Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PIPERACILLIN-TAZOBACTAM 4.5 GRAM MINI-BAG PLUS COMPONENT CUSTOM

Facility

$24.33

Service Code	HCPCS J2543
Hospital Charge Code	301718
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$24.33
Rate for Payer: Aetna Commercial	$21.90
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: ASR ASR	$23.60
Rate for Payer: BCBS Complete	$9.73
Rate for Payer: BCBS Trust/PPO	$20.06
Rate for Payer: BCN Commercial	$20.06
Rate for Payer: Cash Price	$19.47
Rate for Payer: Cash Price	$19.47
Rate for Payer: Cofinity Commercial	$22.87
Rate for Payer: Encore Health Key Benefits Commercial	$19.47
Rate for Payer: Healthscope Commercial	$23.60
Rate for Payer: Healthscope Whirlpool	$24.33
Rate for Payer: Mclaren Commercial	$21.90
Rate for Payer: MI Amish Medical Board Commercial	$19.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.68
Rate for Payer: Nomi Health Commercial	$19.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$18.25
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$1.13
Rate for Payer: Priority Health Narrow Network	$0.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.41

PLEURAL EFFUSION WITH CC

Facility

$13,759.68

Service Code	MSDRG 187
Min. Negotiated Rate	$8,433.35
Max. Negotiated Rate	$13,759.68
Rate for Payer: Aetna Medicare	$8,877.21
Rate for Payer: Allen County Amish Medical Aid Commercial	$11,096.51
Rate for Payer: Amish Plain Church Group Commercial	$11,096.51
Rate for Payer: BCBS MAPPO	$8,877.21
Rate for Payer: BCN Medicare Advantage	$8,877.21
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,877.21
Rate for Payer: Humana Choice PPO Medicare	$8,877.21
Rate for Payer: Mclaren Medicare	$8,877.21
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$9,321.07
Rate for Payer: MI Amish Medical Board Commercial	$10,208.79
Rate for Payer: Molina Medicare/Medicaid	$9,764.93
Rate for Payer: PACE Medicare	$8,433.35
Rate for Payer: PACE SWMI	$8,877.21
Rate for Payer: PHP Commercial	$9,764.93
Rate for Payer: PHP Medicare Advantage	$8,877.21
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$13,589.05
Rate for Payer: Priority Health Medicare	$8,877.21
Rate for Payer: Priority Health Narrow Network	$10,871.24
Rate for Payer: Railroad Medicare Medicare	$8,877.21
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$8,877.21
Rate for Payer: UHC Exchange	$13,759.68
Rate for Payer: UHCCP DNSP	$8,877.21
Rate for Payer: VA VA	$8,877.21

PLEURAL EFFUSION WITH MCC

Facility

$21,411.92

Service Code	MSDRG 186
Min. Negotiated Rate	$12,328.72
Max. Negotiated Rate	$21,411.92
Rate for Payer: Aetna Medicare	$12,977.60
Rate for Payer: Allen County Amish Medical Aid Commercial	$16,222.00
Rate for Payer: Amish Plain Church Group Commercial	$16,222.00
Rate for Payer: BCBS MAPPO	$12,977.60
Rate for Payer: BCN Medicare Advantage	$12,977.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,977.60
Rate for Payer: Humana Choice PPO Medicare	$12,977.60
Rate for Payer: Mclaren Medicare	$12,977.60
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$13,626.48
Rate for Payer: MI Amish Medical Board Commercial	$14,924.24
Rate for Payer: Molina Medicare/Medicaid	$14,275.36
Rate for Payer: PACE Medicare	$12,328.72
Rate for Payer: PACE SWMI	$12,977.60
Rate for Payer: PHP Commercial	$14,275.36
Rate for Payer: PHP Medicare Advantage	$12,977.60
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$21,411.92
Rate for Payer: Priority Health Medicare	$12,977.60
Rate for Payer: Priority Health Narrow Network	$17,129.54
Rate for Payer: Railroad Medicare Medicare	$12,977.60
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$12,977.60
Rate for Payer: UHC Exchange	$20,115.28
Rate for Payer: UHCCP DNSP	$12,977.60
Rate for Payer: VA VA	$12,977.60

PLEURAL EFFUSION WITHOUT CC/MCC

Facility

$10,724.74

Service Code	MSDRG 188
Min. Negotiated Rate	$6,573.23
Max. Negotiated Rate	$10,724.74
Rate for Payer: Aetna Medicare	$6,919.19
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,648.99
Rate for Payer: Amish Plain Church Group Commercial	$8,648.99
Rate for Payer: BCBS MAPPO	$6,919.19
Rate for Payer: BCN Medicare Advantage	$6,919.19
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,919.19
Rate for Payer: Humana Choice PPO Medicare	$6,919.19
Rate for Payer: Mclaren Medicare	$6,919.19
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,265.15
Rate for Payer: MI Amish Medical Board Commercial	$7,957.07
Rate for Payer: Molina Medicare/Medicaid	$7,611.11
Rate for Payer: PACE Medicare	$6,573.23
Rate for Payer: PACE SWMI	$6,919.19
Rate for Payer: PHP Commercial	$7,611.11
Rate for Payer: PHP Medicare Advantage	$6,919.19
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$9,853.47
Rate for Payer: Priority Health Medicare	$6,919.19
Rate for Payer: Priority Health Narrow Network	$7,882.77
Rate for Payer: Railroad Medicare Medicare	$6,919.19
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$6,919.19
Rate for Payer: UHC Exchange	$10,724.74
Rate for Payer: UHCCP DNSP	$6,919.19
Rate for Payer: VA VA	$6,919.19

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE

Facility

$775.68

Service Code	HCPCS 90677
Hospital Charge Code	197781
Hospital Revenue Code	636
Min. Negotiated Rate	$581.76
Max. Negotiated Rate	$775.67
Rate for Payer: Aetna Commercial	$698.11
Rate for Payer: ASR ASR	$752.40
Rate for Payer: BCBS Trust/PPO	$636.98
Rate for Payer: BCN Commercial	$636.98
Rate for Payer: Cash Price	$620.54
Rate for Payer: Cofinity Commercial	$729.13
Rate for Payer: Encore Health Key Benefits Commercial	$620.54
Rate for Payer: Healthscope Commercial	$752.40
Rate for Payer: Healthscope Whirlpool	$775.67
Rate for Payer: Mclaren Commercial	$698.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$659.32
Rate for Payer: Nomi Health Commercial	$636.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$581.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$682.59

PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE

Facility

$775.68

Service Code	HCPCS 90677
Hospital Charge Code	197781
Hospital Revenue Code	636
Min. Negotiated Rate	$272.80
Max. Negotiated Rate	$775.67
Rate for Payer: Aetna Commercial	$698.11
Rate for Payer: Aetna Medicare	$287.00
Rate for Payer: ASR ASR	$752.40
Rate for Payer: BCBS Complete	$310.27
Rate for Payer: BCBS Trust/PPO	$639.54
Rate for Payer: BCN Commercial	$639.54
Rate for Payer: Cash Price	$620.54
Rate for Payer: Cash Price	$620.54
Rate for Payer: Cofinity Commercial	$729.13
Rate for Payer: Encore Health Key Benefits Commercial	$620.54
Rate for Payer: Healthscope Commercial	$752.40
Rate for Payer: Healthscope Whirlpool	$775.67
Rate for Payer: Mclaren Commercial	$698.11
Rate for Payer: MI Amish Medical Board Commercial	$620.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$659.32
Rate for Payer: Nomi Health Commercial	$636.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$581.76
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$341.00
Rate for Payer: Priority Health Narrow Network	$272.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$682.59

PNEUMOTHORAX WITH CC

Facility

$15,103.06

Service Code	MSDRG 200
Min. Negotiated Rate	$9,187.25
Max. Negotiated Rate	$15,103.06
Rate for Payer: Aetna Medicare	$9,670.79
Rate for Payer: Allen County Amish Medical Aid Commercial	$12,088.49
Rate for Payer: Amish Plain Church Group Commercial	$12,088.49
Rate for Payer: BCBS MAPPO	$9,670.79
Rate for Payer: BCN Medicare Advantage	$9,670.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,670.79
Rate for Payer: Humana Choice PPO Medicare	$9,670.79
Rate for Payer: Mclaren Medicare	$9,670.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$10,154.33
Rate for Payer: MI Amish Medical Board Commercial	$11,121.41
Rate for Payer: Molina Medicare/Medicaid	$10,637.87
Rate for Payer: PACE Medicare	$9,187.25
Rate for Payer: PACE SWMI	$9,670.79
Rate for Payer: PHP Commercial	$10,637.87
Rate for Payer: PHP Medicare Advantage	$9,670.79
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$15,103.06
Rate for Payer: Priority Health Medicare	$9,670.79
Rate for Payer: Priority Health Narrow Network	$12,082.45
Rate for Payer: Railroad Medicare Medicare	$9,670.79
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$9,670.79
Rate for Payer: UHC Exchange	$14,989.72
Rate for Payer: UHCCP DNSP	$9,670.79
Rate for Payer: VA VA	$9,670.79

PNEUMOTHORAX WITH MCC

Facility

$24,236.62

Service Code	MSDRG 199
Min. Negotiated Rate	$13,735.27
Max. Negotiated Rate	$24,236.62
Rate for Payer: Aetna Medicare	$14,458.18
Rate for Payer: Allen County Amish Medical Aid Commercial	$18,072.72
Rate for Payer: Amish Plain Church Group Commercial	$18,072.72
Rate for Payer: BCBS MAPPO	$14,458.18
Rate for Payer: BCN Medicare Advantage	$14,458.18
Rate for Payer: Health Alliance Plan Medicare Advantage	$14,458.18
Rate for Payer: Humana Choice PPO Medicare	$14,458.18
Rate for Payer: Mclaren Medicare	$14,458.18
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$15,181.09
Rate for Payer: MI Amish Medical Board Commercial	$16,626.91
Rate for Payer: Molina Medicare/Medicaid	$15,904.00
Rate for Payer: PACE Medicare	$13,735.27
Rate for Payer: PACE SWMI	$14,458.18
Rate for Payer: PHP Commercial	$15,904.00
Rate for Payer: PHP Medicare Advantage	$14,458.18
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$24,236.62
Rate for Payer: Priority Health Medicare	$14,458.18
Rate for Payer: Priority Health Narrow Network	$19,389.29
Rate for Payer: Railroad Medicare Medicare	$14,458.18
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$14,458.18
Rate for Payer: UHC Exchange	$22,410.18
Rate for Payer: UHCCP DNSP	$14,458.18
Rate for Payer: VA VA	$14,458.18

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$10,701.29

Service Code	MSDRG 201
Min. Negotiated Rate	$6,558.86
Max. Negotiated Rate	$10,701.29
Rate for Payer: Aetna Medicare	$6,904.06
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,630.08
Rate for Payer: Amish Plain Church Group Commercial	$8,630.08
Rate for Payer: BCBS MAPPO	$6,904.06
Rate for Payer: BCN Medicare Advantage	$6,904.06
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,904.06
Rate for Payer: Humana Choice PPO Medicare	$6,904.06
Rate for Payer: Mclaren Medicare	$6,904.06
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,249.26
Rate for Payer: MI Amish Medical Board Commercial	$7,939.67
Rate for Payer: Molina Medicare/Medicaid	$7,594.47
Rate for Payer: PACE Medicare	$6,558.86
Rate for Payer: PACE SWMI	$6,904.06
Rate for Payer: PHP Commercial	$7,594.47
Rate for Payer: PHP Medicare Advantage	$6,904.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$9,824.62
Rate for Payer: Priority Health Medicare	$6,904.06
Rate for Payer: Priority Health Narrow Network	$7,859.69
Rate for Payer: Railroad Medicare Medicare	$6,904.06
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$6,904.06
Rate for Payer: UHC Exchange	$10,701.29
Rate for Payer: UHCCP DNSP	$6,904.06
Rate for Payer: VA VA	$6,904.06

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$21,547.93

Service Code	MSDRG 917
Min. Negotiated Rate	$12,396.44
Max. Negotiated Rate	$21,547.93
Rate for Payer: Aetna Medicare	$13,048.88
Rate for Payer: Allen County Amish Medical Aid Commercial	$16,311.10
Rate for Payer: Amish Plain Church Group Commercial	$16,311.10
Rate for Payer: BCBS MAPPO	$13,048.88
Rate for Payer: BCN Medicare Advantage	$13,048.88
Rate for Payer: Health Alliance Plan Medicare Advantage	$13,048.88
Rate for Payer: Humana Choice PPO Medicare	$13,048.88
Rate for Payer: Mclaren Medicare	$13,048.88
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$13,701.32
Rate for Payer: MI Amish Medical Board Commercial	$15,006.21
Rate for Payer: Molina Medicare/Medicaid	$14,353.77
Rate for Payer: PACE Medicare	$12,396.44
Rate for Payer: PACE SWMI	$13,048.88
Rate for Payer: PHP Commercial	$14,353.77
Rate for Payer: PHP Medicare Advantage	$13,048.88
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$21,547.93
Rate for Payer: Priority Health Medicare	$13,048.88
Rate for Payer: Priority Health Narrow Network	$17,238.35
Rate for Payer: Railroad Medicare Medicare	$13,048.88
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$13,048.88
Rate for Payer: UHC Exchange	$20,225.76
Rate for Payer: UHCCP DNSP	$13,048.88
Rate for Payer: VA VA	$13,048.88

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$12,286.31

Service Code	MSDRG 918
Min. Negotiated Rate	$7,530.32
Max. Negotiated Rate	$12,286.31
Rate for Payer: Aetna Medicare	$7,926.65
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,908.31
Rate for Payer: Amish Plain Church Group Commercial	$9,908.31
Rate for Payer: BCBS MAPPO	$7,926.65
Rate for Payer: BCN Medicare Advantage	$7,926.65
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,926.65
Rate for Payer: Humana Choice PPO Medicare	$7,926.65
Rate for Payer: Mclaren Medicare	$7,926.65
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$8,322.98
Rate for Payer: MI Amish Medical Board Commercial	$9,115.65
Rate for Payer: Molina Medicare/Medicaid	$8,719.32
Rate for Payer: PACE Medicare	$7,530.32
Rate for Payer: PACE SWMI	$7,926.65
Rate for Payer: PHP Commercial	$8,719.32
Rate for Payer: PHP Medicare Advantage	$7,926.65
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$11,775.53
Rate for Payer: Priority Health Medicare	$7,926.65
Rate for Payer: Priority Health Narrow Network	$9,420.42
Rate for Payer: Railroad Medicare Medicare	$7,926.65
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$7,926.65
Rate for Payer: UHC Exchange	$12,286.31
Rate for Payer: UHCCP DNSP	$7,926.65
Rate for Payer: VA VA	$7,926.65

POISONING OF MEDICINAL AGENTS

Facility

$10,246.15

Service Code	APR-DRG 8124
Min. Negotiated Rate	$9,263.75
Max. Negotiated Rate	$10,246.15
Rate for Payer: BCBS Complete	$10,246.15
Rate for Payer: Mclaren Medicaid	$9,758.24
Rate for Payer: Meridian Medicaid	$10,246.15
Rate for Payer: PHP Medicaid	$9,263.75
Rate for Payer: Priority Health Choice Medicaid	$9,758.24
Rate for Payer: UHC Medicaid	$9,758.24
Rate for Payer: UHCCP Medicaid	$9,758.24

POISONING OF MEDICINAL AGENTS

Facility

$2,443.56

Service Code	APR-DRG 8121
Min. Negotiated Rate	$2,209.27
Max. Negotiated Rate	$2,443.56
Rate for Payer: BCBS Complete	$2,443.56
Rate for Payer: Mclaren Medicaid	$2,327.20
Rate for Payer: Meridian Medicaid	$2,443.56
Rate for Payer: PHP Medicaid	$2,209.27
Rate for Payer: Priority Health Choice Medicaid	$2,327.20
Rate for Payer: UHC Medicaid	$2,327.20
Rate for Payer: UHCCP Medicaid	$2,327.20

POISONING OF MEDICINAL AGENTS

Facility

$5,244.05

Service Code	APR-DRG 8123
Min. Negotiated Rate	$4,741.25
Max. Negotiated Rate	$5,244.05
Rate for Payer: BCBS Complete	$5,244.05
Rate for Payer: Mclaren Medicaid	$4,994.34
Rate for Payer: Meridian Medicaid	$5,244.05
Rate for Payer: PHP Medicaid	$4,741.25
Rate for Payer: Priority Health Choice Medicaid	$4,994.34
Rate for Payer: UHC Medicaid	$4,994.34
Rate for Payer: UHCCP Medicaid	$4,994.34

POISONING OF MEDICINAL AGENTS

Facility

$3,718.19

Service Code	APR-DRG 8122
Min. Negotiated Rate	$3,361.69
Max. Negotiated Rate	$3,718.19
Rate for Payer: BCBS Complete	$3,718.19
Rate for Payer: Mclaren Medicaid	$3,541.14
Rate for Payer: Meridian Medicaid	$3,718.19
Rate for Payer: PHP Medicaid	$3,361.69
Rate for Payer: Priority Health Choice Medicaid	$3,541.14
Rate for Payer: UHC Medicaid	$3,541.14
Rate for Payer: UHCCP Medicaid	$3,541.14

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$69.89

Service Code	NDC 68084043099
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$25.86
Max. Negotiated Rate	$69.89
Rate for Payer: Aetna Commercial	$62.90
Rate for Payer: Aetna Medicare	$25.86
Rate for Payer: ASR ASR	$67.79
Rate for Payer: BCBS Complete	$27.96
Rate for Payer: BCBS Trust/PPO	$57.62
Rate for Payer: BCN Commercial	$57.62
Rate for Payer: Cash Price	$55.91
Rate for Payer: Cofinity Commercial	$65.69
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$67.79
Rate for Payer: Healthscope Whirlpool	$69.89
Rate for Payer: Mclaren Commercial	$62.90
Rate for Payer: MI Amish Medical Board Commercial	$55.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.40
Rate for Payer: Nomi Health Commercial	$57.31
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.42
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$61.24
Rate for Payer: Priority Health Narrow Network	$48.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.50

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$69.89

Service Code	NDC 68084043098
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$52.42
Max. Negotiated Rate	$69.89
Rate for Payer: Aetna Commercial	$62.90
Rate for Payer: ASR ASR	$67.79
Rate for Payer: BCBS Trust/PPO	$57.39
Rate for Payer: BCN Commercial	$57.39
Rate for Payer: Cash Price	$55.91
Rate for Payer: Cofinity Commercial	$65.69
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$67.79
Rate for Payer: Healthscope Whirlpool	$69.89
Rate for Payer: Mclaren Commercial	$62.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.40
Rate for Payer: Nomi Health Commercial	$57.31
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.50

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$7.01

Service Code	NDC 45802086800
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$5.26
Max. Negotiated Rate	$7.01
Rate for Payer: Aetna Commercial	$6.31
Rate for Payer: ASR ASR	$6.80
Rate for Payer: BCBS Trust/PPO	$5.76
Rate for Payer: BCN Commercial	$5.76
Rate for Payer: Cash Price	$5.61
Rate for Payer: Cofinity Commercial	$6.59
Rate for Payer: Encore Health Key Benefits Commercial	$5.61
Rate for Payer: Healthscope Commercial	$6.80
Rate for Payer: Healthscope Whirlpool	$7.01
Rate for Payer: Mclaren Commercial	$6.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.96
Rate for Payer: Nomi Health Commercial	$5.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$5.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$6.17

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$192.38

Service Code	NDC 51079030630
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$144.29
Max. Negotiated Rate	$192.38
Rate for Payer: Aetna Commercial	$173.15
Rate for Payer: ASR ASR	$186.61
Rate for Payer: BCBS Trust/PPO	$157.99
Rate for Payer: BCN Commercial	$157.99
Rate for Payer: Cash Price	$153.91
Rate for Payer: Cofinity Commercial	$180.84
Rate for Payer: Encore Health Key Benefits Commercial	$153.91
Rate for Payer: Healthscope Commercial	$186.61
Rate for Payer: Healthscope Whirlpool	$192.38
Rate for Payer: Mclaren Commercial	$173.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$163.53
Rate for Payer: Nomi Health Commercial	$157.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$144.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$169.30

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$691.20

Service Code	NDC 17856031201
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$518.40
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna Commercial	$622.08
Rate for Payer: ASR ASR	$670.46
Rate for Payer: BCBS Trust/PPO	$567.61
Rate for Payer: BCN Commercial	$567.61
Rate for Payer: Cash Price	$552.96
Rate for Payer: Cofinity Commercial	$649.73
Rate for Payer: Encore Health Key Benefits Commercial	$552.96
Rate for Payer: Healthscope Commercial	$670.46
Rate for Payer: Healthscope Whirlpool	$691.20
Rate for Payer: Mclaren Commercial	$622.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$587.52
Rate for Payer: Nomi Health Commercial	$566.78
Rate for Payer: Opus (Opus Packaging Group) HMA	$518.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$608.26

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$6.38

Service Code	NDC 904693186
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$4.78
Max. Negotiated Rate	$6.38
Rate for Payer: Aetna Commercial	$5.74
Rate for Payer: ASR ASR	$6.18
Rate for Payer: BCBS Trust/PPO	$5.24
Rate for Payer: BCN Commercial	$5.24
Rate for Payer: Cash Price	$5.10
Rate for Payer: Cofinity Commercial	$5.99
Rate for Payer: Encore Health Key Benefits Commercial	$5.10
Rate for Payer: Healthscope Commercial	$6.18
Rate for Payer: Healthscope Whirlpool	$6.38
Rate for Payer: Mclaren Commercial	$5.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.42
Rate for Payer: Nomi Health Commercial	$5.23
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5.61

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$98.18

Service Code	NDC 45802086866
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$73.64
Max. Negotiated Rate	$98.18
Rate for Payer: Aetna Commercial	$88.36
Rate for Payer: ASR ASR	$95.23
Rate for Payer: BCBS Trust/PPO	$80.63
Rate for Payer: BCN Commercial	$80.63
Rate for Payer: Cash Price	$78.54
Rate for Payer: Cofinity Commercial	$92.29
Rate for Payer: Encore Health Key Benefits Commercial	$78.54
Rate for Payer: Healthscope Commercial	$95.23
Rate for Payer: Healthscope Whirlpool	$98.18
Rate for Payer: Mclaren Commercial	$88.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$83.45
Rate for Payer: Nomi Health Commercial	$80.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$73.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$86.40

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$98.18

Service Code	NDC 45802086866
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$36.33
Max. Negotiated Rate	$98.18
Rate for Payer: Aetna Commercial	$88.36
Rate for Payer: Aetna Medicare	$36.33
Rate for Payer: ASR ASR	$95.23
Rate for Payer: BCBS Complete	$39.27
Rate for Payer: BCBS Trust/PPO	$80.95
Rate for Payer: BCN Commercial	$80.95
Rate for Payer: Cash Price	$78.54
Rate for Payer: Cofinity Commercial	$92.29
Rate for Payer: Encore Health Key Benefits Commercial	$78.54
Rate for Payer: Healthscope Commercial	$95.23
Rate for Payer: Healthscope Whirlpool	$98.18
Rate for Payer: Mclaren Commercial	$88.36
Rate for Payer: MI Amish Medical Board Commercial	$78.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$83.45
Rate for Payer: Nomi Health Commercial	$80.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$73.64
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$86.03
Rate for Payer: Priority Health Narrow Network	$68.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$86.40

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$69.89

Service Code	NDC 68084043099
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$52.42
Max. Negotiated Rate	$69.89
Rate for Payer: Aetna Commercial	$62.90
Rate for Payer: ASR ASR	$67.79
Rate for Payer: BCBS Trust/PPO	$57.39
Rate for Payer: BCN Commercial	$57.39
Rate for Payer: Cash Price	$55.91
Rate for Payer: Cofinity Commercial	$65.69
Rate for Payer: Encore Health Key Benefits Commercial	$55.91
Rate for Payer: Healthscope Commercial	$67.79
Rate for Payer: Healthscope Whirlpool	$69.89
Rate for Payer: Mclaren Commercial	$62.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.40
Rate for Payer: Nomi Health Commercial	$57.31
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.50

POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET

Facility

$192.38

Service Code	NDC 51079030630
Hospital Charge Code	25424
Hospital Revenue Code	637
Min. Negotiated Rate	$71.18
Max. Negotiated Rate	$192.38
Rate for Payer: Aetna Commercial	$173.15
Rate for Payer: Aetna Medicare	$71.18
Rate for Payer: ASR ASR	$186.61
Rate for Payer: BCBS Complete	$76.95
Rate for Payer: BCBS Trust/PPO	$158.62
Rate for Payer: BCN Commercial	$158.62
Rate for Payer: Cash Price	$153.91
Rate for Payer: Cofinity Commercial	$180.84
Rate for Payer: Encore Health Key Benefits Commercial	$153.91
Rate for Payer: Healthscope Commercial	$186.61
Rate for Payer: Healthscope Whirlpool	$192.38
Rate for Payer: Mclaren Commercial	$173.15
Rate for Payer: MI Amish Medical Board Commercial	$153.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$163.53
Rate for Payer: Nomi Health Commercial	$157.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$144.29
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$168.57
Rate for Payer: Priority Health Narrow Network	$134.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$169.30

Know your out-of-pocket cost for care.

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