Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY

Facility

$9,573.02

Service Code	CPT 52224
Hospital Revenue Code	360
Min. Negotiated Rate	$195.16
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	$1,554.40
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)	$214.68
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$195.16
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER

Facility

$5,575.00

Service Code	CPT 52287
Hospital Revenue Code	360
Min. Negotiated Rate	$163.39
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	$1,588.38
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)	$179.73
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$163.39
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)

Facility

$9,573.02

Service Code	CPT 52332
Hospital Revenue Code	360
Min. Negotiated Rate	$150.62
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	$1,556.78
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)	$165.68
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$150.62
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; EACH ADDITIONAL PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$878.00

Service Code	CPT 52442
Hospital Revenue Code	360
Min. Negotiated Rate	$48.79
Max. Negotiated Rate	$878.00
Rate for Payer: UHC All Payor (Choice/PPO)	$53.67
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Exchange	$48.79

CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; SINGLE IMPLANT

Facility

$878.00

Service Code	CPT 52441
Hospital Revenue Code	360
Min. Negotiated Rate	$202.36
Max. Negotiated Rate	$878.00
Rate for Payer: UHC All Payor (Choice/PPO)	$222.60
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Exchange	$202.36

CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANTS

Facility

$12,908.52

Service Code	CPT C9739
Hospital Revenue Code	361
Min. Negotiated Rate	$2,518.44
Max. Negotiated Rate	$12,908.52
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	$3,753.13
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 Medicare	$4,604.10
Rate for Payer: Railroad Medicare Medicare	$4,604.10
Rate for Payer: UHC All Payor (Choice/PPO)	$12,908.52
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$4,604.10
Rate for Payer: UHC Exchange	$8,798.90
Rate for Payer: UHC Medicare Advantage	$4,742.22
Rate for Payer: VA VA	$4,604.10

CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS

Facility

$22,982.07

Service Code	CPT C9740
Hospital Revenue Code	360
Min. Negotiated Rate	$4,483.79
Max. Negotiated Rate	$22,982.07
Rate for Payer: Aetna Medicare	$8,524.93
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,246.31
Rate for Payer: Amish Plain Church Group Commercial	$10,246.31
Rate for Payer: BCBS Complete	$4,708.39
Rate for Payer: BCBS MAPPO	$8,197.05
Rate for Payer: BCBS Trust/PPO	$5,180.65
Rate for Payer: BCN Medicare Advantage	$8,197.05
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,197.05
Rate for Payer: Mclaren Medicaid	$4,483.79
Rate for Payer: Mclaren Medicare	$8,197.05
Rate for Payer: Meridian Medicaid	$4,708.39
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,606.90
Rate for Payer: MI Amish Medical Board Commercial	$9,426.61
Rate for Payer: PACE Medicare	$7,787.20
Rate for Payer: PACE SWMI	$8,197.05
Rate for Payer: PHP Medicare Advantage	$8,197.05
Rate for Payer: Priority Health Choice Medicaid	$4,483.79
Rate for Payer: Priority Health Medicare	$8,197.05
Rate for Payer: Railroad Medicare Medicare	$8,197.05
Rate for Payer: UHC All Payor (Choice/PPO)	$22,982.07
Rate for Payer: UHC Core	$7,632.00
Rate for Payer: UHC Dual Complete DSNP	$8,197.05
Rate for Payer: UHC Exchange	$15,665.38
Rate for Payer: UHC Medicare Advantage	$8,442.96
Rate for Payer: VA VA	$8,197.05

CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY; MALE

Facility

$5,575.00

Service Code	CPT 52275
Hospital Revenue Code	360
Min. Negotiated Rate	$239.69
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	$986.60
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)	$263.66
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$239.69
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING CLOTS

Facility

$9,573.02

Service Code	CPT 52001
Hospital Revenue Code	360
Min. Negotiated Rate	$277.34
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	$791.71
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)	$305.07
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$277.34
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED

Facility

$5,575.00

Service Code	CPT 52315
Hospital Revenue Code	360
Min. Negotiated Rate	$264.90
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	$1,174.53
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)	$291.39
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$264.90
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE

Facility

$5,575.00

Service Code	CPT 52310
Hospital Revenue Code	360
Min. Negotiated Rate	$146.69
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	$766.72
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)	$161.36
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$146.69
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)

Facility

$9,573.02

Service Code	CPT 52341
Hospital Revenue Code	360
Min. Negotiated Rate	$274.40
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	$947.80
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)	$301.84
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$274.40
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE;

Facility

$5,575.00

Service Code	CPT 52005
Hospital Revenue Code	360
Min. Negotiated Rate	$129.34
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	$1,510.92
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)	$142.27
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$1,812.34
Rate for Payer: UHC Exchange	$129.34
Rate for Payer: UHC Medicare Advantage	$1,866.71
Rate for Payer: VA VA	$1,812.34

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC

Facility

$9,573.02

Service Code	CPT 52351
Hospital Revenue Code	360
Min. Negotiated Rate	$292.41
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	$1,609.33
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)	$321.65
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$292.41
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION

Facility

$13,737.10

Service Code	CPT 52354
Hospital Revenue Code	360
Min. Negotiated Rate	$402.10
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	$2,069.77
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)	$442.31
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$4,604.10
Rate for Payer: UHC Exchange	$402.10
Rate for Payer: UHC Medicare Advantage	$4,742.22
Rate for Payer: VA VA	$4,604.10

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)

Facility

$13,737.10

Service Code	CPT 52356
Hospital Revenue Code	360
Min. Negotiated Rate	$400.79
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	$2,140.59
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)	$440.87
Rate for Payer: UHC Core	$6,837.00
Rate for Payer: UHC Dual Complete DSNP	$4,604.10
Rate for Payer: UHC Exchange	$400.79
Rate for Payer: UHC Medicare Advantage	$4,742.22
Rate for Payer: VA VA	$4,604.10

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED)

Facility

$13,737.10

Service Code	CPT 52353
Hospital Revenue Code	360
Min. Negotiated Rate	$377.87
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	$2,146.98
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)	$415.66
Rate for Payer: UHC Core	$6,837.00
Rate for Payer: UHC Dual Complete DSNP	$4,604.10
Rate for Payer: UHC Exchange	$377.87
Rate for Payer: UHC Medicare Advantage	$4,742.22
Rate for Payer: VA VA	$4,604.10

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)

Facility

$9,573.02

Service Code	CPT 52352
Hospital Revenue Code	360
Min. Negotiated Rate	$341.52
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	$1,524.00
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)	$375.67
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$341.52
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR

Facility

$13,737.10

Service Code	CPT 52355
Hospital Revenue Code	360
Min. Negotiated Rate	$450.56
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)	$495.62
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$4,604.10
Rate for Payer: UHC Exchange	$450.56
Rate for Payer: UHC Medicare Advantage	$4,742.22
Rate for Payer: VA VA	$4,604.10

CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)

Facility

$9,573.02

Service Code	CPT 52344
Hospital Revenue Code	360
Min. Negotiated Rate	$356.58
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	$1,025.05
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)	$392.24
Rate for Payer: UHC Core	$4,155.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$356.58
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION

Facility

$212.25

Service Code	HCPCS J9100
Hospital Charge Code	20156
Hospital Revenue Code	636
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$191.02
Rate for Payer: Aetna Commercial	$180.41
Rate for Payer: Aetna New Business (MI Preferred)	$137.96
Rate for Payer: BCBS Complete	$84.90
Rate for Payer: BCBS Trust/PPO	$2.88
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cofinity Commercial	$148.58
Rate for Payer: Cofinity Commercial	$182.54
Rate for Payer: Healthscope Commercial	$191.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$180.41
Rate for Payer: PHP Commercial	$180.41
Rate for Payer: Priority Health Cigna Priority Health	$148.58
Rate for Payer: Priority Health SBD	$133.72

CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION

Facility

$212.25

Service Code	HCPCS J9100
Hospital Charge Code	20156
Hospital Revenue Code	636
Min. Negotiated Rate	$133.72
Max. Negotiated Rate	$191.02
Rate for Payer: Aetna Commercial	$180.41
Rate for Payer: Aetna New Business (MI Preferred)	$137.96
Rate for Payer: Cash Price	$169.80
Rate for Payer: Cofinity Commercial	$148.58
Rate for Payer: Cofinity Commercial	$182.54
Rate for Payer: Healthscope Commercial	$191.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$180.41
Rate for Payer: PHP Commercial	$180.41
Rate for Payer: Priority Health Cigna Priority Health	$148.58
Rate for Payer: Priority Health SBD	$133.72

DABIGATRAN ETEXILATE 75 MG CAPSULE

Facility

$1,048.29

Service Code	NDC 60687-744-21
Hospital Charge Code	106490
Hospital Revenue Code	637
Min. Negotiated Rate	$660.42
Max. Negotiated Rate	$943.46
Rate for Payer: Aetna Commercial	$891.05
Rate for Payer: Aetna New Business (MI Preferred)	$681.39
Rate for Payer: Cash Price	$838.63
Rate for Payer: Cofinity Commercial	$733.80
Rate for Payer: Cofinity Commercial	$901.53
Rate for Payer: Healthscope Commercial	$943.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$891.05
Rate for Payer: PHP Commercial	$891.05
Rate for Payer: Priority Health Cigna Priority Health	$733.80
Rate for Payer: Priority Health SBD	$660.42

DABIGATRAN ETEXILATE 75 MG CAPSULE

Facility

$648.69

Service Code	NDC 0597-0355-56
Hospital Charge Code	106490
Hospital Revenue Code	637
Min. Negotiated Rate	$408.67
Max. Negotiated Rate	$583.82
Rate for Payer: Aetna Commercial	$551.39
Rate for Payer: Aetna New Business (MI Preferred)	$421.65
Rate for Payer: Cash Price	$518.95
Rate for Payer: Cofinity Commercial	$454.08
Rate for Payer: Cofinity Commercial	$557.87
Rate for Payer: Healthscope Commercial	$583.82
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$551.39
Rate for Payer: PHP Commercial	$551.39
Rate for Payer: Priority Health Cigna Priority Health	$454.08
Rate for Payer: Priority Health SBD	$408.67

DABIGATRAN ETEXILATE 75 MG CAPSULE

Facility

$622.71

Service Code	NDC 31722-621-60
Hospital Charge Code	106490
Hospital Revenue Code	637
Min. Negotiated Rate	$392.31
Max. Negotiated Rate	$560.44
Rate for Payer: Aetna Commercial	$529.30
Rate for Payer: Aetna New Business (MI Preferred)	$404.76
Rate for Payer: Cash Price	$498.17
Rate for Payer: Cofinity Commercial	$435.90
Rate for Payer: Cofinity Commercial	$535.53
Rate for Payer: Healthscope Commercial	$560.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$529.30
Rate for Payer: PHP Commercial	$529.30
Rate for Payer: Priority Health Cigna Priority Health	$435.90
Rate for Payer: Priority Health SBD	$392.31

Know your out-of-pocket cost for care.

All Charges