Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

NAFCILLIN 2 GRAM SOLUTION FOR INJECTION

Facility

$24.09

Service Code	NDC 55150-123-15
Hospital Charge Code	5335
Hospital Revenue Code	250
Min. Negotiated Rate	$15.18
Max. Negotiated Rate	$21.68
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: Aetna New Business (MI Preferred)	$15.66
Rate for Payer: Cash Price	$19.27
Rate for Payer: Cofinity Commercial	$16.86
Rate for Payer: Cofinity Commercial	$20.72
Rate for Payer: Healthscope Commercial	$21.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$20.48
Rate for Payer: PHP Commercial	$20.48
Rate for Payer: Priority Health Cigna Priority Health	$16.86
Rate for Payer: Priority Health SBD	$15.18

NAFCILLIN 2 GRAM SOLUTION FOR INJECTION

Facility

$24.09

Service Code	NDC 55150-123-16
Hospital Charge Code	5335
Hospital Revenue Code	250
Min. Negotiated Rate	$15.18
Max. Negotiated Rate	$21.68
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: Aetna New Business (MI Preferred)	$15.66
Rate for Payer: Cash Price	$19.27
Rate for Payer: Cofinity Commercial	$16.86
Rate for Payer: Cofinity Commercial	$20.72
Rate for Payer: Healthscope Commercial	$21.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$20.48
Rate for Payer: PHP Commercial	$20.48
Rate for Payer: Priority Health Cigna Priority Health	$16.86
Rate for Payer: Priority Health SBD	$15.18

NAFCILLIN 2 GRAM SOLUTION FOR INJECTION

Facility

$93.12

Service Code	NDC 25021-140-10
Hospital Charge Code	5335
Hospital Revenue Code	250
Min. Negotiated Rate	$58.67
Max. Negotiated Rate	$83.81
Rate for Payer: Aetna Commercial	$79.15
Rate for Payer: Aetna New Business (MI Preferred)	$60.53
Rate for Payer: Cash Price	$74.50
Rate for Payer: Cofinity Commercial	$65.18
Rate for Payer: Cofinity Commercial	$80.08
Rate for Payer: Healthscope Commercial	$83.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$79.15
Rate for Payer: PHP Commercial	$79.15
Rate for Payer: Priority Health Cigna Priority Health	$65.18
Rate for Payer: Priority Health SBD	$58.67

NAFCILLIN 2 GRAM SOLUTION FOR INJECTION

Facility

$94.39

Service Code	NDC 0781-3125-95
Hospital Charge Code	5335
Hospital Revenue Code	250
Min. Negotiated Rate	$59.47
Max. Negotiated Rate	$84.95
Rate for Payer: Aetna Commercial	$80.23
Rate for Payer: Aetna New Business (MI Preferred)	$61.35
Rate for Payer: Cash Price	$75.51
Rate for Payer: Cofinity Commercial	$66.07
Rate for Payer: Cofinity Commercial	$81.18
Rate for Payer: Healthscope Commercial	$84.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$80.23
Rate for Payer: PHP Commercial	$80.23
Rate for Payer: Priority Health Cigna Priority Health	$66.07
Rate for Payer: Priority Health SBD	$59.47

NAFCILLIN 2 GRAM SOLUTION FOR INJECTION

Facility

$23.97

Service Code	NDC 44567-222-10
Hospital Charge Code	5335
Hospital Revenue Code	250
Min. Negotiated Rate	$15.10
Max. Negotiated Rate	$21.57
Rate for Payer: Aetna Commercial	$20.37
Rate for Payer: Aetna New Business (MI Preferred)	$15.58
Rate for Payer: Cash Price	$19.18
Rate for Payer: Cofinity Commercial	$16.78
Rate for Payer: Cofinity Commercial	$20.61
Rate for Payer: Healthscope Commercial	$21.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$20.37
Rate for Payer: PHP Commercial	$20.37
Rate for Payer: Priority Health Cigna Priority Health	$16.78
Rate for Payer: Priority Health SBD	$15.10

NALOXEGOL 12.5 MG TABLET

Facility

$1,361.97

Service Code	NDC 57841-1300-1
Hospital Charge Code	173967
Hospital Revenue Code	637
Min. Negotiated Rate	$858.04
Max. Negotiated Rate	$1,225.77
Rate for Payer: Aetna Commercial	$1,157.67
Rate for Payer: Aetna New Business (MI Preferred)	$885.28
Rate for Payer: Cash Price	$1,089.58
Rate for Payer: Cofinity Commercial	$1,171.29
Rate for Payer: Cofinity Commercial	$953.38
Rate for Payer: Healthscope Commercial	$1,225.77
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,157.67
Rate for Payer: PHP Commercial	$1,157.67
Rate for Payer: Priority Health Cigna Priority Health	$953.38
Rate for Payer: Priority Health SBD	$858.04

NALOXEGOL 25 MG TABLET

Facility

$1,361.97

Service Code	NDC 57841-1301-1
Hospital Charge Code	173968
Hospital Revenue Code	637
Min. Negotiated Rate	$858.04
Max. Negotiated Rate	$1,225.77
Rate for Payer: Aetna Commercial	$1,157.67
Rate for Payer: Aetna New Business (MI Preferred)	$885.28
Rate for Payer: Cash Price	$1,089.58
Rate for Payer: Cofinity Commercial	$1,171.29
Rate for Payer: Cofinity Commercial	$953.38
Rate for Payer: Healthscope Commercial	$1,225.77
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,157.67
Rate for Payer: PHP Commercial	$1,157.67
Rate for Payer: Priority Health Cigna Priority Health	$953.38
Rate for Payer: Priority Health SBD	$858.04

NALOXEGOL 25 MG TABLET

Facility

$4,404.11

Service Code	NDC 57841-1301-3
Hospital Charge Code	173968
Hospital Revenue Code	637
Min. Negotiated Rate	$2,774.59
Max. Negotiated Rate	$3,963.70
Rate for Payer: Aetna Commercial	$3,743.49
Rate for Payer: Aetna New Business (MI Preferred)	$2,862.67
Rate for Payer: Cash Price	$3,523.29
Rate for Payer: Cofinity Commercial	$3,082.88
Rate for Payer: Cofinity Commercial	$3,787.53
Rate for Payer: Healthscope Commercial	$3,963.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,743.49
Rate for Payer: PHP Commercial	$3,743.49
Rate for Payer: Priority Health Cigna Priority Health	$3,082.88
Rate for Payer: Priority Health SBD	$2,774.59

NALOXONE 0.4 MG/ML INJECTION (CODE)

Facility

$63.57

Service Code	HCPCS J2310
Hospital Charge Code	163714
Hospital Revenue Code	636
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$57.21
Rate for Payer: Aetna Commercial	$54.03
Rate for Payer: Aetna Commercial	$17.03
Rate for Payer: Aetna New Business (MI Preferred)	$41.32
Rate for Payer: Aetna New Business (MI Preferred)	$13.02
Rate for Payer: Cash Price	$50.86
Rate for Payer: Cash Price	$16.02
Rate for Payer: Cofinity Commercial	$17.23
Rate for Payer: Cofinity Commercial	$14.02
Rate for Payer: Cofinity Commercial	$54.67
Rate for Payer: Cofinity Commercial	$44.50
Rate for Payer: Healthscope Commercial	$18.03
Rate for Payer: Healthscope Commercial	$57.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$54.03
Rate for Payer: PHP Commercial	$54.03
Rate for Payer: PHP Commercial	$17.03
Rate for Payer: Priority Health Cigna Priority Health	$44.50
Rate for Payer: Priority Health Cigna Priority Health	$14.02
Rate for Payer: Priority Health SBD	$12.62
Rate for Payer: Priority Health SBD	$40.05

NALOXONE 0.4 MG/ML INJECTION SOLUTION

Facility

$20.03

Service Code	HCPCS J2310
Hospital Charge Code	5373
Hospital Revenue Code	636
Min. Negotiated Rate	$12.62
Max. Negotiated Rate	$18.03
Rate for Payer: Aetna Commercial	$17.03
Rate for Payer: Aetna Commercial	$16.04
Rate for Payer: Aetna Commercial	$16.63
Rate for Payer: Aetna Commercial	$54.03
Rate for Payer: Aetna New Business (MI Preferred)	$12.71
Rate for Payer: Aetna New Business (MI Preferred)	$13.02
Rate for Payer: Aetna New Business (MI Preferred)	$41.32
Rate for Payer: Aetna New Business (MI Preferred)	$12.27
Rate for Payer: Cash Price	$15.10
Rate for Payer: Cash Price	$16.02
Rate for Payer: Cash Price	$50.86
Rate for Payer: Cash Price	$15.65
Rate for Payer: Cofinity Commercial	$13.21
Rate for Payer: Cofinity Commercial	$54.67
Rate for Payer: Cofinity Commercial	$44.50
Rate for Payer: Cofinity Commercial	$17.23
Rate for Payer: Cofinity Commercial	$13.69
Rate for Payer: Cofinity Commercial	$16.82
Rate for Payer: Cofinity Commercial	$14.02
Rate for Payer: Cofinity Commercial	$16.23
Rate for Payer: Healthscope Commercial	$57.21
Rate for Payer: Healthscope Commercial	$16.98
Rate for Payer: Healthscope Commercial	$17.60
Rate for Payer: Healthscope Commercial	$18.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$54.03
Rate for Payer: PHP Commercial	$16.63
Rate for Payer: PHP Commercial	$54.03
Rate for Payer: PHP Commercial	$16.04
Rate for Payer: PHP Commercial	$17.03
Rate for Payer: Priority Health Cigna Priority Health	$44.50
Rate for Payer: Priority Health Cigna Priority Health	$14.02
Rate for Payer: Priority Health Cigna Priority Health	$13.21
Rate for Payer: Priority Health Cigna Priority Health	$13.69
Rate for Payer: Priority Health SBD	$40.05
Rate for Payer: Priority Health SBD	$11.89
Rate for Payer: Priority Health SBD	$12.32
Rate for Payer: Priority Health SBD	$12.62

NALOXONE 1 MG/ML INJECTION SYRINGE

Facility

$70.26

Service Code	HCPCS J2310
Hospital Charge Code	5374
Hospital Revenue Code	636
Min. Negotiated Rate	$44.26
Max. Negotiated Rate	$63.23
Rate for Payer: Aetna Commercial	$59.72
Rate for Payer: Aetna Commercial	$73.70
Rate for Payer: Aetna New Business (MI Preferred)	$56.36
Rate for Payer: Aetna New Business (MI Preferred)	$45.67
Rate for Payer: Cash Price	$56.21
Rate for Payer: Cash Price	$69.37
Rate for Payer: Cofinity Commercial	$60.42
Rate for Payer: Cofinity Commercial	$49.18
Rate for Payer: Cofinity Commercial	$60.70
Rate for Payer: Cofinity Commercial	$74.57
Rate for Payer: Healthscope Commercial	$78.04
Rate for Payer: Healthscope Commercial	$63.23
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$73.70
Rate for Payer: PHP Commercial	$73.70
Rate for Payer: PHP Commercial	$59.72
Rate for Payer: Priority Health Cigna Priority Health	$49.18
Rate for Payer: Priority Health Cigna Priority Health	$60.70
Rate for Payer: Priority Health SBD	$44.26
Rate for Payer: Priority Health SBD	$54.63

NALTREXONE 50 MG TABLET

Facility

$383.52

Service Code	NDC 51224-206-50
Hospital Charge Code	10685
Hospital Revenue Code	637
Min. Negotiated Rate	$241.62
Max. Negotiated Rate	$345.17
Rate for Payer: Aetna Commercial	$325.99
Rate for Payer: Aetna New Business (MI Preferred)	$249.29
Rate for Payer: Cash Price	$306.82
Rate for Payer: Cofinity Commercial	$268.46
Rate for Payer: Cofinity Commercial	$329.83
Rate for Payer: Healthscope Commercial	$345.17
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$325.99
Rate for Payer: PHP Commercial	$325.99
Rate for Payer: Priority Health Cigna Priority Health	$268.46
Rate for Payer: Priority Health SBD	$241.62

NALTREXONE 50 MG TABLET

Facility

$240.65

Service Code	NDC 68094-853-62
Hospital Charge Code	10685
Hospital Revenue Code	637
Min. Negotiated Rate	$151.61
Max. Negotiated Rate	$216.58
Rate for Payer: Aetna Commercial	$204.55
Rate for Payer: Aetna New Business (MI Preferred)	$156.42
Rate for Payer: Cash Price	$192.52
Rate for Payer: Cofinity Commercial	$168.46
Rate for Payer: Cofinity Commercial	$206.96
Rate for Payer: Healthscope Commercial	$216.58
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$204.55
Rate for Payer: PHP Commercial	$204.55
Rate for Payer: Priority Health Cigna Priority Health	$168.46
Rate for Payer: Priority Health SBD	$151.61

NALTREXONE 50 MG TABLET

Facility

$7.83

Service Code	NDC 68084-291-11
Hospital Charge Code	10685
Hospital Revenue Code	637
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$7.05
Rate for Payer: Aetna Commercial	$6.66
Rate for Payer: Aetna New Business (MI Preferred)	$5.09
Rate for Payer: Cash Price	$6.26
Rate for Payer: Cofinity Commercial	$5.48
Rate for Payer: Cofinity Commercial	$6.73
Rate for Payer: Healthscope Commercial	$7.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.66
Rate for Payer: PHP Commercial	$6.66
Rate for Payer: Priority Health Cigna Priority Health	$5.48
Rate for Payer: Priority Health SBD	$4.93

NALTREXONE 50 MG TABLET

Facility

$98.36

Service Code	NDC 47335-326-83
Hospital Charge Code	10685
Hospital Revenue Code	637
Min. Negotiated Rate	$61.97
Max. Negotiated Rate	$88.52
Rate for Payer: Aetna Commercial	$83.61
Rate for Payer: Aetna New Business (MI Preferred)	$63.93
Rate for Payer: Cash Price	$78.69
Rate for Payer: Cofinity Commercial	$84.59
Rate for Payer: Cofinity Commercial	$68.85
Rate for Payer: Healthscope Commercial	$88.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$83.61
Rate for Payer: PHP Commercial	$83.61
Rate for Payer: Priority Health Cigna Priority Health	$68.85
Rate for Payer: Priority Health SBD	$61.97

NALTREXONE 50 MG TABLET

Facility

$224.07

Service Code	NDC 0904-7036-04
Hospital Charge Code	10685
Hospital Revenue Code	637
Min. Negotiated Rate	$141.16
Max. Negotiated Rate	$201.66
Rate for Payer: Aetna Commercial	$190.46
Rate for Payer: Aetna New Business (MI Preferred)	$145.65
Rate for Payer: Cash Price	$179.26
Rate for Payer: Cofinity Commercial	$156.85
Rate for Payer: Cofinity Commercial	$192.70
Rate for Payer: Healthscope Commercial	$201.66
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$190.46
Rate for Payer: PHP Commercial	$190.46
Rate for Payer: Priority Health Cigna Priority Health	$156.85
Rate for Payer: Priority Health SBD	$141.16

NALTREXONE 50 MG TABLET

Facility

$118.37

Service Code	NDC 51224-206-30
Hospital Charge Code	10685
Hospital Revenue Code	637
Min. Negotiated Rate	$74.57
Max. Negotiated Rate	$106.53
Rate for Payer: Aetna Commercial	$100.61
Rate for Payer: Aetna New Business (MI Preferred)	$76.94
Rate for Payer: Cash Price	$94.70
Rate for Payer: Cofinity Commercial	$101.80
Rate for Payer: Cofinity Commercial	$82.86
Rate for Payer: Healthscope Commercial	$106.53
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$100.61
Rate for Payer: PHP Commercial	$100.61
Rate for Payer: Priority Health Cigna Priority Health	$82.86
Rate for Payer: Priority Health SBD	$74.57

NALTREXONE 50 MG TABLET

Facility

$234.77

Service Code	NDC 68084-291-21
Hospital Charge Code	10685
Hospital Revenue Code	637
Min. Negotiated Rate	$147.91
Max. Negotiated Rate	$211.29
Rate for Payer: Aetna Commercial	$199.55
Rate for Payer: Aetna New Business (MI Preferred)	$152.60
Rate for Payer: Cash Price	$187.82
Rate for Payer: Cofinity Commercial	$164.34
Rate for Payer: Cofinity Commercial	$201.90
Rate for Payer: Healthscope Commercial	$211.29
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$199.55
Rate for Payer: PHP Commercial	$199.55
Rate for Payer: Priority Health Cigna Priority Health	$164.34
Rate for Payer: Priority Health SBD	$147.91

NALTREXONE ER 380 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE

Facility

$4,883.94

Service Code	HCPCS J2315
Hospital Charge Code	76527
Hospital Revenue Code	636
Min. Negotiated Rate	$3,076.88
Max. Negotiated Rate	$4,395.55
Rate for Payer: Aetna Commercial	$4,151.35
Rate for Payer: Aetna New Business (MI Preferred)	$3,174.56
Rate for Payer: Cash Price	$3,907.15
Rate for Payer: Cofinity Commercial	$3,418.76
Rate for Payer: Cofinity Commercial	$4,200.19
Rate for Payer: Healthscope Commercial	$4,395.55
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,151.35
Rate for Payer: PHP Commercial	$4,151.35
Rate for Payer: Priority Health Cigna Priority Health	$3,418.76
Rate for Payer: Priority Health SBD	$3,076.88

NAPROXEN 250 MG TABLET

Facility

$4.19

Service Code	NDC 50268-594-11
Hospital Charge Code	5391
Hospital Revenue Code	637
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.77
Rate for Payer: Aetna Commercial	$3.56
Rate for Payer: Aetna New Business (MI Preferred)	$2.72
Rate for Payer: Cash Price	$3.35
Rate for Payer: Cofinity Commercial	$2.93
Rate for Payer: Cofinity Commercial	$3.60
Rate for Payer: Healthscope Commercial	$3.77
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.56
Rate for Payer: PHP Commercial	$3.56
Rate for Payer: Priority Health Cigna Priority Health	$2.93
Rate for Payer: Priority Health SBD	$2.64

NAPROXEN 250 MG TABLET

Facility

$209.15

Service Code	NDC 50268-594-15
Hospital Charge Code	5391
Hospital Revenue Code	637
Min. Negotiated Rate	$131.76
Max. Negotiated Rate	$188.24
Rate for Payer: Aetna Commercial	$177.78
Rate for Payer: Aetna New Business (MI Preferred)	$135.95
Rate for Payer: Cash Price	$167.32
Rate for Payer: Cofinity Commercial	$146.40
Rate for Payer: Cofinity Commercial	$179.87
Rate for Payer: Healthscope Commercial	$188.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$177.78
Rate for Payer: PHP Commercial	$177.78
Rate for Payer: Priority Health Cigna Priority Health	$146.40
Rate for Payer: Priority Health SBD	$131.76

NAPROXEN 250 MG TABLET

Facility

$155.10

Service Code	NDC 65162-188-10
Hospital Charge Code	5391
Hospital Revenue Code	637
Min. Negotiated Rate	$97.71
Max. Negotiated Rate	$139.59
Rate for Payer: Aetna Commercial	$131.84
Rate for Payer: Aetna New Business (MI Preferred)	$100.82
Rate for Payer: Cash Price	$124.08
Rate for Payer: Cofinity Commercial	$108.57
Rate for Payer: Cofinity Commercial	$133.39
Rate for Payer: Healthscope Commercial	$139.59
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$131.84
Rate for Payer: PHP Commercial	$131.84
Rate for Payer: Priority Health Cigna Priority Health	$108.57
Rate for Payer: Priority Health SBD	$97.71

NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)

Facility

$878.00

Service Code	CPT 31231
Hospital Revenue Code	360
Min. Negotiated Rate	$55.60
Max. Negotiated Rate	$878.00
Rate for Payer: Aetna Medicare	$183.30
Rate for Payer: Allen County Amish Medical Aid Commercial	$220.31
Rate for Payer: Amish Plain Church Group Commercial	$220.31
Rate for Payer: BCBS Complete	$101.24
Rate for Payer: BCBS MAPPO	$176.25
Rate for Payer: BCBS Trust/PPO	$55.60
Rate for Payer: BCN Medicare Advantage	$176.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$176.25
Rate for Payer: Mclaren Medicaid	$96.41
Rate for Payer: Mclaren Medicare	$176.25
Rate for Payer: Meridian Medicaid	$101.24
Rate for Payer: Meridian Wellcare - Medicare Advantage	$185.06
Rate for Payer: MI Amish Medical Board Commercial	$202.69
Rate for Payer: PACE Medicare	$167.44
Rate for Payer: PACE SWMI	$176.25
Rate for Payer: PHP Medicare Advantage	$176.25
Rate for Payer: Priority Health Choice Medicaid	$96.41
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$536.00
Rate for Payer: Priority Health Medicare	$176.25
Rate for Payer: Priority Health Narrow Network	$428.80
Rate for Payer: Railroad Medicare Medicare	$176.25
Rate for Payer: UHC All Payor (Choice/PPO)	$69.52
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Dual Complete DSNP	$176.25
Rate for Payer: UHC Exchange	$63.20
Rate for Payer: UHC Medicare Advantage	$181.54
Rate for Payer: VA VA	$176.25

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE)

Facility

$4,793.34

Service Code	CPT 31237
Hospital Revenue Code	360
Min. Negotiated Rate	$156.84
Max. Negotiated Rate	$4,793.34
Rate for Payer: Aetna Medicare	$1,570.62
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,887.76
Rate for Payer: Amish Plain Church Group Commercial	$1,887.76
Rate for Payer: BCBS Complete	$867.46
Rate for Payer: BCBS MAPPO	$1,510.21
Rate for Payer: BCBS Trust/PPO	$759.35
Rate for Payer: BCN Medicare Advantage	$1,510.21
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,510.21
Rate for Payer: Mclaren Medicaid	$826.08
Rate for Payer: Mclaren Medicare	$1,510.21
Rate for Payer: Meridian Medicaid	$867.46
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,585.72
Rate for Payer: MI Amish Medical Board Commercial	$1,736.74
Rate for Payer: PACE Medicare	$1,434.70
Rate for Payer: PACE SWMI	$1,510.21
Rate for Payer: PHP Medicare Advantage	$1,510.21
Rate for Payer: Priority Health Choice Medicaid	$826.08
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,793.34
Rate for Payer: Priority Health Medicare	$1,510.21
Rate for Payer: Priority Health Narrow Network	$3,834.67
Rate for Payer: Railroad Medicare Medicare	$1,510.21
Rate for Payer: UHC All Payor (Choice/PPO)	$172.52
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,510.21
Rate for Payer: UHC Exchange	$156.84
Rate for Payer: UHC Medicare Advantage	$1,555.52
Rate for Payer: VA VA	$1,510.21

NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION

Facility

$4,793.34

Service Code	CPT 31240
Hospital Revenue Code	360
Min. Negotiated Rate	$155.86
Max. Negotiated Rate	$4,793.34
Rate for Payer: Aetna Medicare	$1,570.62
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,887.76
Rate for Payer: Amish Plain Church Group Commercial	$1,887.76
Rate for Payer: BCBS Complete	$867.46
Rate for Payer: BCBS MAPPO	$1,510.21
Rate for Payer: BCBS Trust/PPO	$1,035.28
Rate for Payer: BCN Medicare Advantage	$1,510.21
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,510.21
Rate for Payer: Mclaren Medicaid	$826.08
Rate for Payer: Mclaren Medicare	$1,510.21
Rate for Payer: Meridian Medicaid	$867.46
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,585.72
Rate for Payer: MI Amish Medical Board Commercial	$1,736.74
Rate for Payer: PACE Medicare	$1,434.70
Rate for Payer: PACE SWMI	$1,510.21
Rate for Payer: PHP Medicare Advantage	$1,510.21
Rate for Payer: Priority Health Choice Medicaid	$826.08
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,793.34
Rate for Payer: Priority Health Medicare	$1,510.21
Rate for Payer: Priority Health Narrow Network	$3,834.67
Rate for Payer: Railroad Medicare Medicare	$1,510.21
Rate for Payer: UHC All Payor (Choice/PPO)	$171.45
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,510.21
Rate for Payer: UHC Exchange	$155.86
Rate for Payer: UHC Medicare Advantage	$1,555.52
Rate for Payer: VA VA	$1,510.21

Know your out-of-pocket cost for care.

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