Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

INSERTION OF BREAST IMPLANT ON SAME DAY OF MASTECTOMY (IE, IMMEDIATE)

Facility

$17,903.47

Service Code	CPT 19340
Hospital Revenue Code	360
Min. Negotiated Rate	$3,409.09
Max. Negotiated Rate	$17,903.47
Rate for Payer: Aetna Medicare	$6,614.66
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,950.31
Rate for Payer: Amish Plain Church Group Commercial	$7,950.31
Rate for Payer: BCBS Complete	$3,579.55
Rate for Payer: BCBS MAPPO	$6,360.25
Rate for Payer: BCN Medicare Advantage	$6,360.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,360.25
Rate for Payer: Mclaren Medicaid	$3,409.09
Rate for Payer: Mclaren Medicare	$6,360.25
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,678.26
Rate for Payer: Meridian Medicaid	$3,579.55
Rate for Payer: MI Amish Medical Board Commercial	$7,314.29
Rate for Payer: PACE Medicare	$6,042.24
Rate for Payer: PACE SWMI	$6,360.25
Rate for Payer: PHP Medicare Advantage	$6,360.25
Rate for Payer: Priority Health Choice Medicaid	$3,409.09
Rate for Payer: Priority Health Medicare	$6,360.25
Rate for Payer: Railroad Medicare Medicare	$6,360.25
Rate for Payer: UHC All Payor (Choice/PPO)	$17,903.47
Rate for Payer: UHC Dual Complete DSNP	$6,360.25
Rate for Payer: UHC Medicare Advantage	$6,360.25
Rate for Payer: UHCCP Medicaid	$3,580.82
Rate for Payer: VA VA	$6,360.25

INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF

Facility

$55,259.25

Service Code	CPT 53445
Hospital Revenue Code	360
Min. Negotiated Rate	$10,522.21
Max. Negotiated Rate	$55,259.25
Rate for Payer: Aetna Medicare	$20,416.22
Rate for Payer: Allen County Amish Medical Aid Commercial	$24,538.72
Rate for Payer: Amish Plain Church Group Commercial	$24,538.72
Rate for Payer: BCBS Complete	$11,048.32
Rate for Payer: BCBS MAPPO	$19,630.98
Rate for Payer: BCN Medicare Advantage	$19,630.98
Rate for Payer: Health Alliance Plan Medicare Advantage	$19,630.98
Rate for Payer: Mclaren Medicaid	$10,522.21
Rate for Payer: Mclaren Medicare	$19,630.98
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$20,612.53
Rate for Payer: Meridian Medicaid	$11,048.32
Rate for Payer: MI Amish Medical Board Commercial	$22,575.63
Rate for Payer: PACE Medicare	$18,649.43
Rate for Payer: PACE SWMI	$19,630.98
Rate for Payer: PHP Medicare Advantage	$19,630.98
Rate for Payer: Priority Health Choice Medicaid	$10,522.21
Rate for Payer: Priority Health Medicare	$19,630.98
Rate for Payer: Railroad Medicare Medicare	$19,630.98
Rate for Payer: UHC All Payor (Choice/PPO)	$55,259.25
Rate for Payer: UHC Dual Complete DSNP	$19,630.98
Rate for Payer: UHC Medicare Advantage	$19,630.98
Rate for Payer: UHCCP Medicaid	$11,052.24
Rate for Payer: VA VA	$19,630.98

INSERTION OF INTRAVASCULAR VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE (ULTRASOUND AND FLUOROSCOPY), WHEN PERFORMED

Facility

$14,840.35

Service Code	CPT 37191
Hospital Revenue Code	360
Min. Negotiated Rate	$2,825.83
Max. Negotiated Rate	$14,840.35
Rate for Payer: Aetna Medicare	$5,482.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,590.09
Rate for Payer: Amish Plain Church Group Commercial	$6,590.09
Rate for Payer: BCBS Complete	$2,967.12
Rate for Payer: BCBS MAPPO	$5,272.07
Rate for Payer: BCN Medicare Advantage	$5,272.07
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,272.07
Rate for Payer: Mclaren Medicaid	$2,825.83
Rate for Payer: Mclaren Medicare	$5,272.07
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5,535.67
Rate for Payer: Meridian Medicaid	$2,967.12
Rate for Payer: MI Amish Medical Board Commercial	$6,062.88
Rate for Payer: PACE Medicare	$5,008.47
Rate for Payer: PACE SWMI	$5,272.07
Rate for Payer: PHP Medicare Advantage	$5,272.07
Rate for Payer: Priority Health Choice Medicaid	$2,825.83
Rate for Payer: Priority Health Medicare	$5,272.07
Rate for Payer: Railroad Medicare Medicare	$5,272.07
Rate for Payer: UHC All Payor (Choice/PPO)	$14,840.35
Rate for Payer: UHC Dual Complete DSNP	$5,272.07
Rate for Payer: UHC Medicare Advantage	$5,272.07
Rate for Payer: UHCCP Medicaid	$2,968.18
Rate for Payer: VA VA	$5,272.07

INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR

Facility

$55,259.25

Service Code	CPT 54405
Hospital Revenue Code	360
Min. Negotiated Rate	$10,522.21
Max. Negotiated Rate	$55,259.25
Rate for Payer: Aetna Medicare	$20,416.22
Rate for Payer: Allen County Amish Medical Aid Commercial	$24,538.72
Rate for Payer: Amish Plain Church Group Commercial	$24,538.72
Rate for Payer: BCBS Complete	$11,048.32
Rate for Payer: BCBS MAPPO	$19,630.98
Rate for Payer: BCN Medicare Advantage	$19,630.98
Rate for Payer: Health Alliance Plan Medicare Advantage	$19,630.98
Rate for Payer: Mclaren Medicaid	$10,522.21
Rate for Payer: Mclaren Medicare	$19,630.98
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$20,612.53
Rate for Payer: Meridian Medicaid	$11,048.32
Rate for Payer: MI Amish Medical Board Commercial	$22,575.63
Rate for Payer: PACE Medicare	$18,649.43
Rate for Payer: PACE SWMI	$19,630.98
Rate for Payer: PHP Medicare Advantage	$19,630.98
Rate for Payer: Priority Health Choice Medicaid	$10,522.21
Rate for Payer: Priority Health Medicare	$19,630.98
Rate for Payer: Railroad Medicare Medicare	$19,630.98
Rate for Payer: UHC All Payor (Choice/PPO)	$55,259.25
Rate for Payer: UHC Dual Complete DSNP	$19,630.98
Rate for Payer: UHC Medicare Advantage	$19,630.98
Rate for Payer: UHCCP Medicaid	$11,052.24
Rate for Payer: VA VA	$19,630.98

INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID)

Facility

$35,668.30

Service Code	CPT 54400
Hospital Revenue Code	360
Min. Negotiated Rate	$6,791.79
Max. Negotiated Rate	$35,668.30
Rate for Payer: Aetna Medicare	$13,178.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$15,839.06
Rate for Payer: Amish Plain Church Group Commercial	$15,839.06
Rate for Payer: BCBS Complete	$7,131.38
Rate for Payer: BCBS MAPPO	$12,671.25
Rate for Payer: BCN Medicare Advantage	$12,671.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,671.25
Rate for Payer: Mclaren Medicaid	$6,791.79
Rate for Payer: Mclaren Medicare	$12,671.25
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$13,304.81
Rate for Payer: Meridian Medicaid	$7,131.38
Rate for Payer: MI Amish Medical Board Commercial	$14,571.94
Rate for Payer: PACE Medicare	$12,037.69
Rate for Payer: PACE SWMI	$12,671.25
Rate for Payer: PHP Medicare Advantage	$12,671.25
Rate for Payer: Priority Health Choice Medicaid	$6,791.79
Rate for Payer: Priority Health Medicare	$12,671.25
Rate for Payer: Railroad Medicare Medicare	$12,671.25
Rate for Payer: UHC All Payor (Choice/PPO)	$35,668.30
Rate for Payer: UHC Dual Complete DSNP	$12,671.25
Rate for Payer: UHC Medicare Advantage	$12,671.25
Rate for Payer: UHCCP Medicaid	$7,133.91
Rate for Payer: VA VA	$12,671.25

INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON)

Facility

$429.53

Service Code	CPT 51703
Hospital Revenue Code	360
Min. Negotiated Rate	$81.79
Max. Negotiated Rate	$429.53
Rate for Payer: Aetna Medicare	$158.69
Rate for Payer: Allen County Amish Medical Aid Commercial	$190.74
Rate for Payer: Amish Plain Church Group Commercial	$190.74
Rate for Payer: BCBS Complete	$85.88
Rate for Payer: BCBS MAPPO	$152.59
Rate for Payer: BCN Medicare Advantage	$152.59
Rate for Payer: Health Alliance Plan Medicare Advantage	$152.59
Rate for Payer: Mclaren Medicaid	$81.79
Rate for Payer: Mclaren Medicare	$152.59
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$160.22
Rate for Payer: Meridian Medicaid	$85.88
Rate for Payer: MI Amish Medical Board Commercial	$175.48
Rate for Payer: PACE Medicare	$144.96
Rate for Payer: PACE SWMI	$152.59
Rate for Payer: PHP Medicare Advantage	$152.59
Rate for Payer: Priority Health Choice Medicaid	$81.79
Rate for Payer: Priority Health Medicare	$152.59
Rate for Payer: Railroad Medicare Medicare	$152.59
Rate for Payer: UHC All Payor (Choice/PPO)	$429.53
Rate for Payer: UHC Dual Complete DSNP	$152.59
Rate for Payer: UHC Medicare Advantage	$152.59
Rate for Payer: UHCCP Medicaid	$85.91
Rate for Payer: VA VA	$152.59

INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE)

Facility

$13,956.13

Service Code	CPT 54660
Hospital Revenue Code	360
Min. Negotiated Rate	$2,657.46
Max. Negotiated Rate	$13,956.13
Rate for Payer: Aetna Medicare	$5,156.27
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,197.44
Rate for Payer: Amish Plain Church Group Commercial	$6,197.44
Rate for Payer: BCBS Complete	$2,790.33
Rate for Payer: BCBS MAPPO	$4,957.95
Rate for Payer: BCN Medicare Advantage	$4,957.95
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,957.95
Rate for Payer: Mclaren Medicaid	$2,657.46
Rate for Payer: Mclaren Medicare	$4,957.95
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$5,205.85
Rate for Payer: Meridian Medicaid	$2,790.33
Rate for Payer: MI Amish Medical Board Commercial	$5,701.64
Rate for Payer: PACE Medicare	$4,710.05
Rate for Payer: PACE SWMI	$4,957.95
Rate for Payer: PHP Medicare Advantage	$4,957.95
Rate for Payer: Priority Health Choice Medicaid	$2,657.46
Rate for Payer: Priority Health Medicare	$4,957.95
Rate for Payer: Railroad Medicare Medicare	$4,957.95
Rate for Payer: UHC All Payor (Choice/PPO)	$13,956.13
Rate for Payer: UHC Dual Complete DSNP	$4,957.95
Rate for Payer: UHC Medicare Advantage	$4,957.95
Rate for Payer: UHCCP Medicaid	$2,791.33
Rate for Payer: VA VA	$4,957.95

INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER

Facility

$8,640.87

Service Code	CPT 36561
Hospital Revenue Code	360
Min. Negotiated Rate	$1,645.35
Max. Negotiated Rate	$8,640.87
Rate for Payer: Aetna Medicare	$3,192.48
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,837.11
Rate for Payer: Amish Plain Church Group Commercial	$3,837.11
Rate for Payer: BCBS Complete	$1,727.62
Rate for Payer: BCBS MAPPO	$3,069.69
Rate for Payer: BCN Medicare Advantage	$3,069.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,069.69
Rate for Payer: Mclaren Medicaid	$1,645.35
Rate for Payer: Mclaren Medicare	$3,069.69
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,223.17
Rate for Payer: Meridian Medicaid	$1,727.62
Rate for Payer: MI Amish Medical Board Commercial	$3,530.14
Rate for Payer: PACE Medicare	$2,916.21
Rate for Payer: PACE SWMI	$3,069.69
Rate for Payer: PHP Medicare Advantage	$3,069.69
Rate for Payer: Priority Health Choice Medicaid	$1,645.35
Rate for Payer: Priority Health Medicare	$3,069.69
Rate for Payer: Railroad Medicare Medicare	$3,069.69
Rate for Payer: UHC All Payor (Choice/PPO)	$8,640.87
Rate for Payer: UHC Dual Complete DSNP	$3,069.69
Rate for Payer: UHC Medicare Advantage	$3,069.69
Rate for Payer: UHCCP Medicaid	$1,728.24
Rate for Payer: VA VA	$3,069.69

INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER

Facility

$8,640.87

Service Code	CPT 36558
Hospital Revenue Code	360
Min. Negotiated Rate	$1,645.35
Max. Negotiated Rate	$8,640.87
Rate for Payer: Aetna Medicare	$3,192.48
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,837.11
Rate for Payer: Amish Plain Church Group Commercial	$3,837.11
Rate for Payer: BCBS Complete	$1,727.62
Rate for Payer: BCBS MAPPO	$3,069.69
Rate for Payer: BCN Medicare Advantage	$3,069.69
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,069.69
Rate for Payer: Mclaren Medicaid	$1,645.35
Rate for Payer: Mclaren Medicare	$3,069.69
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,223.17
Rate for Payer: Meridian Medicaid	$1,727.62
Rate for Payer: MI Amish Medical Board Commercial	$3,530.14
Rate for Payer: PACE Medicare	$2,916.21
Rate for Payer: PACE SWMI	$3,069.69
Rate for Payer: PHP Medicare Advantage	$3,069.69
Rate for Payer: Priority Health Choice Medicaid	$1,645.35
Rate for Payer: Priority Health Medicare	$3,069.69
Rate for Payer: Railroad Medicare Medicare	$3,069.69
Rate for Payer: UHC All Payor (Choice/PPO)	$8,640.87
Rate for Payer: UHC Dual Complete DSNP	$3,069.69
Rate for Payer: UHC Medicare Advantage	$3,069.69
Rate for Payer: UHCCP Medicaid	$1,728.24
Rate for Payer: VA VA	$3,069.69

INSERTION OF TUNNELED INTRAPERITONEAL CATHETER FOR DIALYSIS, OPEN

Facility

$9,688.38

Service Code	CPT 49421
Hospital Revenue Code	360
Min. Negotiated Rate	$1,844.82
Max. Negotiated Rate	$9,688.38
Rate for Payer: Aetna Medicare	$3,579.49
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,302.27
Rate for Payer: Amish Plain Church Group Commercial	$4,302.27
Rate for Payer: BCBS Complete	$1,937.06
Rate for Payer: BCBS MAPPO	$3,441.82
Rate for Payer: BCN Medicare Advantage	$3,441.82
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,441.82
Rate for Payer: Mclaren Medicaid	$1,844.82
Rate for Payer: Mclaren Medicare	$3,441.82
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,613.91
Rate for Payer: Meridian Medicaid	$1,937.06
Rate for Payer: MI Amish Medical Board Commercial	$3,958.09
Rate for Payer: PACE Medicare	$3,269.73
Rate for Payer: PACE SWMI	$3,441.82
Rate for Payer: PHP Medicare Advantage	$3,441.82
Rate for Payer: Priority Health Choice Medicaid	$1,844.82
Rate for Payer: Priority Health Medicare	$3,441.82
Rate for Payer: Railroad Medicare Medicare	$3,441.82
Rate for Payer: UHC All Payor (Choice/PPO)	$9,688.38
Rate for Payer: UHC Dual Complete DSNP	$3,441.82
Rate for Payer: UHC Medicare Advantage	$3,441.82
Rate for Payer: UHCCP Medicaid	$1,937.74
Rate for Payer: VA VA	$3,441.82

INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY

Facility

$26,270.05

Service Code	CPT 19342
Hospital Revenue Code	360
Min. Negotiated Rate	$5,002.22
Max. Negotiated Rate	$26,270.05
Rate for Payer: Aetna Medicare	$9,705.80
Rate for Payer: Allen County Amish Medical Aid Commercial	$11,665.62
Rate for Payer: Amish Plain Church Group Commercial	$11,665.62
Rate for Payer: BCBS Complete	$5,252.33
Rate for Payer: BCBS MAPPO	$9,332.50
Rate for Payer: BCN Medicare Advantage	$9,332.50
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,332.50
Rate for Payer: Mclaren Medicaid	$5,002.22
Rate for Payer: Mclaren Medicare	$9,332.50
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$9,799.12
Rate for Payer: Meridian Medicaid	$5,252.33
Rate for Payer: MI Amish Medical Board Commercial	$10,732.38
Rate for Payer: PACE Medicare	$8,865.88
Rate for Payer: PACE SWMI	$9,332.50
Rate for Payer: PHP Medicare Advantage	$9,332.50
Rate for Payer: Priority Health Choice Medicaid	$5,002.22
Rate for Payer: Priority Health Medicare	$9,332.50
Rate for Payer: Railroad Medicare Medicare	$9,332.50
Rate for Payer: UHC All Payor (Choice/PPO)	$26,270.05
Rate for Payer: UHC Dual Complete DSNP	$9,332.50
Rate for Payer: UHC Medicare Advantage	$9,332.50
Rate for Payer: UHCCP Medicaid	$5,254.20
Rate for Payer: VA VA	$9,332.50

INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER

Facility

$58,871.61

Service Code	CPT 64590
Hospital Revenue Code	360
Min. Negotiated Rate	$11,210.05
Max. Negotiated Rate	$58,871.61
Rate for Payer: Aetna Medicare	$21,750.85
Rate for Payer: Allen County Amish Medical Aid Commercial	$26,142.85
Rate for Payer: Amish Plain Church Group Commercial	$26,142.85
Rate for Payer: BCBS Complete	$11,770.56
Rate for Payer: BCBS MAPPO	$20,914.28
Rate for Payer: BCN Medicare Advantage	$20,914.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$20,914.28
Rate for Payer: Mclaren Medicaid	$11,210.05
Rate for Payer: Mclaren Medicare	$20,914.28
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$21,959.99
Rate for Payer: Meridian Medicaid	$11,770.56
Rate for Payer: MI Amish Medical Board Commercial	$24,051.42
Rate for Payer: PACE Medicare	$19,868.57
Rate for Payer: PACE SWMI	$20,914.28
Rate for Payer: PHP Medicare Advantage	$20,914.28
Rate for Payer: Priority Health Choice Medicaid	$11,210.05
Rate for Payer: Priority Health Medicare	$20,914.28
Rate for Payer: Railroad Medicare Medicare	$20,914.28
Rate for Payer: UHC All Payor (Choice/PPO)	$58,871.61
Rate for Payer: UHC Dual Complete DSNP	$20,914.28
Rate for Payer: UHC Medicare Advantage	$20,914.28
Rate for Payer: UHCCP Medicaid	$11,774.74
Rate for Payer: VA VA	$20,914.28

INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER

Facility

$83,659.62

Service Code	CPT 63685
Hospital Revenue Code	360
Min. Negotiated Rate	$15,930.07
Max. Negotiated Rate	$83,659.62
Rate for Payer: Aetna Medicare	$30,909.09
Rate for Payer: Allen County Amish Medical Aid Commercial	$37,150.35
Rate for Payer: Amish Plain Church Group Commercial	$37,150.35
Rate for Payer: BCBS Complete	$16,726.57
Rate for Payer: BCBS MAPPO	$29,720.28
Rate for Payer: BCN Medicare Advantage	$29,720.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$29,720.28
Rate for Payer: Mclaren Medicaid	$15,930.07
Rate for Payer: Mclaren Medicare	$29,720.28
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$31,206.29
Rate for Payer: Meridian Medicaid	$16,726.57
Rate for Payer: MI Amish Medical Board Commercial	$34,178.32
Rate for Payer: PACE Medicare	$28,234.27
Rate for Payer: PACE SWMI	$29,720.28
Rate for Payer: PHP Medicare Advantage	$29,720.28
Rate for Payer: Priority Health Choice Medicaid	$15,930.07
Rate for Payer: Priority Health Medicare	$29,720.28
Rate for Payer: Railroad Medicare Medicare	$29,720.28
Rate for Payer: UHC All Payor (Choice/PPO)	$83,659.62
Rate for Payer: UHC Dual Complete DSNP	$29,720.28
Rate for Payer: UHC Medicare Advantage	$29,720.28
Rate for Payer: UHCCP Medicaid	$16,732.52
Rate for Payer: VA VA	$29,720.28

INSULIN 1 UNIT/ ML INFUSION 100 ML (IV PREMIX)

Facility

$77.40

Service Code	NDC 09900001834
Hospital Charge Code	300906
Hospital Revenue Code	250
Min. Negotiated Rate	$30.96
Max. Negotiated Rate	$69.66
Rate for Payer: Aetna Commercial	$65.79
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: Aetna New Business (MI Preferred)	$50.31
Rate for Payer: BCBS Complete	$30.96
Rate for Payer: Cash Price	$61.92
Rate for Payer: Cofinity Commercial	$66.56
Rate for Payer: Cofinity Commercial	$54.18
Rate for Payer: Cofinity Medicare Advantage	$54.18
Rate for Payer: Encore Health Key Benefits Commercial	$61.92
Rate for Payer: Healthscope Commercial	$69.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.79
Rate for Payer: PHP Commercial	$65.79
Rate for Payer: Priority Health Cigna Priority Health	$50.31
Rate for Payer: Priority Health SBD	$48.76

INSULIN 1 UNIT/ ML INFUSION 100 ML (IV PREMIX)

Facility

$77.40

Service Code	NDC 09900001834
Hospital Charge Code	300906
Hospital Revenue Code	250
Min. Negotiated Rate	$48.76
Max. Negotiated Rate	$69.66
Rate for Payer: Aetna Commercial	$65.79
Rate for Payer: Aetna New Business (MI Preferred)	$50.31
Rate for Payer: Cash Price	$61.92
Rate for Payer: Cofinity Commercial	$54.18
Rate for Payer: Cofinity Commercial	$66.56
Rate for Payer: Cofinity Medicare Advantage	$54.18
Rate for Payer: Encore Health Key Benefits Commercial	$61.92
Rate for Payer: Healthscope Commercial	$69.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.79
Rate for Payer: PHP Commercial	$65.79
Rate for Payer: Priority Health Cigna Priority Health	$50.31
Rate for Payer: Priority Health SBD	$48.76

INSULIN 5 UNIT/5 ML IV PUSH 5 ML

Facility

$20.00

Service Code	NDC 09900001138
Hospital Charge Code	300205
Hospital Revenue Code	637
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

INSULIN 5 UNIT/5 ML IV PUSH 5 ML

Facility

$20.00

Service Code	NDC 09900001138
Hospital Charge Code	300205
Hospital Revenue Code	637
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

INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM

Facility

$63.94

Service Code	NDC 73070010310
Hospital Charge Code	300798
Hospital Revenue Code	637
Min. Negotiated Rate	$40.28
Max. Negotiated Rate	$57.55
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: Aetna New Business (MI Preferred)	$41.56
Rate for Payer: Cash Price	$51.15
Rate for Payer: Cofinity Commercial	$44.76
Rate for Payer: Cofinity Commercial	$54.99
Rate for Payer: Cofinity Medicare Advantage	$44.76
Rate for Payer: Encore Health Key Benefits Commercial	$51.15
Rate for Payer: Healthscope Commercial	$57.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.35
Rate for Payer: PHP Commercial	$54.35
Rate for Payer: Priority Health Cigna Priority Health	$41.56
Rate for Payer: Priority Health SBD	$40.28

INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM

Facility

$63.94

Service Code	NDC 00169633910
Hospital Charge Code	300798
Hospital Revenue Code	637
Min. Negotiated Rate	$40.28
Max. Negotiated Rate	$57.55
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: Aetna New Business (MI Preferred)	$41.56
Rate for Payer: Cash Price	$51.15
Rate for Payer: Cofinity Commercial	$44.76
Rate for Payer: Cofinity Commercial	$54.99
Rate for Payer: Cofinity Medicare Advantage	$44.76
Rate for Payer: Encore Health Key Benefits Commercial	$51.15
Rate for Payer: Healthscope Commercial	$57.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.35
Rate for Payer: PHP Commercial	$54.35
Rate for Payer: Priority Health Cigna Priority Health	$41.56
Rate for Payer: Priority Health SBD	$40.28

INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM

Facility

$63.94

Service Code	NDC 73070010315
Hospital Charge Code	300798
Hospital Revenue Code	637
Min. Negotiated Rate	$40.28
Max. Negotiated Rate	$57.55
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: Aetna New Business (MI Preferred)	$41.56
Rate for Payer: Cash Price	$51.15
Rate for Payer: Cofinity Commercial	$44.76
Rate for Payer: Cofinity Commercial	$54.99
Rate for Payer: Cofinity Medicare Advantage	$44.76
Rate for Payer: Encore Health Key Benefits Commercial	$51.15
Rate for Payer: Healthscope Commercial	$57.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.35
Rate for Payer: PHP Commercial	$54.35
Rate for Payer: Priority Health Cigna Priority Health	$41.56
Rate for Payer: Priority Health SBD	$40.28

INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM

Facility

$63.94

Service Code	NDC 73070010310
Hospital Charge Code	300798
Hospital Revenue Code	637
Min. Negotiated Rate	$25.58
Max. Negotiated Rate	$57.55
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: Aetna Medicare	$31.97
Rate for Payer: Aetna New Business (MI Preferred)	$41.56
Rate for Payer: BCBS Complete	$25.58
Rate for Payer: Cash Price	$51.15
Rate for Payer: Cofinity Commercial	$44.76
Rate for Payer: Cofinity Commercial	$54.99
Rate for Payer: Cofinity Medicare Advantage	$44.76
Rate for Payer: Encore Health Key Benefits Commercial	$51.15
Rate for Payer: Healthscope Commercial	$57.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.35
Rate for Payer: PHP Commercial	$54.35
Rate for Payer: Priority Health Cigna Priority Health	$41.56
Rate for Payer: Priority Health SBD	$40.28

INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM

Facility

$63.94

Service Code	NDC 00169633910
Hospital Charge Code	300798
Hospital Revenue Code	637
Min. Negotiated Rate	$25.58
Max. Negotiated Rate	$57.55
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: Aetna Medicare	$31.97
Rate for Payer: Aetna New Business (MI Preferred)	$41.56
Rate for Payer: BCBS Complete	$25.58
Rate for Payer: Cash Price	$51.15
Rate for Payer: Cofinity Commercial	$44.76
Rate for Payer: Cofinity Commercial	$54.99
Rate for Payer: Cofinity Medicare Advantage	$44.76
Rate for Payer: Encore Health Key Benefits Commercial	$51.15
Rate for Payer: Healthscope Commercial	$57.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.35
Rate for Payer: PHP Commercial	$54.35
Rate for Payer: Priority Health Cigna Priority Health	$41.56
Rate for Payer: Priority Health SBD	$40.28

INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM

Facility

$63.94

Service Code	NDC 73070010315
Hospital Charge Code	300798
Hospital Revenue Code	637
Min. Negotiated Rate	$25.58
Max. Negotiated Rate	$57.55
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: Aetna Medicare	$31.97
Rate for Payer: Aetna New Business (MI Preferred)	$41.56
Rate for Payer: BCBS Complete	$25.58
Rate for Payer: Cash Price	$51.15
Rate for Payer: Cofinity Commercial	$44.76
Rate for Payer: Cofinity Commercial	$54.99
Rate for Payer: Cofinity Medicare Advantage	$44.76
Rate for Payer: Encore Health Key Benefits Commercial	$51.15
Rate for Payer: Healthscope Commercial	$57.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.35
Rate for Payer: PHP Commercial	$54.35
Rate for Payer: Priority Health Cigna Priority Health	$41.56
Rate for Payer: Priority Health SBD	$40.28

INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM OB

Facility

$63.94

Service Code	NDC 00169633910
Hospital Charge Code	301084
Hospital Revenue Code	637
Min. Negotiated Rate	$25.58
Max. Negotiated Rate	$57.55
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: Aetna Medicare	$31.97
Rate for Payer: Aetna New Business (MI Preferred)	$41.56
Rate for Payer: BCBS Complete	$25.58
Rate for Payer: Cash Price	$51.15
Rate for Payer: Cofinity Commercial	$44.76
Rate for Payer: Cofinity Commercial	$54.99
Rate for Payer: Cofinity Medicare Advantage	$44.76
Rate for Payer: Encore Health Key Benefits Commercial	$51.15
Rate for Payer: Healthscope Commercial	$57.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.35
Rate for Payer: PHP Commercial	$54.35
Rate for Payer: Priority Health Cigna Priority Health	$41.56
Rate for Payer: Priority Health SBD	$40.28

INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) HIGH DOSE SUBCUTANEOUS PEN CUSTOM OB

Facility

$63.94

Service Code	NDC 73070010315
Hospital Charge Code	301084
Hospital Revenue Code	637
Min. Negotiated Rate	$25.58
Max. Negotiated Rate	$57.55
Rate for Payer: Aetna Commercial	$54.35
Rate for Payer: Aetna Medicare	$31.97
Rate for Payer: Aetna New Business (MI Preferred)	$41.56
Rate for Payer: BCBS Complete	$25.58
Rate for Payer: Cash Price	$51.15
Rate for Payer: Cofinity Commercial	$44.76
Rate for Payer: Cofinity Commercial	$54.99
Rate for Payer: Cofinity Medicare Advantage	$44.76
Rate for Payer: Encore Health Key Benefits Commercial	$51.15
Rate for Payer: Healthscope Commercial	$57.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.35
Rate for Payer: PHP Commercial	$54.35
Rate for Payer: Priority Health Cigna Priority Health	$41.56
Rate for Payer: Priority Health SBD	$40.28

Know your out-of-pocket cost for care.

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