Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC GRAFIX PRIME 1.5 X 2 PER SQ CM

Facility

$762.97

Service Code	HCPCS Q4133
Hospital Charge Code	63600159
Hospital Revenue Code	636
Min. Negotiated Rate	$480.67
Max. Negotiated Rate	$686.67
Rate for Payer: Aetna Commercial	$648.52
Rate for Payer: Aetna New Business (MI Preferred)	$495.93
Rate for Payer: Cash Price	$610.38
Rate for Payer: Cofinity Commercial	$534.08
Rate for Payer: Cofinity Commercial	$656.15
Rate for Payer: Cofinity Medicare Advantage	$534.08
Rate for Payer: Encore Health Key Benefits Commercial	$610.38
Rate for Payer: Healthscope Commercial	$686.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$648.52
Rate for Payer: PHP Commercial	$648.52
Rate for Payer: Priority Health Cigna Priority Health	$495.93
Rate for Payer: Priority Health SBD	$480.67

HC GRAFIX PRIME (16 MM) DISC PER SQ CM

Facility

$772.50

Service Code	HCPCS Q4133
Hospital Charge Code	63600158
Hospital Revenue Code	636
Min. Negotiated Rate	$486.68
Max. Negotiated Rate	$695.25
Rate for Payer: Aetna Commercial	$656.62
Rate for Payer: Aetna New Business (MI Preferred)	$502.12
Rate for Payer: Cash Price	$618.00
Rate for Payer: Cofinity Commercial	$540.75
Rate for Payer: Cofinity Commercial	$664.35
Rate for Payer: Cofinity Medicare Advantage	$540.75
Rate for Payer: Encore Health Key Benefits Commercial	$618.00
Rate for Payer: Healthscope Commercial	$695.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$656.62
Rate for Payer: PHP Commercial	$656.62
Rate for Payer: Priority Health Cigna Priority Health	$502.12
Rate for Payer: Priority Health SBD	$486.68

HC GRAFIX PRIME (16 MM) DISC PER SQ CM

Facility

$772.50

Service Code	HCPCS Q4133
Hospital Charge Code	63600158
Hospital Revenue Code	636
Min. Negotiated Rate	$309.00
Max. Negotiated Rate	$695.25
Rate for Payer: Aetna Commercial	$656.62
Rate for Payer: Aetna Medicare	$386.25
Rate for Payer: Aetna New Business (MI Preferred)	$502.12
Rate for Payer: BCBS Complete	$309.00
Rate for Payer: Cash Price	$618.00
Rate for Payer: Cofinity Commercial	$540.75
Rate for Payer: Cofinity Commercial	$664.35
Rate for Payer: Cofinity Medicare Advantage	$540.75
Rate for Payer: Encore Health Key Benefits Commercial	$618.00
Rate for Payer: Healthscope Commercial	$695.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$656.62
Rate for Payer: PHP Commercial	$656.62
Rate for Payer: Priority Health Cigna Priority Health	$502.12
Rate for Payer: Priority Health SBD	$486.68

HC GRAFIX PRIME 2 X 3 PER SQ CM

Facility

$476.86

Service Code	HCPCS Q4133
Hospital Charge Code	63600160
Hospital Revenue Code	636
Min. Negotiated Rate	$300.42
Max. Negotiated Rate	$429.17
Rate for Payer: Aetna Commercial	$405.33
Rate for Payer: Aetna New Business (MI Preferred)	$309.96
Rate for Payer: Cash Price	$381.49
Rate for Payer: Cofinity Commercial	$333.80
Rate for Payer: Cofinity Commercial	$410.10
Rate for Payer: Cofinity Medicare Advantage	$333.80
Rate for Payer: Encore Health Key Benefits Commercial	$381.49
Rate for Payer: Healthscope Commercial	$429.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$405.33
Rate for Payer: PHP Commercial	$405.33
Rate for Payer: Priority Health Cigna Priority Health	$309.96
Rate for Payer: Priority Health SBD	$300.42

HC GRAFIX PRIME 2 X 3 PER SQ CM

Facility

$476.86

Service Code	HCPCS Q4133
Hospital Charge Code	63600160
Hospital Revenue Code	636
Min. Negotiated Rate	$190.74
Max. Negotiated Rate	$429.17
Rate for Payer: Aetna Commercial	$405.33
Rate for Payer: Aetna Medicare	$238.43
Rate for Payer: Aetna New Business (MI Preferred)	$309.96
Rate for Payer: BCBS Complete	$190.74
Rate for Payer: Cash Price	$381.49
Rate for Payer: Cofinity Commercial	$333.80
Rate for Payer: Cofinity Commercial	$410.10
Rate for Payer: Cofinity Medicare Advantage	$333.80
Rate for Payer: Encore Health Key Benefits Commercial	$381.49
Rate for Payer: Healthscope Commercial	$429.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$405.33
Rate for Payer: PHP Commercial	$405.33
Rate for Payer: Priority Health Cigna Priority Health	$309.96
Rate for Payer: Priority Health SBD	$300.42

HC GRAFIX PRIME 3 X 3 PER SQ CM

Facility

$336.46

Service Code	HCPCS Q4133
Hospital Charge Code	63600244
Hospital Revenue Code	636
Min. Negotiated Rate	$134.58
Max. Negotiated Rate	$302.81
Rate for Payer: Aetna Commercial	$285.99
Rate for Payer: Aetna Medicare	$168.23
Rate for Payer: Aetna New Business (MI Preferred)	$218.70
Rate for Payer: BCBS Complete	$134.58
Rate for Payer: Cash Price	$269.17
Rate for Payer: Cofinity Commercial	$235.52
Rate for Payer: Cofinity Commercial	$289.36
Rate for Payer: Cofinity Medicare Advantage	$235.52
Rate for Payer: Encore Health Key Benefits Commercial	$269.17
Rate for Payer: Healthscope Commercial	$302.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$285.99
Rate for Payer: PHP Commercial	$285.99
Rate for Payer: Priority Health Cigna Priority Health	$218.70
Rate for Payer: Priority Health SBD	$211.97

HC GRAFIX PRIME 3 X 3 PER SQ CM

Facility

$336.46

Service Code	HCPCS Q4133
Hospital Charge Code	63600244
Hospital Revenue Code	636
Min. Negotiated Rate	$211.97
Max. Negotiated Rate	$302.81
Rate for Payer: Aetna Commercial	$285.99
Rate for Payer: Aetna New Business (MI Preferred)	$218.70
Rate for Payer: Cash Price	$269.17
Rate for Payer: Cofinity Commercial	$235.52
Rate for Payer: Cofinity Commercial	$289.36
Rate for Payer: Cofinity Medicare Advantage	$235.52
Rate for Payer: Encore Health Key Benefits Commercial	$269.17
Rate for Payer: Healthscope Commercial	$302.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$285.99
Rate for Payer: PHP Commercial	$285.99
Rate for Payer: Priority Health Cigna Priority Health	$218.70
Rate for Payer: Priority Health SBD	$211.97

HC GRAFIX PRIME 3 X 4 PER SQ CM

Facility

$277.98

Service Code	HCPCS Q4133
Hospital Charge Code	63600161
Hospital Revenue Code	636
Min. Negotiated Rate	$175.13
Max. Negotiated Rate	$250.18
Rate for Payer: Aetna Commercial	$236.28
Rate for Payer: Aetna New Business (MI Preferred)	$180.69
Rate for Payer: Cash Price	$222.38
Rate for Payer: Cofinity Commercial	$194.59
Rate for Payer: Cofinity Commercial	$239.06
Rate for Payer: Cofinity Medicare Advantage	$194.59
Rate for Payer: Encore Health Key Benefits Commercial	$222.38
Rate for Payer: Healthscope Commercial	$250.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$236.28
Rate for Payer: PHP Commercial	$236.28
Rate for Payer: Priority Health Cigna Priority Health	$180.69
Rate for Payer: Priority Health SBD	$175.13

HC GRAFIX PRIME 3 X 4 PER SQ CM

Facility

$277.98

Service Code	HCPCS Q4133
Hospital Charge Code	63600161
Hospital Revenue Code	636
Min. Negotiated Rate	$111.19
Max. Negotiated Rate	$250.18
Rate for Payer: Aetna Commercial	$236.28
Rate for Payer: Aetna Medicare	$138.99
Rate for Payer: Aetna New Business (MI Preferred)	$180.69
Rate for Payer: BCBS Complete	$111.19
Rate for Payer: Cash Price	$222.38
Rate for Payer: Cofinity Commercial	$194.59
Rate for Payer: Cofinity Commercial	$239.06
Rate for Payer: Cofinity Medicare Advantage	$194.59
Rate for Payer: Encore Health Key Benefits Commercial	$222.38
Rate for Payer: Healthscope Commercial	$250.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$236.28
Rate for Payer: PHP Commercial	$236.28
Rate for Payer: Priority Health Cigna Priority Health	$180.69
Rate for Payer: Priority Health SBD	$175.13

HC GRAFT EPIDERMAL 1ST 100 SQ CM FEET, HANDS, FACE

Facility

$2,458.78

Service Code	CPT 15115
Hospital Charge Code	76100067
Hospital Revenue Code	761
Min. Negotiated Rate	$956.23
Max. Negotiated Rate	$5,021.81
Rate for Payer: Aetna Commercial	$2,089.96
Rate for Payer: Aetna Medicare	$1,855.37
Rate for Payer: Aetna New Business (MI Preferred)	$1,598.21
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,230.01
Rate for Payer: Amish Plain Church Group Commercial	$2,230.01
Rate for Payer: BCBS Complete	$1,004.04
Rate for Payer: BCBS MAPPO	$1,784.01
Rate for Payer: BCN Medicare Advantage	$1,784.01
Rate for Payer: Cash Price	$1,967.02
Rate for Payer: Cash Price	$1,967.02
Rate for Payer: Cofinity Commercial	$2,114.55
Rate for Payer: Cofinity Commercial	$1,721.15
Rate for Payer: Cofinity Medicare Advantage	$1,721.15
Rate for Payer: Encore Health Key Benefits Commercial	$1,967.02
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,784.01
Rate for Payer: Healthscope Commercial	$2,212.90
Rate for Payer: Mclaren Medicaid	$956.23
Rate for Payer: Mclaren Medicare	$1,784.01
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,873.21
Rate for Payer: Meridian Medicaid	$1,004.04
Rate for Payer: MI Amish Medical Board Commercial	$2,051.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,089.96
Rate for Payer: PACE Medicare	$1,694.81
Rate for Payer: PACE SWMI	$1,784.01
Rate for Payer: PHP Commercial	$2,089.96
Rate for Payer: PHP Medicare Advantage	$1,784.01
Rate for Payer: Priority Health Choice Medicaid	$956.23
Rate for Payer: Priority Health Cigna Priority Health	$1,598.21
Rate for Payer: Priority Health Medicare	$1,784.01
Rate for Payer: Priority Health SBD	$1,549.03
Rate for Payer: Railroad Medicare Medicare	$1,784.01
Rate for Payer: UHC All Payor (Choice/PPO)	$5,021.81
Rate for Payer: UHC Dual Complete DSNP	$1,784.01
Rate for Payer: UHC Medicare Advantage	$1,784.01
Rate for Payer: UHCCP Medicaid	$1,004.40
Rate for Payer: VA VA	$1,784.01

HC GRAFT EPIDERMAL 1ST 100 SQ CM FEET, HANDS, FACE

Facility

$2,458.78

Service Code	CPT 15115
Hospital Charge Code	76100067
Hospital Revenue Code	761
Min. Negotiated Rate	$1,549.03
Max. Negotiated Rate	$2,212.90
Rate for Payer: Aetna Commercial	$2,089.96
Rate for Payer: Aetna New Business (MI Preferred)	$1,598.21
Rate for Payer: Cash Price	$1,967.02
Rate for Payer: Cofinity Commercial	$1,721.15
Rate for Payer: Cofinity Commercial	$2,114.55
Rate for Payer: Cofinity Medicare Advantage	$1,721.15
Rate for Payer: Encore Health Key Benefits Commercial	$1,967.02
Rate for Payer: Healthscope Commercial	$2,212.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,089.96
Rate for Payer: PHP Commercial	$2,089.96
Rate for Payer: Priority Health Cigna Priority Health	$1,598.21
Rate for Payer: Priority Health SBD	$1,549.03

HC GRAFT EPIDERMAL 1ST 100 SQ CM LEGS, ARMS, TRUNK

Facility

$3,219.34

Service Code	CPT 15110
Hospital Charge Code	76100066
Hospital Revenue Code	761
Min. Negotiated Rate	$2,028.18
Max. Negotiated Rate	$2,897.41
Rate for Payer: Aetna Commercial	$2,736.44
Rate for Payer: Aetna New Business (MI Preferred)	$2,092.57
Rate for Payer: Cash Price	$2,575.47
Rate for Payer: Cofinity Commercial	$2,253.54
Rate for Payer: Cofinity Commercial	$2,768.63
Rate for Payer: Cofinity Medicare Advantage	$2,253.54
Rate for Payer: Encore Health Key Benefits Commercial	$2,575.47
Rate for Payer: Healthscope Commercial	$2,897.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,736.44
Rate for Payer: PHP Commercial	$2,736.44
Rate for Payer: Priority Health Cigna Priority Health	$2,092.57
Rate for Payer: Priority Health SBD	$2,028.18

HC GRAFT EPIDERMAL 1ST 100 SQ CM LEGS, ARMS, TRUNK

Facility

$3,219.34

Service Code	CPT 15110
Hospital Charge Code	76100066
Hospital Revenue Code	761
Min. Negotiated Rate	$956.23
Max. Negotiated Rate	$5,021.81
Rate for Payer: Aetna Commercial	$2,736.44
Rate for Payer: Aetna Medicare	$1,855.37
Rate for Payer: Aetna New Business (MI Preferred)	$2,092.57
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,230.01
Rate for Payer: Amish Plain Church Group Commercial	$2,230.01
Rate for Payer: BCBS Complete	$1,004.04
Rate for Payer: BCBS MAPPO	$1,784.01
Rate for Payer: BCN Medicare Advantage	$1,784.01
Rate for Payer: Cash Price	$2,575.47
Rate for Payer: Cash Price	$2,575.47
Rate for Payer: Cofinity Commercial	$2,253.54
Rate for Payer: Cofinity Commercial	$2,768.63
Rate for Payer: Cofinity Medicare Advantage	$2,253.54
Rate for Payer: Encore Health Key Benefits Commercial	$2,575.47
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,784.01
Rate for Payer: Healthscope Commercial	$2,897.41
Rate for Payer: Mclaren Medicaid	$956.23
Rate for Payer: Mclaren Medicare	$1,784.01
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,873.21
Rate for Payer: Meridian Medicaid	$1,004.04
Rate for Payer: MI Amish Medical Board Commercial	$2,051.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,736.44
Rate for Payer: PACE Medicare	$1,694.81
Rate for Payer: PACE SWMI	$1,784.01
Rate for Payer: PHP Commercial	$2,736.44
Rate for Payer: PHP Medicare Advantage	$1,784.01
Rate for Payer: Priority Health Choice Medicaid	$956.23
Rate for Payer: Priority Health Cigna Priority Health	$2,092.57
Rate for Payer: Priority Health Medicare	$1,784.01
Rate for Payer: Priority Health SBD	$2,028.18
Rate for Payer: Railroad Medicare Medicare	$1,784.01
Rate for Payer: UHC All Payor (Choice/PPO)	$5,021.81
Rate for Payer: UHC Dual Complete DSNP	$1,784.01
Rate for Payer: UHC Medicare Advantage	$1,784.01
Rate for Payer: UHCCP Medicaid	$1,004.40
Rate for Payer: VA VA	$1,784.01

HC GRAM STAIN

Facility

$51.31

Service Code	CPT 87205
Hospital Charge Code	30600104
Hospital Revenue Code	306
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$46.18
Rate for Payer: Aetna Commercial	$43.61
Rate for Payer: Aetna Medicare	$4.44
Rate for Payer: Aetna New Business (MI Preferred)	$33.35
Rate for Payer: Allen County Amish Medical Aid Commercial	$5.34
Rate for Payer: Amish Plain Church Group Commercial	$5.34
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: BCBS MAPPO	$4.27
Rate for Payer: BCN Medicare Advantage	$4.27
Rate for Payer: Cash Price	$41.05
Rate for Payer: Cash Price	$41.05
Rate for Payer: Cofinity Commercial	$44.13
Rate for Payer: Cofinity Commercial	$35.92
Rate for Payer: Cofinity Medicare Advantage	$35.92
Rate for Payer: Encore Health Key Benefits Commercial	$41.05
Rate for Payer: Health Alliance Plan Medicare Advantage	$4.27
Rate for Payer: Healthscope Commercial	$46.18
Rate for Payer: Mclaren Medicaid	$2.29
Rate for Payer: Mclaren Medicare	$4.27
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$4.48
Rate for Payer: Meridian Medicaid	$2.40
Rate for Payer: MI Amish Medical Board Commercial	$4.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.61
Rate for Payer: PACE Medicare	$4.06
Rate for Payer: PACE SWMI	$4.27
Rate for Payer: PHP Commercial	$43.61
Rate for Payer: PHP Medicare Advantage	$4.27
Rate for Payer: Priority Health Choice Medicaid	$2.29
Rate for Payer: Priority Health Cigna Priority Health	$33.35
Rate for Payer: Priority Health Medicare	$4.27
Rate for Payer: Priority Health SBD	$32.33
Rate for Payer: Railroad Medicare Medicare	$4.27
Rate for Payer: UHC All Payor (Choice/PPO)	$12.02
Rate for Payer: UHC Dual Complete DSNP	$4.27
Rate for Payer: UHC Medicare Advantage	$4.27
Rate for Payer: UHCCP Medicaid	$2.40
Rate for Payer: VA VA	$4.27

HC GRAM STAIN

Facility

$51.31

Service Code	CPT 87205
Hospital Charge Code	30600104
Hospital Revenue Code	306
Min. Negotiated Rate	$32.33
Max. Negotiated Rate	$46.18
Rate for Payer: Aetna Commercial	$43.61
Rate for Payer: Aetna New Business (MI Preferred)	$33.35
Rate for Payer: Cash Price	$41.05
Rate for Payer: Cofinity Commercial	$35.92
Rate for Payer: Cofinity Commercial	$44.13
Rate for Payer: Cofinity Medicare Advantage	$35.92
Rate for Payer: Encore Health Key Benefits Commercial	$41.05
Rate for Payer: Healthscope Commercial	$46.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$43.61
Rate for Payer: PHP Commercial	$43.61
Rate for Payer: Priority Health Cigna Priority Health	$33.35
Rate for Payer: Priority Health SBD	$32.33

HC GRANULOCYTES

Facility

$1,925.76

Service Code	HCPCS P9050
Hospital Charge Code	39000057
Hospital Revenue Code	390
Min. Negotiated Rate	$1,213.23
Max. Negotiated Rate	$1,733.18
Rate for Payer: Aetna Commercial	$1,636.90
Rate for Payer: Aetna New Business (MI Preferred)	$1,251.74
Rate for Payer: Cash Price	$1,540.61
Rate for Payer: Cofinity Commercial	$1,348.03
Rate for Payer: Cofinity Commercial	$1,656.15
Rate for Payer: Cofinity Medicare Advantage	$1,348.03
Rate for Payer: Encore Health Key Benefits Commercial	$1,540.61
Rate for Payer: Healthscope Commercial	$1,733.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,636.90
Rate for Payer: PHP Commercial	$1,636.90
Rate for Payer: Priority Health Cigna Priority Health	$1,251.74
Rate for Payer: Priority Health SBD	$1,213.23

HC GRANULOCYTES

Facility

$1,925.76

Service Code	HCPCS P9050
Hospital Charge Code	39000057
Hospital Revenue Code	390
Min. Negotiated Rate	$770.30
Max. Negotiated Rate	$1,733.18
Rate for Payer: Aetna Commercial	$1,636.90
Rate for Payer: Aetna Medicare	$962.88
Rate for Payer: Aetna New Business (MI Preferred)	$1,251.74
Rate for Payer: BCBS Complete	$770.30
Rate for Payer: Cash Price	$1,540.61
Rate for Payer: Cofinity Commercial	$1,348.03
Rate for Payer: Cofinity Commercial	$1,656.15
Rate for Payer: Cofinity Medicare Advantage	$1,348.03
Rate for Payer: Encore Health Key Benefits Commercial	$1,540.61
Rate for Payer: Healthscope Commercial	$1,733.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,636.90
Rate for Payer: PHP Commercial	$1,636.90
Rate for Payer: Priority Health Cigna Priority Health	$1,251.74
Rate for Payer: Priority Health SBD	$1,213.23
Rate for Payer: UHC Core	$1,425.06
Rate for Payer: UHC Exchange	$1,425.06

HC GRASS ALLERGEN PANEL

Facility

$25.39

Service Code	CPT 86003
Hospital Charge Code	30200122
Hospital Revenue Code	302
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$22.85
Rate for Payer: Aetna Commercial	$21.58
Rate for Payer: Aetna Medicare	$5.43
Rate for Payer: Aetna New Business (MI Preferred)	$16.50
Rate for Payer: Allen County Amish Medical Aid Commercial	$6.53
Rate for Payer: Amish Plain Church Group Commercial	$6.53
Rate for Payer: BCBS Complete	$2.94
Rate for Payer: BCBS MAPPO	$5.22
Rate for Payer: BCN Medicare Advantage	$5.22
Rate for Payer: Cash Price	$20.31
Rate for Payer: Cash Price	$20.31
Rate for Payer: Cofinity Commercial	$21.84
Rate for Payer: Cofinity Commercial	$17.77
Rate for Payer: Cofinity Medicare Advantage	$17.77
Rate for Payer: Encore Health Key Benefits Commercial	$20.31
Rate for Payer: Health Alliance Plan Medicare Advantage	$5.22
Rate for Payer: Healthscope Commercial	$22.85
Rate for Payer: Mclaren Medicaid	$2.80
Rate for Payer: Mclaren Medicare	$5.22
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5.48
Rate for Payer: Meridian Medicaid	$2.94
Rate for Payer: MI Amish Medical Board Commercial	$6.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.58
Rate for Payer: PACE Medicare	$4.96
Rate for Payer: PACE SWMI	$5.22
Rate for Payer: PHP Commercial	$21.58
Rate for Payer: PHP Medicare Advantage	$5.22
Rate for Payer: Priority Health Choice Medicaid	$2.80
Rate for Payer: Priority Health Cigna Priority Health	$16.50
Rate for Payer: Priority Health Medicare	$5.22
Rate for Payer: Priority Health SBD	$16.00
Rate for Payer: Railroad Medicare Medicare	$5.22
Rate for Payer: UHC All Payor (Choice/PPO)	$14.69
Rate for Payer: UHC Dual Complete DSNP	$5.22
Rate for Payer: UHC Medicare Advantage	$5.22
Rate for Payer: UHCCP Medicaid	$2.94
Rate for Payer: VA VA	$5.22

HC GRASS ALLERGEN PANEL

Facility

$25.39

Service Code	CPT 86003
Hospital Charge Code	30200122
Hospital Revenue Code	302
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$22.85
Rate for Payer: Aetna Commercial	$21.58
Rate for Payer: Aetna New Business (MI Preferred)	$16.50
Rate for Payer: Cash Price	$20.31
Rate for Payer: Cofinity Commercial	$17.77
Rate for Payer: Cofinity Commercial	$21.84
Rate for Payer: Cofinity Medicare Advantage	$17.77
Rate for Payer: Encore Health Key Benefits Commercial	$20.31
Rate for Payer: Healthscope Commercial	$22.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.58
Rate for Payer: PHP Commercial	$21.58
Rate for Payer: Priority Health Cigna Priority Health	$16.50
Rate for Payer: Priority Health SBD	$16.00

HC GREAT LAKES DISABILITY FILM(EACH)

Facility

$20.00

Hospital Charge Code	32000267
Hospital Revenue Code	320
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.00
Rate for Payer: Aetna Medicare	$10.00
Rate for Payer: Aetna New Business (MI Preferred)	$13.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$14.00
Rate for Payer: Cofinity Commercial	$17.20
Rate for Payer: Cofinity Medicare Advantage	$14.00
Rate for Payer: Encore Health Key Benefits Commercial	$16.00
Rate for Payer: Healthscope Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.00
Rate for Payer: PHP Commercial	$17.00
Rate for Payer: Priority Health Cigna Priority Health	$13.00
Rate for Payer: Priority Health SBD	$12.60
Rate for Payer: UHC Core	$14.80
Rate for Payer: UHC Exchange	$14.80

HC GREAT LAKES DISABILITY FILM(EACH)

Facility

$20.00

Hospital Charge Code	32000267
Hospital Revenue Code	320
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.00
Rate for Payer: Aetna New Business (MI Preferred)	$13.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$14.00
Rate for Payer: Cofinity Commercial	$17.20
Rate for Payer: Cofinity Medicare Advantage	$14.00
Rate for Payer: Encore Health Key Benefits Commercial	$16.00
Rate for Payer: Healthscope Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.00
Rate for Payer: PHP Commercial	$17.00
Rate for Payer: Priority Health Cigna Priority Health	$13.00
Rate for Payer: Priority Health SBD	$12.60

HC GROIN/PSEUDO IMAGING BILATERAL

Facility

$1,443.73

Service Code	CPT 93925
Hospital Charge Code	92100027
Hospital Revenue Code	921
Min. Negotiated Rate	$909.55
Max. Negotiated Rate	$1,299.36
Rate for Payer: Aetna Commercial	$1,227.17
Rate for Payer: Aetna New Business (MI Preferred)	$938.42
Rate for Payer: Cash Price	$1,154.98
Rate for Payer: Cofinity Commercial	$1,010.61
Rate for Payer: Cofinity Commercial	$1,241.61
Rate for Payer: Cofinity Medicare Advantage	$1,010.61
Rate for Payer: Encore Health Key Benefits Commercial	$1,154.98
Rate for Payer: Healthscope Commercial	$1,299.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,227.17
Rate for Payer: PHP Commercial	$1,227.17
Rate for Payer: Priority Health Cigna Priority Health	$938.42
Rate for Payer: Priority Health SBD	$909.55

HC GROIN/PSEUDO IMAGING BILATERAL

Facility

$1,443.73

Service Code	CPT 93925
Hospital Charge Code	92100027
Hospital Revenue Code	921
Min. Negotiated Rate	$126.36
Max. Negotiated Rate	$1,299.36
Rate for Payer: Aetna Commercial	$1,227.17
Rate for Payer: Aetna Medicare	$245.17
Rate for Payer: Aetna New Business (MI Preferred)	$938.42
Rate for Payer: Allen County Amish Medical Aid Commercial	$294.68
Rate for Payer: Amish Plain Church Group Commercial	$294.68
Rate for Payer: BCBS Complete	$132.67
Rate for Payer: BCBS MAPPO	$235.74
Rate for Payer: BCN Medicare Advantage	$235.74
Rate for Payer: Cash Price	$1,154.98
Rate for Payer: Cash Price	$1,154.98
Rate for Payer: Cofinity Commercial	$1,241.61
Rate for Payer: Cofinity Commercial	$1,010.61
Rate for Payer: Cofinity Medicare Advantage	$1,010.61
Rate for Payer: Encore Health Key Benefits Commercial	$1,154.98
Rate for Payer: Health Alliance Plan Medicare Advantage	$235.74
Rate for Payer: Healthscope Commercial	$1,299.36
Rate for Payer: Mclaren Medicaid	$126.36
Rate for Payer: Mclaren Medicare	$235.74
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$247.53
Rate for Payer: Meridian Medicaid	$132.67
Rate for Payer: MI Amish Medical Board Commercial	$271.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,227.17
Rate for Payer: PACE Medicare	$223.95
Rate for Payer: PACE SWMI	$235.74
Rate for Payer: PHP Commercial	$1,227.17
Rate for Payer: PHP Medicare Advantage	$235.74
Rate for Payer: Priority Health Choice Medicaid	$126.36
Rate for Payer: Priority Health Cigna Priority Health	$938.42
Rate for Payer: Priority Health Medicare	$235.74
Rate for Payer: Priority Health SBD	$909.55
Rate for Payer: Railroad Medicare Medicare	$235.74
Rate for Payer: UHC All Payor (Choice/PPO)	$663.58
Rate for Payer: UHC Core	$1,068.36
Rate for Payer: UHC Dual Complete DSNP	$235.74
Rate for Payer: UHC Exchange	$1,068.36
Rate for Payer: UHC Medicare Advantage	$235.74
Rate for Payer: UHCCP Medicaid	$132.72
Rate for Payer: VA VA	$235.74

HC GROIN/PSEUDO IMAGING (R OR L)

Facility

$922.21

Service Code	CPT 93926
Hospital Charge Code	92100026
Hospital Revenue Code	921
Min. Negotiated Rate	$580.99
Max. Negotiated Rate	$829.99
Rate for Payer: Aetna Commercial	$783.88
Rate for Payer: Aetna New Business (MI Preferred)	$599.44
Rate for Payer: Cash Price	$737.77
Rate for Payer: Cofinity Commercial	$645.55
Rate for Payer: Cofinity Commercial	$793.10
Rate for Payer: Cofinity Medicare Advantage	$645.55
Rate for Payer: Encore Health Key Benefits Commercial	$737.77
Rate for Payer: Healthscope Commercial	$829.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$783.88
Rate for Payer: PHP Commercial	$783.88
Rate for Payer: Priority Health Cigna Priority Health	$599.44
Rate for Payer: Priority Health SBD	$580.99

HC GROIN/PSEUDO IMAGING (R OR L)

Facility

$922.21

Service Code	CPT 93926
Hospital Charge Code	92100026
Hospital Revenue Code	921
Min. Negotiated Rate	$55.59
Max. Negotiated Rate	$829.99
Rate for Payer: Aetna Commercial	$783.88
Rate for Payer: Aetna Medicare	$107.86
Rate for Payer: Aetna New Business (MI Preferred)	$599.44
Rate for Payer: Allen County Amish Medical Aid Commercial	$129.64
Rate for Payer: Amish Plain Church Group Commercial	$129.64
Rate for Payer: BCBS Complete	$58.37
Rate for Payer: BCBS MAPPO	$103.71
Rate for Payer: BCN Medicare Advantage	$103.71
Rate for Payer: Cash Price	$737.77
Rate for Payer: Cash Price	$737.77
Rate for Payer: Cofinity Commercial	$793.10
Rate for Payer: Cofinity Commercial	$645.55
Rate for Payer: Cofinity Medicare Advantage	$645.55
Rate for Payer: Encore Health Key Benefits Commercial	$737.77
Rate for Payer: Health Alliance Plan Medicare Advantage	$103.71
Rate for Payer: Healthscope Commercial	$829.99
Rate for Payer: Mclaren Medicaid	$55.59
Rate for Payer: Mclaren Medicare	$103.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$108.90
Rate for Payer: Meridian Medicaid	$58.37
Rate for Payer: MI Amish Medical Board Commercial	$119.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$783.88
Rate for Payer: PACE Medicare	$98.52
Rate for Payer: PACE SWMI	$103.71
Rate for Payer: PHP Commercial	$783.88
Rate for Payer: PHP Medicare Advantage	$103.71
Rate for Payer: Priority Health Choice Medicaid	$55.59
Rate for Payer: Priority Health Cigna Priority Health	$599.44
Rate for Payer: Priority Health Medicare	$103.71
Rate for Payer: Priority Health SBD	$580.99
Rate for Payer: Railroad Medicare Medicare	$103.71
Rate for Payer: UHC All Payor (Choice/PPO)	$291.93
Rate for Payer: UHC Core	$682.44
Rate for Payer: UHC Dual Complete DSNP	$103.71
Rate for Payer: UHC Exchange	$682.44
Rate for Payer: UHC Medicare Advantage	$103.71
Rate for Payer: UHCCP Medicaid	$58.39
Rate for Payer: VA VA	$103.71

Know your out-of-pocket cost for care.

All Charges