Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC INTRODUCER

Facility

$299.58

Service Code	HCPCS C1894
Hospital Charge Code	27200049
Hospital Revenue Code	272
Min. Negotiated Rate	$188.74
Max. Negotiated Rate	$269.62
Rate for Payer: Aetna Commercial	$254.64
Rate for Payer: Aetna New Business (MI Preferred)	$194.73
Rate for Payer: Cash Price	$239.66
Rate for Payer: Cofinity Commercial	$209.71
Rate for Payer: Cofinity Commercial	$257.64
Rate for Payer: Cofinity Medicare Advantage	$209.71
Rate for Payer: Encore Health Key Benefits Commercial	$239.66
Rate for Payer: Healthscope Commercial	$269.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$254.64
Rate for Payer: PHP Commercial	$254.64
Rate for Payer: Priority Health Cigna Priority Health	$194.73
Rate for Payer: Priority Health SBD	$188.74

HC INTRODUCER

Facility

$299.58

Service Code	HCPCS C1894
Hospital Charge Code	27200049
Hospital Revenue Code	272
Min. Negotiated Rate	$119.83
Max. Negotiated Rate	$269.62
Rate for Payer: Aetna Commercial	$254.64
Rate for Payer: Aetna Medicare	$149.79
Rate for Payer: Aetna New Business (MI Preferred)	$194.73
Rate for Payer: BCBS Complete	$119.83
Rate for Payer: Cash Price	$239.66
Rate for Payer: Cofinity Commercial	$209.71
Rate for Payer: Cofinity Commercial	$257.64
Rate for Payer: Cofinity Medicare Advantage	$209.71
Rate for Payer: Encore Health Key Benefits Commercial	$239.66
Rate for Payer: Healthscope Commercial	$269.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$254.64
Rate for Payer: PHP Commercial	$254.64
Rate for Payer: Priority Health Cigna Priority Health	$194.73
Rate for Payer: Priority Health SBD	$188.74

HC INTRODUCER LONG

Facility

$254.93

Service Code	HCPCS C1894
Hospital Charge Code	27200050
Hospital Revenue Code	272
Min. Negotiated Rate	$160.61
Max. Negotiated Rate	$229.44
Rate for Payer: Aetna Commercial	$216.69
Rate for Payer: Aetna New Business (MI Preferred)	$165.70
Rate for Payer: Cash Price	$203.94
Rate for Payer: Cofinity Commercial	$178.45
Rate for Payer: Cofinity Commercial	$219.24
Rate for Payer: Cofinity Medicare Advantage	$178.45
Rate for Payer: Encore Health Key Benefits Commercial	$203.94
Rate for Payer: Healthscope Commercial	$229.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$216.69
Rate for Payer: PHP Commercial	$216.69
Rate for Payer: Priority Health Cigna Priority Health	$165.70
Rate for Payer: Priority Health SBD	$160.61

HC INTRODUCER LONG

Facility

$254.93

Service Code	HCPCS C1894
Hospital Charge Code	27200050
Hospital Revenue Code	272
Min. Negotiated Rate	$101.97
Max. Negotiated Rate	$229.44
Rate for Payer: Aetna Commercial	$216.69
Rate for Payer: Aetna Medicare	$127.46
Rate for Payer: Aetna New Business (MI Preferred)	$165.70
Rate for Payer: BCBS Complete	$101.97
Rate for Payer: Cash Price	$203.94
Rate for Payer: Cofinity Commercial	$178.45
Rate for Payer: Cofinity Commercial	$219.24
Rate for Payer: Cofinity Medicare Advantage	$178.45
Rate for Payer: Encore Health Key Benefits Commercial	$203.94
Rate for Payer: Healthscope Commercial	$229.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$216.69
Rate for Payer: PHP Commercial	$216.69
Rate for Payer: Priority Health Cigna Priority Health	$165.70
Rate for Payer: Priority Health SBD	$160.61

HC INTRODUCER REGULAR

Facility

$94.68

Service Code	HCPCS C1893
Hospital Charge Code	27200051
Hospital Revenue Code	272
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$85.21
Rate for Payer: Aetna Commercial	$80.48
Rate for Payer: Aetna Medicare	$47.34
Rate for Payer: Aetna New Business (MI Preferred)	$61.54
Rate for Payer: BCBS Complete	$37.87
Rate for Payer: BCBS Trust/PPO	$0.03
Rate for Payer: BCN Commercial	$0.03
Rate for Payer: Cash Price	$75.74
Rate for Payer: Cash Price	$75.74
Rate for Payer: Cofinity Commercial	$66.28
Rate for Payer: Cofinity Commercial	$81.42
Rate for Payer: Cofinity Medicare Advantage	$66.28
Rate for Payer: Encore Health Key Benefits Commercial	$75.74
Rate for Payer: Healthscope Commercial	$85.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$80.48
Rate for Payer: PHP Commercial	$80.48
Rate for Payer: Priority Health Cigna Priority Health	$61.54
Rate for Payer: Priority Health SBD	$59.65

HC INTRODUCER REGULAR

Facility

$94.68

Service Code	HCPCS C1893
Hospital Charge Code	27200051
Hospital Revenue Code	272
Min. Negotiated Rate	$59.65
Max. Negotiated Rate	$85.21
Rate for Payer: Aetna Commercial	$80.48
Rate for Payer: Aetna New Business (MI Preferred)	$61.54
Rate for Payer: Cash Price	$75.74
Rate for Payer: Cofinity Commercial	$66.28
Rate for Payer: Cofinity Commercial	$81.42
Rate for Payer: Cofinity Medicare Advantage	$66.28
Rate for Payer: Encore Health Key Benefits Commercial	$75.74
Rate for Payer: Healthscope Commercial	$85.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$80.48
Rate for Payer: PHP Commercial	$80.48
Rate for Payer: Priority Health Cigna Priority Health	$61.54
Rate for Payer: Priority Health SBD	$59.65

HC INTRODUCTION OF URETRAL CATH VIA NEPHROSTOMY

Facility

$3,457.60

Service Code	CPT 50553
Hospital Charge Code	36100246
Hospital Revenue Code	361
Min. Negotiated Rate	$2,178.29
Max. Negotiated Rate	$3,111.84
Rate for Payer: Aetna Commercial	$2,938.96
Rate for Payer: Aetna New Business (MI Preferred)	$2,247.44
Rate for Payer: Cash Price	$2,766.08
Rate for Payer: Cofinity Commercial	$2,420.32
Rate for Payer: Cofinity Commercial	$2,973.54
Rate for Payer: Cofinity Medicare Advantage	$2,420.32
Rate for Payer: Encore Health Key Benefits Commercial	$2,766.08
Rate for Payer: Healthscope Commercial	$3,111.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,938.96
Rate for Payer: PHP Commercial	$2,938.96
Rate for Payer: Priority Health Cigna Priority Health	$2,247.44
Rate for Payer: Priority Health SBD	$2,178.29

HC INTRODUCTION OF URETRAL CATH VIA NEPHROSTOMY

Facility

$3,457.60

Service Code	CPT 50553
Hospital Charge Code	36100246
Hospital Revenue Code	361
Min. Negotiated Rate	$329.91
Max. Negotiated Rate	$15,654.68
Rate for Payer: Aetna Commercial	$2,938.96
Rate for Payer: Aetna Medicare	$5,180.06
Rate for Payer: Aetna New Business (MI Preferred)	$2,247.44
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,226.04
Rate for Payer: Amish Plain Church Group Commercial	$6,226.04
Rate for Payer: BCBS Complete	$2,803.21
Rate for Payer: BCBS MAPPO	$4,980.83
Rate for Payer: BCBS Trust/PPO	$1,555.60
Rate for Payer: BCN Commercial	$1,555.60
Rate for Payer: BCN Medicare Advantage	$4,980.83
Rate for Payer: Cash Price	$2,766.08
Rate for Payer: Cash Price	$2,766.08
Rate for Payer: Cash Price	$2,766.08
Rate for Payer: Cofinity Commercial	$2,420.32
Rate for Payer: Cofinity Commercial	$2,973.54
Rate for Payer: Cofinity Medicare Advantage	$2,420.32
Rate for Payer: Encore Health Key Benefits Commercial	$2,766.08
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,980.83
Rate for Payer: Healthscope Commercial	$3,111.84
Rate for Payer: Mclaren Medicaid	$2,669.72
Rate for Payer: Mclaren Medicare	$4,980.83
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5,229.87
Rate for Payer: Meridian Medicaid	$2,803.21
Rate for Payer: MI Amish Medical Board Commercial	$5,727.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,938.96
Rate for Payer: Nomi Health Commercial	$10,459.74
Rate for Payer: PACE Medicare	$4,731.79
Rate for Payer: PACE SWMI	$4,980.83
Rate for Payer: PHP Commercial	$2,938.96
Rate for Payer: PHP Medicare Advantage	$4,980.83
Rate for Payer: Priority Health Choice Medicaid	$2,669.72
Rate for Payer: Priority Health Cigna Priority Health	$2,247.44
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15,654.68
Rate for Payer: Priority Health Medicare	$4,980.83
Rate for Payer: Priority Health Narrow Network	$12,523.74
Rate for Payer: Priority Health SBD	$2,178.29
Rate for Payer: Railroad Medicare Medicare	$4,980.83
Rate for Payer: UHC All Payor (Choice/PPO)	$329.91
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$4,980.83
Rate for Payer: UHC Exchange	$4,450.00
Rate for Payer: UHC Medicare Advantage	$4,980.83
Rate for Payer: UHCCP Medicaid	$2,804.21
Rate for Payer: VA VA	$4,980.83

HC INTRO SHEATH NON GUIDE LVL 1

Facility

$41.77

Service Code	HCPCS C1894
Hospital Charge Code	27200276
Hospital Revenue Code	272
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$37.59
Rate for Payer: Aetna Commercial	$35.50
Rate for Payer: Aetna Medicare	$20.88
Rate for Payer: Aetna New Business (MI Preferred)	$27.15
Rate for Payer: BCBS Complete	$16.71
Rate for Payer: Cash Price	$33.42
Rate for Payer: Cofinity Commercial	$29.24
Rate for Payer: Cofinity Commercial	$35.92
Rate for Payer: Cofinity Medicare Advantage	$29.24
Rate for Payer: Encore Health Key Benefits Commercial	$33.42
Rate for Payer: Healthscope Commercial	$37.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.50
Rate for Payer: PHP Commercial	$35.50
Rate for Payer: Priority Health Cigna Priority Health	$27.15
Rate for Payer: Priority Health SBD	$26.32

HC INTRO SHEATH NON GUIDE LVL 1

Facility

$41.77

Service Code	HCPCS C1894
Hospital Charge Code	27200276
Hospital Revenue Code	272
Min. Negotiated Rate	$26.32
Max. Negotiated Rate	$37.59
Rate for Payer: Aetna Commercial	$35.50
Rate for Payer: Aetna New Business (MI Preferred)	$27.15
Rate for Payer: Cash Price	$33.42
Rate for Payer: Cofinity Commercial	$29.24
Rate for Payer: Cofinity Commercial	$35.92
Rate for Payer: Cofinity Medicare Advantage	$29.24
Rate for Payer: Encore Health Key Benefits Commercial	$33.42
Rate for Payer: Healthscope Commercial	$37.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.50
Rate for Payer: PHP Commercial	$35.50
Rate for Payer: Priority Health Cigna Priority Health	$27.15
Rate for Payer: Priority Health SBD	$26.32

HC INTRO SHEATH NON GUIDE LVL 11

Facility

$1,195.00

Service Code	HCPCS C1894
Hospital Charge Code	27200322
Hospital Revenue Code	272
Min. Negotiated Rate	$478.00
Max. Negotiated Rate	$1,075.50
Rate for Payer: Aetna Commercial	$1,015.75
Rate for Payer: Aetna Medicare	$597.50
Rate for Payer: Aetna New Business (MI Preferred)	$776.75
Rate for Payer: BCBS Complete	$478.00
Rate for Payer: Cash Price	$956.00
Rate for Payer: Cofinity Commercial	$1,027.70
Rate for Payer: Cofinity Commercial	$836.50
Rate for Payer: Cofinity Medicare Advantage	$836.50
Rate for Payer: Encore Health Key Benefits Commercial	$956.00
Rate for Payer: Healthscope Commercial	$1,075.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,015.75
Rate for Payer: PHP Commercial	$1,015.75
Rate for Payer: Priority Health Cigna Priority Health	$776.75
Rate for Payer: Priority Health SBD	$752.85

HC INTRO SHEATH NON GUIDE LVL 11

Facility

$1,195.00

Service Code	HCPCS C1894
Hospital Charge Code	27200322
Hospital Revenue Code	272
Min. Negotiated Rate	$752.85
Max. Negotiated Rate	$1,075.50
Rate for Payer: Aetna Commercial	$1,015.75
Rate for Payer: Aetna New Business (MI Preferred)	$776.75
Rate for Payer: Cash Price	$956.00
Rate for Payer: Cofinity Commercial	$1,027.70
Rate for Payer: Cofinity Commercial	$836.50
Rate for Payer: Cofinity Medicare Advantage	$836.50
Rate for Payer: Encore Health Key Benefits Commercial	$956.00
Rate for Payer: Healthscope Commercial	$1,075.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,015.75
Rate for Payer: PHP Commercial	$1,015.75
Rate for Payer: Priority Health Cigna Priority Health	$776.75
Rate for Payer: Priority Health SBD	$752.85

HC INTRO SHEATH NON GUIDE LVL 2

Facility

$162.30

Service Code	HCPCS C1894
Hospital Charge Code	27200020
Hospital Revenue Code	272
Min. Negotiated Rate	$64.92
Max. Negotiated Rate	$146.07
Rate for Payer: Aetna Commercial	$137.96
Rate for Payer: Aetna Medicare	$81.15
Rate for Payer: Aetna New Business (MI Preferred)	$105.50
Rate for Payer: BCBS Complete	$64.92
Rate for Payer: Cash Price	$129.84
Rate for Payer: Cofinity Commercial	$113.61
Rate for Payer: Cofinity Commercial	$139.58
Rate for Payer: Cofinity Medicare Advantage	$113.61
Rate for Payer: Encore Health Key Benefits Commercial	$129.84
Rate for Payer: Healthscope Commercial	$146.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$137.96
Rate for Payer: PHP Commercial	$137.96
Rate for Payer: Priority Health Cigna Priority Health	$105.50
Rate for Payer: Priority Health SBD	$102.25

HC INTRO SHEATH NON GUIDE LVL 2

Facility

$162.30

Service Code	HCPCS C1894
Hospital Charge Code	27200020
Hospital Revenue Code	272
Min. Negotiated Rate	$102.25
Max. Negotiated Rate	$146.07
Rate for Payer: Aetna Commercial	$137.96
Rate for Payer: Aetna New Business (MI Preferred)	$105.50
Rate for Payer: Cash Price	$129.84
Rate for Payer: Cofinity Commercial	$113.61
Rate for Payer: Cofinity Commercial	$139.58
Rate for Payer: Cofinity Medicare Advantage	$113.61
Rate for Payer: Encore Health Key Benefits Commercial	$129.84
Rate for Payer: Healthscope Commercial	$146.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$137.96
Rate for Payer: PHP Commercial	$137.96
Rate for Payer: Priority Health Cigna Priority Health	$105.50
Rate for Payer: Priority Health SBD	$102.25

HC INTRO SHEATH NON GUIDE LVL 3

Facility

$337.50

Service Code	HCPCS C1894
Hospital Charge Code	27200042
Hospital Revenue Code	272
Min. Negotiated Rate	$212.62
Max. Negotiated Rate	$303.75
Rate for Payer: Aetna Commercial	$286.88
Rate for Payer: Aetna New Business (MI Preferred)	$219.38
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cofinity Commercial	$236.25
Rate for Payer: Cofinity Commercial	$290.25
Rate for Payer: Cofinity Medicare Advantage	$236.25
Rate for Payer: Encore Health Key Benefits Commercial	$270.00
Rate for Payer: Healthscope Commercial	$303.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$286.88
Rate for Payer: PHP Commercial	$286.88
Rate for Payer: Priority Health Cigna Priority Health	$219.38
Rate for Payer: Priority Health SBD	$212.62

HC INTRO SHEATH NON GUIDE LVL 3

Facility

$337.50

Service Code	HCPCS C1894
Hospital Charge Code	27200042
Hospital Revenue Code	272
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$303.75
Rate for Payer: Aetna Commercial	$286.88
Rate for Payer: Aetna Medicare	$168.75
Rate for Payer: Aetna New Business (MI Preferred)	$219.38
Rate for Payer: BCBS Complete	$135.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cofinity Commercial	$236.25
Rate for Payer: Cofinity Commercial	$290.25
Rate for Payer: Cofinity Medicare Advantage	$236.25
Rate for Payer: Encore Health Key Benefits Commercial	$270.00
Rate for Payer: Healthscope Commercial	$303.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$286.88
Rate for Payer: PHP Commercial	$286.88
Rate for Payer: Priority Health Cigna Priority Health	$219.38
Rate for Payer: Priority Health SBD	$212.62

HC INTRO SHEATH NON GUIDE LVL 4

Facility

$485.16

Service Code	HCPCS C1894
Hospital Charge Code	27200277
Hospital Revenue Code	272
Min. Negotiated Rate	$305.65
Max. Negotiated Rate	$436.64
Rate for Payer: Aetna Commercial	$412.39
Rate for Payer: Aetna New Business (MI Preferred)	$315.35
Rate for Payer: Cash Price	$388.13
Rate for Payer: Cofinity Commercial	$339.61
Rate for Payer: Cofinity Commercial	$417.24
Rate for Payer: Cofinity Medicare Advantage	$339.61
Rate for Payer: Encore Health Key Benefits Commercial	$388.13
Rate for Payer: Healthscope Commercial	$436.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$412.39
Rate for Payer: PHP Commercial	$412.39
Rate for Payer: Priority Health Cigna Priority Health	$315.35
Rate for Payer: Priority Health SBD	$305.65

HC INTRO SHEATH NON GUIDE LVL 4

Facility

$485.16

Service Code	HCPCS C1894
Hospital Charge Code	27200277
Hospital Revenue Code	272
Min. Negotiated Rate	$194.06
Max. Negotiated Rate	$436.64
Rate for Payer: Aetna Commercial	$412.39
Rate for Payer: Aetna Medicare	$242.58
Rate for Payer: Aetna New Business (MI Preferred)	$315.35
Rate for Payer: BCBS Complete	$194.06
Rate for Payer: Cash Price	$388.13
Rate for Payer: Cofinity Commercial	$339.61
Rate for Payer: Cofinity Commercial	$417.24
Rate for Payer: Cofinity Medicare Advantage	$339.61
Rate for Payer: Encore Health Key Benefits Commercial	$388.13
Rate for Payer: Healthscope Commercial	$436.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$412.39
Rate for Payer: PHP Commercial	$412.39
Rate for Payer: Priority Health Cigna Priority Health	$315.35
Rate for Payer: Priority Health SBD	$305.65

HC IODINE, S

Facility

$62.42

Service Code	CPT 83789
Hospital Charge Code	30100687
Hospital Revenue Code	301
Min. Negotiated Rate	$12.92
Max. Negotiated Rate	$56.18
Rate for Payer: Aetna Commercial	$53.06
Rate for Payer: Aetna Medicare	$25.07
Rate for Payer: Aetna New Business (MI Preferred)	$40.57
Rate for Payer: Allen County Amish Medical Aid Commercial	$30.14
Rate for Payer: Amish Plain Church Group Commercial	$30.14
Rate for Payer: BCBS Complete	$13.57
Rate for Payer: BCBS MAPPO	$24.11
Rate for Payer: BCBS Trust/PPO	$21.34
Rate for Payer: BCN Commercial	$21.34
Rate for Payer: BCN Medicare Advantage	$24.11
Rate for Payer: Cash Price	$49.94
Rate for Payer: Cash Price	$49.94
Rate for Payer: Cofinity Commercial	$53.68
Rate for Payer: Cofinity Commercial	$43.69
Rate for Payer: Cofinity Medicare Advantage	$43.69
Rate for Payer: Encore Health Key Benefits Commercial	$49.94
Rate for Payer: Health Alliance Plan Medicare Advantage	$24.11
Rate for Payer: Healthscope Commercial	$56.18
Rate for Payer: Mclaren Medicaid	$12.92
Rate for Payer: Mclaren Medicare	$24.11
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$25.32
Rate for Payer: Meridian Medicaid	$13.57
Rate for Payer: MI Amish Medical Board Commercial	$27.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.06
Rate for Payer: Nomi Health Commercial	$36.16
Rate for Payer: PACE Medicare	$22.90
Rate for Payer: PACE SWMI	$24.11
Rate for Payer: PHP Commercial	$53.06
Rate for Payer: PHP Medicare Advantage	$24.11
Rate for Payer: Priority Health Choice Medicaid	$12.92
Rate for Payer: Priority Health Cigna Priority Health	$40.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24.11
Rate for Payer: Priority Health Medicare	$24.11
Rate for Payer: Priority Health Narrow Network	$19.29
Rate for Payer: Priority Health SBD	$39.32
Rate for Payer: Railroad Medicare Medicare	$24.11
Rate for Payer: UHC All Payor (Choice/PPO)	$28.93
Rate for Payer: UHC Dual Complete DSNP	$24.11
Rate for Payer: UHC Medicare Advantage	$24.11
Rate for Payer: UHCCP Medicaid	$13.57
Rate for Payer: VA VA	$24.11

HC IODINE, S

Facility

$62.42

Service Code	CPT 83789
Hospital Charge Code	30100687
Hospital Revenue Code	301
Min. Negotiated Rate	$39.32
Max. Negotiated Rate	$56.18
Rate for Payer: Aetna Commercial	$53.06
Rate for Payer: Aetna New Business (MI Preferred)	$40.57
Rate for Payer: Cash Price	$49.94
Rate for Payer: Cofinity Commercial	$43.69
Rate for Payer: Cofinity Commercial	$53.68
Rate for Payer: Cofinity Medicare Advantage	$43.69
Rate for Payer: Encore Health Key Benefits Commercial	$49.94
Rate for Payer: Healthscope Commercial	$56.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.06
Rate for Payer: PHP Commercial	$53.06
Rate for Payer: Priority Health Cigna Priority Health	$40.57
Rate for Payer: Priority Health SBD	$39.32

HC IOFLUPANE I-123 PER STUDY

Facility

$5,436.63

Service Code	HCPCS A9584
Hospital Charge Code	34300035
Hospital Revenue Code	343
Min. Negotiated Rate	$743.98
Max. Negotiated Rate	$4,892.97
Rate for Payer: Aetna Commercial	$4,621.14
Rate for Payer: Aetna Medicare	$1,443.54
Rate for Payer: Aetna New Business (MI Preferred)	$3,533.81
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,735.02
Rate for Payer: Amish Plain Church Group Commercial	$1,735.02
Rate for Payer: BCBS Complete	$781.18
Rate for Payer: BCBS MAPPO	$1,388.02
Rate for Payer: BCBS Trust/PPO	$1,346.11
Rate for Payer: BCN Commercial	$1,346.11
Rate for Payer: BCN Medicare Advantage	$1,388.02
Rate for Payer: Cash Price	$4,349.30
Rate for Payer: Cash Price	$4,349.30
Rate for Payer: Cofinity Commercial	$4,675.50
Rate for Payer: Cofinity Commercial	$3,805.64
Rate for Payer: Cofinity Medicare Advantage	$3,805.64
Rate for Payer: Encore Health Key Benefits Commercial	$4,349.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,388.02
Rate for Payer: Healthscope Commercial	$4,892.97
Rate for Payer: Mclaren Medicaid	$743.98
Rate for Payer: Mclaren Medicare	$1,388.02
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,457.42
Rate for Payer: Meridian Medicaid	$781.18
Rate for Payer: MI Amish Medical Board Commercial	$1,596.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,621.14
Rate for Payer: Nomi Health Commercial	$4,164.06
Rate for Payer: PACE Medicare	$1,318.62
Rate for Payer: PACE SWMI	$1,388.02
Rate for Payer: PHP Commercial	$4,621.14
Rate for Payer: PHP Medicare Advantage	$1,388.02
Rate for Payer: Priority Health Choice Medicaid	$743.98
Rate for Payer: Priority Health Cigna Priority Health	$3,533.81
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,994.75
Rate for Payer: Priority Health Medicare	$1,388.02
Rate for Payer: Priority Health Narrow Network	$3,195.80
Rate for Payer: Priority Health SBD	$3,425.08
Rate for Payer: Railroad Medicare Medicare	$1,388.02
Rate for Payer: UHC All Payor (Choice/PPO)	$3,907.14
Rate for Payer: UHC Dual Complete DSNP	$1,388.02
Rate for Payer: UHC Medicare Advantage	$1,388.02
Rate for Payer: UHCCP Medicaid	$781.46
Rate for Payer: VA VA	$1,388.02

HC IOFLUPANE I-123 PER STUDY

Facility

$5,436.63

Service Code	HCPCS A9584
Hospital Charge Code	34300035
Hospital Revenue Code	343
Min. Negotiated Rate	$3,425.08
Max. Negotiated Rate	$4,892.97
Rate for Payer: Aetna Commercial	$4,621.14
Rate for Payer: Aetna New Business (MI Preferred)	$3,533.81
Rate for Payer: Cash Price	$4,349.30
Rate for Payer: Cofinity Commercial	$3,805.64
Rate for Payer: Cofinity Commercial	$4,675.50
Rate for Payer: Cofinity Medicare Advantage	$3,805.64
Rate for Payer: Encore Health Key Benefits Commercial	$4,349.30
Rate for Payer: Healthscope Commercial	$4,892.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,621.14
Rate for Payer: PHP Commercial	$4,621.14
Rate for Payer: Priority Health Cigna Priority Health	$3,533.81
Rate for Payer: Priority Health SBD	$3,425.08

HC IOM EEG CAROTID ENDARTERECTOMY

Facility

$1,297.89

Service Code	CPT 95955
Hospital Charge Code	74000014
Hospital Revenue Code	740
Min. Negotiated Rate	$191.07
Max. Negotiated Rate	$1,168.10
Rate for Payer: Aetna Commercial	$1,103.21
Rate for Payer: Aetna Medicare	$648.94
Rate for Payer: Aetna New Business (MI Preferred)	$843.63
Rate for Payer: BCBS Complete	$519.16
Rate for Payer: BCBS Trust/PPO	$612.81
Rate for Payer: BCN Commercial	$612.81
Rate for Payer: Cash Price	$1,038.31
Rate for Payer: Cash Price	$1,038.31
Rate for Payer: Cofinity Commercial	$908.52
Rate for Payer: Cofinity Commercial	$1,116.19
Rate for Payer: Cofinity Medicare Advantage	$908.52
Rate for Payer: Encore Health Key Benefits Commercial	$1,038.31
Rate for Payer: Healthscope Commercial	$1,168.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,103.21
Rate for Payer: PHP Commercial	$1,103.21
Rate for Payer: Priority Health Cigna Priority Health	$843.63
Rate for Payer: Priority Health SBD	$817.67
Rate for Payer: UHC All Payor (Choice/PPO)	$191.07
Rate for Payer: UHC Exchange	$960.44

HC IOM EEG CAROTID ENDARTERECTOMY

Facility

$1,297.89

Service Code	CPT 95955
Hospital Charge Code	74000014
Hospital Revenue Code	740
Min. Negotiated Rate	$817.67
Max. Negotiated Rate	$1,168.10
Rate for Payer: Aetna Commercial	$1,103.21
Rate for Payer: Aetna New Business (MI Preferred)	$843.63
Rate for Payer: Cash Price	$1,038.31
Rate for Payer: Cofinity Commercial	$1,116.19
Rate for Payer: Cofinity Commercial	$908.52
Rate for Payer: Cofinity Medicare Advantage	$908.52
Rate for Payer: Encore Health Key Benefits Commercial	$1,038.31
Rate for Payer: Healthscope Commercial	$1,168.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,103.21
Rate for Payer: PHP Commercial	$1,103.21
Rate for Payer: Priority Health Cigna Priority Health	$843.63
Rate for Payer: Priority Health SBD	$817.67

HC IOM INTRAOPERATIVE MONITOR/15 MINUTES

Facility

$187.07

Service Code	CPT 95940
Hospital Charge Code	74000017
Hospital Revenue Code	740
Min. Negotiated Rate	$117.85
Max. Negotiated Rate	$168.36
Rate for Payer: Aetna Commercial	$159.01
Rate for Payer: Aetna New Business (MI Preferred)	$121.60
Rate for Payer: Cash Price	$149.66
Rate for Payer: Cofinity Commercial	$130.95
Rate for Payer: Cofinity Commercial	$160.88
Rate for Payer: Cofinity Medicare Advantage	$130.95
Rate for Payer: Encore Health Key Benefits Commercial	$149.66
Rate for Payer: Healthscope Commercial	$168.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$159.01
Rate for Payer: PHP Commercial	$159.01
Rate for Payer: Priority Health Cigna Priority Health	$121.60
Rate for Payer: Priority Health SBD	$117.85

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