Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

CHOLECYSTECTOMY WITH C.D.E. WITH MCC

Facility

$45,383.38

Service Code	MSDRG 411
Min. Negotiated Rate	$24,265.20
Max. Negotiated Rate	$45,383.38
Rate for Payer: Aetna Medicare	$25,542.32
Rate for Payer: Allen County Amish Medical Aid Commercial	$31,927.90
Rate for Payer: Amish Plain Church Group Commercial	$31,927.90
Rate for Payer: BCBS MAPPO	$25,542.32
Rate for Payer: BCN Medicare Advantage	$25,542.32
Rate for Payer: Health Alliance Plan Medicare Advantage	$25,542.32
Rate for Payer: Humana Choice PPO Medicare	$25,542.32
Rate for Payer: Mclaren Medicare	$25,542.32
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$26,819.44
Rate for Payer: MI Amish Medical Board Commercial	$29,373.67
Rate for Payer: Molina Medicare/Medicaid	$28,096.55
Rate for Payer: PACE Medicare	$24,265.20
Rate for Payer: PACE SWMI	$25,542.32
Rate for Payer: PHP Commercial	$28,096.55
Rate for Payer: PHP Medicare Advantage	$25,542.32
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$45,383.38
Rate for Payer: Priority Health Medicare	$25,542.32
Rate for Payer: Priority Health Narrow Network	$36,306.70
Rate for Payer: Railroad Medicare Medicare	$25,542.32
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$25,542.32
Rate for Payer: UHC Exchange	$39,590.60
Rate for Payer: UHCCP DNSP	$25,542.32
Rate for Payer: VA VA	$25,542.32

CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC

Facility

$22,813.28

Service Code	MSDRG 413
Min. Negotiated Rate	$13,026.52
Max. Negotiated Rate	$22,813.28
Rate for Payer: Aetna Medicare	$13,712.13
Rate for Payer: Allen County Amish Medical Aid Commercial	$17,140.16
Rate for Payer: Amish Plain Church Group Commercial	$17,140.16
Rate for Payer: BCBS MAPPO	$13,712.13
Rate for Payer: BCN Medicare Advantage	$13,712.13
Rate for Payer: Health Alliance Plan Medicare Advantage	$13,712.13
Rate for Payer: Humana Choice PPO Medicare	$13,712.13
Rate for Payer: Mclaren Medicare	$13,712.13
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$14,397.74
Rate for Payer: MI Amish Medical Board Commercial	$15,768.95
Rate for Payer: Molina Medicare/Medicaid	$15,083.34
Rate for Payer: PACE Medicare	$13,026.52
Rate for Payer: PACE SWMI	$13,712.13
Rate for Payer: PHP Commercial	$15,083.34
Rate for Payer: PHP Medicare Advantage	$13,712.13
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$22,813.28
Rate for Payer: Priority Health Medicare	$13,712.13
Rate for Payer: Priority Health Narrow Network	$18,250.62
Rate for Payer: Railroad Medicare Medicare	$13,712.13
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$13,712.13
Rate for Payer: UHC Exchange	$21,253.80
Rate for Payer: UHCCP DNSP	$13,712.13
Rate for Payer: VA VA	$13,712.13

CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET

Facility

$4.94

Service Code	NDC 49884046564
Hospital Charge Code	9588
Hospital Revenue Code	637
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$4.94
Rate for Payer: Aetna Commercial	$4.45
Rate for Payer: ASR ASR	$4.80
Rate for Payer: BCBS Trust/PPO	$4.06
Rate for Payer: BCN Commercial	$4.06
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cofinity Commercial	$4.65
Rate for Payer: Encore Health Key Benefits Commercial	$3.96
Rate for Payer: Healthscope Commercial	$4.80
Rate for Payer: Healthscope Whirlpool	$4.94
Rate for Payer: Mclaren Commercial	$4.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.20
Rate for Payer: Nomi Health Commercial	$4.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.35

CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET

Facility

$4.94

Service Code	NDC 49884046564
Hospital Charge Code	9588
Hospital Revenue Code	637
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$4.94
Rate for Payer: Aetna Commercial	$4.45
Rate for Payer: Aetna Medicare	$1.83
Rate for Payer: ASR ASR	$4.80
Rate for Payer: BCBS Complete	$1.98
Rate for Payer: BCBS Trust/PPO	$4.08
Rate for Payer: BCN Commercial	$4.08
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cofinity Commercial	$4.65
Rate for Payer: Encore Health Key Benefits Commercial	$3.96
Rate for Payer: Healthscope Commercial	$4.80
Rate for Payer: Healthscope Whirlpool	$4.94
Rate for Payer: Mclaren Commercial	$4.45
Rate for Payer: MI Amish Medical Board Commercial	$3.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.20
Rate for Payer: Nomi Health Commercial	$4.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.71
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.33
Rate for Payer: Priority Health Narrow Network	$3.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.35

CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET

Facility

$296.64

Service Code	NDC 49884046565
Hospital Charge Code	9588
Hospital Revenue Code	637
Min. Negotiated Rate	$109.76
Max. Negotiated Rate	$296.64
Rate for Payer: Aetna Commercial	$266.98
Rate for Payer: Aetna Medicare	$109.76
Rate for Payer: ASR ASR	$287.74
Rate for Payer: BCBS Complete	$118.66
Rate for Payer: BCBS Trust/PPO	$244.58
Rate for Payer: BCN Commercial	$244.58
Rate for Payer: Cash Price	$237.31
Rate for Payer: Cofinity Commercial	$278.84
Rate for Payer: Encore Health Key Benefits Commercial	$237.31
Rate for Payer: Healthscope Commercial	$287.74
Rate for Payer: Healthscope Whirlpool	$296.64
Rate for Payer: Mclaren Commercial	$266.98
Rate for Payer: MI Amish Medical Board Commercial	$237.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$252.14
Rate for Payer: Nomi Health Commercial	$243.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$222.48
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$259.92
Rate for Payer: Priority Health Narrow Network	$207.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$261.04

CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET

Facility

$296.64

Service Code	NDC 49884046565
Hospital Charge Code	9588
Hospital Revenue Code	637
Min. Negotiated Rate	$222.48
Max. Negotiated Rate	$296.64
Rate for Payer: Aetna Commercial	$266.98
Rate for Payer: ASR ASR	$287.74
Rate for Payer: BCBS Trust/PPO	$243.60
Rate for Payer: BCN Commercial	$243.60
Rate for Payer: Cash Price	$237.31
Rate for Payer: Cofinity Commercial	$278.84
Rate for Payer: Encore Health Key Benefits Commercial	$237.31
Rate for Payer: Healthscope Commercial	$287.74
Rate for Payer: Healthscope Whirlpool	$296.64
Rate for Payer: Mclaren Commercial	$266.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$252.14
Rate for Payer: Nomi Health Commercial	$243.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$222.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$261.04

CHONDROITIN-SOD HYALURON 3 %-4 %(0.5 ML)1 %(0.55 ML)INTRAOCULAR SYRING

Facility

$345.53

Service Code	NDC 8065183150
Hospital Charge Code	28917
Hospital Revenue Code	250
Min. Negotiated Rate	$127.85
Max. Negotiated Rate	$345.53
Rate for Payer: Aetna Commercial	$310.98
Rate for Payer: Aetna Medicare	$127.85
Rate for Payer: ASR ASR	$335.17
Rate for Payer: BCBS Complete	$138.21
Rate for Payer: BCBS Trust/PPO	$284.89
Rate for Payer: BCN Commercial	$284.89
Rate for Payer: Cash Price	$276.43
Rate for Payer: Cofinity Commercial	$324.80
Rate for Payer: Encore Health Key Benefits Commercial	$276.43
Rate for Payer: Healthscope Commercial	$335.17
Rate for Payer: Healthscope Whirlpool	$345.53
Rate for Payer: Mclaren Commercial	$310.98
Rate for Payer: MI Amish Medical Board Commercial	$276.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$293.70
Rate for Payer: Nomi Health Commercial	$283.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$259.15
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$302.76
Rate for Payer: Priority Health Narrow Network	$242.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$304.07

CHONDROITIN-SOD HYALURON 3 %-4 %(0.5 ML)1 %(0.55 ML)INTRAOCULAR SYRING

Facility

$345.53

Service Code	NDC 8065183150
Hospital Charge Code	28917
Hospital Revenue Code	250
Min. Negotiated Rate	$259.15
Max. Negotiated Rate	$345.53
Rate for Payer: Aetna Commercial	$310.98
Rate for Payer: ASR ASR	$335.17
Rate for Payer: BCBS Trust/PPO	$283.75
Rate for Payer: BCN Commercial	$283.75
Rate for Payer: Cash Price	$276.43
Rate for Payer: Cofinity Commercial	$324.80
Rate for Payer: Encore Health Key Benefits Commercial	$276.43
Rate for Payer: Healthscope Commercial	$335.17
Rate for Payer: Healthscope Whirlpool	$345.53
Rate for Payer: Mclaren Commercial	$310.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$293.70
Rate for Payer: Nomi Health Commercial	$283.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$259.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$304.07

CHONDROITIN-SOD HYALURON 4 %-3 % (40 MG-30 MG/ML) INTRAOCULAR SYRINGE

Facility

$218.01

Service Code	HCPCS J7327
Hospital Charge Code	28923
Hospital Revenue Code	250
Min. Negotiated Rate	$163.50
Max. Negotiated Rate	$218.01
Rate for Payer: Aetna Commercial	$196.21
Rate for Payer: ASR ASR	$211.47
Rate for Payer: BCBS Trust/PPO	$179.03
Rate for Payer: BCN Commercial	$179.03
Rate for Payer: Cash Price	$174.40
Rate for Payer: Cofinity Commercial	$204.93
Rate for Payer: Encore Health Key Benefits Commercial	$174.40
Rate for Payer: Healthscope Commercial	$211.47
Rate for Payer: Healthscope Whirlpool	$218.01
Rate for Payer: Mclaren Commercial	$196.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$185.31
Rate for Payer: Nomi Health Commercial	$178.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$163.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$191.85

CHONDROITIN-SOD HYALURON 4 %-3 % (40 MG-30 MG/ML) INTRAOCULAR SYRINGE

Facility

$218.01

Service Code	HCPCS J7327
Hospital Charge Code	28923
Hospital Revenue Code	250
Min. Negotiated Rate	$163.50
Max. Negotiated Rate	$1,015.78
Rate for Payer: Aetna Commercial	$196.21
Rate for Payer: Aetna Medicare	$655.34
Rate for Payer: Allen County Amish Medical Aid Commercial	$819.17
Rate for Payer: Amish Plain Church Group Commercial	$819.17
Rate for Payer: ASR ASR	$211.47
Rate for Payer: BCBS Complete	$359.91
Rate for Payer: BCBS MAPPO	$655.34
Rate for Payer: BCBS Trust/PPO	$179.75
Rate for Payer: BCN Commercial	$179.75
Rate for Payer: BCN Medicare Advantage	$655.34
Rate for Payer: Cash Price	$174.40
Rate for Payer: Cash Price	$174.40
Rate for Payer: Cofinity Commercial	$204.93
Rate for Payer: Encore Health Key Benefits Commercial	$174.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$655.34
Rate for Payer: Healthscope Commercial	$211.47
Rate for Payer: Healthscope Whirlpool	$218.01
Rate for Payer: Humana Choice PPO Medicare	$655.34
Rate for Payer: Mclaren Commercial	$196.21
Rate for Payer: Mclaren Medicaid	$655.34
Rate for Payer: Mclaren Medicare	$655.34
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$688.11
Rate for Payer: Meridian Medicaid	$359.91
Rate for Payer: MI Amish Medical Board Commercial	$753.64
Rate for Payer: Molina Medicare/Medicaid	$720.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$185.31
Rate for Payer: Nomi Health Commercial	$178.76
Rate for Payer: Opus (Opus Packaging Group) HMA	$163.50
Rate for Payer: PACE Medicare	$622.57
Rate for Payer: PACE SWMI	$655.34
Rate for Payer: PHP Commercial	$720.87
Rate for Payer: PHP Medicaid	$351.26
Rate for Payer: PHP Medicare Advantage	$655.34
Rate for Payer: Priority Health Choice Medicaid	$342.74
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$586.08
Rate for Payer: Priority Health Medicare	$655.34
Rate for Payer: Priority Health Narrow Network	$468.86
Rate for Payer: Railroad Medicare Medicare	$655.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$191.85
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$655.34
Rate for Payer: UHC Exchange	$1,015.78
Rate for Payer: UHC Medicaid	$342.74
Rate for Payer: UHCCP DNSP	$655.34
Rate for Payer: UHCCP Medicaid	$342.74
Rate for Payer: VA VA	$655.34

CHRONIC KIDNEY DISEASE

Facility

$7,146.47

Service Code	APR-DRG 4703
Min. Negotiated Rate	$6,461.27
Max. Negotiated Rate	$7,146.47
Rate for Payer: BCBS Complete	$7,146.47
Rate for Payer: Mclaren Medicaid	$6,806.17
Rate for Payer: Meridian Medicaid	$7,146.47
Rate for Payer: PHP Medicaid	$6,461.27
Rate for Payer: Priority Health Choice Medicaid	$6,806.17
Rate for Payer: UHC Medicaid	$6,806.17
Rate for Payer: UHCCP Medicaid	$6,806.17

CHRONIC KIDNEY DISEASE

Facility

$3,856.07

Service Code	APR-DRG 4702
Min. Negotiated Rate	$3,486.35
Max. Negotiated Rate	$3,856.07
Rate for Payer: BCBS Complete	$3,856.07
Rate for Payer: Mclaren Medicaid	$3,672.44
Rate for Payer: Meridian Medicaid	$3,856.07
Rate for Payer: PHP Medicaid	$3,486.35
Rate for Payer: Priority Health Choice Medicaid	$3,672.44
Rate for Payer: UHC Medicaid	$3,672.44
Rate for Payer: UHCCP Medicaid	$3,672.44

CHRONIC KIDNEY DISEASE

Facility

$13,474.98

Service Code	APR-DRG 4704
Min. Negotiated Rate	$12,182.99
Max. Negotiated Rate	$13,474.98
Rate for Payer: BCBS Complete	$13,474.98
Rate for Payer: Mclaren Medicaid	$12,833.31
Rate for Payer: Meridian Medicaid	$13,474.98
Rate for Payer: PHP Medicaid	$12,182.99
Rate for Payer: Priority Health Choice Medicaid	$12,833.31
Rate for Payer: UHC Medicaid	$12,833.31
Rate for Payer: UHCCP Medicaid	$12,833.31

CHRONIC KIDNEY DISEASE

Facility

$3,094.77

Service Code	APR-DRG 4701
Min. Negotiated Rate	$2,798.04
Max. Negotiated Rate	$3,094.77
Rate for Payer: BCBS Complete	$3,094.77
Rate for Payer: Mclaren Medicaid	$2,947.40
Rate for Payer: Meridian Medicaid	$3,094.77
Rate for Payer: PHP Medicaid	$2,798.04
Rate for Payer: Priority Health Choice Medicaid	$2,947.40
Rate for Payer: UHC Medicaid	$2,947.40
Rate for Payer: UHCCP Medicaid	$2,947.40

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$8,766.07

Service Code	APR-DRG 1404
Min. Negotiated Rate	$7,925.57
Max. Negotiated Rate	$8,766.07
Rate for Payer: BCBS Complete	$8,766.07
Rate for Payer: Mclaren Medicaid	$8,348.63
Rate for Payer: Meridian Medicaid	$8,766.07
Rate for Payer: PHP Medicaid	$7,925.57
Rate for Payer: Priority Health Choice Medicaid	$8,348.63
Rate for Payer: UHC Medicaid	$8,348.63
Rate for Payer: UHCCP Medicaid	$8,348.63

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$3,488.77

Service Code	APR-DRG 1401
Min. Negotiated Rate	$3,154.27
Max. Negotiated Rate	$3,488.77
Rate for Payer: BCBS Complete	$3,488.77
Rate for Payer: Mclaren Medicaid	$3,322.64
Rate for Payer: Meridian Medicaid	$3,488.77
Rate for Payer: PHP Medicaid	$3,154.27
Rate for Payer: Priority Health Choice Medicaid	$3,322.64
Rate for Payer: UHC Medicaid	$3,322.64
Rate for Payer: UHCCP Medicaid	$3,322.64

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$4,154.15

Service Code	APR-DRG 1402
Min. Negotiated Rate	$3,755.85
Max. Negotiated Rate	$4,154.15
Rate for Payer: BCBS Complete	$4,154.15
Rate for Payer: Mclaren Medicaid	$3,956.34
Rate for Payer: Meridian Medicaid	$4,154.15
Rate for Payer: PHP Medicaid	$3,755.85
Rate for Payer: Priority Health Choice Medicaid	$3,956.34
Rate for Payer: UHC Medicaid	$3,956.34
Rate for Payer: UHCCP Medicaid	$3,956.34

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$5,476.20

Service Code	APR-DRG 1403
Min. Negotiated Rate	$4,951.14
Max. Negotiated Rate	$5,476.20
Rate for Payer: BCBS Complete	$5,476.20
Rate for Payer: Mclaren Medicaid	$5,215.43
Rate for Payer: Meridian Medicaid	$5,476.20
Rate for Payer: PHP Medicaid	$4,951.14
Rate for Payer: Priority Health Choice Medicaid	$5,215.43
Rate for Payer: UHC Medicaid	$5,215.43
Rate for Payer: UHCCP Medicaid	$5,215.43

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC

Facility

$12,128.92

Service Code	MSDRG 191
Min. Negotiated Rate	$7,433.85
Max. Negotiated Rate	$12,128.92
Rate for Payer: Aetna Medicare	$7,825.11
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,781.39
Rate for Payer: Amish Plain Church Group Commercial	$9,781.39
Rate for Payer: BCBS MAPPO	$7,825.11
Rate for Payer: BCN Medicare Advantage	$7,825.11
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,825.11
Rate for Payer: Humana Choice PPO Medicare	$7,825.11
Rate for Payer: Mclaren Medicare	$7,825.11
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$8,216.37
Rate for Payer: MI Amish Medical Board Commercial	$8,998.88
Rate for Payer: Molina Medicare/Medicaid	$8,607.62
Rate for Payer: PACE Medicare	$7,433.85
Rate for Payer: PACE SWMI	$7,825.11
Rate for Payer: PHP Commercial	$8,607.62
Rate for Payer: PHP Medicare Advantage	$7,825.11
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$11,581.81
Rate for Payer: Priority Health Medicare	$7,825.11
Rate for Payer: Priority Health Narrow Network	$9,265.45
Rate for Payer: Railroad Medicare Medicare	$7,825.11
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$7,825.11
Rate for Payer: UHC Exchange	$12,128.92
Rate for Payer: UHCCP DNSP	$7,825.11
Rate for Payer: VA VA	$7,825.11

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC

Facility

$15,218.47

Service Code	MSDRG 190
Min. Negotiated Rate	$9,244.72
Max. Negotiated Rate	$15,218.47
Rate for Payer: Aetna Medicare	$9,731.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$12,164.10
Rate for Payer: Amish Plain Church Group Commercial	$12,164.10
Rate for Payer: BCBS MAPPO	$9,731.28
Rate for Payer: BCN Medicare Advantage	$9,731.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,731.28
Rate for Payer: Humana Choice PPO Medicare	$9,731.28
Rate for Payer: Mclaren Medicare	$9,731.28
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$10,217.84
Rate for Payer: MI Amish Medical Board Commercial	$11,190.97
Rate for Payer: Molina Medicare/Medicaid	$10,704.41
Rate for Payer: PACE Medicare	$9,244.72
Rate for Payer: PACE SWMI	$9,731.28
Rate for Payer: PHP Commercial	$10,704.41
Rate for Payer: PHP Medicare Advantage	$9,731.28
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$15,218.47
Rate for Payer: Priority Health Medicare	$9,731.28
Rate for Payer: Priority Health Narrow Network	$12,174.78
Rate for Payer: Railroad Medicare Medicare	$9,731.28
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$9,731.28
Rate for Payer: UHC Exchange	$15,083.48
Rate for Payer: UHCCP DNSP	$9,731.28
Rate for Payer: VA VA	$9,731.28

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC

Facility

$9,885.37

Service Code	MSDRG 192
Min. Negotiated Rate	$6,058.78
Max. Negotiated Rate	$9,885.37
Rate for Payer: Aetna Medicare	$6,377.66
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,972.07
Rate for Payer: Amish Plain Church Group Commercial	$7,972.07
Rate for Payer: BCBS MAPPO	$6,377.66
Rate for Payer: BCN Medicare Advantage	$6,377.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,377.66
Rate for Payer: Humana Choice PPO Medicare	$6,377.66
Rate for Payer: Mclaren Medicare	$6,377.66
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,696.54
Rate for Payer: MI Amish Medical Board Commercial	$7,334.31
Rate for Payer: Molina Medicare/Medicaid	$7,015.43
Rate for Payer: PACE Medicare	$6,058.78
Rate for Payer: PACE SWMI	$6,377.66
Rate for Payer: PHP Commercial	$7,015.43
Rate for Payer: PHP Medicare Advantage	$6,377.66
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$8,820.31
Rate for Payer: Priority Health Medicare	$6,377.66
Rate for Payer: Priority Health Narrow Network	$7,056.25
Rate for Payer: Railroad Medicare Medicare	$6,377.66
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$6,377.66
Rate for Payer: UHC Exchange	$9,885.37
Rate for Payer: UHCCP DNSP	$6,377.66
Rate for Payer: VA VA	$6,377.66

CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION

Facility

$729.72

Service Code	NDC 781618667
Hospital Charge Code	36576
Hospital Revenue Code	637
Min. Negotiated Rate	$547.29
Max. Negotiated Rate	$729.72
Rate for Payer: Aetna Commercial	$656.75
Rate for Payer: ASR ASR	$707.83
Rate for Payer: BCBS Trust/PPO	$599.25
Rate for Payer: BCN Commercial	$599.25
Rate for Payer: Cash Price	$583.78
Rate for Payer: Cofinity Commercial	$685.94
Rate for Payer: Encore Health Key Benefits Commercial	$583.78
Rate for Payer: Healthscope Commercial	$707.83
Rate for Payer: Healthscope Whirlpool	$729.72
Rate for Payer: Mclaren Commercial	$656.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$620.27
Rate for Payer: Nomi Health Commercial	$598.37
Rate for Payer: Opus (Opus Packaging Group) HMA	$547.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$642.16

CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION

Facility

$375.48

Service Code	NDC 43598032675
Hospital Charge Code	36576
Hospital Revenue Code	637
Min. Negotiated Rate	$138.93
Max. Negotiated Rate	$375.48
Rate for Payer: Aetna Commercial	$337.93
Rate for Payer: Aetna Medicare	$138.93
Rate for Payer: ASR ASR	$364.22
Rate for Payer: BCBS Complete	$150.19
Rate for Payer: BCBS Trust/PPO	$309.58
Rate for Payer: BCN Commercial	$309.58
Rate for Payer: Cash Price	$300.38
Rate for Payer: Cofinity Commercial	$352.95
Rate for Payer: Encore Health Key Benefits Commercial	$300.38
Rate for Payer: Healthscope Commercial	$364.22
Rate for Payer: Healthscope Whirlpool	$375.48
Rate for Payer: Mclaren Commercial	$337.93
Rate for Payer: MI Amish Medical Board Commercial	$300.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$319.16
Rate for Payer: Nomi Health Commercial	$307.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$281.61
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$329.00
Rate for Payer: Priority Health Narrow Network	$263.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$330.42

CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION

Facility

$261.56

Service Code	NDC 72485062513
Hospital Charge Code	36576
Hospital Revenue Code	637
Min. Negotiated Rate	$96.78
Max. Negotiated Rate	$261.56
Rate for Payer: Aetna Commercial	$235.40
Rate for Payer: Aetna Medicare	$96.78
Rate for Payer: ASR ASR	$253.71
Rate for Payer: BCBS Complete	$104.62
Rate for Payer: BCBS Trust/PPO	$215.65
Rate for Payer: BCN Commercial	$215.65
Rate for Payer: Cash Price	$209.24
Rate for Payer: Cofinity Commercial	$245.86
Rate for Payer: Encore Health Key Benefits Commercial	$209.24
Rate for Payer: Healthscope Commercial	$253.71
Rate for Payer: Healthscope Whirlpool	$261.56
Rate for Payer: Mclaren Commercial	$235.40
Rate for Payer: MI Amish Medical Board Commercial	$209.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$222.32
Rate for Payer: Nomi Health Commercial	$214.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$196.17
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$229.17
Rate for Payer: Priority Health Narrow Network	$183.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$230.17

CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION

Facility

$729.72

Service Code	NDC 781618667
Hospital Charge Code	36576
Hospital Revenue Code	637
Min. Negotiated Rate	$270.00
Max. Negotiated Rate	$729.72
Rate for Payer: Aetna Commercial	$656.75
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: ASR ASR	$707.83
Rate for Payer: BCBS Complete	$291.89
Rate for Payer: BCBS Trust/PPO	$601.66
Rate for Payer: BCN Commercial	$601.66
Rate for Payer: Cash Price	$583.78
Rate for Payer: Cofinity Commercial	$685.94
Rate for Payer: Encore Health Key Benefits Commercial	$583.78
Rate for Payer: Healthscope Commercial	$707.83
Rate for Payer: Healthscope Whirlpool	$729.72
Rate for Payer: Mclaren Commercial	$656.75
Rate for Payer: MI Amish Medical Board Commercial	$583.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$620.27
Rate for Payer: Nomi Health Commercial	$598.37
Rate for Payer: Opus (Opus Packaging Group) HMA	$547.29
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$639.38
Rate for Payer: Priority Health Narrow Network	$511.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$642.16

Know your out-of-pocket cost for care.

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