Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

TROPICAMIDE 1 % EYE DROPS

Facility

$33.71

Service Code	NDC 61314035501
Hospital Charge Code	8250
Hospital Revenue Code	637
Min. Negotiated Rate	$21.24
Max. Negotiated Rate	$30.34
Rate for Payer: Aetna Commercial	$28.65
Rate for Payer: Aetna New Business (MI Preferred)	$21.91
Rate for Payer: Cash Price	$26.97
Rate for Payer: Cofinity Advantage	$23.60
Rate for Payer: Cofinity Commercial	$28.99
Rate for Payer: Encore Health Key Benefits Commercial	$26.97
Rate for Payer: Healthscope Commercial	$30.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$28.65
Rate for Payer: Opus (Opus Packaging Group) HMA	$25.28
Rate for Payer: PHP Commercial	$28.65
Rate for Payer: Priority Health SBD	$21.24

TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OF PERFORATION FOR CLOSURE, WITH OR WITHOUT PATCH

Facility

$4,999.64

Service Code	CPT 69610
Hospital Revenue Code	360
Min. Negotiated Rate	$202.81
Max. Negotiated Rate	$4,999.64
Rate for Payer: Aetna Medicare	$1,607.84
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,932.50
Rate for Payer: Amish Plain Church Group Commercial	$1,932.50
Rate for Payer: BCBS Complete	$849.06
Rate for Payer: BCBS MAPPO	$1,546.00
Rate for Payer: BCBS Trust/PPO	$202.81
Rate for Payer: BCN Commercial	$202.81
Rate for Payer: BCN Medicare Advantage	$1,546.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,546.00
Rate for Payer: Mclaren Medicaid	$808.56
Rate for Payer: Mclaren Medicare	$1,546.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,623.30
Rate for Payer: Meridian Medicaid	$1,623.30
Rate for Payer: MI Amish Medical Board Commercial	$1,777.90
Rate for Payer: Molina Medicare/Medicaid	$1,700.60
Rate for Payer: Nomi Health Commercial	$4,638.00
Rate for Payer: PACE Medicare	$1,468.70
Rate for Payer: PACE SWMI	$1,546.00
Rate for Payer: PHP Medicare Advantage	$1,546.00
Rate for Payer: Priority Health Choice Medicaid	$808.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$4,999.64
Rate for Payer: Priority Health Medicare	$1,546.00
Rate for Payer: Priority Health Tiered Network	$3,999.71
Rate for Payer: Railroad Medicare Medicare	$1,546.00
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$1,546.00
Rate for Payer: UHC Medicaid	$808.56
Rate for Payer: UHCCP Medicaid	$808.56
Rate for Payer: VA VA	$1,546.00

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION

Facility

$19,075.37

Service Code	CPT 69631
Hospital Revenue Code	360
Min. Negotiated Rate	$3,084.94
Max. Negotiated Rate	$19,075.37
Rate for Payer: Aetna Medicare	$6,134.48
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,373.18
Rate for Payer: Amish Plain Church Group Commercial	$7,373.18
Rate for Payer: BCBS Complete	$3,239.48
Rate for Payer: BCBS MAPPO	$5,898.54
Rate for Payer: BCBS Trust/PPO	$4,435.32
Rate for Payer: BCN Commercial	$4,435.32
Rate for Payer: BCN Medicare Advantage	$5,898.54
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,898.54
Rate for Payer: Mclaren Medicaid	$3,084.94
Rate for Payer: Mclaren Medicare	$5,898.54
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,193.47
Rate for Payer: Meridian Medicaid	$6,193.47
Rate for Payer: MI Amish Medical Board Commercial	$6,783.32
Rate for Payer: Molina Medicare/Medicaid	$6,488.39
Rate for Payer: Nomi Health Commercial	$17,695.62
Rate for Payer: PACE Medicare	$5,603.61
Rate for Payer: PACE SWMI	$5,898.54
Rate for Payer: PHP Medicare Advantage	$5,898.54
Rate for Payer: Priority Health Choice Medicaid	$3,084.94
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$19,075.37
Rate for Payer: Priority Health Medicare	$5,898.54
Rate for Payer: Priority Health Tiered Network	$15,260.30
Rate for Payer: Railroad Medicare Medicare	$5,898.54
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$5,898.54
Rate for Payer: UHC Medicaid	$3,084.94
Rate for Payer: UHCCP Medicaid	$3,084.94
Rate for Payer: VA VA	$5,898.54

TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA

Facility

$4,999.64

Service Code	CPT 69436
Hospital Revenue Code	360
Min. Negotiated Rate	$808.56
Max. Negotiated Rate	$4,999.64
Rate for Payer: Aetna Medicare	$1,607.84
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,932.50
Rate for Payer: Amish Plain Church Group Commercial	$1,932.50
Rate for Payer: BCBS Complete	$849.06
Rate for Payer: BCBS MAPPO	$1,546.00
Rate for Payer: BCBS Trust/PPO	$1,345.86
Rate for Payer: BCN Commercial	$1,345.86
Rate for Payer: BCN Medicare Advantage	$1,546.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,546.00
Rate for Payer: Mclaren Medicaid	$808.56
Rate for Payer: Mclaren Medicare	$1,546.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,623.30
Rate for Payer: Meridian Medicaid	$1,623.30
Rate for Payer: MI Amish Medical Board Commercial	$1,777.90
Rate for Payer: Molina Medicare/Medicaid	$1,700.60
Rate for Payer: Nomi Health Commercial	$4,638.00
Rate for Payer: PACE Medicare	$1,468.70
Rate for Payer: PACE SWMI	$1,546.00
Rate for Payer: PHP Medicare Advantage	$1,546.00
Rate for Payer: Priority Health Choice Medicaid	$808.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$4,999.64
Rate for Payer: Priority Health Medicare	$1,546.00
Rate for Payer: Priority Health Tiered Network	$3,999.71
Rate for Payer: Railroad Medicare Medicare	$1,546.00
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$1,546.00
Rate for Payer: UHC Medicaid	$808.56
Rate for Payer: UHCCP Medicaid	$808.56
Rate for Payer: VA VA	$1,546.00

UBLITUXIMAB-XIIY 25 MG/ML INTRAVENOUS SOLUTION

Facility

$30,763.59

Service Code	HCPCS J2329
Hospital Charge Code	202689
Hospital Revenue Code	636
Min. Negotiated Rate	$35.96
Max. Negotiated Rate	$27,687.23
Rate for Payer: Aetna Commercial	$26,149.05
Rate for Payer: Aetna Medicare	$71.50
Rate for Payer: Aetna New Business (MI Preferred)	$19,996.33
Rate for Payer: Allen County Amish Medical Aid Commercial	$85.94
Rate for Payer: Amish Plain Church Group Commercial	$85.94
Rate for Payer: BCBS Complete	$37.76
Rate for Payer: BCBS MAPPO	$68.75
Rate for Payer: BCBS Trust/PPO	$176.06
Rate for Payer: BCN Commercial	$176.06
Rate for Payer: BCN Medicare Advantage	$68.75
Rate for Payer: Cash Price	$24,610.87
Rate for Payer: Cash Price	$24,610.87
Rate for Payer: Cofinity Advantage	$21,534.51
Rate for Payer: Cofinity Commercial	$26,456.69
Rate for Payer: Encore Health Key Benefits Commercial	$24,610.87
Rate for Payer: Health Alliance Plan Medicare Advantage	$68.75
Rate for Payer: Healthscope Commercial	$27,687.23
Rate for Payer: Mclaren Medicaid	$35.96
Rate for Payer: Mclaren Medicare	$68.75
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$72.19
Rate for Payer: Meridian Medicaid	$72.19
Rate for Payer: MI Amish Medical Board Commercial	$79.06
Rate for Payer: Molina Medicare/Medicaid	$75.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26,149.05
Rate for Payer: Nomi Health Commercial	$206.25
Rate for Payer: Opus (Opus Packaging Group) HMA	$23,072.69
Rate for Payer: PACE Medicare	$65.31
Rate for Payer: PACE SWMI	$68.75
Rate for Payer: PHP Commercial	$26,149.05
Rate for Payer: PHP Medicare Advantage	$68.75
Rate for Payer: Priority Health Choice Medicaid	$35.96
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$223.16
Rate for Payer: Priority Health Medicare	$68.75
Rate for Payer: Priority Health SBD	$19,381.06
Rate for Payer: Priority Health Tiered Network	$178.53
Rate for Payer: Railroad Medicare Medicare	$68.75
Rate for Payer: UHC All Payor (Choice/PPO)	$115.80
Rate for Payer: UHC Core	$115.80
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$68.75
Rate for Payer: UHC Exchange	$115.80
Rate for Payer: UHC Medicaid	$35.96
Rate for Payer: UHCCP Medicaid	$35.96
Rate for Payer: VA VA	$68.75

UBLITUXIMAB-XIIY 25 MG/ML INTRAVENOUS SOLUTION

Facility

$30,763.59

Service Code	HCPCS J2329
Hospital Charge Code	202689
Hospital Revenue Code	636
Min. Negotiated Rate	$19,381.06
Max. Negotiated Rate	$27,687.23
Rate for Payer: Aetna Commercial	$26,149.05
Rate for Payer: Aetna New Business (MI Preferred)	$19,996.33
Rate for Payer: Cash Price	$24,610.87
Rate for Payer: Cofinity Advantage	$21,534.51
Rate for Payer: Cofinity Commercial	$26,456.69
Rate for Payer: Encore Health Key Benefits Commercial	$24,610.87
Rate for Payer: Healthscope Commercial	$27,687.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$26,149.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$23,072.69
Rate for Payer: PHP Commercial	$26,149.05
Rate for Payer: Priority Health SBD	$19,381.06

ULIPRISTAL 30 MG TABLET

Facility

$139.79

Service Code	NDC 73302045601
Hospital Charge Code	106079
Hospital Revenue Code	637
Min. Negotiated Rate	$88.07
Max. Negotiated Rate	$125.81
Rate for Payer: Aetna Commercial	$118.82
Rate for Payer: Aetna New Business (MI Preferred)	$90.86
Rate for Payer: Cash Price	$111.83
Rate for Payer: Cofinity Advantage	$97.85
Rate for Payer: Cofinity Commercial	$120.22
Rate for Payer: Encore Health Key Benefits Commercial	$111.83
Rate for Payer: Healthscope Commercial	$125.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$118.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$104.84
Rate for Payer: PHP Commercial	$118.82
Rate for Payer: Priority Health SBD	$88.07

ULIPRISTAL 30 MG TABLET

Facility

$139.79

Service Code	NDC 73302045601
Hospital Charge Code	106079
Hospital Revenue Code	637
Min. Negotiated Rate	$54.94
Max. Negotiated Rate	$125.81
Rate for Payer: Aetna Commercial	$118.82
Rate for Payer: Aetna Medicare	$69.89
Rate for Payer: Aetna New Business (MI Preferred)	$90.86
Rate for Payer: BCBS Complete	$55.92
Rate for Payer: Cash Price	$111.83
Rate for Payer: Cofinity Advantage	$97.85
Rate for Payer: Cofinity Commercial	$120.22
Rate for Payer: Encore Health Key Benefits Commercial	$111.83
Rate for Payer: Healthscope Commercial	$125.81
Rate for Payer: MI Amish Medical Board Commercial	$111.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$118.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$104.84
Rate for Payer: PHP Commercial	$118.82
Rate for Payer: Priority Health SBD	$88.07
Rate for Payer: UHC All Payor (Choice/PPO)	$90.86
Rate for Payer: UHC Core	$72.83
Rate for Payer: UHC Exchange	$54.94

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$103,631.90

Service Code	MSDRG 278
Min. Negotiated Rate	$41,416.08
Max. Negotiated Rate	$103,631.90
Rate for Payer: Aetna Medicare	$45,339.70
Rate for Payer: Allen County Amish Medical Aid Commercial	$54,494.84
Rate for Payer: Amish Plain Church Group Commercial	$54,494.84
Rate for Payer: BCBS MAPPO	$43,595.87
Rate for Payer: BCBS Trust/PPO	$103,631.90
Rate for Payer: BCN Commercial	$103,631.90
Rate for Payer: BCN Medicare Advantage	$43,595.87
Rate for Payer: Health Alliance Plan Medicare Advantage	$43,595.87
Rate for Payer: Mclaren Medicare	$43,595.87
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$45,775.66
Rate for Payer: MI Amish Medical Board Commercial	$50,135.25
Rate for Payer: Molina Medicare/Medicaid	$47,955.46
Rate for Payer: Nomi Health Commercial	$71,803.98
Rate for Payer: PACE Medicare	$41,416.08
Rate for Payer: PACE SWMI	$43,595.87
Rate for Payer: PHP Medicare Advantage	$43,595.87
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$89,739.06
Rate for Payer: Priority Health Medicare	$43,595.87
Rate for Payer: Priority Health Tiered Network	$71,791.23
Rate for Payer: Railroad Medicare Medicare	$43,595.87
Rate for Payer: UHC All Payor (Choice/PPO)	$90,729.06
Rate for Payer: UHC Core	$75,906.27
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$43,595.87
Rate for Payer: UHC Exchange	$61,990.77
Rate for Payer: VA VA	$43,595.87

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$58,784.32

Service Code	MSDRG 279
Min. Negotiated Rate	$27,027.60
Max. Negotiated Rate	$58,784.32
Rate for Payer: Aetna Medicare	$29,588.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$35,562.62
Rate for Payer: Amish Plain Church Group Commercial	$35,562.62
Rate for Payer: BCBS MAPPO	$28,450.10
Rate for Payer: BCBS Trust/PPO	$52,185.80
Rate for Payer: BCN Commercial	$52,185.80
Rate for Payer: BCN Medicare Advantage	$28,450.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$28,450.10
Rate for Payer: Mclaren Medicare	$28,450.10
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$29,872.60
Rate for Payer: MI Amish Medical Board Commercial	$32,717.62
Rate for Payer: Molina Medicare/Medicaid	$31,295.11
Rate for Payer: Nomi Health Commercial	$46,522.56
Rate for Payer: PACE Medicare	$27,027.60
Rate for Payer: PACE SWMI	$28,450.10
Rate for Payer: PHP Medicare Advantage	$28,450.10
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$58,142.89
Rate for Payer: Priority Health Medicare	$28,450.10
Rate for Payer: Priority Health Tiered Network	$46,514.30
Rate for Payer: Railroad Medicare Medicare	$28,450.10
Rate for Payer: UHC All Payor (Choice/PPO)	$58,784.32
Rate for Payer: UHC Core	$49,180.48
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$28,450.10
Rate for Payer: UHC Exchange	$40,164.48
Rate for Payer: VA VA	$28,450.10

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$50,512.12

Service Code	MSDRG 173
Min. Negotiated Rate	$22,402.23
Max. Negotiated Rate	$50,512.12
Rate for Payer: Aetna Medicare	$24,524.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$29,476.61
Rate for Payer: Amish Plain Church Group Commercial	$29,476.61
Rate for Payer: BCBS MAPPO	$23,581.29
Rate for Payer: BCBS Trust/PPO	$50,512.12
Rate for Payer: BCN Commercial	$50,512.12
Rate for Payer: BCN Medicare Advantage	$23,581.29
Rate for Payer: Health Alliance Plan Medicare Advantage	$23,581.29
Rate for Payer: Mclaren Medicare	$23,581.29
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$24,760.35
Rate for Payer: MI Amish Medical Board Commercial	$27,118.48
Rate for Payer: Molina Medicare/Medicaid	$25,939.42
Rate for Payer: Nomi Health Commercial	$38,395.56
Rate for Payer: PACE Medicare	$22,402.23
Rate for Payer: PACE SWMI	$23,581.29
Rate for Payer: PHP Medicare Advantage	$23,581.29
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$47,985.94
Rate for Payer: Priority Health Medicare	$23,581.29
Rate for Payer: Priority Health Tiered Network	$38,388.74
Rate for Payer: Railroad Medicare Medicare	$23,581.29
Rate for Payer: UHC All Payor (Choice/PPO)	$48,515.32
Rate for Payer: UHC Core	$40,589.17
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$23,581.29
Rate for Payer: UHC Exchange	$33,148.17
Rate for Payer: VA VA	$23,581.29

UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION

Facility

$108.71

Service Code	NDC 00173087306
Hospital Charge Code	173272
Hospital Revenue Code	637
Min. Negotiated Rate	$42.72
Max. Negotiated Rate	$97.84
Rate for Payer: Aetna Commercial	$92.40
Rate for Payer: Aetna Medicare	$54.35
Rate for Payer: Aetna New Business (MI Preferred)	$70.66
Rate for Payer: BCBS Complete	$43.48
Rate for Payer: Cash Price	$86.97
Rate for Payer: Cofinity Advantage	$76.10
Rate for Payer: Cofinity Commercial	$93.49
Rate for Payer: Encore Health Key Benefits Commercial	$86.97
Rate for Payer: Healthscope Commercial	$97.84
Rate for Payer: MI Amish Medical Board Commercial	$86.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$92.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$81.53
Rate for Payer: PHP Commercial	$92.40
Rate for Payer: Priority Health SBD	$68.49
Rate for Payer: UHC All Payor (Choice/PPO)	$70.66
Rate for Payer: UHC Core	$56.64
Rate for Payer: UHC Exchange	$42.72

UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION

Facility

$108.71

Service Code	NDC 00173087306
Hospital Charge Code	173272
Hospital Revenue Code	637
Min. Negotiated Rate	$68.49
Max. Negotiated Rate	$97.84
Rate for Payer: Aetna Commercial	$92.40
Rate for Payer: Aetna New Business (MI Preferred)	$70.66
Rate for Payer: Cash Price	$86.97
Rate for Payer: Cofinity Advantage	$76.10
Rate for Payer: Cofinity Commercial	$93.49
Rate for Payer: Encore Health Key Benefits Commercial	$86.97
Rate for Payer: Healthscope Commercial	$97.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$92.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$81.53
Rate for Payer: PHP Commercial	$92.40
Rate for Payer: Priority Health SBD	$68.49

UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$22,505.41

Service Code	MSDRG 383
Min. Negotiated Rate	$10,686.89
Max. Negotiated Rate	$22,505.41
Rate for Payer: Aetna Medicare	$11,699.33
Rate for Payer: Allen County Amish Medical Aid Commercial	$14,061.70
Rate for Payer: Amish Plain Church Group Commercial	$14,061.70
Rate for Payer: BCBS MAPPO	$11,249.36
Rate for Payer: BCBS Trust/PPO	$20,755.87
Rate for Payer: BCN Commercial	$20,755.87
Rate for Payer: BCN Medicare Advantage	$11,249.36
Rate for Payer: Health Alliance Plan Medicare Advantage	$11,249.36
Rate for Payer: Mclaren Medicare	$11,249.36
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$11,811.83
Rate for Payer: MI Amish Medical Board Commercial	$12,936.76
Rate for Payer: Molina Medicare/Medicaid	$12,374.30
Rate for Payer: Nomi Health Commercial	$17,811.03
Rate for Payer: PACE Medicare	$10,686.89
Rate for Payer: PACE SWMI	$11,249.36
Rate for Payer: PHP Medicare Advantage	$11,249.36
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$22,259.84
Rate for Payer: Priority Health Medicare	$11,249.36
Rate for Payer: Priority Health Tiered Network	$17,807.87
Rate for Payer: Railroad Medicare Medicare	$11,249.36
Rate for Payer: UHC All Payor (Choice/PPO)	$22,505.41
Rate for Payer: UHC Core	$18,828.61
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$11,249.36
Rate for Payer: UHC Exchange	$15,376.86
Rate for Payer: VA VA	$11,249.36

UNCOMPLICATED PEPTIC ULCER WITHOUT MCC

Facility

$13,933.24

Service Code	MSDRG 384
Min. Negotiated Rate	$6,825.85
Max. Negotiated Rate	$13,933.24
Rate for Payer: Aetna Medicare	$7,472.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,981.38
Rate for Payer: Amish Plain Church Group Commercial	$8,981.38
Rate for Payer: BCBS MAPPO	$7,185.10
Rate for Payer: BCBS Trust/PPO	$12,998.46
Rate for Payer: BCN Commercial	$12,998.46
Rate for Payer: BCN Medicare Advantage	$7,185.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,185.10
Rate for Payer: Mclaren Medicare	$7,185.10
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,544.35
Rate for Payer: MI Amish Medical Board Commercial	$8,262.86
Rate for Payer: Molina Medicare/Medicaid	$7,903.61
Rate for Payer: Nomi Health Commercial	$11,026.92
Rate for Payer: PACE Medicare	$6,825.85
Rate for Payer: PACE SWMI	$7,185.10
Rate for Payer: PHP Medicare Advantage	$7,185.10
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$13,781.21
Rate for Payer: Priority Health Medicare	$7,185.10
Rate for Payer: Priority Health Tiered Network	$11,024.96
Rate for Payer: Railroad Medicare Medicare	$7,185.10
Rate for Payer: UHC All Payor (Choice/PPO)	$13,933.24
Rate for Payer: UHC Core	$11,656.91
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$7,185.10
Rate for Payer: UHC Exchange	$9,519.91
Rate for Payer: VA VA	$7,185.10

UNLISTED LAPAROSCOPIC PROCEDURE, LIVER

Facility

$19,480.40

Service Code	CPT 47379
Hospital Revenue Code	360
Min. Negotiated Rate	$2,883.05
Max. Negotiated Rate	$19,480.40
Rate for Payer: Aetna Medicare	$6,264.74
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,529.74
Rate for Payer: Amish Plain Church Group Commercial	$7,529.74
Rate for Payer: BCBS Complete	$3,308.27
Rate for Payer: BCBS MAPPO	$6,023.79
Rate for Payer: BCBS Trust/PPO	$2,883.05
Rate for Payer: BCN Commercial	$2,883.05
Rate for Payer: BCN Medicare Advantage	$6,023.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,023.79
Rate for Payer: Mclaren Medicaid	$3,150.44
Rate for Payer: Mclaren Medicare	$6,023.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,324.98
Rate for Payer: Meridian Medicaid	$6,324.98
Rate for Payer: MI Amish Medical Board Commercial	$6,927.36
Rate for Payer: Molina Medicare/Medicaid	$6,626.17
Rate for Payer: Nomi Health Commercial	$18,071.37
Rate for Payer: PACE Medicare	$5,722.60
Rate for Payer: PACE SWMI	$6,023.79
Rate for Payer: PHP Medicare Advantage	$6,023.79
Rate for Payer: Priority Health Choice Medicaid	$3,150.44
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$19,480.40
Rate for Payer: Priority Health Medicare	$6,023.79
Rate for Payer: Priority Health Tiered Network	$15,584.32
Rate for Payer: Railroad Medicare Medicare	$6,023.79
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$6,023.79
Rate for Payer: UHC Medicaid	$3,150.44
Rate for Payer: UHCCP Medicaid	$3,150.44
Rate for Payer: VA VA	$6,023.79

UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM

Facility

$19,480.40

Service Code	CPT 49329
Hospital Revenue Code	360
Min. Negotiated Rate	$2,964.14
Max. Negotiated Rate	$19,480.40
Rate for Payer: UHCCP Medicaid	$3,150.44
Rate for Payer: VA VA	$6,023.79
Rate for Payer: Aetna Medicare	$6,264.74
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,529.74
Rate for Payer: Amish Plain Church Group Commercial	$7,529.74
Rate for Payer: BCBS Complete	$3,308.27
Rate for Payer: BCBS MAPPO	$6,023.79
Rate for Payer: BCBS Trust/PPO	$2,964.14
Rate for Payer: BCN Commercial	$2,964.14
Rate for Payer: BCN Medicare Advantage	$6,023.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,023.79
Rate for Payer: Mclaren Medicaid	$3,150.44
Rate for Payer: Mclaren Medicare	$6,023.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,324.98
Rate for Payer: Meridian Medicaid	$6,324.98
Rate for Payer: MI Amish Medical Board Commercial	$6,927.36
Rate for Payer: Molina Medicare/Medicaid	$6,626.17
Rate for Payer: Nomi Health Commercial	$18,071.37
Rate for Payer: PACE Medicare	$5,722.60
Rate for Payer: PACE SWMI	$6,023.79
Rate for Payer: PHP Medicare Advantage	$6,023.79
Rate for Payer: Priority Health Choice Medicaid	$3,150.44
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$19,480.40
Rate for Payer: Priority Health Medicare	$6,023.79
Rate for Payer: Priority Health Tiered Network	$15,584.32
Rate for Payer: Railroad Medicare Medicare	$6,023.79
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$6,023.79
Rate for Payer: UHC Medicaid	$3,150.44

UNLISTED LAPAROSCOPY PROCEDURE, SPERMATIC CORD

Facility

$19,480.40

Service Code	CPT 55559
Hospital Revenue Code	360
Min. Negotiated Rate	$2,883.05
Max. Negotiated Rate	$19,480.40
Rate for Payer: Aetna Medicare	$6,264.74
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,529.74
Rate for Payer: Amish Plain Church Group Commercial	$7,529.74
Rate for Payer: BCBS Complete	$3,308.27
Rate for Payer: BCBS MAPPO	$6,023.79
Rate for Payer: BCBS Trust/PPO	$2,883.05
Rate for Payer: BCN Commercial	$2,883.05
Rate for Payer: BCN Medicare Advantage	$6,023.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,023.79
Rate for Payer: Mclaren Medicaid	$3,150.44
Rate for Payer: Mclaren Medicare	$6,023.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,324.98
Rate for Payer: Meridian Medicaid	$6,324.98
Rate for Payer: MI Amish Medical Board Commercial	$6,927.36
Rate for Payer: Molina Medicare/Medicaid	$6,626.17
Rate for Payer: Nomi Health Commercial	$18,071.37
Rate for Payer: PACE Medicare	$5,722.60
Rate for Payer: PACE SWMI	$6,023.79
Rate for Payer: PHP Medicare Advantage	$6,023.79
Rate for Payer: Priority Health Choice Medicaid	$3,150.44
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$19,480.40
Rate for Payer: Priority Health Medicare	$6,023.79
Rate for Payer: Priority Health Tiered Network	$15,584.32
Rate for Payer: Railroad Medicare Medicare	$6,023.79
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$6,023.79
Rate for Payer: UHC Medicaid	$3,150.44
Rate for Payer: UHCCP Medicaid	$3,150.44
Rate for Payer: VA VA	$6,023.79

UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN

Facility

$19,480.40

Service Code	CPT 38129
Hospital Revenue Code	360
Min. Negotiated Rate	$2,883.05
Max. Negotiated Rate	$19,480.40
Rate for Payer: Aetna Medicare	$6,264.74
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,529.74
Rate for Payer: Amish Plain Church Group Commercial	$7,529.74
Rate for Payer: BCBS Complete	$3,308.27
Rate for Payer: BCBS MAPPO	$6,023.79
Rate for Payer: BCBS Trust/PPO	$2,883.05
Rate for Payer: BCN Commercial	$2,883.05
Rate for Payer: BCN Medicare Advantage	$6,023.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,023.79
Rate for Payer: Mclaren Medicaid	$3,150.44
Rate for Payer: Mclaren Medicare	$6,023.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,324.98
Rate for Payer: Meridian Medicaid	$6,324.98
Rate for Payer: MI Amish Medical Board Commercial	$6,927.36
Rate for Payer: Molina Medicare/Medicaid	$6,626.17
Rate for Payer: Nomi Health Commercial	$18,071.37
Rate for Payer: PACE Medicare	$5,722.60
Rate for Payer: PACE SWMI	$6,023.79
Rate for Payer: PHP Medicare Advantage	$6,023.79
Rate for Payer: Priority Health Choice Medicaid	$3,150.44
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$19,480.40
Rate for Payer: Priority Health Medicare	$6,023.79
Rate for Payer: Priority Health Tiered Network	$15,584.32
Rate for Payer: Railroad Medicare Medicare	$6,023.79
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$6,023.79
Rate for Payer: UHC Medicaid	$3,150.44
Rate for Payer: UHCCP Medicaid	$3,150.44
Rate for Payer: VA VA	$6,023.79

UNLISTED PROCEDURE, ARTHROSCOPY

Facility

$794.84

Service Code	CPT 29999
Hospital Revenue Code	360
Min. Negotiated Rate	$128.54
Max. Negotiated Rate	$794.84
Rate for Payer: Aetna Medicare	$255.61
Rate for Payer: Allen County Amish Medical Aid Commercial	$307.23
Rate for Payer: Amish Plain Church Group Commercial	$307.23
Rate for Payer: BCBS Complete	$134.98
Rate for Payer: BCBS MAPPO	$245.78
Rate for Payer: BCBS Trust/PPO	$428.01
Rate for Payer: BCN Commercial	$428.01
Rate for Payer: BCN Medicare Advantage	$245.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$245.78
Rate for Payer: Mclaren Medicaid	$128.54
Rate for Payer: Mclaren Medicare	$245.78
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$258.07
Rate for Payer: Meridian Medicaid	$258.07
Rate for Payer: MI Amish Medical Board Commercial	$282.65
Rate for Payer: Molina Medicare/Medicaid	$270.36
Rate for Payer: Nomi Health Commercial	$737.34
Rate for Payer: PACE Medicare	$233.49
Rate for Payer: PACE SWMI	$245.78
Rate for Payer: PHP Medicare Advantage	$245.78
Rate for Payer: Priority Health Choice Medicaid	$128.54
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$794.84
Rate for Payer: Priority Health Medicare	$245.78
Rate for Payer: Priority Health Tiered Network	$635.87
Rate for Payer: Railroad Medicare Medicare	$245.78
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$245.78
Rate for Payer: UHC Medicaid	$128.54
Rate for Payer: UHCCP Medicaid	$128.54
Rate for Payer: VA VA	$245.78

UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES

Facility

$1,320.17

Service Code	CPT 41899
Hospital Revenue Code	361
Min. Negotiated Rate	$123.43
Max. Negotiated Rate	$1,320.17
Rate for Payer: Aetna Medicare	$245.44
Rate for Payer: Allen County Amish Medical Aid Commercial	$295.00
Rate for Payer: Amish Plain Church Group Commercial	$295.00
Rate for Payer: BCBS Complete	$129.61
Rate for Payer: BCBS MAPPO	$236.00
Rate for Payer: BCBS Trust/PPO	$1,320.17
Rate for Payer: BCN Commercial	$1,320.17
Rate for Payer: BCN Medicare Advantage	$236.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$236.00
Rate for Payer: Mclaren Medicaid	$123.43
Rate for Payer: Mclaren Medicare	$236.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$247.80
Rate for Payer: Meridian Medicaid	$247.80
Rate for Payer: MI Amish Medical Board Commercial	$271.40
Rate for Payer: Molina Medicare/Medicaid	$259.60
Rate for Payer: Nomi Health Commercial	$708.00
Rate for Payer: PACE Medicare	$224.20
Rate for Payer: PACE SWMI	$236.00
Rate for Payer: PHP Medicare Advantage	$236.00
Rate for Payer: Priority Health Choice Medicaid	$123.43
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$763.21
Rate for Payer: Priority Health Medicare	$236.00
Rate for Payer: Priority Health Tiered Network	$610.57
Rate for Payer: Railroad Medicare Medicare	$236.00
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$236.00
Rate for Payer: UHC Medicaid	$123.43
Rate for Payer: UHCCP Medicaid	$123.43
Rate for Payer: VA VA	$236.00

UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL)

Facility

$651.46

Service Code	CPT 58999
Hospital Revenue Code	360
Min. Negotiated Rate	$104.50
Max. Negotiated Rate	$651.46
Rate for Payer: Aetna Medicare	$209.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$251.80
Rate for Payer: Amish Plain Church Group Commercial	$251.80
Rate for Payer: BCBS Complete	$110.63
Rate for Payer: BCBS MAPPO	$201.44
Rate for Payer: BCBS Trust/PPO	$104.50
Rate for Payer: BCN Commercial	$104.50
Rate for Payer: BCN Medicare Advantage	$201.44
Rate for Payer: Health Alliance Plan Medicare Advantage	$201.44
Rate for Payer: Mclaren Medicaid	$105.35
Rate for Payer: Mclaren Medicare	$201.44
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$211.51
Rate for Payer: Meridian Medicaid	$211.51
Rate for Payer: MI Amish Medical Board Commercial	$231.66
Rate for Payer: Molina Medicare/Medicaid	$221.58
Rate for Payer: Nomi Health Commercial	$604.32
Rate for Payer: PACE Medicare	$191.37
Rate for Payer: PACE SWMI	$201.44
Rate for Payer: PHP Medicare Advantage	$201.44
Rate for Payer: Priority Health Choice Medicaid	$105.35
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$651.46
Rate for Payer: Priority Health Medicare	$201.44
Rate for Payer: Priority Health Tiered Network	$521.17
Rate for Payer: Railroad Medicare Medicare	$201.44
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$201.44
Rate for Payer: UHC Medicaid	$105.35
Rate for Payer: UHCCP Medicaid	$105.35
Rate for Payer: VA VA	$201.44

UNLISTED PROCEDURE, FEMUR OR KNEE

Facility

$794.84

Service Code	CPT 27599
Hospital Revenue Code	360
Min. Negotiated Rate	$128.54
Max. Negotiated Rate	$794.84
Rate for Payer: Aetna Medicare	$255.61
Rate for Payer: Allen County Amish Medical Aid Commercial	$307.23
Rate for Payer: Amish Plain Church Group Commercial	$307.23
Rate for Payer: BCBS Complete	$134.98
Rate for Payer: BCBS MAPPO	$245.78
Rate for Payer: BCBS Trust/PPO	$137.20
Rate for Payer: BCN Commercial	$137.20
Rate for Payer: BCN Medicare Advantage	$245.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$245.78
Rate for Payer: Mclaren Medicaid	$128.54
Rate for Payer: Mclaren Medicare	$245.78
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$258.07
Rate for Payer: Meridian Medicaid	$258.07
Rate for Payer: MI Amish Medical Board Commercial	$282.65
Rate for Payer: Molina Medicare/Medicaid	$270.36
Rate for Payer: Nomi Health Commercial	$737.34
Rate for Payer: PACE Medicare	$233.49
Rate for Payer: PACE SWMI	$245.78
Rate for Payer: PHP Medicare Advantage	$245.78
Rate for Payer: Priority Health Choice Medicaid	$128.54
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$794.84
Rate for Payer: Priority Health Medicare	$245.78
Rate for Payer: Priority Health Tiered Network	$635.87
Rate for Payer: Railroad Medicare Medicare	$245.78
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$245.78
Rate for Payer: UHC Medicaid	$128.54
Rate for Payer: UHCCP Medicaid	$128.54
Rate for Payer: VA VA	$245.78

UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL

Facility

$794.84

Service Code	CPT 20999
Hospital Revenue Code	360
Min. Negotiated Rate	$128.54
Max. Negotiated Rate	$794.84
Rate for Payer: Aetna Medicare	$255.61
Rate for Payer: Allen County Amish Medical Aid Commercial	$307.23
Rate for Payer: Amish Plain Church Group Commercial	$307.23
Rate for Payer: BCBS Complete	$134.98
Rate for Payer: BCBS MAPPO	$245.78
Rate for Payer: BCBS Trust/PPO	$137.20
Rate for Payer: BCN Commercial	$137.20
Rate for Payer: BCN Medicare Advantage	$245.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$245.78
Rate for Payer: Mclaren Medicaid	$128.54
Rate for Payer: Mclaren Medicare	$245.78
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$258.07
Rate for Payer: Meridian Medicaid	$258.07
Rate for Payer: MI Amish Medical Board Commercial	$282.65
Rate for Payer: Molina Medicare/Medicaid	$270.36
Rate for Payer: Nomi Health Commercial	$737.34
Rate for Payer: PACE Medicare	$233.49
Rate for Payer: PACE SWMI	$245.78
Rate for Payer: PHP Medicare Advantage	$245.78
Rate for Payer: Priority Health Choice Medicaid	$128.54
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$794.84
Rate for Payer: Priority Health Medicare	$245.78
Rate for Payer: Priority Health Tiered Network	$635.87
Rate for Payer: Railroad Medicare Medicare	$245.78
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$245.78
Rate for Payer: UHC Medicaid	$128.54
Rate for Payer: UHCCP Medicaid	$128.54
Rate for Payer: VA VA	$245.78

UNLISTED PROCEDURE, NERVOUS SYSTEM

Facility

$989.08

Service Code	CPT 64999
Hospital Revenue Code	360
Min. Negotiated Rate	$158.59
Max. Negotiated Rate	$989.08
Rate for Payer: Aetna Medicare	$318.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$382.31
Rate for Payer: Amish Plain Church Group Commercial	$382.31
Rate for Payer: BCBS Complete	$167.97
Rate for Payer: BCBS MAPPO	$305.85
Rate for Payer: BCBS Trust/PPO	$158.59
Rate for Payer: BCN Commercial	$158.59
Rate for Payer: BCN Medicare Advantage	$305.85
Rate for Payer: Health Alliance Plan Medicare Advantage	$305.85
Rate for Payer: Mclaren Medicaid	$159.96
Rate for Payer: Mclaren Medicare	$305.85
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$321.14
Rate for Payer: Meridian Medicaid	$321.14
Rate for Payer: MI Amish Medical Board Commercial	$351.73
Rate for Payer: Molina Medicare/Medicaid	$336.44
Rate for Payer: Nomi Health Commercial	$917.55
Rate for Payer: PACE Medicare	$290.56
Rate for Payer: PACE SWMI	$305.85
Rate for Payer: PHP Medicare Advantage	$305.85
Rate for Payer: Priority Health Choice Medicaid	$159.96
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$989.08
Rate for Payer: Priority Health Medicare	$305.85
Rate for Payer: Priority Health Tiered Network	$791.26
Rate for Payer: Railroad Medicare Medicare	$305.85
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$305.85
Rate for Payer: UHC Medicaid	$159.96
Rate for Payer: UHCCP Medicaid	$159.96
Rate for Payer: VA VA	$305.85

Know your out-of-pocket cost for care.

All Charges