: Priority Health Cigna Priority Health	$11.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.83

Know your out-of-pocket cost for care.

All Charges