Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CYCLOBENZAPRINE 5 MG TABLET

Facility

$103.40

Service Code	NDC 10702-006-01
Hospital Charge Code	35184
Hospital Revenue Code	637
Min. Negotiated Rate	$65.14
Max. Negotiated Rate	$93.06
Rate for Payer: Aetna Commercial	$87.89
Rate for Payer: Aetna New Business (MI Preferred)	$67.21
Rate for Payer: Cash Price	$82.72
Rate for Payer: Cofinity Commercial	$72.38
Rate for Payer: Cofinity Commercial	$88.92
Rate for Payer: Healthscope Commercial	$93.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$87.89
Rate for Payer: PHP Commercial	$87.89
Rate for Payer: Priority Health Cigna Priority Health	$72.38
Rate for Payer: Priority Health SBD	$65.14

CYCLOPENTOLATE 1 % EYE DROPS

Facility

$94.64

Service Code	NDC 0065-0396-02
Hospital Charge Code	2025
Hospital Revenue Code	637
Min. Negotiated Rate	$59.62
Max. Negotiated Rate	$85.18
Rate for Payer: Aetna Commercial	$80.44
Rate for Payer: Aetna New Business (MI Preferred)	$61.52
Rate for Payer: Cash Price	$75.71
Rate for Payer: Cofinity Commercial	$66.25
Rate for Payer: Cofinity Commercial	$81.39
Rate for Payer: Healthscope Commercial	$85.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$80.44
Rate for Payer: PHP Commercial	$80.44
Rate for Payer: Priority Health Cigna Priority Health	$66.25
Rate for Payer: Priority Health SBD	$59.62

CYCLOPENTOLATE 1 % EYE DROPS

Facility

$40.25

Service Code	NDC 24208-735-01
Hospital Charge Code	2025
Hospital Revenue Code	637
Min. Negotiated Rate	$25.36
Max. Negotiated Rate	$36.22
Rate for Payer: Aetna Commercial	$34.21
Rate for Payer: Aetna New Business (MI Preferred)	$26.16
Rate for Payer: Cash Price	$32.20
Rate for Payer: Cofinity Commercial	$28.18
Rate for Payer: Cofinity Commercial	$34.62
Rate for Payer: Healthscope Commercial	$36.22
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.21
Rate for Payer: PHP Commercial	$34.21
Rate for Payer: Priority Health Cigna Priority Health	$28.18
Rate for Payer: Priority Health SBD	$25.36

CYCLOPENTOLATE 1 % EYE DROPS

Facility

$18.86

Service Code	NDC 17478-100-02
Hospital Charge Code	2025
Hospital Revenue Code	637
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$16.97
Rate for Payer: Aetna Commercial	$16.03
Rate for Payer: Aetna New Business (MI Preferred)	$12.26
Rate for Payer: Cash Price	$15.09
Rate for Payer: Cofinity Commercial	$13.20
Rate for Payer: Cofinity Commercial	$16.22
Rate for Payer: Healthscope Commercial	$16.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.03
Rate for Payer: PHP Commercial	$16.03
Rate for Payer: Priority Health Cigna Priority Health	$13.20
Rate for Payer: Priority Health SBD	$11.88

CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION

Facility

$2,526.83

Service Code	HCPCS J9070
Hospital Charge Code	194691
Hospital Revenue Code	636
Min. Negotiated Rate	$11.02
Max. Negotiated Rate	$2,274.15
Rate for Payer: Aetna Commercial	$2,147.81
Rate for Payer: Aetna Commercial	$2,090.88
Rate for Payer: Aetna Medicare	$20.96
Rate for Payer: Aetna Medicare	$20.96
Rate for Payer: Aetna New Business (MI Preferred)	$1,598.91
Rate for Payer: Aetna New Business (MI Preferred)	$1,642.44
Rate for Payer: Allen County Amish Medical Aid Commercial	$25.19
Rate for Payer: Allen County Amish Medical Aid Commercial	$25.19
Rate for Payer: Amish Plain Church Group Commercial	$25.19
Rate for Payer: Amish Plain Church Group Commercial	$25.19
Rate for Payer: BCBS Complete	$11.58
Rate for Payer: BCBS Complete	$11.58
Rate for Payer: BCBS MAPPO	$20.15
Rate for Payer: BCBS MAPPO	$20.15
Rate for Payer: BCBS Trust/PPO	$59.65
Rate for Payer: BCBS Trust/PPO	$59.65
Rate for Payer: BCN Medicare Advantage	$20.15
Rate for Payer: BCN Medicare Advantage	$20.15
Rate for Payer: Cash Price	$1,967.89
Rate for Payer: Cash Price	$2,021.46
Rate for Payer: Cash Price	$1,967.89
Rate for Payer: Cash Price	$2,021.46
Rate for Payer: Cofinity Commercial	$1,721.90
Rate for Payer: Cofinity Commercial	$2,115.48
Rate for Payer: Cofinity Commercial	$1,768.78
Rate for Payer: Cofinity Commercial	$2,173.07
Rate for Payer: Health Alliance Plan Medicare Advantage	$20.15
Rate for Payer: Health Alliance Plan Medicare Advantage	$20.15
Rate for Payer: Healthscope Commercial	$2,213.87
Rate for Payer: Healthscope Commercial	$2,274.15
Rate for Payer: Mclaren Medicaid	$11.02
Rate for Payer: Mclaren Medicaid	$11.02
Rate for Payer: Mclaren Medicare	$20.15
Rate for Payer: Mclaren Medicare	$20.15
Rate for Payer: Meridian Medicaid	$11.58
Rate for Payer: Meridian Medicaid	$11.58
Rate for Payer: Meridian Wellcare - Medicare Advantage	$21.16
Rate for Payer: Meridian Wellcare - Medicare Advantage	$21.16
Rate for Payer: MI Amish Medical Board Commercial	$23.18
Rate for Payer: MI Amish Medical Board Commercial	$23.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,090.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,147.81
Rate for Payer: PACE Medicare	$19.15
Rate for Payer: PACE Medicare	$19.15
Rate for Payer: PACE SWMI	$20.15
Rate for Payer: PACE SWMI	$20.15
Rate for Payer: PHP Commercial	$2,147.81
Rate for Payer: PHP Commercial	$2,090.88
Rate for Payer: PHP Medicare Advantage	$20.15
Rate for Payer: PHP Medicare Advantage	$20.15
Rate for Payer: Priority Health Choice Medicaid	$11.02
Rate for Payer: Priority Health Choice Medicaid	$11.02
Rate for Payer: Priority Health Cigna Priority Health	$1,768.78
Rate for Payer: Priority Health Cigna Priority Health	$1,721.90
Rate for Payer: Priority Health Medicare	$20.15
Rate for Payer: Priority Health Medicare	$20.15
Rate for Payer: Priority Health SBD	$1,591.90
Rate for Payer: Priority Health SBD	$1,549.71
Rate for Payer: Railroad Medicare Medicare	$20.15
Rate for Payer: Railroad Medicare Medicare	$20.15
Rate for Payer: UHC Dual Complete DSNP	$20.15
Rate for Payer: UHC Dual Complete DSNP	$20.15
Rate for Payer: UHC Medicare Advantage	$20.76
Rate for Payer: UHC Medicare Advantage	$20.76
Rate for Payer: VA VA	$20.15
Rate for Payer: VA VA	$20.15

CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION

Facility

$2,526.83

Service Code	HCPCS J9070
Hospital Charge Code	194691
Hospital Revenue Code	636
Min. Negotiated Rate	$1,591.90
Max. Negotiated Rate	$2,274.15
Rate for Payer: Aetna Commercial	$2,147.81
Rate for Payer: Aetna New Business (MI Preferred)	$1,642.44
Rate for Payer: Cash Price	$2,021.46
Rate for Payer: Cofinity Commercial	$1,768.78
Rate for Payer: Cofinity Commercial	$2,173.07
Rate for Payer: Healthscope Commercial	$2,274.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,147.81
Rate for Payer: PHP Commercial	$2,147.81
Rate for Payer: Priority Health Cigna Priority Health	$1,768.78
Rate for Payer: Priority Health SBD	$1,591.90

CYCLOSPORINE 25 MG CAPSULE

Facility

$436.35

Service Code	HCPCS J7515
Hospital Charge Code	9707
Hospital Revenue Code	636
Min. Negotiated Rate	$274.90
Max. Negotiated Rate	$392.72
Rate for Payer: Aetna Commercial	$370.90
Rate for Payer: Aetna New Business (MI Preferred)	$283.63
Rate for Payer: Cash Price	$349.08
Rate for Payer: Cofinity Commercial	$305.44
Rate for Payer: Cofinity Commercial	$375.26
Rate for Payer: Healthscope Commercial	$392.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$370.90
Rate for Payer: PHP Commercial	$370.90
Rate for Payer: Priority Health Cigna Priority Health	$305.44
Rate for Payer: Priority Health SBD	$274.90

CYCLOSPORINE MODIFIED 100 MG CAPSULE

Facility

$1,072.38

Service Code	HCPCS J7502
Hospital Charge Code	28843
Hospital Revenue Code	636
Min. Negotiated Rate	$675.60
Max. Negotiated Rate	$965.14
Rate for Payer: Aetna Commercial	$911.52
Rate for Payer: Aetna Commercial	$219.22
Rate for Payer: Aetna Commercial	$7.31
Rate for Payer: Aetna New Business (MI Preferred)	$167.64
Rate for Payer: Aetna New Business (MI Preferred)	$5.59
Rate for Payer: Aetna New Business (MI Preferred)	$697.05
Rate for Payer: Cash Price	$206.33
Rate for Payer: Cash Price	$6.88
Rate for Payer: Cash Price	$857.90
Rate for Payer: Cofinity Commercial	$180.54
Rate for Payer: Cofinity Commercial	$750.67
Rate for Payer: Cofinity Commercial	$922.25
Rate for Payer: Cofinity Commercial	$221.80
Rate for Payer: Cofinity Commercial	$6.02
Rate for Payer: Cofinity Commercial	$7.40
Rate for Payer: Healthscope Commercial	$7.74
Rate for Payer: Healthscope Commercial	$965.14
Rate for Payer: Healthscope Commercial	$232.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$219.22
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$911.52
Rate for Payer: PHP Commercial	$7.31
Rate for Payer: PHP Commercial	$911.52
Rate for Payer: PHP Commercial	$219.22
Rate for Payer: Priority Health Cigna Priority Health	$6.02
Rate for Payer: Priority Health Cigna Priority Health	$750.67
Rate for Payer: Priority Health Cigna Priority Health	$180.54
Rate for Payer: Priority Health SBD	$5.42
Rate for Payer: Priority Health SBD	$162.48
Rate for Payer: Priority Health SBD	$675.60

CYCLOSPORINE MODIFIED 25 MG CAPSULE

Facility

$268.40

Service Code	HCPCS J7515
Hospital Charge Code	28842
Hospital Revenue Code	636
Min. Negotiated Rate	$169.09
Max. Negotiated Rate	$241.56
Rate for Payer: Aetna Commercial	$228.14
Rate for Payer: Aetna New Business (MI Preferred)	$174.46
Rate for Payer: Cash Price	$214.72
Rate for Payer: Cofinity Commercial	$187.88
Rate for Payer: Cofinity Commercial	$230.82
Rate for Payer: Healthscope Commercial	$241.56
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$228.14
Rate for Payer: PHP Commercial	$228.14
Rate for Payer: Priority Health Cigna Priority Health	$187.88
Rate for Payer: Priority Health SBD	$169.09

CYPROHEPTADINE 4 MG TABLET

Facility

$223.25

Service Code	NDC 50268-189-15
Hospital Charge Code	2033
Hospital Revenue Code	637
Min. Negotiated Rate	$140.65
Max. Negotiated Rate	$200.92
Rate for Payer: Aetna Commercial	$189.76
Rate for Payer: Aetna New Business (MI Preferred)	$145.11
Rate for Payer: Cash Price	$178.60
Rate for Payer: Cofinity Commercial	$156.28
Rate for Payer: Cofinity Commercial	$192.00
Rate for Payer: Healthscope Commercial	$200.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$189.76
Rate for Payer: PHP Commercial	$189.76
Rate for Payer: Priority Health Cigna Priority Health	$156.28
Rate for Payer: Priority Health SBD	$140.65

CYPROHEPTADINE 4 MG TABLET

Facility

$229.90

Service Code	NDC 52817-210-10
Hospital Charge Code	2033
Hospital Revenue Code	637
Min. Negotiated Rate	$144.84
Max. Negotiated Rate	$206.91
Rate for Payer: Aetna Commercial	$195.42
Rate for Payer: Aetna New Business (MI Preferred)	$149.44
Rate for Payer: Cash Price	$183.92
Rate for Payer: Cofinity Commercial	$160.93
Rate for Payer: Cofinity Commercial	$197.71
Rate for Payer: Healthscope Commercial	$206.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$195.42
Rate for Payer: PHP Commercial	$195.42
Rate for Payer: Priority Health Cigna Priority Health	$160.93
Rate for Payer: Priority Health SBD	$144.84

CYPROHEPTADINE 4 MG TABLET

Facility

$4.47

Service Code	NDC 50268-189-11
Hospital Charge Code	2033
Hospital Revenue Code	637
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna New Business (MI Preferred)	$2.91
Rate for Payer: Cash Price	$3.58
Rate for Payer: Cofinity Commercial	$3.13
Rate for Payer: Cofinity Commercial	$3.84
Rate for Payer: Healthscope Commercial	$4.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.80
Rate for Payer: PHP Commercial	$3.80
Rate for Payer: Priority Health Cigna Priority Health	$3.13
Rate for Payer: Priority Health SBD	$2.82

CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE

Facility

$5,561.92

Service Code	CPT 51040
Hospital Revenue Code	360
Min. Negotiated Rate	$288.15
Max. Negotiated Rate	$5,561.92
Rate for Payer: Aetna Medicare	$1,884.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,265.42
Rate for Payer: Amish Plain Church Group Commercial	$2,265.42
Rate for Payer: BCBS Complete	$1,041.01
Rate for Payer: BCBS MAPPO	$1,812.34
Rate for Payer: BCBS Trust/PPO	$925.69
Rate for Payer: BCN Medicare Advantage	$1,812.34
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,812.34
Rate for Payer: Mclaren Medicaid	$991.35
Rate for Payer: Mclaren Medicare	$1,812.34
Rate for Payer: Meridian Medicaid	$1,041.01
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,902.96
Rate for Payer: MI Amish Medical Board Commercial	$2,084.19
Rate for Payer: PACE Medicare	$1,721.72
Rate for Payer: PACE SWMI	$1,812.34
Rate for Payer: PHP Medicare Advantage	$1,812.34
Rate for Payer: Priority Health Choice Medicaid	$991.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,561.92
Rate for Payer: Priority Health Medicare	$1,812.34
Rate for Payer: Priority Health Narrow Network	$4,449.54
Rate for Payer: Railroad Medicare Medicare	$1,812.34
Rate for Payer: UHC All Payor (Choice/PPO)	$316.96
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$288.15
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOTOMY; FOR EXCISION OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE (SEPARATE PROCEDURE)

Facility

$5,427.00

Service Code	CPT 51525
Hospital Revenue Code	360
Min. Negotiated Rate	$837.60
Max. Negotiated Rate	$5,427.00
Rate for Payer: BCBS Trust/PPO	$1,747.75
Rate for Payer: UHC All Payor (Choice/PPO)	$921.36
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Exchange	$837.60

CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF URETERAL CALCULUS

Facility

$9,573.02

Service Code	CPT 52320
Hospital Revenue Code	360
Min. Negotiated Rate	$237.40
Max. Negotiated Rate	$9,573.02
Rate for Payer: Aetna Medicare	$3,226.04
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,877.45
Rate for Payer: Amish Plain Church Group Commercial	$3,877.45
Rate for Payer: BCBS Complete	$1,781.77
Rate for Payer: BCBS MAPPO	$3,101.96
Rate for Payer: BCBS Trust/PPO	$1,564.94
Rate for Payer: BCN Medicare Advantage	$3,101.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,101.96
Rate for Payer: Mclaren Medicaid	$1,696.77
Rate for Payer: Mclaren Medicare	$3,101.96
Rate for Payer: Meridian Medicaid	$1,781.77
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,257.06
Rate for Payer: MI Amish Medical Board Commercial	$3,567.25
Rate for Payer: PACE Medicare	$2,946.86
Rate for Payer: PACE SWMI	$3,101.96
Rate for Payer: PHP Medicare Advantage	$3,101.96
Rate for Payer: Priority Health Choice Medicaid	$1,696.77
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,573.02
Rate for Payer: Priority Health Medicare	$3,101.96
Rate for Payer: Priority Health Narrow Network	$7,658.42
Rate for Payer: Railroad Medicare Medicare	$3,101.96
Rate for Payer: UHC All Payor (Choice/PPO)	$261.14
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$237.40
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH SUBURETERIC INJECTION OF IMPLANT MATERIAL

Facility

$13,737.10

Service Code	CPT 52327
Hospital Revenue Code	360
Min. Negotiated Rate	$249.51
Max. Negotiated Rate	$13,737.10
Rate for Payer: Aetna Medicare	$4,788.26
Rate for Payer: Allen County Amish Medical Aid Commercial	$5,755.12
Rate for Payer: Amish Plain Church Group Commercial	$5,755.12
Rate for Payer: BCBS Complete	$2,644.60
Rate for Payer: BCBS MAPPO	$4,604.10
Rate for Payer: BCBS Trust/PPO	$1,510.65
Rate for Payer: BCN Medicare Advantage	$4,604.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,604.10
Rate for Payer: Mclaren Medicaid	$2,518.44
Rate for Payer: Mclaren Medicare	$4,604.10
Rate for Payer: Meridian Medicaid	$2,644.60
Rate for Payer: Meridian Wellcare - Medicare Advantage	$4,834.30
Rate for Payer: MI Amish Medical Board Commercial	$5,294.72
Rate for Payer: PACE Medicare	$4,373.90
Rate for Payer: PACE SWMI	$4,604.10
Rate for Payer: PHP Medicare Advantage	$4,604.10
Rate for Payer: Priority Health Choice Medicaid	$2,518.44
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13,737.10
Rate for Payer: Priority Health Medicare	$4,604.10
Rate for Payer: Priority Health Narrow Network	$10,989.68
Rate for Payer: Railroad Medicare Medicare	$4,604.10
Rate for Payer: UHC All Payor (Choice/PPO)	$274.46
Rate for Payer: UHC Core	$6,837.00
Rate for Payer: UHC Dual Complete DSNP	$4,604.10
Rate for Payer: UHC Exchange	$249.51
Rate for Payer: UHC Medicare Advantage	$4,742.22
Rate for Payer: VA VA	$4,604.10

CYSTOURETHROSCOPY (SEPARATE PROCEDURE)

Facility

$1,791.30

Service Code	CPT 52000
Hospital Revenue Code	360
Min. Negotiated Rate	$77.93
Max. Negotiated Rate	$1,791.30
Rate for Payer: Aetna Medicare	$632.14
Rate for Payer: Allen County Amish Medical Aid Commercial	$759.79
Rate for Payer: Amish Plain Church Group Commercial	$759.79
Rate for Payer: BCBS Complete	$349.14
Rate for Payer: BCBS MAPPO	$607.83
Rate for Payer: BCBS Trust/PPO	$425.94
Rate for Payer: BCN Medicare Advantage	$607.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$607.83
Rate for Payer: Mclaren Medicaid	$332.48
Rate for Payer: Mclaren Medicare	$607.83
Rate for Payer: Meridian Medicaid	$349.14
Rate for Payer: Meridian Wellcare - Medicare Advantage	$638.22
Rate for Payer: MI Amish Medical Board Commercial	$699.00
Rate for Payer: PACE Medicare	$577.44
Rate for Payer: PACE SWMI	$607.83
Rate for Payer: PHP Medicare Advantage	$607.83
Rate for Payer: Priority Health Choice Medicaid	$332.48
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,791.30
Rate for Payer: Priority Health Medicare	$607.83
Rate for Payer: Priority Health Narrow Network	$1,433.04
Rate for Payer: Railroad Medicare Medicare	$607.83
Rate for Payer: UHC All Payor (Choice/PPO)	$85.72
Rate for Payer: UHC Core	$1,463.00
Rate for Payer: UHC Dual Complete DSNP	$607.83
Rate for Payer: UHC Exchange	$77.93
Rate for Payer: UHC Medicare Advantage	$626.06
Rate for Payer: VA VA	$607.83

CYSTOURETHROSCOPY, WITH BIOPSY(S)

Facility

$5,575.00

Service Code	CPT 52204
Hospital Revenue Code	360
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$5,575.00
Rate for Payer: Aetna Medicare	$1,884.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,265.42
Rate for Payer: Amish Plain Church Group Commercial	$2,265.42
Rate for Payer: BCBS Complete	$1,041.01
Rate for Payer: BCBS MAPPO	$1,812.34
Rate for Payer: BCBS Trust/PPO	$1,376.44
Rate for Payer: BCN Medicare Advantage	$1,812.34
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,812.34
Rate for Payer: Mclaren Medicaid	$991.35
Rate for Payer: Mclaren Medicare	$1,812.34
Rate for Payer: Meridian Medicaid	$1,041.01
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,902.96
Rate for Payer: MI Amish Medical Board Commercial	$2,084.19
Rate for Payer: PACE Medicare	$1,721.72
Rate for Payer: PACE SWMI	$1,812.34
Rate for Payer: PHP Medicare Advantage	$1,812.34
Rate for Payer: Priority Health Choice Medicaid	$991.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,575.00
Rate for Payer: Priority Health Medicare	$1,812.34
Rate for Payer: Priority Health Narrow Network	$4,460.00
Rate for Payer: Railroad Medicare Medicare	$1,812.34
Rate for Payer: UHC All Payor (Choice/PPO)	$150.92
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$137.20
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE

Facility

$5,575.00

Service Code	CPT 52281
Hospital Revenue Code	360
Min. Negotiated Rate	$147.35
Max. Negotiated Rate	$5,575.00
Rate for Payer: Aetna Medicare	$1,884.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,265.42
Rate for Payer: Amish Plain Church Group Commercial	$2,265.42
Rate for Payer: BCBS Complete	$1,041.01
Rate for Payer: BCBS MAPPO	$1,812.34
Rate for Payer: BCBS Trust/PPO	$1,196.79
Rate for Payer: BCN Medicare Advantage	$1,812.34
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,812.34
Rate for Payer: Mclaren Medicaid	$991.35
Rate for Payer: Mclaren Medicare	$1,812.34
Rate for Payer: Meridian Medicaid	$1,041.01
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,902.96
Rate for Payer: MI Amish Medical Board Commercial	$2,084.19
Rate for Payer: PACE Medicare	$1,721.72
Rate for Payer: PACE SWMI	$1,812.34
Rate for Payer: PHP Medicare Advantage	$1,812.34
Rate for Payer: Priority Health Choice Medicaid	$991.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,575.00
Rate for Payer: Priority Health Medicare	$1,812.34
Rate for Payer: Priority Health Narrow Network	$4,460.00
Rate for Payer: Railroad Medicare Medicare	$1,812.34
Rate for Payer: UHC All Payor (Choice/PPO)	$162.08
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$147.35
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA

Facility

$5,575.00

Service Code	CPT 52260
Hospital Revenue Code	360
Min. Negotiated Rate	$203.67
Max. Negotiated Rate	$5,575.00
Rate for Payer: Aetna Medicare	$1,884.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,265.42
Rate for Payer: Amish Plain Church Group Commercial	$2,265.42
Rate for Payer: BCBS Complete	$1,041.01
Rate for Payer: BCBS MAPPO	$1,812.34
Rate for Payer: BCBS Trust/PPO	$1,498.05
Rate for Payer: BCN Medicare Advantage	$1,812.34
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,812.34
Rate for Payer: Mclaren Medicaid	$991.35
Rate for Payer: Mclaren Medicare	$1,812.34
Rate for Payer: Meridian Medicaid	$1,041.01
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,902.96
Rate for Payer: MI Amish Medical Board Commercial	$2,084.19
Rate for Payer: PACE Medicare	$1,721.72
Rate for Payer: PACE SWMI	$1,812.34
Rate for Payer: PHP Medicare Advantage	$1,812.34
Rate for Payer: Priority Health Choice Medicaid	$991.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,575.00
Rate for Payer: Priority Health Medicare	$1,812.34
Rate for Payer: Priority Health Narrow Network	$4,460.00
Rate for Payer: Railroad Medicare Medicare	$1,812.34
Rate for Payer: UHC All Payor (Choice/PPO)	$224.04
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$203.67
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY

Facility

$5,575.00

Service Code	CPT 52276
Hospital Revenue Code	360
Min. Negotiated Rate	$255.08
Max. Negotiated Rate	$5,575.00
Rate for Payer: Aetna Medicare	$1,884.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,265.42
Rate for Payer: Amish Plain Church Group Commercial	$2,265.42
Rate for Payer: BCBS Complete	$1,041.01
Rate for Payer: BCBS MAPPO	$1,812.34
Rate for Payer: BCBS Trust/PPO	$1,370.18
Rate for Payer: BCN Medicare Advantage	$1,812.34
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,812.34
Rate for Payer: Mclaren Medicaid	$991.35
Rate for Payer: Mclaren Medicare	$1,812.34
Rate for Payer: Meridian Medicaid	$1,041.01
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,902.96
Rate for Payer: MI Amish Medical Board Commercial	$2,084.19
Rate for Payer: PACE Medicare	$1,721.72
Rate for Payer: PACE SWMI	$1,812.34
Rate for Payer: PHP Medicare Advantage	$1,812.34
Rate for Payer: Priority Health Choice Medicaid	$991.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,575.00
Rate for Payer: Priority Health Medicare	$1,812.34
Rate for Payer: Priority Health Narrow Network	$4,460.00
Rate for Payer: Railroad Medicare Medicare	$1,812.34
Rate for Payer: UHC All Payor (Choice/PPO)	$280.59
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$255.08
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)

Facility

$13,737.10

Service Code	CPT 52240
Hospital Revenue Code	360
Min. Negotiated Rate	$378.20
Max. Negotiated Rate	$13,737.10
Rate for Payer: Aetna Medicare	$4,788.26
Rate for Payer: Allen County Amish Medical Aid Commercial	$5,755.12
Rate for Payer: Amish Plain Church Group Commercial	$5,755.12
Rate for Payer: BCBS Complete	$2,644.60
Rate for Payer: BCBS MAPPO	$4,604.10
Rate for Payer: BCBS Trust/PPO	$2,333.22
Rate for Payer: BCN Medicare Advantage	$4,604.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,604.10
Rate for Payer: Mclaren Medicaid	$2,518.44
Rate for Payer: Mclaren Medicare	$4,604.10
Rate for Payer: Meridian Medicaid	$2,644.60
Rate for Payer: Meridian Wellcare - Medicare Advantage	$4,834.30
Rate for Payer: MI Amish Medical Board Commercial	$5,294.72
Rate for Payer: PACE Medicare	$4,373.90
Rate for Payer: PACE SWMI	$4,604.10
Rate for Payer: PHP Medicare Advantage	$4,604.10
Rate for Payer: Priority Health Choice Medicaid	$2,518.44
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13,737.10
Rate for Payer: Priority Health Medicare	$4,604.10
Rate for Payer: Priority Health Narrow Network	$10,989.68
Rate for Payer: Railroad Medicare Medicare	$4,604.10
Rate for Payer: UHC All Payor (Choice/PPO)	$416.02
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$4,604.10
Rate for Payer: UHC Exchange	$378.20
Rate for Payer: UHC Medicare Advantage	$4,742.22
Rate for Payer: VA VA	$4,604.10

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)

Facility

$9,573.02

Service Code	CPT 52235
Hospital Revenue Code	360
Min. Negotiated Rate	$278.65
Max. Negotiated Rate	$9,573.02
Rate for Payer: Aetna Medicare	$3,226.04
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,877.45
Rate for Payer: Amish Plain Church Group Commercial	$3,877.45
Rate for Payer: BCBS Complete	$1,781.77
Rate for Payer: BCBS MAPPO	$3,101.96
Rate for Payer: BCBS Trust/PPO	$1,998.36
Rate for Payer: BCN Medicare Advantage	$3,101.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,101.96
Rate for Payer: Mclaren Medicaid	$1,696.77
Rate for Payer: Mclaren Medicare	$3,101.96
Rate for Payer: Meridian Medicaid	$1,781.77
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,257.06
Rate for Payer: MI Amish Medical Board Commercial	$3,567.25
Rate for Payer: PACE Medicare	$2,946.86
Rate for Payer: PACE SWMI	$3,101.96
Rate for Payer: PHP Medicare Advantage	$3,101.96
Rate for Payer: Priority Health Choice Medicaid	$1,696.77
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,573.02
Rate for Payer: Priority Health Medicare	$3,101.96
Rate for Payer: Priority Health Narrow Network	$7,658.42
Rate for Payer: Railroad Medicare Medicare	$3,101.96
Rate for Payer: UHC All Payor (Choice/PPO)	$306.52
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$278.65
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)

Facility

$9,573.02

Service Code	CPT 52234
Hospital Revenue Code	360
Min. Negotiated Rate	$237.40
Max. Negotiated Rate	$9,573.02
Rate for Payer: Aetna Medicare	$3,226.04
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,877.45
Rate for Payer: Amish Plain Church Group Commercial	$3,877.45
Rate for Payer: BCBS Complete	$1,781.77
Rate for Payer: BCBS MAPPO	$3,101.96
Rate for Payer: BCBS Trust/PPO	$1,705.47
Rate for Payer: BCN Medicare Advantage	$3,101.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,101.96
Rate for Payer: Mclaren Medicaid	$1,696.77
Rate for Payer: Mclaren Medicare	$3,101.96
Rate for Payer: Meridian Medicaid	$1,781.77
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,257.06
Rate for Payer: MI Amish Medical Board Commercial	$3,567.25
Rate for Payer: PACE Medicare	$2,946.86
Rate for Payer: PACE SWMI	$3,101.96
Rate for Payer: PHP Medicare Advantage	$3,101.96
Rate for Payer: Priority Health Choice Medicaid	$1,696.77
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,573.02
Rate for Payer: Priority Health Medicare	$3,101.96
Rate for Payer: Priority Health Narrow Network	$7,658.42
Rate for Payer: Railroad Medicare Medicare	$3,101.96
Rate for Payer: UHC All Payor (Choice/PPO)	$261.14
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$237.40
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS

Facility

$9,573.02

Service Code	CPT 52214
Hospital Revenue Code	360
Min. Negotiated Rate	$168.63
Max. Negotiated Rate	$9,573.02
Rate for Payer: Aetna Medicare	$3,226.04
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,877.45
Rate for Payer: Amish Plain Church Group Commercial	$3,877.45
Rate for Payer: BCBS Complete	$1,781.77
Rate for Payer: BCBS MAPPO	$3,101.96
Rate for Payer: BCBS Trust/PPO	$986.60
Rate for Payer: BCN Medicare Advantage	$3,101.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,101.96
Rate for Payer: Mclaren Medicaid	$1,696.77
Rate for Payer: Mclaren Medicare	$3,101.96
Rate for Payer: Meridian Medicaid	$1,781.77
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,257.06
Rate for Payer: MI Amish Medical Board Commercial	$3,567.25
Rate for Payer: PACE Medicare	$2,946.86
Rate for Payer: PACE SWMI	$3,101.96
Rate for Payer: PHP Medicare Advantage	$3,101.96
Rate for Payer: Priority Health Choice Medicaid	$1,696.77
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,573.02
Rate for Payer: Priority Health Medicare	$3,101.96
Rate for Payer: Priority Health Narrow Network	$7,658.42
Rate for Payer: Railroad Medicare Medicare	$3,101.96
Rate for Payer: UHC All Payor (Choice/PPO)	$185.49
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$168.63
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

Know your out-of-pocket cost for care.

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