Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

IMPACT PEPTIDE 1.5 CONTINUOUS FEED

Facility

$15.73

Service Code	NDC 43900097399
Hospital Charge Code	168957
Hospital Revenue Code	637
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$15.72
Rate for Payer: Aetna Commercial	$14.15
Rate for Payer: Aetna Medicare	$5.82
Rate for Payer: ASR ASR	$15.25
Rate for Payer: BCBS Complete	$6.29
Rate for Payer: BCBS Trust/PPO	$12.97
Rate for Payer: BCN Commercial	$12.97
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	$15.25
Rate for Payer: Healthscope Whirlpool	$15.72
Rate for Payer: Mclaren Commercial	$14.15
Rate for Payer: MI Amish Medical Board Commercial	$12.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.37
Rate for Payer: Nomi Health Commercial	$12.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.79
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$13.78
Rate for Payer: Priority Health Narrow Network	$11.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.84

IMPACT PEPTIDE 1.5 CYCLIC FEED

Facility

$15.73

Service Code	NDC 43900097399
Hospital Charge Code	200091
Hospital Revenue Code	637
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$15.72
Rate for Payer: Aetna Commercial	$14.15
Rate for Payer: Aetna Medicare	$5.82
Rate for Payer: ASR ASR	$15.25
Rate for Payer: BCBS Complete	$6.29
Rate for Payer: BCBS Trust/PPO	$12.97
Rate for Payer: BCN Commercial	$12.97
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	$15.25
Rate for Payer: Healthscope Whirlpool	$15.72
Rate for Payer: Mclaren Commercial	$14.15
Rate for Payer: MI Amish Medical Board Commercial	$12.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.37
Rate for Payer: Nomi Health Commercial	$12.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.79
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$13.78
Rate for Payer: Priority Health Narrow Network	$11.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.84

IMPACT PEPTIDE 1.5 CYCLIC FEED

Facility

$15.73

Service Code	NDC 43900097399
Hospital Charge Code	200091
Hospital Revenue Code	637
Min. Negotiated Rate	$11.79
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	$12.91
Rate for Payer: BCN Commercial	$12.91
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	$15.25
Rate for Payer: Healthscope Whirlpool	$15.72
Rate for Payer: Mclaren Commercial	$14.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.37
Rate for Payer: Nomi Health Commercial	$12.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.84

IMPACT PEPTIDE 1.5 INTERMITTENT FEED

Facility

$15.73

Service Code	NDC 43900097399
Hospital Charge Code	200090
Hospital Revenue Code	637
Min. Negotiated Rate	$11.79
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	$12.91
Rate for Payer: BCN Commercial	$12.91
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	$15.25
Rate for Payer: Healthscope Whirlpool	$15.72
Rate for Payer: Mclaren Commercial	$14.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.37
Rate for Payer: Nomi Health Commercial	$12.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.84

IMPACT PEPTIDE 1.5 INTERMITTENT FEED

Facility

$15.73

Service Code	NDC 43900097399
Hospital Charge Code	200090
Hospital Revenue Code	637
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$15.72
Rate for Payer: Aetna Commercial	$14.15
Rate for Payer: Aetna Medicare	$5.82
Rate for Payer: ASR ASR	$15.25
Rate for Payer: BCBS Complete	$6.29
Rate for Payer: BCBS Trust/PPO	$12.97
Rate for Payer: BCN Commercial	$12.97
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	$15.25
Rate for Payer: Healthscope Whirlpool	$15.72
Rate for Payer: Mclaren Commercial	$14.15
Rate for Payer: MI Amish Medical Board Commercial	$12.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.37
Rate for Payer: Nomi Health Commercial	$12.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.79
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$13.78
Rate for Payer: Priority Health Narrow Network	$11.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.84

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$89,431.74

Service Code	APR-DRG 1613
Min. Negotiated Rate	$80,857.00
Max. Negotiated Rate	$89,431.74
Rate for Payer: BCBS Complete	$89,431.74
Rate for Payer: Mclaren Medicaid	$85,173.09
Rate for Payer: Meridian Medicaid	$89,431.74
Rate for Payer: PHP Medicaid	$80,857.00
Rate for Payer: Priority Health Choice Medicaid	$85,173.09
Rate for Payer: UHC Medicaid	$85,173.09
Rate for Payer: UHCCP Medicaid	$85,173.09

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$81,223.71

Service Code	APR-DRG 1612
Min. Negotiated Rate	$73,435.95
Max. Negotiated Rate	$81,223.71
Rate for Payer: BCBS Complete	$81,223.71
Rate for Payer: Mclaren Medicaid	$77,355.91
Rate for Payer: Meridian Medicaid	$81,223.71
Rate for Payer: PHP Medicaid	$73,435.95
Rate for Payer: Priority Health Choice Medicaid	$77,355.91
Rate for Payer: UHC Medicaid	$77,355.91
Rate for Payer: UHCCP Medicaid	$77,355.91

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$165,150.37

Service Code	APR-DRG 1614
Min. Negotiated Rate	$149,315.69
Max. Negotiated Rate	$165,150.37
Rate for Payer: BCBS Complete	$165,150.37
Rate for Payer: Mclaren Medicaid	$157,286.06
Rate for Payer: Meridian Medicaid	$165,150.37
Rate for Payer: PHP Medicaid	$149,315.69
Rate for Payer: Priority Health Choice Medicaid	$157,286.06
Rate for Payer: UHC Medicaid	$157,286.06
Rate for Payer: UHCCP Medicaid	$157,286.06

IMPLANTABLE HEART ASSIST SYSTEMS

Facility

$68,454.98

Service Code	APR-DRG 1611
Min. Negotiated Rate	$61,891.50
Max. Negotiated Rate	$68,454.98
Rate for Payer: BCBS Complete	$68,454.98
Rate for Payer: Mclaren Medicaid	$65,195.22
Rate for Payer: Meridian Medicaid	$68,454.98
Rate for Payer: PHP Medicaid	$61,891.50
Rate for Payer: Priority Health Choice Medicaid	$65,195.22
Rate for Payer: UHC Medicaid	$65,195.22
Rate for Payer: UHCCP Medicaid	$65,195.22

INBORN AND OTHER DISORDERS OF METABOLISM

Facility

$19,537.95

Service Code	MSDRG 642
Min. Negotiated Rate	$11,395.58
Max. Negotiated Rate	$19,537.95
Rate for Payer: Aetna Medicare	$11,995.35
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,994.19
Rate for Payer: Amish Plain Church Group Commercial	$14,994.19
Rate for Payer: BCBS MAPPO	$11,995.35
Rate for Payer: BCN Medicare Advantage	$11,995.35
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,995.35
Rate for Payer: Humana Choice PPO Medicare	$11,995.35
Rate for Payer: Mclaren Medicare	$11,995.35
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$12,595.12
Rate for Payer: MI Amish Medical Board Commercial	$13,794.65
Rate for Payer: Molina Medicare/Medicaid	$13,194.89
Rate for Payer: PACE Medicare	$11,395.58
Rate for Payer: PACE SWMI	$11,995.35
Rate for Payer: PHP Commercial	$13,194.89
Rate for Payer: PHP Medicare Advantage	$11,995.35
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$19,537.95
Rate for Payer: Priority Health Medicare	$11,995.35
Rate for Payer: Priority Health Narrow Network	$15,630.36
Rate for Payer: Railroad Medicare Medicare	$11,995.35
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$11,995.35
Rate for Payer: UHC Exchange	$18,592.79
Rate for Payer: UHCCP DNSP	$11,995.35
Rate for Payer: VA VA	$11,995.35

INBORN ERRORS OF METABOLISM

Facility

$27,174.48

Service Code	APR-DRG 4234
Min. Negotiated Rate	$24,568.98
Max. Negotiated Rate	$27,174.48
Rate for Payer: BCBS Complete	$27,174.48
Rate for Payer: Mclaren Medicaid	$25,880.45
Rate for Payer: Meridian Medicaid	$27,174.48
Rate for Payer: PHP Medicaid	$24,568.98
Rate for Payer: Priority Health Choice Medicaid	$25,880.45
Rate for Payer: UHC Medicaid	$25,880.45
Rate for Payer: UHCCP Medicaid	$25,880.45

INBORN ERRORS OF METABOLISM

Facility

$10,396.01

Service Code	APR-DRG 4233
Min. Negotiated Rate	$9,399.24
Max. Negotiated Rate	$10,396.01
Rate for Payer: BCBS Complete	$10,396.01
Rate for Payer: Mclaren Medicaid	$9,900.96
Rate for Payer: Meridian Medicaid	$10,396.01
Rate for Payer: PHP Medicaid	$9,399.24
Rate for Payer: Priority Health Choice Medicaid	$9,900.96
Rate for Payer: UHC Medicaid	$9,900.96
Rate for Payer: UHCCP Medicaid	$9,900.96

INBORN ERRORS OF METABOLISM

Facility

$3,192.32

Service Code	APR-DRG 4231
Min. Negotiated Rate	$2,886.24
Max. Negotiated Rate	$3,192.32
Rate for Payer: BCBS Complete	$3,192.32
Rate for Payer: Mclaren Medicaid	$3,040.30
Rate for Payer: Meridian Medicaid	$3,192.32
Rate for Payer: PHP Medicaid	$2,886.24
Rate for Payer: Priority Health Choice Medicaid	$3,040.30
Rate for Payer: UHC Medicaid	$3,040.30
Rate for Payer: UHCCP Medicaid	$3,040.30

INBORN ERRORS OF METABOLISM

Facility

$7,378.08

Service Code	APR-DRG 4232
Min. Negotiated Rate	$6,670.67
Max. Negotiated Rate	$7,378.08
Rate for Payer: BCBS Complete	$7,378.08
Rate for Payer: Mclaren Medicaid	$7,026.74
Rate for Payer: Meridian Medicaid	$7,378.08
Rate for Payer: PHP Medicaid	$6,670.67
Rate for Payer: Priority Health Choice Medicaid	$7,026.74
Rate for Payer: UHC Medicaid	$7,026.74
Rate for Payer: UHCCP Medicaid	$7,026.74

INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION

Facility

$2,550.77

Service Code	CPT 10140
Hospital Revenue Code	361
Min. Negotiated Rate	$860.68
Max. Negotiated Rate	$2,550.77
Rate for Payer: Aetna Medicare	$1,645.66
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,057.07
Rate for Payer: Amish Plain Church Group Commercial	$2,057.07
Rate for Payer: BCBS Complete	$903.80
Rate for Payer: BCBS MAPPO	$1,645.66
Rate for Payer: BCN Medicare Advantage	$1,645.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,645.66
Rate for Payer: Humana Choice PPO Medicare	$1,645.66
Rate for Payer: Mclaren Medicaid	$1,645.66
Rate for Payer: Mclaren Medicare	$1,645.66
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,727.94
Rate for Payer: Meridian Medicaid	$903.80
Rate for Payer: MI Amish Medical Board Commercial	$1,892.51
Rate for Payer: Molina Medicare/Medicaid	$1,810.23
Rate for Payer: PACE Medicare	$1,563.38
Rate for Payer: PACE SWMI	$1,645.66
Rate for Payer: PHP Commercial	$1,810.23
Rate for Payer: PHP Medicaid	$882.07
Rate for Payer: PHP Medicare Advantage	$1,645.66
Rate for Payer: Priority Health Choice Medicaid	$860.68
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$2,170.54
Rate for Payer: Priority Health Medicare	$1,645.66
Rate for Payer: Priority Health Narrow Network	$1,736.43
Rate for Payer: Railroad Medicare Medicare	$1,645.66
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$1,645.66
Rate for Payer: UHC Exchange	$2,550.77
Rate for Payer: UHC Medicaid	$860.68
Rate for Payer: UHCCP DNSP	$1,645.66
Rate for Payer: UHCCP Medicaid	$860.68
Rate for Payer: VA VA	$1,645.66

INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE

Facility

$9,701.22

Service Code	HCPCS J1306
Hospital Charge Code	198874
Hospital Revenue Code	636
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9,701.22
Rate for Payer: Aetna Commercial	$8,731.10
Rate for Payer: Aetna Medicare	$12.61
Rate for Payer: Allen County Amish Medical Aid Commercial	$15.76
Rate for Payer: Amish Plain Church Group Commercial	$15.76
Rate for Payer: ASR ASR	$9,410.19
Rate for Payer: BCBS Complete	$6.93
Rate for Payer: BCBS MAPPO	$12.61
Rate for Payer: BCBS Trust/PPO	$7,998.66
Rate for Payer: BCN Commercial	$7,998.66
Rate for Payer: BCN Medicare Advantage	$12.61
Rate for Payer: Cash Price	$7,760.98
Rate for Payer: Cash Price	$7,760.98
Rate for Payer: Cofinity Commercial	$9,119.15
Rate for Payer: Encore Health Key Benefits Commercial	$7,760.98
Rate for Payer: Health Alliance Plan Medicare Advantage	$12.61
Rate for Payer: Healthscope Commercial	$9,410.19
Rate for Payer: Healthscope Whirlpool	$9,701.22
Rate for Payer: Humana Choice PPO Medicare	$12.61
Rate for Payer: Mclaren Commercial	$8,731.10
Rate for Payer: Mclaren Medicaid	$12.61
Rate for Payer: Mclaren Medicare	$12.61
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$13.24
Rate for Payer: Meridian Medicaid	$6.93
Rate for Payer: MI Amish Medical Board Commercial	$14.50
Rate for Payer: Molina Medicare/Medicaid	$13.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8,246.04
Rate for Payer: Nomi Health Commercial	$7,955.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7,275.92
Rate for Payer: PACE Medicare	$11.98
Rate for Payer: PACE SWMI	$12.61
Rate for Payer: PHP Commercial	$13.87
Rate for Payer: PHP Medicaid	$6.76
Rate for Payer: PHP Medicare Advantage	$12.61
Rate for Payer: Priority Health Choice Medicaid	$6.60
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$13.17
Rate for Payer: Priority Health Medicare	$12.61
Rate for Payer: Priority Health Narrow Network	$10.54
Rate for Payer: Railroad Medicare Medicare	$12.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8,537.08
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$12.61
Rate for Payer: UHC Exchange	$19.55
Rate for Payer: UHC Medicaid	$6.60
Rate for Payer: UHCCP DNSP	$12.61
Rate for Payer: UHCCP Medicaid	$6.60
Rate for Payer: VA VA	$12.61

INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE

Facility

$9,701.22

Service Code	HCPCS J1306
Hospital Charge Code	198874
Hospital Revenue Code	636
Min. Negotiated Rate	$7,275.92
Max. Negotiated Rate	$9,701.22
Rate for Payer: Aetna Commercial	$8,731.10
Rate for Payer: ASR ASR	$9,410.19
Rate for Payer: BCBS Trust/PPO	$7,966.64
Rate for Payer: BCN Commercial	$7,966.64
Rate for Payer: Cash Price	$7,760.98
Rate for Payer: Cofinity Commercial	$9,119.15
Rate for Payer: Encore Health Key Benefits Commercial	$7,760.98
Rate for Payer: Healthscope Commercial	$9,410.19
Rate for Payer: Healthscope Whirlpool	$9,701.22
Rate for Payer: Mclaren Commercial	$8,731.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8,246.04
Rate for Payer: Nomi Health Commercial	$7,955.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7,275.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8,537.08

INDAPAMIDE 2.5 MG TABLET

Facility

$350.15

Service Code	NDC 43975030410
Hospital Charge Code	3879
Hospital Revenue Code	637
Min. Negotiated Rate	$262.61
Max. Negotiated Rate	$350.15
Rate for Payer: Aetna Commercial	$315.13
Rate for Payer: ASR ASR	$339.65
Rate for Payer: BCBS Trust/PPO	$287.54
Rate for Payer: BCN Commercial	$287.54
Rate for Payer: Cash Price	$280.12
Rate for Payer: Cofinity Commercial	$329.14
Rate for Payer: Encore Health Key Benefits Commercial	$280.12
Rate for Payer: Healthscope Commercial	$339.65
Rate for Payer: Healthscope Whirlpool	$350.15
Rate for Payer: Mclaren Commercial	$315.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$297.63
Rate for Payer: Nomi Health Commercial	$287.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$262.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$308.13

INDAPAMIDE 2.5 MG TABLET

Facility

$350.15

Service Code	NDC 43975030410
Hospital Charge Code	3879
Hospital Revenue Code	637
Min. Negotiated Rate	$129.56
Max. Negotiated Rate	$350.15
Rate for Payer: Aetna Commercial	$315.13
Rate for Payer: Aetna Medicare	$129.56
Rate for Payer: ASR ASR	$339.65
Rate for Payer: BCBS Complete	$140.06
Rate for Payer: BCBS Trust/PPO	$288.70
Rate for Payer: BCN Commercial	$288.70
Rate for Payer: Cash Price	$280.12
Rate for Payer: Cofinity Commercial	$329.14
Rate for Payer: Encore Health Key Benefits Commercial	$280.12
Rate for Payer: Healthscope Commercial	$339.65
Rate for Payer: Healthscope Whirlpool	$350.15
Rate for Payer: Mclaren Commercial	$315.13
Rate for Payer: MI Amish Medical Board Commercial	$280.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$297.63
Rate for Payer: Nomi Health Commercial	$287.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$262.61
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$306.80
Rate for Payer: Priority Health Narrow Network	$245.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$308.13

INDAPAMIDE 2.5 MG TABLET

Facility

$293.75

Service Code	NDC 62559051101
Hospital Charge Code	3879
Hospital Revenue Code	637
Min. Negotiated Rate	$220.31
Max. Negotiated Rate	$293.75
Rate for Payer: Aetna Commercial	$264.38
Rate for Payer: ASR ASR	$284.94
Rate for Payer: BCBS Trust/PPO	$241.23
Rate for Payer: BCN Commercial	$241.23
Rate for Payer: Cash Price	$235.00
Rate for Payer: Cofinity Commercial	$276.12
Rate for Payer: Encore Health Key Benefits Commercial	$235.00
Rate for Payer: Healthscope Commercial	$284.94
Rate for Payer: Healthscope Whirlpool	$293.75
Rate for Payer: Mclaren Commercial	$264.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$249.69
Rate for Payer: Nomi Health Commercial	$240.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$220.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$258.50

INDAPAMIDE 2.5 MG TABLET

Facility

$293.75

Service Code	NDC 62559051101
Hospital Charge Code	3879
Hospital Revenue Code	637
Min. Negotiated Rate	$108.69
Max. Negotiated Rate	$293.75
Rate for Payer: Aetna Commercial	$264.38
Rate for Payer: Aetna Medicare	$108.69
Rate for Payer: ASR ASR	$284.94
Rate for Payer: BCBS Complete	$117.50
Rate for Payer: BCBS Trust/PPO	$242.20
Rate for Payer: BCN Commercial	$242.20
Rate for Payer: Cash Price	$235.00
Rate for Payer: Cofinity Commercial	$276.12
Rate for Payer: Encore Health Key Benefits Commercial	$235.00
Rate for Payer: Healthscope Commercial	$284.94
Rate for Payer: Healthscope Whirlpool	$293.75
Rate for Payer: Mclaren Commercial	$264.38
Rate for Payer: MI Amish Medical Board Commercial	$235.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$249.69
Rate for Payer: Nomi Health Commercial	$240.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$220.31
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$257.38
Rate for Payer: Priority Health Narrow Network	$205.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$258.50

INDOMETHACIN 25 MG CAPSULE

Facility

$2.58

Service Code	NDC 50268043011
Hospital Charge Code	3897
Hospital Revenue Code	637
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.58
Rate for Payer: Aetna Commercial	$2.32
Rate for Payer: Aetna Medicare	$0.95
Rate for Payer: ASR ASR	$2.50
Rate for Payer: BCBS Complete	$1.03
Rate for Payer: BCBS Trust/PPO	$2.12
Rate for Payer: BCN Commercial	$2.12
Rate for Payer: Cash Price	$2.06
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.06
Rate for Payer: Healthscope Commercial	$2.50
Rate for Payer: Healthscope Whirlpool	$2.58
Rate for Payer: Mclaren Commercial	$2.32
Rate for Payer: MI Amish Medical Board Commercial	$2.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.19
Rate for Payer: Nomi Health Commercial	$2.11
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.93
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$2.26
Rate for Payer: Priority Health Narrow Network	$1.81
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.27

INDOMETHACIN 25 MG CAPSULE

Facility

$197.40

Service Code	NDC 68462040601
Hospital Charge Code	3897
Hospital Revenue Code	637
Min. Negotiated Rate	$148.05
Max. Negotiated Rate	$197.40
Rate for Payer: Aetna Commercial	$177.66
Rate for Payer: ASR ASR	$191.48
Rate for Payer: BCBS Trust/PPO	$162.10
Rate for Payer: BCN Commercial	$162.10
Rate for Payer: Cash Price	$157.92
Rate for Payer: Cofinity Commercial	$185.56
Rate for Payer: Encore Health Key Benefits Commercial	$157.92
Rate for Payer: Healthscope Commercial	$191.48
Rate for Payer: Healthscope Whirlpool	$197.40
Rate for Payer: Mclaren Commercial	$177.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.79
Rate for Payer: Nomi Health Commercial	$161.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$148.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$173.71

INDOMETHACIN 25 MG CAPSULE

Facility

$128.73

Service Code	NDC 50268043015
Hospital Charge Code	3897
Hospital Revenue Code	637
Min. Negotiated Rate	$47.63
Max. Negotiated Rate	$128.72
Rate for Payer: Aetna Commercial	$115.85
Rate for Payer: Aetna Medicare	$47.63
Rate for Payer: ASR ASR	$124.86
Rate for Payer: BCBS Complete	$51.49
Rate for Payer: BCBS Trust/PPO	$106.13
Rate for Payer: BCN Commercial	$106.13
Rate for Payer: Cash Price	$102.98
Rate for Payer: Cofinity Commercial	$121.00
Rate for Payer: Encore Health Key Benefits Commercial	$102.98
Rate for Payer: Healthscope Commercial	$124.86
Rate for Payer: Healthscope Whirlpool	$128.72
Rate for Payer: Mclaren Commercial	$115.85
Rate for Payer: MI Amish Medical Board Commercial	$102.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$109.42
Rate for Payer: Nomi Health Commercial	$105.55
Rate for Payer: Opus (Opus Packaging Group) HMA	$96.54
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$112.79
Rate for Payer: Priority Health Narrow Network	$90.24
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$113.28

INDOMETHACIN 25 MG CAPSULE

Facility

$2.58

Service Code	NDC 50268043011
Hospital Charge Code	3897
Hospital Revenue Code	637
Min. Negotiated Rate	$1.93
Max. Negotiated Rate	$2.58
Rate for Payer: Aetna Commercial	$2.32
Rate for Payer: ASR ASR	$2.50
Rate for Payer: BCBS Trust/PPO	$2.11
Rate for Payer: BCN Commercial	$2.11
Rate for Payer: Cash Price	$2.06
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.06
Rate for Payer: Healthscope Commercial	$2.50
Rate for Payer: Healthscope Whirlpool	$2.58
Rate for Payer: Mclaren Commercial	$2.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.19
Rate for Payer: Nomi Health Commercial	$2.11
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.27

Know your out-of-pocket cost for care.

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