Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

INSULIN REGULAR HUMAN U-500 (CONCENTRATE) 500 UNIT/ML(3 ML) SUBCUT PEN

Facility

$938.39

Service Code	NDC 00002882401
Hospital Charge Code	178095
Hospital Revenue Code	637
Min. Negotiated Rate	$609.95
Max. Negotiated Rate	$938.39
Rate for Payer: Aetna Commercial	$844.55
Rate for Payer: ASR ASR	$910.24
Rate for Payer: ASR Commercial	$910.24
Rate for Payer: BCBS Trust/PPO	$764.69
Rate for Payer: BCN Commercial	$727.53
Rate for Payer: Cash Price	$750.71
Rate for Payer: Cofinity Commercial	$882.09
Rate for Payer: Encore Health Key Benefits Commercial	$750.71
Rate for Payer: Healthscope Commercial	$938.39
Rate for Payer: Healthscope Whirlpool	$910.24
Rate for Payer: Mclaren Commercial	$844.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$797.63
Rate for Payer: Nomi Health Commercial	$769.48
Rate for Payer: Priority Health Cigna Priority Health	$609.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$825.78

INSULIN REGULAR HUMAN U-500"CONCENTRATE" 500 UNIT/ML SQ FOR INSULIN PUMP REFILL

Facility

$4,860.23

Service Code	NDC 00002850101
Hospital Charge Code	301808
Hospital Revenue Code	637
Min. Negotiated Rate	$3,159.15
Max. Negotiated Rate	$4,860.23
Rate for Payer: Aetna Commercial	$4,374.21
Rate for Payer: ASR ASR	$4,714.42
Rate for Payer: ASR Commercial	$4,714.42
Rate for Payer: BCBS Trust/PPO	$3,960.60
Rate for Payer: BCN Commercial	$3,768.14
Rate for Payer: Cash Price	$3,888.19
Rate for Payer: Cofinity Commercial	$4,568.62
Rate for Payer: Encore Health Key Benefits Commercial	$3,888.18
Rate for Payer: Healthscope Commercial	$4,860.23
Rate for Payer: Healthscope Whirlpool	$4,714.42
Rate for Payer: Mclaren Commercial	$4,374.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,131.20
Rate for Payer: Nomi Health Commercial	$3,985.39
Rate for Payer: Priority Health Cigna Priority Health	$3,159.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,277.00

INSULIN REGULAR HUMAN U-500"CONCENTRATE" 500 UNIT/ML SQ FOR INSULIN PUMP REFILL

Facility

$4,860.23

Service Code	NDC 00002850101
Hospital Charge Code	301808
Hospital Revenue Code	637
Min. Negotiated Rate	$1,944.09
Max. Negotiated Rate	$4,860.23
Rate for Payer: Aetna Commercial	$4,374.21
Rate for Payer: Aetna Medicare	$2,430.12
Rate for Payer: ASR ASR	$4,714.42
Rate for Payer: ASR Commercial	$4,714.42
Rate for Payer: BCBS Complete	$1,944.09
Rate for Payer: BCBS Trust/PPO	$3,980.04
Rate for Payer: BCN Commercial	$3,768.14
Rate for Payer: Cash Price	$3,888.19
Rate for Payer: Cofinity Commercial	$4,568.62
Rate for Payer: Encore Health Key Benefits Commercial	$3,888.18
Rate for Payer: Healthscope Commercial	$4,860.23
Rate for Payer: Healthscope Whirlpool	$4,714.42
Rate for Payer: Mclaren Commercial	$4,374.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,131.20
Rate for Payer: Nomi Health Commercial	$3,985.39
Rate for Payer: Priority Health Cigna Priority Health	$3,159.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,258.53
Rate for Payer: Priority Health Narrow Network	$3,407.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,277.00

INSULIN SUBCUTANEOUS BASAL PUMP - HUMAN (HUMULIN R)

Facility

$141.16

Service Code	NDC 00169183311
Hospital Charge Code	180910
Hospital Revenue Code	637
Min. Negotiated Rate	$91.75
Max. Negotiated Rate	$141.16
Rate for Payer: Aetna Commercial	$127.04
Rate for Payer: ASR ASR	$136.93
Rate for Payer: ASR Commercial	$136.93
Rate for Payer: BCBS Trust/PPO	$115.03
Rate for Payer: BCN Commercial	$109.44
Rate for Payer: Cash Price	$112.92
Rate for Payer: Cofinity Commercial	$132.69
Rate for Payer: Encore Health Key Benefits Commercial	$112.93
Rate for Payer: Healthscope Commercial	$141.16
Rate for Payer: Healthscope Whirlpool	$136.93
Rate for Payer: Mclaren Commercial	$127.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.99
Rate for Payer: Nomi Health Commercial	$115.75
Rate for Payer: Priority Health Cigna Priority Health	$91.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$124.22

INSULIN SUBCUTANEOUS BASAL PUMP - HUMAN (HUMULIN R)

Facility

$141.16

Service Code	NDC 00169183311
Hospital Charge Code	180910
Hospital Revenue Code	637
Min. Negotiated Rate	$56.46
Max. Negotiated Rate	$141.16
Rate for Payer: Aetna Commercial	$127.04
Rate for Payer: Aetna Medicare	$70.58
Rate for Payer: ASR ASR	$136.93
Rate for Payer: ASR Commercial	$136.93
Rate for Payer: BCBS Complete	$56.46
Rate for Payer: BCBS Trust/PPO	$115.60
Rate for Payer: BCN Commercial	$109.44
Rate for Payer: Cash Price	$112.92
Rate for Payer: Cofinity Commercial	$132.69
Rate for Payer: Encore Health Key Benefits Commercial	$112.93
Rate for Payer: Healthscope Commercial	$141.16
Rate for Payer: Healthscope Whirlpool	$136.93
Rate for Payer: Mclaren Commercial	$127.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.99
Rate for Payer: Nomi Health Commercial	$115.75
Rate for Payer: Priority Health Cigna Priority Health	$91.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$123.68
Rate for Payer: Priority Health Narrow Network	$98.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$124.22

INSULIN SUBCUTANEOUS BASAL PUMP - INSULIN GLULISINE (APIDRA)

Facility

$290.23

Service Code	HCPCS J1815
Hospital Charge Code	180908
Hospital Revenue Code	637
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$290.23
Rate for Payer: Aetna Commercial	$261.21
Rate for Payer: Aetna Medicare	$145.12
Rate for Payer: ASR ASR	$281.52
Rate for Payer: ASR Commercial	$281.52
Rate for Payer: BCBS Complete	$116.09
Rate for Payer: BCBS Trust/PPO	$237.67
Rate for Payer: BCN Commercial	$225.02
Rate for Payer: Cash Price	$232.18
Rate for Payer: Cash Price	$232.18
Rate for Payer: Cofinity Commercial	$272.82
Rate for Payer: Encore Health Key Benefits Commercial	$232.18
Rate for Payer: Healthscope Commercial	$290.23
Rate for Payer: Healthscope Whirlpool	$281.52
Rate for Payer: Mclaren Commercial	$261.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$246.70
Rate for Payer: Nomi Health Commercial	$237.99
Rate for Payer: Priority Health Cigna Priority Health	$188.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$0.23
Rate for Payer: Priority Health Narrow Network	$0.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$255.40

INSULIN SUBCUTANEOUS BASAL PUMP - INSULIN GLULISINE (APIDRA)

Facility

$290.23

Service Code	HCPCS J1815
Hospital Charge Code	180908
Hospital Revenue Code	637
Min. Negotiated Rate	$188.65
Max. Negotiated Rate	$290.23
Rate for Payer: Aetna Commercial	$261.21
Rate for Payer: ASR ASR	$281.52
Rate for Payer: ASR Commercial	$281.52
Rate for Payer: BCBS Trust/PPO	$236.51
Rate for Payer: BCN Commercial	$225.02
Rate for Payer: Cash Price	$232.18
Rate for Payer: Cofinity Commercial	$272.82
Rate for Payer: Encore Health Key Benefits Commercial	$232.18
Rate for Payer: Healthscope Commercial	$290.23
Rate for Payer: Healthscope Whirlpool	$281.52
Rate for Payer: Mclaren Commercial	$261.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$246.70
Rate for Payer: Nomi Health Commercial	$237.99
Rate for Payer: Priority Health Cigna Priority Health	$188.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$255.40

INSULIN SUBCUTANEOUS BASAL PUMP - LISPRO (HUMALOG)

Facility

$177.23

Service Code	NDC 00002751001
Hospital Charge Code	180914
Hospital Revenue Code	637
Min. Negotiated Rate	$70.89
Max. Negotiated Rate	$177.23
Rate for Payer: Aetna Commercial	$159.51
Rate for Payer: Aetna Medicare	$88.62
Rate for Payer: ASR ASR	$171.91
Rate for Payer: ASR Commercial	$171.91
Rate for Payer: BCBS Complete	$70.89
Rate for Payer: BCBS Trust/PPO	$145.13
Rate for Payer: BCN Commercial	$137.41
Rate for Payer: Cash Price	$141.78
Rate for Payer: Cofinity Commercial	$166.60
Rate for Payer: Encore Health Key Benefits Commercial	$141.78
Rate for Payer: Healthscope Commercial	$177.23
Rate for Payer: Healthscope Whirlpool	$171.91
Rate for Payer: Mclaren Commercial	$159.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$150.65
Rate for Payer: Nomi Health Commercial	$145.33
Rate for Payer: Priority Health Cigna Priority Health	$115.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$155.29
Rate for Payer: Priority Health Narrow Network	$124.24
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$155.96

INSULIN SUBCUTANEOUS BASAL PUMP - LISPRO (HUMALOG)

Facility

$177.23

Service Code	NDC 00002751001
Hospital Charge Code	180914
Hospital Revenue Code	637
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$177.23
Rate for Payer: Aetna Commercial	$159.51
Rate for Payer: ASR ASR	$171.91
Rate for Payer: ASR Commercial	$171.91
Rate for Payer: BCBS Trust/PPO	$144.42
Rate for Payer: BCN Commercial	$137.41
Rate for Payer: Cash Price	$141.78
Rate for Payer: Cofinity Commercial	$166.60
Rate for Payer: Encore Health Key Benefits Commercial	$141.78
Rate for Payer: Healthscope Commercial	$177.23
Rate for Payer: Healthscope Whirlpool	$171.91
Rate for Payer: Mclaren Commercial	$159.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$150.65
Rate for Payer: Nomi Health Commercial	$145.33
Rate for Payer: Priority Health Cigna Priority Health	$115.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$155.96

INSULIN SUBCUTANEOUS BASAL PUMP - REGULAR HUMAN (U-500)

Facility

$5,065.60

Service Code	NDC 00002850101
Hospital Charge Code	180916
Hospital Revenue Code	637
Min. Negotiated Rate	$2,026.24
Max. Negotiated Rate	$5,065.60
Rate for Payer: Aetna Commercial	$4,559.04
Rate for Payer: Aetna Medicare	$2,532.80
Rate for Payer: ASR ASR	$4,913.63
Rate for Payer: ASR Commercial	$4,913.63
Rate for Payer: BCBS Complete	$2,026.24
Rate for Payer: BCBS Trust/PPO	$4,148.22
Rate for Payer: BCN Commercial	$3,927.36
Rate for Payer: Cash Price	$4,052.48
Rate for Payer: Cofinity Commercial	$4,761.66
Rate for Payer: Encore Health Key Benefits Commercial	$4,052.48
Rate for Payer: Healthscope Commercial	$5,065.60
Rate for Payer: Healthscope Whirlpool	$4,913.63
Rate for Payer: Mclaren Commercial	$4,559.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,305.76
Rate for Payer: Nomi Health Commercial	$4,153.79
Rate for Payer: Priority Health Cigna Priority Health	$3,292.64
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,438.48
Rate for Payer: Priority Health Narrow Network	$3,550.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,457.73

INSULIN SUBCUTANEOUS BASAL PUMP - REGULAR HUMAN (U-500)

Facility

$5,065.60

Service Code	NDC 00002850101
Hospital Charge Code	180916
Hospital Revenue Code	637
Min. Negotiated Rate	$3,292.64
Max. Negotiated Rate	$5,065.60
Rate for Payer: Aetna Commercial	$4,559.04
Rate for Payer: ASR ASR	$4,913.63
Rate for Payer: ASR Commercial	$4,913.63
Rate for Payer: BCBS Trust/PPO	$4,127.96
Rate for Payer: BCN Commercial	$3,927.36
Rate for Payer: Cash Price	$4,052.48
Rate for Payer: Cofinity Commercial	$4,761.66
Rate for Payer: Encore Health Key Benefits Commercial	$4,052.48
Rate for Payer: Healthscope Commercial	$5,065.60
Rate for Payer: Healthscope Whirlpool	$4,913.63
Rate for Payer: Mclaren Commercial	$4,559.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,305.76
Rate for Payer: Nomi Health Commercial	$4,153.79
Rate for Payer: Priority Health Cigna Priority Health	$3,292.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,457.73

INSULIN SUBCUTANEOUS BOLUS PUMP - HUMAN (HUMULIN R)

Facility

$141.16

Service Code	NDC 00169183311
Hospital Charge Code	180911
Hospital Revenue Code	637
Min. Negotiated Rate	$56.46
Max. Negotiated Rate	$141.16
Rate for Payer: Aetna Commercial	$127.04
Rate for Payer: Aetna Medicare	$70.58
Rate for Payer: ASR ASR	$136.93
Rate for Payer: ASR Commercial	$136.93
Rate for Payer: BCBS Complete	$56.46
Rate for Payer: BCBS Trust/PPO	$115.60
Rate for Payer: BCN Commercial	$109.44
Rate for Payer: Cash Price	$112.92
Rate for Payer: Cofinity Commercial	$132.69
Rate for Payer: Encore Health Key Benefits Commercial	$112.93
Rate for Payer: Healthscope Commercial	$141.16
Rate for Payer: Healthscope Whirlpool	$136.93
Rate for Payer: Mclaren Commercial	$127.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.99
Rate for Payer: Nomi Health Commercial	$115.75
Rate for Payer: Priority Health Cigna Priority Health	$91.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$123.68
Rate for Payer: Priority Health Narrow Network	$98.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$124.22

INSULIN SUBCUTANEOUS BOLUS PUMP - HUMAN (HUMULIN R)

Facility

$141.16

Service Code	NDC 00169183311
Hospital Charge Code	180911
Hospital Revenue Code	637
Min. Negotiated Rate	$91.75
Max. Negotiated Rate	$141.16
Rate for Payer: Aetna Commercial	$127.04
Rate for Payer: ASR ASR	$136.93
Rate for Payer: ASR Commercial	$136.93
Rate for Payer: BCBS Trust/PPO	$115.03
Rate for Payer: BCN Commercial	$109.44
Rate for Payer: Cash Price	$112.92
Rate for Payer: Cofinity Commercial	$132.69
Rate for Payer: Encore Health Key Benefits Commercial	$112.93
Rate for Payer: Healthscope Commercial	$141.16
Rate for Payer: Healthscope Whirlpool	$136.93
Rate for Payer: Mclaren Commercial	$127.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.99
Rate for Payer: Nomi Health Commercial	$115.75
Rate for Payer: Priority Health Cigna Priority Health	$91.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$124.22

INSULIN SUBCUTANEOUS BOLUS PUMP - INSULIN GLULISINE (APIDRA)

Facility

$0.23

Service Code	HCPCS J1815
Hospital Charge Code	180909
Hospital Revenue Code	637
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.23
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$0.23
Rate for Payer: Priority Health Narrow Network	$0.18

INSULIN SUBCUTANEOUS CONTINUOUS BASAL PUMP - ASPARTATE (NOVOLOG)

Facility

$137.64

Service Code	NDC 00169750111
Hospital Charge Code	180912
Hospital Revenue Code	637
Min. Negotiated Rate	$89.47
Max. Negotiated Rate	$137.64
Rate for Payer: Aetna Commercial	$123.88
Rate for Payer: ASR ASR	$133.51
Rate for Payer: ASR Commercial	$133.51
Rate for Payer: BCBS Trust/PPO	$112.16
Rate for Payer: BCN Commercial	$106.71
Rate for Payer: Cash Price	$110.11
Rate for Payer: Cofinity Commercial	$129.38
Rate for Payer: Encore Health Key Benefits Commercial	$110.11
Rate for Payer: Healthscope Commercial	$137.64
Rate for Payer: Healthscope Whirlpool	$133.51
Rate for Payer: Mclaren Commercial	$123.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$116.99
Rate for Payer: Nomi Health Commercial	$112.86
Rate for Payer: Priority Health Cigna Priority Health	$89.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$121.12

INSULIN SUBCUTANEOUS CONTINUOUS BASAL PUMP - ASPARTATE (NOVOLOG)

Facility

$137.64

Service Code	NDC 00169750111
Hospital Charge Code	180912
Hospital Revenue Code	637
Min. Negotiated Rate	$55.06
Max. Negotiated Rate	$137.64
Rate for Payer: Aetna Commercial	$123.88
Rate for Payer: Aetna Medicare	$68.82
Rate for Payer: ASR ASR	$133.51
Rate for Payer: ASR Commercial	$133.51
Rate for Payer: BCBS Complete	$55.06
Rate for Payer: BCBS Trust/PPO	$112.71
Rate for Payer: BCN Commercial	$106.71
Rate for Payer: Cash Price	$110.11
Rate for Payer: Cofinity Commercial	$129.38
Rate for Payer: Encore Health Key Benefits Commercial	$110.11
Rate for Payer: Healthscope Commercial	$137.64
Rate for Payer: Healthscope Whirlpool	$133.51
Rate for Payer: Mclaren Commercial	$123.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$116.99
Rate for Payer: Nomi Health Commercial	$112.86
Rate for Payer: Priority Health Cigna Priority Health	$89.47
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$120.60
Rate for Payer: Priority Health Narrow Network	$96.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$121.12

INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION

Facility

$60.35

Service Code	NDC 00002821501
Hospital Charge Code	10289
Hospital Revenue Code	637
Min. Negotiated Rate	$39.23
Max. Negotiated Rate	$60.35
Rate for Payer: Aetna Commercial	$54.32
Rate for Payer: ASR ASR	$58.54
Rate for Payer: ASR Commercial	$58.54
Rate for Payer: BCBS Trust/PPO	$49.18
Rate for Payer: BCN Commercial	$46.79
Rate for Payer: Cash Price	$48.28
Rate for Payer: Cofinity Commercial	$56.73
Rate for Payer: Encore Health Key Benefits Commercial	$48.28
Rate for Payer: Healthscope Commercial	$60.35
Rate for Payer: Healthscope Whirlpool	$58.54
Rate for Payer: Mclaren Commercial	$54.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$51.30
Rate for Payer: Nomi Health Commercial	$49.49
Rate for Payer: Priority Health Cigna Priority Health	$39.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$53.11

INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION

Facility

$60.35

Service Code	NDC 00002821501
Hospital Charge Code	10289
Hospital Revenue Code	637
Min. Negotiated Rate	$24.14
Max. Negotiated Rate	$60.35
Rate for Payer: Aetna Commercial	$54.32
Rate for Payer: Aetna Medicare	$30.18
Rate for Payer: ASR ASR	$58.54
Rate for Payer: ASR Commercial	$58.54
Rate for Payer: BCBS Complete	$24.14
Rate for Payer: BCBS Trust/PPO	$49.42
Rate for Payer: BCN Commercial	$46.79
Rate for Payer: Cash Price	$48.28
Rate for Payer: Cofinity Commercial	$56.73
Rate for Payer: Encore Health Key Benefits Commercial	$48.28
Rate for Payer: Healthscope Commercial	$60.35
Rate for Payer: Healthscope Whirlpool	$58.54
Rate for Payer: Mclaren Commercial	$54.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$51.30
Rate for Payer: Nomi Health Commercial	$49.49
Rate for Payer: Priority Health Cigna Priority Health	$39.23
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$52.88
Rate for Payer: Priority Health Narrow Network	$42.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$53.11

INSULIN U-100 REGULAR HUMAN 100 UNIT/ML SQ FOR INSULIN PUMP REFILL

Facility

$141.16

Service Code	NDC 00169183311
Hospital Charge Code	301806
Hospital Revenue Code	637
Min. Negotiated Rate	$91.75
Max. Negotiated Rate	$141.16
Rate for Payer: Aetna Commercial	$127.04
Rate for Payer: ASR ASR	$136.93
Rate for Payer: ASR Commercial	$136.93
Rate for Payer: BCBS Trust/PPO	$115.03
Rate for Payer: BCN Commercial	$109.44
Rate for Payer: Cash Price	$112.92
Rate for Payer: Cofinity Commercial	$132.69
Rate for Payer: Encore Health Key Benefits Commercial	$112.93
Rate for Payer: Healthscope Commercial	$141.16
Rate for Payer: Healthscope Whirlpool	$136.93
Rate for Payer: Mclaren Commercial	$127.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.99
Rate for Payer: Nomi Health Commercial	$115.75
Rate for Payer: Priority Health Cigna Priority Health	$91.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$124.22

INSULIN U-100 REGULAR HUMAN 100 UNIT/ML SQ FOR INSULIN PUMP REFILL

Facility

$141.16

Service Code	NDC 00169183311
Hospital Charge Code	301806
Hospital Revenue Code	637
Min. Negotiated Rate	$56.46
Max. Negotiated Rate	$141.16
Rate for Payer: Aetna Commercial	$127.04
Rate for Payer: Aetna Medicare	$70.58
Rate for Payer: ASR ASR	$136.93
Rate for Payer: ASR Commercial	$136.93
Rate for Payer: BCBS Complete	$56.46
Rate for Payer: BCBS Trust/PPO	$115.60
Rate for Payer: BCN Commercial	$109.44
Rate for Payer: Cash Price	$112.92
Rate for Payer: Cofinity Commercial	$132.69
Rate for Payer: Encore Health Key Benefits Commercial	$112.93
Rate for Payer: Healthscope Commercial	$141.16
Rate for Payer: Healthscope Whirlpool	$136.93
Rate for Payer: Mclaren Commercial	$127.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$119.99
Rate for Payer: Nomi Health Commercial	$115.75
Rate for Payer: Priority Health Cigna Priority Health	$91.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$123.68
Rate for Payer: Priority Health Narrow Network	$98.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$124.22

INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR PEN INJECTOR

Facility

$3,496.74

Service Code	HCPCS Q3027
Hospital Charge Code	159694
Hospital Revenue Code	636
Min. Negotiated Rate	$29.81
Max. Negotiated Rate	$3,496.74
Rate for Payer: Aetna Commercial	$3,147.07
Rate for Payer: Aetna Medicare	$55.62
Rate for Payer: Allen County Amish Medical Aid Commercial	$69.52
Rate for Payer: Amish Plain Church Group Commercial	$69.52
Rate for Payer: ASR ASR	$3,391.84
Rate for Payer: ASR Commercial	$3,391.84
Rate for Payer: BCBS Complete	$31.30
Rate for Payer: BCBS MAPPO	$55.62
Rate for Payer: BCBS Trust/PPO	$2,863.48
Rate for Payer: BCN Commercial	$2,711.02
Rate for Payer: BCN Medicare Advantage	$55.62
Rate for Payer: Cash Price	$2,797.40
Rate for Payer: Cash Price	$2,797.40
Rate for Payer: Cofinity Commercial	$3,286.94
Rate for Payer: Encore Health Key Benefits Commercial	$2,797.39
Rate for Payer: Health Alliance Plan Medicare Advantage	$55.62
Rate for Payer: Healthscope Commercial	$3,496.74
Rate for Payer: Healthscope Whirlpool	$3,391.84
Rate for Payer: Humana Choice PPO Medicare	$55.62
Rate for Payer: Mclaren Commercial	$3,147.07
Rate for Payer: Mclaren Medicaid	$29.81
Rate for Payer: Mclaren Medicare	$55.62
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$58.40
Rate for Payer: Meridian Medicaid	$31.30
Rate for Payer: MI Amish Medical Board Commercial	$63.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,972.23
Rate for Payer: Nomi Health Commercial	$2,867.33
Rate for Payer: PACE Medicare	$52.84
Rate for Payer: PACE SWMI	$55.62
Rate for Payer: PHP Commercial	$61.18
Rate for Payer: PHP Medicaid	$29.81
Rate for Payer: PHP Medicare Advantage	$55.62
Rate for Payer: Priority Health Choice Medicaid	$29.81
Rate for Payer: Priority Health Cigna Priority Health	$2,272.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$73.42
Rate for Payer: Priority Health Medicare	$55.62
Rate for Payer: Priority Health Narrow Network	$58.74
Rate for Payer: Railroad Medicare Medicare	$55.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,077.13
Rate for Payer: UHC Dual Complete DSNP	$55.62
Rate for Payer: UHC Exchange	$86.21
Rate for Payer: UHC Medicare Advantage	$55.62
Rate for Payer: UHCCP DNSP	$55.62
Rate for Payer: UHCCP Medicaid	$29.81
Rate for Payer: VA VA	$55.62

INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR PEN INJECTOR

Facility

$3,496.74

Service Code	HCPCS Q3027
Hospital Charge Code	159694
Hospital Revenue Code	636
Min. Negotiated Rate	$2,272.88
Max. Negotiated Rate	$3,496.74
Rate for Payer: Aetna Commercial	$3,147.07
Rate for Payer: ASR ASR	$3,391.84
Rate for Payer: ASR Commercial	$3,391.84
Rate for Payer: BCBS Trust/PPO	$2,849.49
Rate for Payer: BCN Commercial	$2,711.02
Rate for Payer: Cash Price	$2,797.40
Rate for Payer: Cofinity Commercial	$3,286.94
Rate for Payer: Encore Health Key Benefits Commercial	$2,797.39
Rate for Payer: Healthscope Commercial	$3,496.74
Rate for Payer: Healthscope Whirlpool	$3,391.84
Rate for Payer: Mclaren Commercial	$3,147.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,972.23
Rate for Payer: Nomi Health Commercial	$2,867.33
Rate for Payer: Priority Health Cigna Priority Health	$2,272.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,077.13

INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE

Facility

$5,993.30

Service Code	HCPCS Q3027
Hospital Charge Code	161584
Hospital Revenue Code	636
Min. Negotiated Rate	$29.81
Max. Negotiated Rate	$5,993.30
Rate for Payer: Aetna Commercial	$5,393.97
Rate for Payer: Aetna Medicare	$55.62
Rate for Payer: Allen County Amish Medical Aid Commercial	$69.52
Rate for Payer: Amish Plain Church Group Commercial	$69.52
Rate for Payer: ASR ASR	$5,813.50
Rate for Payer: ASR Commercial	$5,813.50
Rate for Payer: BCBS Complete	$31.30
Rate for Payer: BCBS MAPPO	$55.62
Rate for Payer: BCBS Trust/PPO	$4,907.91
Rate for Payer: BCN Commercial	$4,646.61
Rate for Payer: BCN Medicare Advantage	$55.62
Rate for Payer: Cash Price	$4,794.64
Rate for Payer: Cash Price	$4,794.64
Rate for Payer: Cofinity Commercial	$5,633.70
Rate for Payer: Encore Health Key Benefits Commercial	$4,794.64
Rate for Payer: Health Alliance Plan Medicare Advantage	$55.62
Rate for Payer: Healthscope Commercial	$5,993.30
Rate for Payer: Healthscope Whirlpool	$5,813.50
Rate for Payer: Humana Choice PPO Medicare	$55.62
Rate for Payer: Mclaren Commercial	$5,393.97
Rate for Payer: Mclaren Medicaid	$29.81
Rate for Payer: Mclaren Medicare	$55.62
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$58.40
Rate for Payer: Meridian Medicaid	$31.30
Rate for Payer: MI Amish Medical Board Commercial	$63.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,094.30
Rate for Payer: Nomi Health Commercial	$4,914.51
Rate for Payer: PACE Medicare	$52.84
Rate for Payer: PACE SWMI	$55.62
Rate for Payer: PHP Commercial	$61.18
Rate for Payer: PHP Medicaid	$29.81
Rate for Payer: PHP Medicare Advantage	$55.62
Rate for Payer: Priority Health Choice Medicaid	$29.81
Rate for Payer: Priority Health Cigna Priority Health	$3,895.64
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$73.42
Rate for Payer: Priority Health Medicare	$55.62
Rate for Payer: Priority Health Narrow Network	$58.74
Rate for Payer: Railroad Medicare Medicare	$55.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,274.10
Rate for Payer: UHC Dual Complete DSNP	$55.62
Rate for Payer: UHC Exchange	$86.21
Rate for Payer: UHC Medicare Advantage	$55.62
Rate for Payer: UHCCP DNSP	$55.62
Rate for Payer: UHCCP Medicaid	$29.81
Rate for Payer: VA VA	$55.62

INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE

Facility

$5,993.30

Service Code	HCPCS Q3027
Hospital Charge Code	161584
Hospital Revenue Code	636
Min. Negotiated Rate	$3,895.64
Max. Negotiated Rate	$5,993.30
Rate for Payer: Aetna Commercial	$5,393.97
Rate for Payer: ASR ASR	$5,813.50
Rate for Payer: ASR Commercial	$5,813.50
Rate for Payer: BCBS Trust/PPO	$4,883.94
Rate for Payer: BCN Commercial	$4,646.61
Rate for Payer: Cash Price	$4,794.64
Rate for Payer: Cofinity Commercial	$5,633.70
Rate for Payer: Encore Health Key Benefits Commercial	$4,794.64
Rate for Payer: Healthscope Commercial	$5,993.30
Rate for Payer: Healthscope Whirlpool	$5,813.50
Rate for Payer: Mclaren Commercial	$5,393.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,094.30
Rate for Payer: Nomi Health Commercial	$4,914.51
Rate for Payer: Priority Health Cigna Priority Health	$3,895.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,274.10

INTERFERON BETA-1A 30 MCG/0.5 ML INTRAMUSCULAR SYRINGE KIT

Facility

$5,238.48

Service Code	HCPCS Q3027
Hospital Charge Code	36417
Hospital Revenue Code	636
Min. Negotiated Rate	$3,405.01
Max. Negotiated Rate	$5,238.48
Rate for Payer: Aetna Commercial	$4,714.63
Rate for Payer: ASR ASR	$5,081.33
Rate for Payer: ASR Commercial	$5,081.33
Rate for Payer: BCBS Trust/PPO	$4,268.84
Rate for Payer: BCN Commercial	$4,061.39
Rate for Payer: Cash Price	$4,190.78
Rate for Payer: Cofinity Commercial	$4,924.17
Rate for Payer: Encore Health Key Benefits Commercial	$4,190.78
Rate for Payer: Healthscope Commercial	$5,238.48
Rate for Payer: Healthscope Whirlpool	$5,081.33
Rate for Payer: Mclaren Commercial	$4,714.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,452.71
Rate for Payer: Nomi Health Commercial	$4,295.55
Rate for Payer: Priority Health Cigna Priority Health	$3,405.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,609.86

Know your out-of-pocket cost for care.

All Charges