Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC INJECTION, CERTOLIZUMAB PEGOL, 1 MG

Facility

$10.40

Service Code	CPT J0717
Hospital Charge Code	63600090
Hospital Revenue Code	636
Min. Negotiated Rate	$6.55
Max. Negotiated Rate	$9.36
Rate for Payer: Aetna Commercial	$8.84
Rate for Payer: Aetna New Business (MI Preferred)	$6.76
Rate for Payer: Cash Price	$8.32
Rate for Payer: Cofinity Advantage	$7.28
Rate for Payer: Cofinity Commercial	$8.94
Rate for Payer: Encore Health Key Benefits Commercial	$8.32
Rate for Payer: Healthscope Commercial	$9.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.80
Rate for Payer: PHP Commercial	$8.84
Rate for Payer: Priority Health SBD	$6.55

HC INJECTION CERVICAL OR THORACIC

Facility

$1,031.17

Service Code	CPT 62291
Hospital Charge Code	36100283
Hospital Revenue Code	361
Min. Negotiated Rate	$649.64
Max. Negotiated Rate	$928.05
Rate for Payer: Aetna Commercial	$876.49
Rate for Payer: Aetna New Business (MI Preferred)	$670.26
Rate for Payer: Cash Price	$824.94
Rate for Payer: Cofinity Advantage	$721.82
Rate for Payer: Cofinity Commercial	$886.81
Rate for Payer: Encore Health Key Benefits Commercial	$824.94
Rate for Payer: Healthscope Commercial	$928.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$876.49
Rate for Payer: Opus (Opus Packaging Group) HMA	$773.38
Rate for Payer: PHP Commercial	$876.49
Rate for Payer: Priority Health SBD	$649.64

HC INJECTION CERVICAL OR THORACIC

Facility

$1,031.17

Service Code	CPT 62291
Hospital Charge Code	36100283
Hospital Revenue Code	361
Min. Negotiated Rate	$412.47
Max. Negotiated Rate	$928.05
Rate for Payer: Aetna Commercial	$876.49
Rate for Payer: Aetna Medicare	$515.59
Rate for Payer: Aetna New Business (MI Preferred)	$670.26
Rate for Payer: BCBS Complete	$412.47
Rate for Payer: BCBS Trust/PPO	$873.99
Rate for Payer: BCN Commercial	$873.99
Rate for Payer: Cash Price	$824.94
Rate for Payer: Cash Price	$824.94
Rate for Payer: Cofinity Advantage	$721.82
Rate for Payer: Cofinity Commercial	$886.81
Rate for Payer: Encore Health Key Benefits Commercial	$824.94
Rate for Payer: Healthscope Commercial	$928.05
Rate for Payer: MI Amish Medical Board Commercial	$824.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$876.49
Rate for Payer: Opus (Opus Packaging Group) HMA	$773.38
Rate for Payer: PHP Commercial	$876.49
Rate for Payer: Priority Health SBD	$649.64

HC INJECTION CONTRAST FOR TUBE ASSESSMENT

Facility

$1,039.24

Service Code	CPT 49424
Hospital Charge Code	36100223
Hospital Revenue Code	361
Min. Negotiated Rate	$654.72
Max. Negotiated Rate	$935.32
Rate for Payer: Aetna Commercial	$883.35
Rate for Payer: Aetna New Business (MI Preferred)	$675.51
Rate for Payer: Cash Price	$831.39
Rate for Payer: Cofinity Advantage	$727.47
Rate for Payer: Cofinity Commercial	$893.75
Rate for Payer: Encore Health Key Benefits Commercial	$831.39
Rate for Payer: Healthscope Commercial	$935.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$883.35
Rate for Payer: Opus (Opus Packaging Group) HMA	$779.43
Rate for Payer: PHP Commercial	$883.35
Rate for Payer: Priority Health SBD	$654.72

HC INJECTION CONTRAST FOR TUBE ASSESSMENT

Facility

$1,039.24

Service Code	CPT 49424
Hospital Charge Code	36100223
Hospital Revenue Code	361
Min. Negotiated Rate	$232.73
Max. Negotiated Rate	$935.32
Rate for Payer: Aetna Commercial	$883.35
Rate for Payer: Aetna Medicare	$519.62
Rate for Payer: Aetna New Business (MI Preferred)	$675.51
Rate for Payer: BCBS Complete	$415.70
Rate for Payer: BCBS Trust/PPO	$232.73
Rate for Payer: BCN Commercial	$232.73
Rate for Payer: Cash Price	$831.39
Rate for Payer: Cash Price	$831.39
Rate for Payer: Cofinity Advantage	$727.47
Rate for Payer: Cofinity Commercial	$893.75
Rate for Payer: Encore Health Key Benefits Commercial	$831.39
Rate for Payer: Healthscope Commercial	$935.32
Rate for Payer: MI Amish Medical Board Commercial	$831.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$883.35
Rate for Payer: Opus (Opus Packaging Group) HMA	$779.43
Rate for Payer: PHP Commercial	$883.35
Rate for Payer: Priority Health SBD	$654.72

HC INJECTION, DENOSUMAB, 1MG

Facility

$26.01

Service Code	CPT J0897
Hospital Charge Code	63600091
Hospital Revenue Code	636
Min. Negotiated Rate	$15.43
Max. Negotiated Rate	$92.67
Rate for Payer: Aetna Commercial	$22.11
Rate for Payer: Aetna Medicare	$30.69
Rate for Payer: Aetna New Business (MI Preferred)	$16.91
Rate for Payer: Allen County Amish Medical Aid Commercial	$36.89
Rate for Payer: Amish Plain Church Group Commercial	$36.89
Rate for Payer: BCBS Complete	$16.21
Rate for Payer: BCBS MAPPO	$29.51
Rate for Payer: BCBS Trust/PPO	$73.90
Rate for Payer: BCN Commercial	$73.90
Rate for Payer: BCN Medicare Advantage	$29.51
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cofinity Advantage	$18.21
Rate for Payer: Cofinity Commercial	$22.37
Rate for Payer: Encore Health Key Benefits Commercial	$20.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$29.51
Rate for Payer: Healthscope Commercial	$23.41
Rate for Payer: Mclaren Medicaid	$15.43
Rate for Payer: Mclaren Medicare	$29.51
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$30.99
Rate for Payer: Meridian Medicaid	$30.99
Rate for Payer: MI Amish Medical Board Commercial	$33.94
Rate for Payer: Molina Medicare/Medicaid	$32.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.11
Rate for Payer: Nomi Health Commercial	$88.53
Rate for Payer: Opus (Opus Packaging Group) HMA	$19.51
Rate for Payer: PACE Medicare	$28.03
Rate for Payer: PACE SWMI	$29.51
Rate for Payer: PHP Commercial	$22.11
Rate for Payer: PHP Medicare Advantage	$29.51
Rate for Payer: Priority Health Choice Medicaid	$15.43
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$92.67
Rate for Payer: Priority Health Medicare	$29.51
Rate for Payer: Priority Health SBD	$16.39
Rate for Payer: Priority Health Tiered Network	$74.14
Rate for Payer: Railroad Medicare Medicare	$29.51
Rate for Payer: UHC All Payor (Choice/PPO)	$48.61
Rate for Payer: UHC Core	$48.61
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$29.51
Rate for Payer: UHC Exchange	$48.61
Rate for Payer: UHC Medicaid	$15.43
Rate for Payer: UHCCP Medicaid	$15.43
Rate for Payer: VA VA	$29.51

HC INJECTION, DENOSUMAB, 1MG

Facility

$26.01

Service Code	CPT J0897
Hospital Charge Code	63600091
Hospital Revenue Code	636
Min. Negotiated Rate	$16.39
Max. Negotiated Rate	$23.41
Rate for Payer: Aetna Commercial	$22.11
Rate for Payer: Aetna New Business (MI Preferred)	$16.91
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cofinity Advantage	$18.21
Rate for Payer: Cofinity Commercial	$22.37
Rate for Payer: Encore Health Key Benefits Commercial	$20.81
Rate for Payer: Healthscope Commercial	$23.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.11
Rate for Payer: Opus (Opus Packaging Group) HMA	$19.51
Rate for Payer: PHP Commercial	$22.11
Rate for Payer: Priority Health SBD	$16.39

HC INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG

Facility

$14.86

Service Code	CPT J1000
Hospital Charge Code	63600092
Hospital Revenue Code	636
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$13.37
Rate for Payer: Aetna Commercial	$12.63
Rate for Payer: Aetna New Business (MI Preferred)	$9.66
Rate for Payer: Cash Price	$11.89
Rate for Payer: Cofinity Advantage	$10.40
Rate for Payer: Cofinity Commercial	$12.78
Rate for Payer: Encore Health Key Benefits Commercial	$11.89
Rate for Payer: Healthscope Commercial	$13.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.14
Rate for Payer: PHP Commercial	$12.63
Rate for Payer: Priority Health SBD	$9.36

HC INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG

Facility

$14.86

Service Code	CPT J1000
Hospital Charge Code	63600092
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$129.99
Rate for Payer: Aetna Commercial	$12.63
Rate for Payer: Aetna Medicare	$7.43
Rate for Payer: Aetna New Business (MI Preferred)	$9.66
Rate for Payer: BCBS Complete	$5.94
Rate for Payer: BCBS Trust/PPO	$129.99
Rate for Payer: BCN Commercial	$129.99
Rate for Payer: Cash Price	$11.89
Rate for Payer: Cash Price	$11.89
Rate for Payer: Cofinity Advantage	$10.40
Rate for Payer: Cofinity Commercial	$12.78
Rate for Payer: Encore Health Key Benefits Commercial	$11.89
Rate for Payer: Healthscope Commercial	$13.37
Rate for Payer: MI Amish Medical Board Commercial	$11.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.14
Rate for Payer: PHP Commercial	$12.63
Rate for Payer: Priority Health SBD	$9.36
Rate for Payer: UHC All Payor (Choice/PPO)	$85.50
Rate for Payer: UHC Core	$85.50
Rate for Payer: UHC Exchange	$85.50

HC INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG

Facility

$2.12

Service Code	HCPCS J1200
Hospital Charge Code	63600167
Hospital Revenue Code	636
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.91
Rate for Payer: Aetna Commercial	$1.80
Rate for Payer: Aetna New Business (MI Preferred)	$1.38
Rate for Payer: Cash Price	$1.70
Rate for Payer: Cofinity Advantage	$1.48
Rate for Payer: Cofinity Commercial	$1.82
Rate for Payer: Encore Health Key Benefits Commercial	$1.70
Rate for Payer: Healthscope Commercial	$1.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.59
Rate for Payer: PHP Commercial	$1.80
Rate for Payer: Priority Health SBD	$1.34

HC INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG

Facility

$2.12

Service Code	HCPCS J1200
Hospital Charge Code	63600167
Hospital Revenue Code	636
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.91
Rate for Payer: Aetna Commercial	$1.80
Rate for Payer: Aetna Medicare	$1.06
Rate for Payer: Aetna New Business (MI Preferred)	$1.38
Rate for Payer: BCBS Complete	$0.85
Rate for Payer: BCBS Trust/PPO	$1.77
Rate for Payer: BCN Commercial	$1.77
Rate for Payer: Cash Price	$1.70
Rate for Payer: Cash Price	$1.70
Rate for Payer: Cofinity Advantage	$1.48
Rate for Payer: Cofinity Commercial	$1.82
Rate for Payer: Encore Health Key Benefits Commercial	$1.70
Rate for Payer: Healthscope Commercial	$1.91
Rate for Payer: MI Amish Medical Board Commercial	$1.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.59
Rate for Payer: PHP Commercial	$1.80
Rate for Payer: Priority Health SBD	$1.34
Rate for Payer: UHC All Payor (Choice/PPO)	$1.17
Rate for Payer: UHC Core	$1.17
Rate for Payer: UHC Exchange	$1.17

HC INJECTION ELBOW ARTHROGRAM

Facility

$1,154.72

Service Code	CPT 24220
Hospital Charge Code	36100038
Hospital Revenue Code	361
Min. Negotiated Rate	$727.47
Max. Negotiated Rate	$1,039.25
Rate for Payer: Aetna Commercial	$981.51
Rate for Payer: Aetna New Business (MI Preferred)	$750.57
Rate for Payer: Cash Price	$923.78
Rate for Payer: Cofinity Advantage	$808.30
Rate for Payer: Cofinity Commercial	$993.06
Rate for Payer: Encore Health Key Benefits Commercial	$923.78
Rate for Payer: Healthscope Commercial	$1,039.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$981.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$866.04
Rate for Payer: PHP Commercial	$981.51
Rate for Payer: Priority Health SBD	$727.47

HC INJECTION ELBOW ARTHROGRAM

Facility

$1,154.72

Service Code	CPT 24220
Hospital Charge Code	36100038
Hospital Revenue Code	361
Min. Negotiated Rate	$316.87
Max. Negotiated Rate	$1,039.25
Rate for Payer: Aetna Commercial	$981.51
Rate for Payer: Aetna Medicare	$577.36
Rate for Payer: Aetna New Business (MI Preferred)	$750.57
Rate for Payer: BCBS Complete	$461.89
Rate for Payer: BCBS Trust/PPO	$316.87
Rate for Payer: BCN Commercial	$316.87
Rate for Payer: Cash Price	$923.78
Rate for Payer: Cash Price	$923.78
Rate for Payer: Cofinity Advantage	$808.30
Rate for Payer: Cofinity Commercial	$993.06
Rate for Payer: Encore Health Key Benefits Commercial	$923.78
Rate for Payer: Healthscope Commercial	$1,039.25
Rate for Payer: MI Amish Medical Board Commercial	$923.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$981.51
Rate for Payer: Opus (Opus Packaging Group) HMA	$866.04
Rate for Payer: PHP Commercial	$981.51
Rate for Payer: Priority Health SBD	$727.47

HC INJECTION FACET JOINT C OR T 1ST LEVEL BIL

Facility

$1,939.68

Service Code	CPT 64490
Hospital Charge Code	36100626
Hospital Revenue Code	361
Min. Negotiated Rate	$1,222.00
Max. Negotiated Rate	$1,745.71
Rate for Payer: Aetna Commercial	$1,648.73
Rate for Payer: Aetna New Business (MI Preferred)	$1,260.79
Rate for Payer: Cash Price	$1,551.74
Rate for Payer: Cofinity Advantage	$1,357.78
Rate for Payer: Cofinity Commercial	$1,668.12
Rate for Payer: Encore Health Key Benefits Commercial	$1,551.74
Rate for Payer: Healthscope Commercial	$1,745.71
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,648.73
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,454.76
Rate for Payer: PHP Commercial	$1,648.73
Rate for Payer: Priority Health SBD	$1,222.00

HC INJECTION FACET JOINT C OR T 1ST LEVEL BIL

Facility

$1,939.68

Service Code	CPT 64490
Hospital Charge Code	36100626
Hospital Revenue Code	361
Min. Negotiated Rate	$460.91
Max. Negotiated Rate	$2,850.01
Rate for Payer: Aetna Commercial	$1,648.73
Rate for Payer: Aetna Medicare	$916.54
Rate for Payer: Aetna New Business (MI Preferred)	$1,260.79
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,101.61
Rate for Payer: Amish Plain Church Group Commercial	$1,101.61
Rate for Payer: BCBS Complete	$484.00
Rate for Payer: BCBS MAPPO	$881.29
Rate for Payer: BCBS Trust/PPO	$1,044.70
Rate for Payer: BCN Commercial	$1,044.70
Rate for Payer: BCN Medicare Advantage	$881.29
Rate for Payer: Cash Price	$1,551.74
Rate for Payer: Cash Price	$1,551.74
Rate for Payer: Cash Price	$1,551.74
Rate for Payer: Cofinity Advantage	$1,357.78
Rate for Payer: Cofinity Commercial	$1,668.12
Rate for Payer: Encore Health Key Benefits Commercial	$1,551.74
Rate for Payer: Health Alliance Plan Medicare Advantage	$881.29
Rate for Payer: Healthscope Commercial	$1,745.71
Rate for Payer: Mclaren Medicaid	$460.91
Rate for Payer: Mclaren Medicare	$881.29
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$925.35
Rate for Payer: Meridian Medicaid	$925.35
Rate for Payer: MI Amish Medical Board Commercial	$1,013.48
Rate for Payer: Molina Medicare/Medicaid	$969.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,648.73
Rate for Payer: Nomi Health Commercial	$2,643.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,454.76
Rate for Payer: PACE Medicare	$837.23
Rate for Payer: PACE SWMI	$881.29
Rate for Payer: PHP Commercial	$1,648.73
Rate for Payer: PHP Medicare Advantage	$881.29
Rate for Payer: Priority Health Choice Medicaid	$460.91
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$2,850.01
Rate for Payer: Priority Health Medicare	$881.29
Rate for Payer: Priority Health SBD	$1,222.00
Rate for Payer: Priority Health Tiered Network	$2,280.01
Rate for Payer: Railroad Medicare Medicare	$881.29
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$881.29
Rate for Payer: UHC Medicaid	$460.91
Rate for Payer: UHCCP Medicaid	$460.91
Rate for Payer: VA VA	$881.29

HC INJECTION FACET JOINT C OR T 2ND LEVEL

Facility

$347.15

Service Code	CPT 64491
Hospital Charge Code	36100291
Hospital Revenue Code	361
Min. Negotiated Rate	$138.86
Max. Negotiated Rate	$312.44
Rate for Payer: Aetna Commercial	$295.08
Rate for Payer: Aetna Medicare	$173.57
Rate for Payer: Aetna New Business (MI Preferred)	$225.65
Rate for Payer: BCBS Complete	$138.86
Rate for Payer: BCBS Trust/PPO	$246.13
Rate for Payer: BCN Commercial	$246.13
Rate for Payer: Cash Price	$277.72
Rate for Payer: Cash Price	$277.72
Rate for Payer: Cofinity Advantage	$243.00
Rate for Payer: Cofinity Commercial	$298.55
Rate for Payer: Encore Health Key Benefits Commercial	$277.72
Rate for Payer: Healthscope Commercial	$312.44
Rate for Payer: MI Amish Medical Board Commercial	$277.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$295.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$260.36
Rate for Payer: PHP Commercial	$295.08
Rate for Payer: Priority Health SBD	$218.70

HC INJECTION FACET JOINT C OR T 2ND LEVEL

Facility

$347.15

Service Code	CPT 64491
Hospital Charge Code	36100291
Hospital Revenue Code	361
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$312.44
Rate for Payer: Aetna Commercial	$295.08
Rate for Payer: Aetna New Business (MI Preferred)	$225.65
Rate for Payer: Cash Price	$277.72
Rate for Payer: Cofinity Advantage	$243.00
Rate for Payer: Cofinity Commercial	$298.55
Rate for Payer: Encore Health Key Benefits Commercial	$277.72
Rate for Payer: Healthscope Commercial	$312.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$295.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$260.36
Rate for Payer: PHP Commercial	$295.08
Rate for Payer: Priority Health SBD	$218.70

HC INJECTION FACET JOINT C OR T 2ND LEVEL BIL

Facility

$520.73

Service Code	CPT 64491
Hospital Charge Code	36100627
Hospital Revenue Code	361
Min. Negotiated Rate	$328.06
Max. Negotiated Rate	$468.66
Rate for Payer: Aetna Commercial	$442.62
Rate for Payer: Aetna New Business (MI Preferred)	$338.47
Rate for Payer: Cash Price	$416.58
Rate for Payer: Cofinity Advantage	$364.51
Rate for Payer: Cofinity Commercial	$447.83
Rate for Payer: Encore Health Key Benefits Commercial	$416.58
Rate for Payer: Healthscope Commercial	$468.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$442.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$390.55
Rate for Payer: PHP Commercial	$442.62
Rate for Payer: Priority Health SBD	$328.06

HC INJECTION FACET JOINT C OR T 2ND LEVEL BIL

Facility

$520.73

Service Code	CPT 64491
Hospital Charge Code	36100627
Hospital Revenue Code	361
Min. Negotiated Rate	$208.29
Max. Negotiated Rate	$468.66
Rate for Payer: Aetna Commercial	$442.62
Rate for Payer: Aetna Medicare	$260.37
Rate for Payer: Aetna New Business (MI Preferred)	$338.47
Rate for Payer: BCBS Complete	$208.29
Rate for Payer: BCBS Trust/PPO	$246.13
Rate for Payer: BCN Commercial	$246.13
Rate for Payer: Cash Price	$416.58
Rate for Payer: Cash Price	$416.58
Rate for Payer: Cofinity Advantage	$364.51
Rate for Payer: Cofinity Commercial	$447.83
Rate for Payer: Encore Health Key Benefits Commercial	$416.58
Rate for Payer: Healthscope Commercial	$468.66
Rate for Payer: MI Amish Medical Board Commercial	$416.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$442.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$390.55
Rate for Payer: PHP Commercial	$442.62
Rate for Payer: Priority Health SBD	$328.06

HC INJECTION FACET JOINT C OR T 3RD + LEVEL

Facility

$347.15

Service Code	CPT 64492
Hospital Charge Code	36100292
Hospital Revenue Code	361
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$312.44
Rate for Payer: Aetna Commercial	$295.08
Rate for Payer: Aetna New Business (MI Preferred)	$225.65
Rate for Payer: Cash Price	$277.72
Rate for Payer: Cofinity Advantage	$243.00
Rate for Payer: Cofinity Commercial	$298.55
Rate for Payer: Encore Health Key Benefits Commercial	$277.72
Rate for Payer: Healthscope Commercial	$312.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$295.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$260.36
Rate for Payer: PHP Commercial	$295.08
Rate for Payer: Priority Health SBD	$218.70

HC INJECTION FACET JOINT C OR T 3RD + LEVEL

Facility

$347.15

Service Code	CPT 64492
Hospital Charge Code	36100292
Hospital Revenue Code	361
Min. Negotiated Rate	$138.86
Max. Negotiated Rate	$312.44
Rate for Payer: Aetna Commercial	$295.08
Rate for Payer: Aetna Medicare	$173.57
Rate for Payer: Aetna New Business (MI Preferred)	$225.65
Rate for Payer: BCBS Complete	$138.86
Rate for Payer: BCBS Trust/PPO	$247.06
Rate for Payer: BCN Commercial	$247.06
Rate for Payer: Cash Price	$277.72
Rate for Payer: Cash Price	$277.72
Rate for Payer: Cofinity Advantage	$243.00
Rate for Payer: Cofinity Commercial	$298.55
Rate for Payer: Encore Health Key Benefits Commercial	$277.72
Rate for Payer: Healthscope Commercial	$312.44
Rate for Payer: MI Amish Medical Board Commercial	$277.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$295.08
Rate for Payer: Opus (Opus Packaging Group) HMA	$260.36
Rate for Payer: PHP Commercial	$295.08
Rate for Payer: Priority Health SBD	$218.70

HC INJECTION FACET JOINT C OR T 3RD + LEVEL BIL

Facility

$520.73

Service Code	CPT 64492
Hospital Charge Code	36100628
Hospital Revenue Code	361
Min. Negotiated Rate	$208.29
Max. Negotiated Rate	$468.66
Rate for Payer: Aetna Commercial	$442.62
Rate for Payer: Aetna Medicare	$260.37
Rate for Payer: Aetna New Business (MI Preferred)	$338.47
Rate for Payer: BCBS Complete	$208.29
Rate for Payer: BCBS Trust/PPO	$247.06
Rate for Payer: BCN Commercial	$247.06
Rate for Payer: Cash Price	$416.58
Rate for Payer: Cash Price	$416.58
Rate for Payer: Cofinity Advantage	$364.51
Rate for Payer: Cofinity Commercial	$447.83
Rate for Payer: Encore Health Key Benefits Commercial	$416.58
Rate for Payer: Healthscope Commercial	$468.66
Rate for Payer: MI Amish Medical Board Commercial	$416.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$442.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$390.55
Rate for Payer: PHP Commercial	$442.62
Rate for Payer: Priority Health SBD	$328.06

HC INJECTION FACET JOINT C OR T 3RD + LEVEL BIL

Facility

$520.73

Service Code	CPT 64492
Hospital Charge Code	36100628
Hospital Revenue Code	361
Min. Negotiated Rate	$328.06
Max. Negotiated Rate	$468.66
Rate for Payer: Aetna Commercial	$442.62
Rate for Payer: Aetna New Business (MI Preferred)	$338.47
Rate for Payer: Cash Price	$416.58
Rate for Payer: Cofinity Advantage	$364.51
Rate for Payer: Cofinity Commercial	$447.83
Rate for Payer: Encore Health Key Benefits Commercial	$416.58
Rate for Payer: Healthscope Commercial	$468.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$442.62
Rate for Payer: Opus (Opus Packaging Group) HMA	$390.55
Rate for Payer: PHP Commercial	$442.62
Rate for Payer: Priority Health SBD	$328.06

HC INJECTION FACET JOINT L OR S 1ST LEVEL BIL

Facility

$2,525.86

Service Code	CPT 64493
Hospital Charge Code	36100629
Hospital Revenue Code	361
Min. Negotiated Rate	$1,591.29
Max. Negotiated Rate	$2,273.27
Rate for Payer: Aetna Commercial	$2,146.98
Rate for Payer: Aetna New Business (MI Preferred)	$1,641.81
Rate for Payer: Cash Price	$2,020.69
Rate for Payer: Cofinity Advantage	$1,768.10
Rate for Payer: Cofinity Commercial	$2,172.24
Rate for Payer: Encore Health Key Benefits Commercial	$2,020.69
Rate for Payer: Healthscope Commercial	$2,273.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,146.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,894.39
Rate for Payer: PHP Commercial	$2,146.98
Rate for Payer: Priority Health SBD	$1,591.29

HC INJECTION FACET JOINT L OR S 1ST LEVEL BIL

Facility

$2,525.86

Service Code	CPT 64493
Hospital Charge Code	36100629
Hospital Revenue Code	361
Min. Negotiated Rate	$460.91
Max. Negotiated Rate	$2,850.01
Rate for Payer: Aetna Commercial	$2,146.98
Rate for Payer: Aetna Medicare	$916.54
Rate for Payer: Aetna New Business (MI Preferred)	$1,641.81
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,101.61
Rate for Payer: Amish Plain Church Group Commercial	$1,101.61
Rate for Payer: BCBS Complete	$484.00
Rate for Payer: BCBS MAPPO	$881.29
Rate for Payer: BCBS Trust/PPO	$752.05
Rate for Payer: BCN Commercial	$752.05
Rate for Payer: BCN Medicare Advantage	$881.29
Rate for Payer: Cash Price	$2,020.69
Rate for Payer: Cash Price	$2,020.69
Rate for Payer: Cash Price	$2,020.69
Rate for Payer: Cofinity Advantage	$1,768.10
Rate for Payer: Cofinity Commercial	$2,172.24
Rate for Payer: Encore Health Key Benefits Commercial	$2,020.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$881.29
Rate for Payer: Healthscope Commercial	$2,273.27
Rate for Payer: Mclaren Medicaid	$460.91
Rate for Payer: Mclaren Medicare	$881.29
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$925.35
Rate for Payer: Meridian Medicaid	$925.35
Rate for Payer: MI Amish Medical Board Commercial	$1,013.48
Rate for Payer: Molina Medicare/Medicaid	$969.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,146.98
Rate for Payer: Nomi Health Commercial	$2,643.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,894.39
Rate for Payer: PACE Medicare	$837.23
Rate for Payer: PACE SWMI	$881.29
Rate for Payer: PHP Commercial	$2,146.98
Rate for Payer: PHP Medicare Advantage	$881.29
Rate for Payer: Priority Health Choice Medicaid	$460.91
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network	$2,850.01
Rate for Payer: Priority Health Medicare	$881.29
Rate for Payer: Priority Health SBD	$1,591.29
Rate for Payer: Priority Health Tiered Network	$2,280.01
Rate for Payer: Railroad Medicare Medicare	$881.29
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$881.29
Rate for Payer: UHC Medicaid	$460.91
Rate for Payer: UHCCP Medicaid	$460.91
Rate for Payer: VA VA	$881.29

Know your out-of-pocket cost for care.

All Charges