Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY NEEDLE OR CATHETER);

Facility

$2,132.58

Service Code	CPT 62272
Hospital Revenue Code	361
Min. Negotiated Rate	$99.64
Max. Negotiated Rate	$2,132.58
Rate for Payer: Aetna Medicare	$705.66
Rate for Payer: Allen County Amish Medical Aid Commercial	$848.15
Rate for Payer: Amish Plain Church Group Commercial	$848.15
Rate for Payer: BCBS Complete	$381.87
Rate for Payer: BCBS MAPPO	$678.52
Rate for Payer: BCBS Trust/PPO	$245.00
Rate for Payer: BCN Commercial	$245.00
Rate for Payer: BCN Medicare Advantage	$678.52
Rate for Payer: Health Alliance Plan Medicare Advantage	$678.52
Rate for Payer: Mclaren Medicaid	$363.69
Rate for Payer: Mclaren Medicare	$678.52
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$712.45
Rate for Payer: Meridian Medicaid	$381.87
Rate for Payer: MI Amish Medical Board Commercial	$780.30
Rate for Payer: Nomi Health Commercial	$1,424.89
Rate for Payer: PACE Medicare	$644.59
Rate for Payer: PACE SWMI	$678.52
Rate for Payer: PHP Medicare Advantage	$678.52
Rate for Payer: Priority Health Choice Medicaid	$363.69
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,132.58
Rate for Payer: Priority Health Medicare	$678.52
Rate for Payer: Priority Health Narrow Network	$1,706.06
Rate for Payer: Railroad Medicare Medicare	$678.52
Rate for Payer: UHC All Payor (Choice/PPO)	$99.64
Rate for Payer: UHC Core	$1,463.00
Rate for Payer: UHC Dual Complete DSNP	$678.52
Rate for Payer: UHC Exchange	$1,566.00
Rate for Payer: UHC Medicare Advantage	$678.52
Rate for Payer: UHCCP Medicaid	$382.01
Rate for Payer: VA VA	$678.52

SPIRONOLACTONE 25 MG TABLET

Facility

$274.95

Service Code	NDC 53746051101
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$109.98
Max. Negotiated Rate	$247.46
Rate for Payer: Aetna Commercial	$233.71
Rate for Payer: Aetna Medicare	$137.48
Rate for Payer: Aetna New Business (MI Preferred)	$178.72
Rate for Payer: BCBS Complete	$109.98
Rate for Payer: Cash Price	$219.96
Rate for Payer: Cofinity Commercial	$192.46
Rate for Payer: Cofinity Commercial	$236.46
Rate for Payer: Cofinity Medicare Advantage	$192.46
Rate for Payer: Encore Health Key Benefits Commercial	$219.96
Rate for Payer: Healthscope Commercial	$247.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$233.71
Rate for Payer: PHP Commercial	$233.71
Rate for Payer: Priority Health Cigna Priority Health	$178.72
Rate for Payer: Priority Health SBD	$173.22

SPIRONOLACTONE 25 MG TABLET

Facility

$274.95

Service Code	NDC 53746051101
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$173.22
Max. Negotiated Rate	$247.46
Rate for Payer: Aetna Commercial	$233.71
Rate for Payer: Aetna New Business (MI Preferred)	$178.72
Rate for Payer: Cash Price	$219.96
Rate for Payer: Cofinity Commercial	$192.46
Rate for Payer: Cofinity Commercial	$236.46
Rate for Payer: Cofinity Medicare Advantage	$192.46
Rate for Payer: Encore Health Key Benefits Commercial	$219.96
Rate for Payer: Healthscope Commercial	$247.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$233.71
Rate for Payer: PHP Commercial	$233.71
Rate for Payer: Priority Health Cigna Priority Health	$178.72
Rate for Payer: Priority Health SBD	$173.22

SPIRONOLACTONE 25 MG TABLET

Facility

$3.37

Service Code	NDC 60687046511
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$3.03
Rate for Payer: Aetna Commercial	$2.86
Rate for Payer: Aetna Medicare	$1.68
Rate for Payer: Aetna New Business (MI Preferred)	$2.19
Rate for Payer: BCBS Complete	$1.35
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cofinity Commercial	$2.36
Rate for Payer: Cofinity Commercial	$2.90
Rate for Payer: Cofinity Medicare Advantage	$2.36
Rate for Payer: Encore Health Key Benefits Commercial	$2.70
Rate for Payer: Healthscope Commercial	$3.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.86
Rate for Payer: PHP Commercial	$2.86
Rate for Payer: Priority Health Cigna Priority Health	$2.19
Rate for Payer: Priority Health SBD	$2.12

SPIRONOLACTONE 25 MG TABLET

Facility

$336.05

Service Code	NDC 60687046501
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$134.42
Max. Negotiated Rate	$302.44
Rate for Payer: Aetna Commercial	$285.64
Rate for Payer: Aetna Medicare	$168.02
Rate for Payer: Aetna New Business (MI Preferred)	$218.43
Rate for Payer: BCBS Complete	$134.42
Rate for Payer: Cash Price	$268.84
Rate for Payer: Cofinity Commercial	$235.24
Rate for Payer: Cofinity Commercial	$289.00
Rate for Payer: Cofinity Medicare Advantage	$235.24
Rate for Payer: Encore Health Key Benefits Commercial	$268.84
Rate for Payer: Healthscope Commercial	$302.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$285.64
Rate for Payer: PHP Commercial	$285.64
Rate for Payer: Priority Health Cigna Priority Health	$218.43
Rate for Payer: Priority Health SBD	$211.71

SPIRONOLACTONE 25 MG TABLET

Facility

$282.00

Service Code	NDC 63739054410
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$112.80
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna Commercial	$239.70
Rate for Payer: Aetna Medicare	$141.00
Rate for Payer: Aetna New Business (MI Preferred)	$183.30
Rate for Payer: BCBS Complete	$112.80
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cofinity Commercial	$197.40
Rate for Payer: Cofinity Commercial	$242.52
Rate for Payer: Cofinity Medicare Advantage	$197.40
Rate for Payer: Encore Health Key Benefits Commercial	$225.60
Rate for Payer: Healthscope Commercial	$253.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$239.70
Rate for Payer: PHP Commercial	$239.70
Rate for Payer: Priority Health Cigna Priority Health	$183.30
Rate for Payer: Priority Health SBD	$177.66

SPIRONOLACTONE 25 MG TABLET

Facility

$336.05

Service Code	NDC 60687046501
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$211.71
Max. Negotiated Rate	$302.44
Rate for Payer: Aetna Commercial	$285.64
Rate for Payer: Aetna New Business (MI Preferred)	$218.43
Rate for Payer: Cash Price	$268.84
Rate for Payer: Cofinity Commercial	$235.24
Rate for Payer: Cofinity Commercial	$289.00
Rate for Payer: Cofinity Medicare Advantage	$235.24
Rate for Payer: Encore Health Key Benefits Commercial	$268.84
Rate for Payer: Healthscope Commercial	$302.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$285.64
Rate for Payer: PHP Commercial	$285.64
Rate for Payer: Priority Health Cigna Priority Health	$218.43
Rate for Payer: Priority Health SBD	$211.71

SPIRONOLACTONE 25 MG TABLET

Facility

$3.37

Service Code	NDC 60687046511
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.03
Rate for Payer: Aetna Commercial	$2.86
Rate for Payer: Aetna New Business (MI Preferred)	$2.19
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cofinity Commercial	$2.36
Rate for Payer: Cofinity Commercial	$2.90
Rate for Payer: Cofinity Medicare Advantage	$2.36
Rate for Payer: Encore Health Key Benefits Commercial	$2.70
Rate for Payer: Healthscope Commercial	$3.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.86
Rate for Payer: PHP Commercial	$2.86
Rate for Payer: Priority Health Cigna Priority Health	$2.19
Rate for Payer: Priority Health SBD	$2.12

SPIRONOLACTONE 25 MG TABLET

Facility

$387.75

Service Code	NDC 51079010320
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$155.10
Max. Negotiated Rate	$348.98
Rate for Payer: Aetna Commercial	$329.59
Rate for Payer: Aetna Medicare	$193.88
Rate for Payer: Aetna New Business (MI Preferred)	$252.04
Rate for Payer: BCBS Complete	$155.10
Rate for Payer: Cash Price	$310.20
Rate for Payer: Cofinity Commercial	$271.42
Rate for Payer: Cofinity Commercial	$333.46
Rate for Payer: Cofinity Medicare Advantage	$271.42
Rate for Payer: Encore Health Key Benefits Commercial	$310.20
Rate for Payer: Healthscope Commercial	$348.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$329.59
Rate for Payer: PHP Commercial	$329.59
Rate for Payer: Priority Health Cigna Priority Health	$252.04
Rate for Payer: Priority Health SBD	$244.28

SPIRONOLACTONE 25 MG TABLET

Facility

$162.15

Service Code	NDC 68382066001
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$102.15
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$137.83
Rate for Payer: Aetna New Business (MI Preferred)	$105.40
Rate for Payer: Cash Price	$129.72
Rate for Payer: Cofinity Commercial	$113.50
Rate for Payer: Cofinity Commercial	$139.45
Rate for Payer: Cofinity Medicare Advantage	$113.50
Rate for Payer: Encore Health Key Benefits Commercial	$129.72
Rate for Payer: Healthscope Commercial	$145.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$137.83
Rate for Payer: PHP Commercial	$137.83
Rate for Payer: Priority Health Cigna Priority Health	$105.40
Rate for Payer: Priority Health SBD	$102.15

SPIRONOLACTONE 25 MG TABLET

Facility

$387.75

Service Code	NDC 51079010320
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$244.28
Max. Negotiated Rate	$348.98
Rate for Payer: Aetna Commercial	$329.59
Rate for Payer: Aetna New Business (MI Preferred)	$252.04
Rate for Payer: Cash Price	$310.20
Rate for Payer: Cofinity Commercial	$271.42
Rate for Payer: Cofinity Commercial	$333.46
Rate for Payer: Cofinity Medicare Advantage	$271.42
Rate for Payer: Encore Health Key Benefits Commercial	$310.20
Rate for Payer: Healthscope Commercial	$348.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$329.59
Rate for Payer: PHP Commercial	$329.59
Rate for Payer: Priority Health Cigna Priority Health	$252.04
Rate for Payer: Priority Health SBD	$244.28

SPIRONOLACTONE 25 MG TABLET

Facility

$282.00

Service Code	NDC 63739054410
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$177.66
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna Commercial	$239.70
Rate for Payer: Aetna New Business (MI Preferred)	$183.30
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cofinity Commercial	$197.40
Rate for Payer: Cofinity Commercial	$242.52
Rate for Payer: Cofinity Medicare Advantage	$197.40
Rate for Payer: Encore Health Key Benefits Commercial	$225.60
Rate for Payer: Healthscope Commercial	$253.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$239.70
Rate for Payer: PHP Commercial	$239.70
Rate for Payer: Priority Health Cigna Priority Health	$183.30
Rate for Payer: Priority Health SBD	$177.66

SPIRONOLACTONE 25 MG TABLET

Facility

$3.88

Service Code	NDC 51079010301
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$3.49
Rate for Payer: Aetna Commercial	$3.30
Rate for Payer: Aetna New Business (MI Preferred)	$2.52
Rate for Payer: Cash Price	$3.10
Rate for Payer: Cofinity Commercial	$2.72
Rate for Payer: Cofinity Commercial	$3.34
Rate for Payer: Cofinity Medicare Advantage	$2.72
Rate for Payer: Encore Health Key Benefits Commercial	$3.10
Rate for Payer: Healthscope Commercial	$3.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.30
Rate for Payer: PHP Commercial	$3.30
Rate for Payer: Priority Health Cigna Priority Health	$2.52
Rate for Payer: Priority Health SBD	$2.44

SPIRONOLACTONE 25 MG TABLET

Facility

$3.88

Service Code	NDC 51079010301
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$3.49
Rate for Payer: Aetna Commercial	$3.30
Rate for Payer: Aetna Medicare	$1.94
Rate for Payer: Aetna New Business (MI Preferred)	$2.52
Rate for Payer: BCBS Complete	$1.55
Rate for Payer: Cash Price	$3.10
Rate for Payer: Cofinity Commercial	$2.72
Rate for Payer: Cofinity Commercial	$3.34
Rate for Payer: Cofinity Medicare Advantage	$2.72
Rate for Payer: Encore Health Key Benefits Commercial	$3.10
Rate for Payer: Healthscope Commercial	$3.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.30
Rate for Payer: PHP Commercial	$3.30
Rate for Payer: Priority Health Cigna Priority Health	$2.52
Rate for Payer: Priority Health SBD	$2.44

SPIRONOLACTONE 25 MG TABLET

Facility

$162.15

Service Code	NDC 68382066001
Hospital Charge Code	7437
Hospital Revenue Code	637
Min. Negotiated Rate	$64.86
Max. Negotiated Rate	$145.94
Rate for Payer: Aetna Commercial	$137.83
Rate for Payer: Aetna Medicare	$81.08
Rate for Payer: Aetna New Business (MI Preferred)	$105.40
Rate for Payer: BCBS Complete	$64.86
Rate for Payer: Cash Price	$129.72
Rate for Payer: Cofinity Commercial	$113.50
Rate for Payer: Cofinity Commercial	$139.45
Rate for Payer: Cofinity Medicare Advantage	$113.50
Rate for Payer: Encore Health Key Benefits Commercial	$129.72
Rate for Payer: Healthscope Commercial	$145.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$137.83
Rate for Payer: PHP Commercial	$137.83
Rate for Payer: Priority Health Cigna Priority Health	$105.40
Rate for Payer: Priority Health SBD	$102.15

SPIRONOLACTONE 50 MG TABLET

Facility

$264.10

Service Code	NDC 60687047601
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$105.64
Max. Negotiated Rate	$237.69
Rate for Payer: Aetna Commercial	$224.48
Rate for Payer: Aetna Medicare	$132.05
Rate for Payer: Aetna New Business (MI Preferred)	$171.66
Rate for Payer: BCBS Complete	$105.64
Rate for Payer: Cash Price	$211.28
Rate for Payer: Cofinity Commercial	$184.87
Rate for Payer: Cofinity Commercial	$227.13
Rate for Payer: Cofinity Medicare Advantage	$184.87
Rate for Payer: Encore Health Key Benefits Commercial	$211.28
Rate for Payer: Healthscope Commercial	$237.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$224.48
Rate for Payer: PHP Commercial	$224.48
Rate for Payer: Priority Health Cigna Priority Health	$171.66
Rate for Payer: Priority Health SBD	$166.38

SPIRONOLACTONE 50 MG TABLET

Facility

$290.70

Service Code	NDC 63739054510
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$183.14
Max. Negotiated Rate	$261.63
Rate for Payer: Aetna Commercial	$247.10
Rate for Payer: Aetna New Business (MI Preferred)	$188.96
Rate for Payer: Cash Price	$232.56
Rate for Payer: Cofinity Commercial	$203.49
Rate for Payer: Cofinity Commercial	$250.00
Rate for Payer: Cofinity Medicare Advantage	$203.49
Rate for Payer: Encore Health Key Benefits Commercial	$232.56
Rate for Payer: Healthscope Commercial	$261.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$247.10
Rate for Payer: PHP Commercial	$247.10
Rate for Payer: Priority Health Cigna Priority Health	$188.96
Rate for Payer: Priority Health SBD	$183.14

SPIRONOLACTONE 50 MG TABLET

Facility

$2.65

Service Code	NDC 60687047611
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Aetna New Business (MI Preferred)	$1.72
Rate for Payer: Cash Price	$2.12
Rate for Payer: Cofinity Commercial	$1.86
Rate for Payer: Cofinity Commercial	$2.28
Rate for Payer: Cofinity Medicare Advantage	$1.86
Rate for Payer: Encore Health Key Benefits Commercial	$2.12
Rate for Payer: Healthscope Commercial	$2.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.25
Rate for Payer: PHP Commercial	$2.25
Rate for Payer: Priority Health Cigna Priority Health	$1.72
Rate for Payer: Priority Health SBD	$1.67

SPIRONOLACTONE 50 MG TABLET

Facility

$2.65

Service Code	NDC 60687047611
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.25
Rate for Payer: Aetna Medicare	$1.32
Rate for Payer: Aetna New Business (MI Preferred)	$1.72
Rate for Payer: BCBS Complete	$1.06
Rate for Payer: Cash Price	$2.12
Rate for Payer: Cofinity Commercial	$1.86
Rate for Payer: Cofinity Commercial	$2.28
Rate for Payer: Cofinity Medicare Advantage	$1.86
Rate for Payer: Encore Health Key Benefits Commercial	$2.12
Rate for Payer: Healthscope Commercial	$2.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.25
Rate for Payer: PHP Commercial	$2.25
Rate for Payer: Priority Health Cigna Priority Health	$1.72
Rate for Payer: Priority Health SBD	$1.67

SPIRONOLACTONE 50 MG TABLET

Facility

$262.20

Service Code	NDC 53746051401
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$165.19
Max. Negotiated Rate	$235.98
Rate for Payer: Aetna Commercial	$222.87
Rate for Payer: Aetna New Business (MI Preferred)	$170.43
Rate for Payer: Cash Price	$209.76
Rate for Payer: Cofinity Commercial	$183.54
Rate for Payer: Cofinity Commercial	$225.49
Rate for Payer: Cofinity Medicare Advantage	$183.54
Rate for Payer: Encore Health Key Benefits Commercial	$209.76
Rate for Payer: Healthscope Commercial	$235.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$222.87
Rate for Payer: PHP Commercial	$222.87
Rate for Payer: Priority Health Cigna Priority Health	$170.43
Rate for Payer: Priority Health SBD	$165.19

SPIRONOLACTONE 50 MG TABLET

Facility

$264.10

Service Code	NDC 60687047601
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$166.38
Max. Negotiated Rate	$237.69
Rate for Payer: Aetna Commercial	$224.48
Rate for Payer: Aetna New Business (MI Preferred)	$171.66
Rate for Payer: Cash Price	$211.28
Rate for Payer: Cofinity Commercial	$184.87
Rate for Payer: Cofinity Commercial	$227.13
Rate for Payer: Cofinity Medicare Advantage	$184.87
Rate for Payer: Encore Health Key Benefits Commercial	$211.28
Rate for Payer: Healthscope Commercial	$237.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$224.48
Rate for Payer: PHP Commercial	$224.48
Rate for Payer: Priority Health Cigna Priority Health	$171.66
Rate for Payer: Priority Health SBD	$166.38

SPIRONOLACTONE 50 MG TABLET

Facility

$262.20

Service Code	NDC 53746051401
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$104.88
Max. Negotiated Rate	$235.98
Rate for Payer: Aetna Commercial	$222.87
Rate for Payer: Aetna Medicare	$131.10
Rate for Payer: Aetna New Business (MI Preferred)	$170.43
Rate for Payer: BCBS Complete	$104.88
Rate for Payer: Cash Price	$209.76
Rate for Payer: Cofinity Commercial	$183.54
Rate for Payer: Cofinity Commercial	$225.49
Rate for Payer: Cofinity Medicare Advantage	$183.54
Rate for Payer: Encore Health Key Benefits Commercial	$209.76
Rate for Payer: Healthscope Commercial	$235.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$222.87
Rate for Payer: PHP Commercial	$222.87
Rate for Payer: Priority Health Cigna Priority Health	$170.43
Rate for Payer: Priority Health SBD	$165.19

SPIRONOLACTONE 50 MG TABLET

Facility

$290.70

Service Code	NDC 63739054510
Hospital Charge Code	11426
Hospital Revenue Code	637
Min. Negotiated Rate	$116.28
Max. Negotiated Rate	$261.63
Rate for Payer: Aetna Commercial	$247.10
Rate for Payer: Aetna Medicare	$145.35
Rate for Payer: Aetna New Business (MI Preferred)	$188.96
Rate for Payer: BCBS Complete	$116.28
Rate for Payer: Cash Price	$232.56
Rate for Payer: Cofinity Commercial	$203.49
Rate for Payer: Cofinity Commercial	$250.00
Rate for Payer: Cofinity Medicare Advantage	$203.49
Rate for Payer: Encore Health Key Benefits Commercial	$232.56
Rate for Payer: Healthscope Commercial	$261.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$247.10
Rate for Payer: PHP Commercial	$247.10
Rate for Payer: Priority Health Cigna Priority Health	$188.96
Rate for Payer: Priority Health SBD	$183.14

SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)

Facility

$11,273.70

Service Code	CPT 15120
Hospital Revenue Code	360
Min. Negotiated Rate	$728.51
Max. Negotiated Rate	$11,273.70
Rate for Payer: Aetna Medicare	$3,730.43
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,483.69
Rate for Payer: Amish Plain Church Group Commercial	$4,483.69
Rate for Payer: BCBS Complete	$2,018.74
Rate for Payer: BCBS MAPPO	$3,586.95
Rate for Payer: BCBS Trust/PPO	$2,753.94
Rate for Payer: BCN Commercial	$2,753.94
Rate for Payer: BCN Medicare Advantage	$3,586.95
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,586.95
Rate for Payer: Mclaren Medicaid	$1,922.61
Rate for Payer: Mclaren Medicare	$3,586.95
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,766.30
Rate for Payer: Meridian Medicaid	$2,018.74
Rate for Payer: MI Amish Medical Board Commercial	$4,124.99
Rate for Payer: Nomi Health Commercial	$7,532.60
Rate for Payer: PACE Medicare	$3,407.60
Rate for Payer: PACE SWMI	$3,586.95
Rate for Payer: PHP Medicare Advantage	$3,586.95
Rate for Payer: Priority Health Choice Medicaid	$1,922.61
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11,273.70
Rate for Payer: Priority Health Medicare	$3,586.95
Rate for Payer: Priority Health Narrow Network	$9,018.96
Rate for Payer: Railroad Medicare Medicare	$3,586.95
Rate for Payer: UHC All Payor (Choice/PPO)	$728.51
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$3,586.95
Rate for Payer: UHC Exchange	$5,811.00
Rate for Payer: UHC Medicare Advantage	$3,586.95
Rate for Payer: UHCCP Medicaid	$2,019.45
Rate for Payer: VA VA	$3,586.95

SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)

Facility

$5,632.99

Service Code	CPT 15100
Hospital Revenue Code	360
Min. Negotiated Rate	$755.76
Max. Negotiated Rate	$5,632.99
Rate for Payer: Aetna Medicare	$1,863.93
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,240.30
Rate for Payer: Amish Plain Church Group Commercial	$2,240.30
Rate for Payer: BCBS Complete	$1,008.67
Rate for Payer: BCBS MAPPO	$1,792.24
Rate for Payer: BCBS Trust/PPO	$2,261.16
Rate for Payer: BCN Commercial	$2,261.16
Rate for Payer: BCN Medicare Advantage	$1,792.24
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,792.24
Rate for Payer: Mclaren Medicaid	$960.64
Rate for Payer: Mclaren Medicare	$1,792.24
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,881.85
Rate for Payer: Meridian Medicaid	$1,008.67
Rate for Payer: MI Amish Medical Board Commercial	$2,061.08
Rate for Payer: Nomi Health Commercial	$3,763.70
Rate for Payer: PACE Medicare	$1,702.63
Rate for Payer: PACE SWMI	$1,792.24
Rate for Payer: PHP Medicare Advantage	$1,792.24
Rate for Payer: Priority Health Choice Medicaid	$960.64
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,632.99
Rate for Payer: Priority Health Medicare	$1,792.24
Rate for Payer: Priority Health Narrow Network	$4,506.39
Rate for Payer: Railroad Medicare Medicare	$1,792.24
Rate for Payer: UHC All Payor (Choice/PPO)	$755.76
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,792.24
Rate for Payer: UHC Exchange	$3,362.00
Rate for Payer: UHC Medicare Advantage	$1,792.24
Rate for Payer: UHCCP Medicaid	$1,009.03
Rate for Payer: VA VA	$1,792.24

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