Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION

Facility

$24.84

Service Code	NDC 62372063015
Hospital Charge Code	7228
Hospital Revenue Code	637
Min. Negotiated Rate	$9.94
Max. Negotiated Rate	$22.36
Rate for Payer: Aetna Commercial	$21.11
Rate for Payer: Aetna Medicare	$12.42
Rate for Payer: Aetna New Business (MI Preferred)	$16.15
Rate for Payer: BCBS Complete	$9.94
Rate for Payer: Cash Price	$19.87
Rate for Payer: Cofinity Commercial	$17.39
Rate for Payer: Cofinity Commercial	$21.36
Rate for Payer: Cofinity Medicare Advantage	$17.39
Rate for Payer: Encore Health Key Benefits Commercial	$19.87
Rate for Payer: Healthscope Commercial	$22.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.11
Rate for Payer: PHP Commercial	$21.11
Rate for Payer: Priority Health Cigna Priority Health	$16.15
Rate for Payer: Priority Health SBD	$15.65

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION

Facility

$24.84

Service Code	NDC 62372063015
Hospital Charge Code	7228
Hospital Revenue Code	637
Min. Negotiated Rate	$15.65
Max. Negotiated Rate	$22.36
Rate for Payer: Aetna Commercial	$21.11
Rate for Payer: Aetna New Business (MI Preferred)	$16.15
Rate for Payer: Cash Price	$19.87
Rate for Payer: Cofinity Commercial	$17.39
Rate for Payer: Cofinity Commercial	$21.36
Rate for Payer: Cofinity Medicare Advantage	$17.39
Rate for Payer: Encore Health Key Benefits Commercial	$19.87
Rate for Payer: Healthscope Commercial	$22.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.11
Rate for Payer: PHP Commercial	$21.11
Rate for Payer: Priority Health Cigna Priority Health	$16.15
Rate for Payer: Priority Health SBD	$15.65

SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION

Facility

$9.05

Service Code	NDC 00536130375
Hospital Charge Code	7228
Hospital Revenue Code	637
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$8.14
Rate for Payer: Aetna Commercial	$7.69
Rate for Payer: Aetna Medicare	$4.53
Rate for Payer: Aetna New Business (MI Preferred)	$5.88
Rate for Payer: BCBS Complete	$3.62
Rate for Payer: Cash Price	$7.24
Rate for Payer: Cofinity Commercial	$6.33
Rate for Payer: Cofinity Commercial	$7.78
Rate for Payer: Cofinity Medicare Advantage	$6.33
Rate for Payer: Encore Health Key Benefits Commercial	$7.24
Rate for Payer: Healthscope Commercial	$8.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.69
Rate for Payer: PHP Commercial	$7.69
Rate for Payer: Priority Health Cigna Priority Health	$5.88
Rate for Payer: Priority Health SBD	$5.70

SIMETHICONE 80 MG CHEWABLE TABLET

Facility

$72.85

Service Code	NDC 09629513606
Hospital Charge Code	7227
Hospital Revenue Code	637
Min. Negotiated Rate	$29.14
Max. Negotiated Rate	$65.56
Rate for Payer: Aetna Commercial	$61.92
Rate for Payer: Aetna Medicare	$36.42
Rate for Payer: Aetna New Business (MI Preferred)	$47.35
Rate for Payer: BCBS Complete	$29.14
Rate for Payer: Cash Price	$58.28
Rate for Payer: Cofinity Commercial	$50.99
Rate for Payer: Cofinity Commercial	$62.65
Rate for Payer: Cofinity Medicare Advantage	$50.99
Rate for Payer: Encore Health Key Benefits Commercial	$58.28
Rate for Payer: Healthscope Commercial	$65.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$61.92
Rate for Payer: PHP Commercial	$61.92
Rate for Payer: Priority Health Cigna Priority Health	$47.35
Rate for Payer: Priority Health SBD	$45.90

SIMETHICONE 80 MG CHEWABLE TABLET

Facility

$77.55

Service Code	NDC 70000043401
Hospital Charge Code	7227
Hospital Revenue Code	637
Min. Negotiated Rate	$48.86
Max. Negotiated Rate	$69.80
Rate for Payer: Aetna Commercial	$65.92
Rate for Payer: Aetna New Business (MI Preferred)	$50.41
Rate for Payer: Cash Price	$62.04
Rate for Payer: Cofinity Commercial	$54.28
Rate for Payer: Cofinity Commercial	$66.69
Rate for Payer: Cofinity Medicare Advantage	$54.28
Rate for Payer: Encore Health Key Benefits Commercial	$62.04
Rate for Payer: Healthscope Commercial	$69.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.92
Rate for Payer: PHP Commercial	$65.92
Rate for Payer: Priority Health Cigna Priority Health	$50.41
Rate for Payer: Priority Health SBD	$48.86

SIMETHICONE 80 MG CHEWABLE TABLET

Facility

$72.85

Service Code	NDC 09629513606
Hospital Charge Code	7227
Hospital Revenue Code	637
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$65.56
Rate for Payer: Aetna Commercial	$61.92
Rate for Payer: Aetna New Business (MI Preferred)	$47.35
Rate for Payer: Cash Price	$58.28
Rate for Payer: Cofinity Commercial	$50.99
Rate for Payer: Cofinity Commercial	$62.65
Rate for Payer: Cofinity Medicare Advantage	$50.99
Rate for Payer: Encore Health Key Benefits Commercial	$58.28
Rate for Payer: Healthscope Commercial	$65.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$61.92
Rate for Payer: PHP Commercial	$61.92
Rate for Payer: Priority Health Cigna Priority Health	$47.35
Rate for Payer: Priority Health SBD	$45.90

SIMETHICONE 80 MG CHEWABLE TABLET

Facility

$77.55

Service Code	NDC 70000043401
Hospital Charge Code	7227
Hospital Revenue Code	637
Min. Negotiated Rate	$31.02
Max. Negotiated Rate	$69.80
Rate for Payer: Aetna Commercial	$65.92
Rate for Payer: Aetna Medicare	$38.77
Rate for Payer: Aetna New Business (MI Preferred)	$50.41
Rate for Payer: BCBS Complete	$31.02
Rate for Payer: Cash Price	$62.04
Rate for Payer: Cofinity Commercial	$54.28
Rate for Payer: Cofinity Commercial	$66.69
Rate for Payer: Cofinity Medicare Advantage	$54.28
Rate for Payer: Encore Health Key Benefits Commercial	$62.04
Rate for Payer: Healthscope Commercial	$69.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.92
Rate for Payer: PHP Commercial	$65.92
Rate for Payer: Priority Health Cigna Priority Health	$50.41
Rate for Payer: Priority Health SBD	$48.86

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS

Facility

$545.50

Service Code	CPT 12011
Hospital Revenue Code	361
Min. Negotiated Rate	$103.87
Max. Negotiated Rate	$545.50
Rate for Payer: Aetna Medicare	$201.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$242.24
Rate for Payer: Amish Plain Church Group Commercial	$242.24
Rate for Payer: BCBS Complete	$109.07
Rate for Payer: BCBS MAPPO	$193.79
Rate for Payer: BCN Medicare Advantage	$193.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$193.79
Rate for Payer: Mclaren Medicaid	$103.87
Rate for Payer: Mclaren Medicare	$193.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$203.48
Rate for Payer: Meridian Medicaid	$109.07
Rate for Payer: MI Amish Medical Board Commercial	$222.86
Rate for Payer: PACE Medicare	$184.10
Rate for Payer: PACE SWMI	$193.79
Rate for Payer: PHP Medicare Advantage	$193.79
Rate for Payer: Priority Health Choice Medicaid	$103.87
Rate for Payer: Priority Health Medicare	$193.79
Rate for Payer: Railroad Medicare Medicare	$193.79
Rate for Payer: UHC All Payor (Choice/PPO)	$545.50
Rate for Payer: UHC Dual Complete DSNP	$193.79
Rate for Payer: UHC Medicare Advantage	$193.79
Rate for Payer: UHCCP Medicaid	$109.10
Rate for Payer: VA VA	$193.79

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM

Facility

$545.50

Service Code	CPT 12013
Hospital Revenue Code	361
Min. Negotiated Rate	$103.87
Max. Negotiated Rate	$545.50
Rate for Payer: Aetna Medicare	$201.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$242.24
Rate for Payer: Amish Plain Church Group Commercial	$242.24
Rate for Payer: BCBS Complete	$109.07
Rate for Payer: BCBS MAPPO	$193.79
Rate for Payer: BCN Medicare Advantage	$193.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$193.79
Rate for Payer: Mclaren Medicaid	$103.87
Rate for Payer: Mclaren Medicare	$193.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$203.48
Rate for Payer: Meridian Medicaid	$109.07
Rate for Payer: MI Amish Medical Board Commercial	$222.86
Rate for Payer: PACE Medicare	$184.10
Rate for Payer: PACE SWMI	$193.79
Rate for Payer: PHP Medicare Advantage	$193.79
Rate for Payer: Priority Health Choice Medicaid	$103.87
Rate for Payer: Priority Health Medicare	$193.79
Rate for Payer: Railroad Medicare Medicare	$193.79
Rate for Payer: UHC All Payor (Choice/PPO)	$545.50
Rate for Payer: UHC Dual Complete DSNP	$193.79
Rate for Payer: UHC Medicare Advantage	$193.79
Rate for Payer: UHCCP Medicaid	$109.10
Rate for Payer: VA VA	$193.79

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM

Facility

$1,096.83

Service Code	CPT 12005
Hospital Revenue Code	361
Min. Negotiated Rate	$208.85
Max. Negotiated Rate	$1,096.83
Rate for Payer: Aetna Medicare	$405.24
Rate for Payer: Allen County Amish Medical Aid Commercial	$487.06
Rate for Payer: Amish Plain Church Group Commercial	$487.06
Rate for Payer: BCBS Complete	$219.30
Rate for Payer: BCBS MAPPO	$389.65
Rate for Payer: BCN Medicare Advantage	$389.65
Rate for Payer: Health Alliance Plan Medicare Advantage	$389.65
Rate for Payer: Mclaren Medicaid	$208.85
Rate for Payer: Mclaren Medicare	$389.65
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$409.13
Rate for Payer: Meridian Medicaid	$219.30
Rate for Payer: MI Amish Medical Board Commercial	$448.10
Rate for Payer: PACE Medicare	$370.17
Rate for Payer: PACE SWMI	$389.65
Rate for Payer: PHP Medicare Advantage	$389.65
Rate for Payer: Priority Health Choice Medicaid	$208.85
Rate for Payer: Priority Health Medicare	$389.65
Rate for Payer: Railroad Medicare Medicare	$389.65
Rate for Payer: UHC All Payor (Choice/PPO)	$1,096.83
Rate for Payer: UHC Dual Complete DSNP	$389.65
Rate for Payer: UHC Medicare Advantage	$389.65
Rate for Payer: UHCCP Medicaid	$219.37
Rate for Payer: VA VA	$389.65

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM

Facility

$1,096.83

Service Code	CPT 12006
Hospital Revenue Code	360
Min. Negotiated Rate	$208.85
Max. Negotiated Rate	$1,096.83
Rate for Payer: Aetna Medicare	$405.24
Rate for Payer: Allen County Amish Medical Aid Commercial	$487.06
Rate for Payer: Amish Plain Church Group Commercial	$487.06
Rate for Payer: BCBS Complete	$219.30
Rate for Payer: BCBS MAPPO	$389.65
Rate for Payer: BCN Medicare Advantage	$389.65
Rate for Payer: Health Alliance Plan Medicare Advantage	$389.65
Rate for Payer: Mclaren Medicaid	$208.85
Rate for Payer: Mclaren Medicare	$389.65
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$409.13
Rate for Payer: Meridian Medicaid	$219.30
Rate for Payer: MI Amish Medical Board Commercial	$448.10
Rate for Payer: PACE Medicare	$370.17
Rate for Payer: PACE SWMI	$389.65
Rate for Payer: PHP Medicare Advantage	$389.65
Rate for Payer: Priority Health Choice Medicaid	$208.85
Rate for Payer: Priority Health Medicare	$389.65
Rate for Payer: Railroad Medicare Medicare	$389.65
Rate for Payer: UHC All Payor (Choice/PPO)	$1,096.83
Rate for Payer: UHC Dual Complete DSNP	$389.65
Rate for Payer: UHC Medicare Advantage	$389.65
Rate for Payer: UHCCP Medicaid	$219.37
Rate for Payer: VA VA	$389.65

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS

Facility

$545.50

Service Code	CPT 12001
Hospital Revenue Code	361
Min. Negotiated Rate	$103.87
Max. Negotiated Rate	$545.50
Rate for Payer: Aetna Medicare	$201.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$242.24
Rate for Payer: Amish Plain Church Group Commercial	$242.24
Rate for Payer: BCBS Complete	$109.07
Rate for Payer: BCBS MAPPO	$193.79
Rate for Payer: BCN Medicare Advantage	$193.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$193.79
Rate for Payer: Mclaren Medicaid	$103.87
Rate for Payer: Mclaren Medicare	$193.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$203.48
Rate for Payer: Meridian Medicaid	$109.07
Rate for Payer: MI Amish Medical Board Commercial	$222.86
Rate for Payer: PACE Medicare	$184.10
Rate for Payer: PACE SWMI	$193.79
Rate for Payer: PHP Medicare Advantage	$193.79
Rate for Payer: Priority Health Choice Medicaid	$103.87
Rate for Payer: Priority Health Medicare	$193.79
Rate for Payer: Railroad Medicare Medicare	$193.79
Rate for Payer: UHC All Payor (Choice/PPO)	$545.50
Rate for Payer: UHC Dual Complete DSNP	$193.79
Rate for Payer: UHC Medicare Advantage	$193.79
Rate for Payer: UHCCP Medicaid	$109.10
Rate for Payer: VA VA	$193.79

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM

Facility

$545.50

Service Code	CPT 12002
Hospital Revenue Code	361
Min. Negotiated Rate	$103.87
Max. Negotiated Rate	$545.50
Rate for Payer: Aetna Medicare	$201.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$242.24
Rate for Payer: Amish Plain Church Group Commercial	$242.24
Rate for Payer: BCBS Complete	$109.07
Rate for Payer: BCBS MAPPO	$193.79
Rate for Payer: BCN Medicare Advantage	$193.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$193.79
Rate for Payer: Mclaren Medicaid	$103.87
Rate for Payer: Mclaren Medicare	$193.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$203.48
Rate for Payer: Meridian Medicaid	$109.07
Rate for Payer: MI Amish Medical Board Commercial	$222.86
Rate for Payer: PACE Medicare	$184.10
Rate for Payer: PACE SWMI	$193.79
Rate for Payer: PHP Medicare Advantage	$193.79
Rate for Payer: Priority Health Choice Medicaid	$103.87
Rate for Payer: Priority Health Medicare	$193.79
Rate for Payer: Railroad Medicare Medicare	$193.79
Rate for Payer: UHC All Payor (Choice/PPO)	$545.50
Rate for Payer: UHC Dual Complete DSNP	$193.79
Rate for Payer: UHC Medicare Advantage	$193.79
Rate for Payer: UHCCP Medicaid	$109.10
Rate for Payer: VA VA	$193.79

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM

Facility

$545.50

Service Code	CPT 12004
Hospital Revenue Code	361
Min. Negotiated Rate	$103.87
Max. Negotiated Rate	$545.50
Rate for Payer: Aetna Medicare	$201.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$242.24
Rate for Payer: Amish Plain Church Group Commercial	$242.24
Rate for Payer: BCBS Complete	$109.07
Rate for Payer: BCBS MAPPO	$193.79
Rate for Payer: BCN Medicare Advantage	$193.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$193.79
Rate for Payer: Mclaren Medicaid	$103.87
Rate for Payer: Mclaren Medicare	$193.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$203.48
Rate for Payer: Meridian Medicaid	$109.07
Rate for Payer: MI Amish Medical Board Commercial	$222.86
Rate for Payer: PACE Medicare	$184.10
Rate for Payer: PACE SWMI	$193.79
Rate for Payer: PHP Medicare Advantage	$193.79
Rate for Payer: Priority Health Choice Medicaid	$103.87
Rate for Payer: Priority Health Medicare	$193.79
Rate for Payer: Railroad Medicare Medicare	$193.79
Rate for Payer: UHC All Payor (Choice/PPO)	$545.50
Rate for Payer: UHC Dual Complete DSNP	$193.79
Rate for Payer: UHC Medicare Advantage	$193.79
Rate for Payer: UHCCP Medicaid	$109.10
Rate for Payer: VA VA	$193.79

SIMPLE SYRUP

Facility

$144.00

Service Code	NDC 00395266116
Hospital Charge Code	7242
Hospital Revenue Code	637
Min. Negotiated Rate	$90.72
Max. Negotiated Rate	$129.60
Rate for Payer: Aetna Commercial	$122.40
Rate for Payer: Aetna New Business (MI Preferred)	$93.60
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cofinity Commercial	$100.80
Rate for Payer: Cofinity Commercial	$123.84
Rate for Payer: Cofinity Medicare Advantage	$100.80
Rate for Payer: Encore Health Key Benefits Commercial	$115.20
Rate for Payer: Healthscope Commercial	$129.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$122.40
Rate for Payer: PHP Commercial	$122.40
Rate for Payer: Priority Health Cigna Priority Health	$93.60
Rate for Payer: Priority Health SBD	$90.72

SIMPLE SYRUP

Facility

$144.00

Service Code	NDC 00395266116
Hospital Charge Code	7242
Hospital Revenue Code	637
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$129.60
Rate for Payer: Aetna Commercial	$122.40
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: Aetna New Business (MI Preferred)	$93.60
Rate for Payer: BCBS Complete	$57.60
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cofinity Commercial	$100.80
Rate for Payer: Cofinity Commercial	$123.84
Rate for Payer: Cofinity Medicare Advantage	$100.80
Rate for Payer: Encore Health Key Benefits Commercial	$115.20
Rate for Payer: Healthscope Commercial	$129.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$122.40
Rate for Payer: PHP Commercial	$122.40
Rate for Payer: Priority Health Cigna Priority Health	$93.60
Rate for Payer: Priority Health SBD	$90.72

SINCALIDE 5 MCG SOLUTION FOR INJECTION

Facility

$439.34

Service Code	HCPCS J2805
Hospital Charge Code	11368
Hospital Revenue Code	636
Min. Negotiated Rate	$175.74
Max. Negotiated Rate	$395.41
Rate for Payer: Aetna Commercial	$373.44
Rate for Payer: Aetna Medicare	$219.67
Rate for Payer: Aetna New Business (MI Preferred)	$285.57
Rate for Payer: BCBS Complete	$175.74
Rate for Payer: Cash Price	$351.47
Rate for Payer: Cofinity Commercial	$307.54
Rate for Payer: Cofinity Commercial	$377.83
Rate for Payer: Cofinity Medicare Advantage	$307.54
Rate for Payer: Encore Health Key Benefits Commercial	$351.47
Rate for Payer: Healthscope Commercial	$395.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$373.44
Rate for Payer: PHP Commercial	$373.44
Rate for Payer: Priority Health Cigna Priority Health	$285.57
Rate for Payer: Priority Health SBD	$276.78

SINCALIDE 5 MCG SOLUTION FOR INJECTION

Facility

$439.34

Service Code	HCPCS J2805
Hospital Charge Code	11368
Hospital Revenue Code	636
Min. Negotiated Rate	$276.78
Max. Negotiated Rate	$395.41
Rate for Payer: Aetna Commercial	$373.44
Rate for Payer: Aetna New Business (MI Preferred)	$285.57
Rate for Payer: Cash Price	$351.47
Rate for Payer: Cofinity Commercial	$307.54
Rate for Payer: Cofinity Commercial	$377.83
Rate for Payer: Cofinity Medicare Advantage	$307.54
Rate for Payer: Encore Health Key Benefits Commercial	$351.47
Rate for Payer: Healthscope Commercial	$395.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$373.44
Rate for Payer: PHP Commercial	$373.44
Rate for Payer: Priority Health Cigna Priority Health	$285.57
Rate for Payer: Priority Health SBD	$276.78

SIPULEUCEL-T IN LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSPENSION

Facility

$328,138.18

Service Code	HCPCS Q2043
Hospital Charge Code	104852
Hospital Revenue Code	636
Min. Negotiated Rate	$29,625.96
Max. Negotiated Rate	$295,324.36
Rate for Payer: Aetna Commercial	$278,917.45
Rate for Payer: Aetna Medicare	$57,483.21
Rate for Payer: Aetna New Business (MI Preferred)	$213,289.82
Rate for Payer: Allen County Amish Medical Aid Commercial	$69,090.40
Rate for Payer: Amish Plain Church Group Commercial	$69,090.40
Rate for Payer: BCBS Complete	$31,107.26
Rate for Payer: BCBS MAPPO	$55,272.32
Rate for Payer: BCN Medicare Advantage	$55,272.32
Rate for Payer: Cash Price	$262,510.54
Rate for Payer: Cash Price	$262,510.54
Rate for Payer: Cofinity Commercial	$229,696.73
Rate for Payer: Cofinity Commercial	$282,198.83
Rate for Payer: Cofinity Medicare Advantage	$229,696.73
Rate for Payer: Encore Health Key Benefits Commercial	$262,510.54
Rate for Payer: Health Alliance Plan Medicare Advantage	$55,272.32
Rate for Payer: Healthscope Commercial	$295,324.36
Rate for Payer: Mclaren Medicaid	$29,625.96
Rate for Payer: Mclaren Medicare	$55,272.32
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$58,035.94
Rate for Payer: Meridian Medicaid	$31,107.26
Rate for Payer: MI Amish Medical Board Commercial	$63,563.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$278,917.45
Rate for Payer: PACE Medicare	$52,508.70
Rate for Payer: PACE SWMI	$55,272.32
Rate for Payer: PHP Commercial	$278,917.45
Rate for Payer: PHP Medicare Advantage	$55,272.32
Rate for Payer: Priority Health Choice Medicaid	$29,625.96
Rate for Payer: Priority Health Cigna Priority Health	$213,289.82
Rate for Payer: Priority Health Medicare	$55,272.32
Rate for Payer: Priority Health SBD	$206,727.05
Rate for Payer: Railroad Medicare Medicare	$55,272.32
Rate for Payer: UHC All Payor (Choice/PPO)	$155,586.05
Rate for Payer: UHC Dual Complete DSNP	$55,272.32
Rate for Payer: UHC Medicare Advantage	$55,272.32
Rate for Payer: UHCCP Medicaid	$31,118.32
Rate for Payer: VA VA	$55,272.32

SKIN CARE CONSULT

Professional

Both

$26.00

Service Code	HCPCS 00177
Hospital Revenue Code	960
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$16.90
Rate for Payer: Aetna Medicare	$13.00
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: Cash Price	$20.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.90
Rate for Payer: Priority Health Cigna Priority Health	$16.90

SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR SYNTHETIC)

Facility

$35,668.30

Service Code	CPT 53440
Hospital Revenue Code	360
Min. Negotiated Rate	$6,791.79
Max. Negotiated Rate	$35,668.30
Rate for Payer: Aetna Medicare	$13,178.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$15,839.06
Rate for Payer: Amish Plain Church Group Commercial	$15,839.06
Rate for Payer: BCBS Complete	$7,131.38
Rate for Payer: BCBS MAPPO	$12,671.25
Rate for Payer: BCN Medicare Advantage	$12,671.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,671.25
Rate for Payer: Mclaren Medicaid	$6,791.79
Rate for Payer: Mclaren Medicare	$12,671.25
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$13,304.81
Rate for Payer: Meridian Medicaid	$7,131.38
Rate for Payer: MI Amish Medical Board Commercial	$14,571.94
Rate for Payer: PACE Medicare	$12,037.69
Rate for Payer: PACE SWMI	$12,671.25
Rate for Payer: PHP Medicare Advantage	$12,671.25
Rate for Payer: Priority Health Choice Medicaid	$6,791.79
Rate for Payer: Priority Health Medicare	$12,671.25
Rate for Payer: Railroad Medicare Medicare	$12,671.25
Rate for Payer: UHC All Payor (Choice/PPO)	$35,668.30
Rate for Payer: UHC Dual Complete DSNP	$12,671.25
Rate for Payer: UHC Medicare Advantage	$12,671.25
Rate for Payer: UHCCP Medicaid	$7,133.91
Rate for Payer: VA VA	$12,671.25

SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR SYNTHETIC)

Facility

$13,552.11

Service Code	CPT 57288
Hospital Revenue Code	360
Min. Negotiated Rate	$2,580.53
Max. Negotiated Rate	$13,552.11
Rate for Payer: Aetna Medicare	$5,007.00
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,018.02
Rate for Payer: Amish Plain Church Group Commercial	$6,018.02
Rate for Payer: BCBS Complete	$2,709.56
Rate for Payer: BCBS MAPPO	$4,814.42
Rate for Payer: BCN Medicare Advantage	$4,814.42
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,814.42
Rate for Payer: Mclaren Medicaid	$2,580.53
Rate for Payer: Mclaren Medicare	$4,814.42
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5,055.14
Rate for Payer: Meridian Medicaid	$2,709.56
Rate for Payer: MI Amish Medical Board Commercial	$5,536.58
Rate for Payer: PACE Medicare	$4,573.70
Rate for Payer: PACE SWMI	$4,814.42
Rate for Payer: PHP Medicare Advantage	$4,814.42
Rate for Payer: Priority Health Choice Medicaid	$2,580.53
Rate for Payer: Priority Health Medicare	$4,814.42
Rate for Payer: Railroad Medicare Medicare	$4,814.42
Rate for Payer: UHC All Payor (Choice/PPO)	$13,552.11
Rate for Payer: UHC Dual Complete DSNP	$4,814.42
Rate for Payer: UHC Medicare Advantage	$4,814.42
Rate for Payer: UHCCP Medicaid	$2,710.52
Rate for Payer: VA VA	$4,814.42

SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN

Facility

$5,623.80

Service Code	CPT 54001
Hospital Revenue Code	360
Min. Negotiated Rate	$1,070.86
Max. Negotiated Rate	$5,623.80
Rate for Payer: Aetna Medicare	$2,077.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,497.34
Rate for Payer: Amish Plain Church Group Commercial	$2,497.34
Rate for Payer: BCBS Complete	$1,124.40
Rate for Payer: BCBS MAPPO	$1,997.87
Rate for Payer: BCN Medicare Advantage	$1,997.87
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,997.87
Rate for Payer: Mclaren Medicaid	$1,070.86
Rate for Payer: Mclaren Medicare	$1,997.87
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$2,097.76
Rate for Payer: Meridian Medicaid	$1,124.40
Rate for Payer: MI Amish Medical Board Commercial	$2,297.55
Rate for Payer: PACE Medicare	$1,897.98
Rate for Payer: PACE SWMI	$1,997.87
Rate for Payer: PHP Medicare Advantage	$1,997.87
Rate for Payer: Priority Health Choice Medicaid	$1,070.86
Rate for Payer: Priority Health Medicare	$1,997.87
Rate for Payer: Railroad Medicare Medicare	$1,997.87
Rate for Payer: UHC All Payor (Choice/PPO)	$5,623.80
Rate for Payer: UHC Dual Complete DSNP	$1,997.87
Rate for Payer: UHC Medicare Advantage	$1,997.87
Rate for Payer: UHCCP Medicaid	$1,124.80
Rate for Payer: VA VA	$1,997.87

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$5,207.85

Service Code	CPT 44360
Hospital Revenue Code	360
Min. Negotiated Rate	$991.65
Max. Negotiated Rate	$5,207.85
Rate for Payer: Aetna Medicare	$1,924.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,312.62
Rate for Payer: Amish Plain Church Group Commercial	$2,312.62
Rate for Payer: BCBS Complete	$1,041.24
Rate for Payer: BCBS MAPPO	$1,850.10
Rate for Payer: BCN Medicare Advantage	$1,850.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,850.10
Rate for Payer: Mclaren Medicaid	$991.65
Rate for Payer: Mclaren Medicare	$1,850.10
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,942.61
Rate for Payer: Meridian Medicaid	$1,041.24
Rate for Payer: MI Amish Medical Board Commercial	$2,127.61
Rate for Payer: PACE Medicare	$1,757.60
Rate for Payer: PACE SWMI	$1,850.10
Rate for Payer: PHP Medicare Advantage	$1,850.10
Rate for Payer: Priority Health Choice Medicaid	$991.65
Rate for Payer: Priority Health Medicare	$1,850.10
Rate for Payer: Railroad Medicare Medicare	$1,850.10
Rate for Payer: UHC All Payor (Choice/PPO)	$5,207.85
Rate for Payer: UHC Dual Complete DSNP	$1,850.10
Rate for Payer: UHC Medicare Advantage	$1,850.10
Rate for Payer: UHCCP Medicaid	$1,041.61
Rate for Payer: VA VA	$1,850.10

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$5,207.85

Service Code	CPT 44361
Hospital Revenue Code	360
Min. Negotiated Rate	$991.65
Max. Negotiated Rate	$5,207.85
Rate for Payer: Aetna Medicare	$1,924.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,312.62
Rate for Payer: Amish Plain Church Group Commercial	$2,312.62
Rate for Payer: BCBS Complete	$1,041.24
Rate for Payer: BCBS MAPPO	$1,850.10
Rate for Payer: BCN Medicare Advantage	$1,850.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,850.10
Rate for Payer: Mclaren Medicaid	$991.65
Rate for Payer: Mclaren Medicare	$1,850.10
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,942.61
Rate for Payer: Meridian Medicaid	$1,041.24
Rate for Payer: MI Amish Medical Board Commercial	$2,127.61
Rate for Payer: PACE Medicare	$1,757.60
Rate for Payer: PACE SWMI	$1,850.10
Rate for Payer: PHP Medicare Advantage	$1,850.10
Rate for Payer: Priority Health Choice Medicaid	$991.65
Rate for Payer: Priority Health Medicare	$1,850.10
Rate for Payer: Railroad Medicare Medicare	$1,850.10
Rate for Payer: UHC All Payor (Choice/PPO)	$5,207.85
Rate for Payer: UHC Dual Complete DSNP	$1,850.10
Rate for Payer: UHC Medicare Advantage	$1,850.10
Rate for Payer: UHCCP Medicaid	$1,041.61
Rate for Payer: VA VA	$1,850.10

Know your out-of-pocket cost for care.

All Charges