Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS

Facility

$19,611.80

Service Code	CPT 29828
Hospital Revenue Code	360
Min. Negotiated Rate	$3,734.39
Max. Negotiated Rate	$19,611.80
Rate for Payer: Aetna Medicare	$7,245.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,708.92
Rate for Payer: Amish Plain Church Group Commercial	$8,708.92
Rate for Payer: BCBS Complete	$3,921.11
Rate for Payer: BCBS MAPPO	$6,967.14
Rate for Payer: BCN Medicare Advantage	$6,967.14
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,967.14
Rate for Payer: Mclaren Medicaid	$3,734.39
Rate for Payer: Mclaren Medicare	$6,967.14
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,315.50
Rate for Payer: Meridian Medicaid	$3,921.11
Rate for Payer: MI Amish Medical Board Commercial	$8,012.21
Rate for Payer: PACE Medicare	$6,618.78
Rate for Payer: PACE SWMI	$6,967.14
Rate for Payer: PHP Medicare Advantage	$6,967.14
Rate for Payer: Priority Health Choice Medicaid	$3,734.39
Rate for Payer: Priority Health Medicare	$6,967.14
Rate for Payer: Railroad Medicare Medicare	$6,967.14
Rate for Payer: UHC All Payor (Choice/PPO)	$19,611.80
Rate for Payer: UHC Dual Complete DSNP	$6,967.14
Rate for Payer: UHC Medicare Advantage	$6,967.14
Rate for Payer: UHCCP Medicaid	$3,922.50
Rate for Payer: VA VA	$6,967.14

ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY

Facility

$19,611.80

Service Code	CPT 29806
Hospital Revenue Code	360
Min. Negotiated Rate	$3,734.39
Max. Negotiated Rate	$19,611.80
Rate for Payer: Aetna Medicare	$7,245.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,708.92
Rate for Payer: Amish Plain Church Group Commercial	$8,708.92
Rate for Payer: BCBS Complete	$3,921.11
Rate for Payer: BCBS MAPPO	$6,967.14
Rate for Payer: BCN Medicare Advantage	$6,967.14
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,967.14
Rate for Payer: Mclaren Medicaid	$3,734.39
Rate for Payer: Mclaren Medicare	$6,967.14
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,315.50
Rate for Payer: Meridian Medicaid	$3,921.11
Rate for Payer: MI Amish Medical Board Commercial	$8,012.21
Rate for Payer: PACE Medicare	$6,618.78
Rate for Payer: PACE SWMI	$6,967.14
Rate for Payer: PHP Medicare Advantage	$6,967.14
Rate for Payer: Priority Health Choice Medicaid	$3,734.39
Rate for Payer: Priority Health Medicare	$6,967.14
Rate for Payer: Railroad Medicare Medicare	$6,967.14
Rate for Payer: UHC All Payor (Choice/PPO)	$19,611.80
Rate for Payer: UHC Dual Complete DSNP	$6,967.14
Rate for Payer: UHC Medicare Advantage	$6,967.14
Rate for Payer: UHCCP Medicaid	$3,922.50
Rate for Payer: VA VA	$6,967.14

ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE, 3 OR MORE DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])

Facility

$8,907.47

Service Code	CPT 29823
Hospital Revenue Code	360
Min. Negotiated Rate	$1,696.12
Max. Negotiated Rate	$8,907.47
Rate for Payer: Aetna Medicare	$3,290.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,955.50
Rate for Payer: Amish Plain Church Group Commercial	$3,955.50
Rate for Payer: BCBS Complete	$1,780.92
Rate for Payer: BCBS MAPPO	$3,164.40
Rate for Payer: BCN Medicare Advantage	$3,164.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,164.40
Rate for Payer: Mclaren Medicaid	$1,696.12
Rate for Payer: Mclaren Medicare	$3,164.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,322.62
Rate for Payer: Meridian Medicaid	$1,780.92
Rate for Payer: MI Amish Medical Board Commercial	$3,639.06
Rate for Payer: PACE Medicare	$3,006.18
Rate for Payer: PACE SWMI	$3,164.40
Rate for Payer: PHP Medicare Advantage	$3,164.40
Rate for Payer: Priority Health Choice Medicaid	$1,696.12
Rate for Payer: Priority Health Medicare	$3,164.40
Rate for Payer: Railroad Medicare Medicare	$3,164.40
Rate for Payer: UHC All Payor (Choice/PPO)	$8,907.47
Rate for Payer: UHC Dual Complete DSNP	$3,164.40
Rate for Payer: UHC Medicare Advantage	$3,164.40
Rate for Payer: UHCCP Medicaid	$1,781.56
Rate for Payer: VA VA	$3,164.40

ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])

Facility

$8,907.47

Service Code	CPT 29822
Hospital Revenue Code	360
Min. Negotiated Rate	$1,696.12
Max. Negotiated Rate	$8,907.47
Rate for Payer: Aetna Medicare	$3,290.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,955.50
Rate for Payer: Amish Plain Church Group Commercial	$3,955.50
Rate for Payer: BCBS Complete	$1,780.92
Rate for Payer: BCBS MAPPO	$3,164.40
Rate for Payer: BCN Medicare Advantage	$3,164.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,164.40
Rate for Payer: Mclaren Medicaid	$1,696.12
Rate for Payer: Mclaren Medicare	$3,164.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,322.62
Rate for Payer: Meridian Medicaid	$1,780.92
Rate for Payer: MI Amish Medical Board Commercial	$3,639.06
Rate for Payer: PACE Medicare	$3,006.18
Rate for Payer: PACE SWMI	$3,164.40
Rate for Payer: PHP Medicare Advantage	$3,164.40
Rate for Payer: Priority Health Choice Medicaid	$1,696.12
Rate for Payer: Priority Health Medicare	$3,164.40
Rate for Payer: Railroad Medicare Medicare	$3,164.40
Rate for Payer: UHC All Payor (Choice/PPO)	$8,907.47
Rate for Payer: UHC Dual Complete DSNP	$3,164.40
Rate for Payer: UHC Medicare Advantage	$3,164.40
Rate for Payer: UHCCP Medicaid	$1,781.56
Rate for Payer: VA VA	$3,164.40

ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)

Facility

$8,907.47

Service Code	CPT 29824
Hospital Revenue Code	360
Min. Negotiated Rate	$1,696.12
Max. Negotiated Rate	$8,907.47
Rate for Payer: Aetna Medicare	$3,290.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,955.50
Rate for Payer: Amish Plain Church Group Commercial	$3,955.50
Rate for Payer: BCBS Complete	$1,780.92
Rate for Payer: BCBS MAPPO	$3,164.40
Rate for Payer: BCN Medicare Advantage	$3,164.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,164.40
Rate for Payer: Mclaren Medicaid	$1,696.12
Rate for Payer: Mclaren Medicare	$3,164.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,322.62
Rate for Payer: Meridian Medicaid	$1,780.92
Rate for Payer: MI Amish Medical Board Commercial	$3,639.06
Rate for Payer: PACE Medicare	$3,006.18
Rate for Payer: PACE SWMI	$3,164.40
Rate for Payer: PHP Medicare Advantage	$3,164.40
Rate for Payer: Priority Health Choice Medicaid	$1,696.12
Rate for Payer: Priority Health Medicare	$3,164.40
Rate for Payer: Railroad Medicare Medicare	$3,164.40
Rate for Payer: UHC All Payor (Choice/PPO)	$8,907.47
Rate for Payer: UHC Dual Complete DSNP	$3,164.40
Rate for Payer: UHC Medicare Advantage	$3,164.40
Rate for Payer: UHCCP Medicaid	$1,781.56
Rate for Payer: VA VA	$3,164.40

ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION

Facility

$19,611.80

Service Code	CPT 29807
Hospital Revenue Code	360
Min. Negotiated Rate	$3,734.39
Max. Negotiated Rate	$19,611.80
Rate for Payer: Aetna Medicare	$7,245.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,708.92
Rate for Payer: Amish Plain Church Group Commercial	$8,708.92
Rate for Payer: BCBS Complete	$3,921.11
Rate for Payer: BCBS MAPPO	$6,967.14
Rate for Payer: BCN Medicare Advantage	$6,967.14
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,967.14
Rate for Payer: Mclaren Medicaid	$3,734.39
Rate for Payer: Mclaren Medicare	$6,967.14
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,315.50
Rate for Payer: Meridian Medicaid	$3,921.11
Rate for Payer: MI Amish Medical Board Commercial	$8,012.21
Rate for Payer: PACE Medicare	$6,618.78
Rate for Payer: PACE SWMI	$6,967.14
Rate for Payer: PHP Medicare Advantage	$6,967.14
Rate for Payer: Priority Health Choice Medicaid	$3,734.39
Rate for Payer: Priority Health Medicare	$6,967.14
Rate for Payer: Railroad Medicare Medicare	$6,967.14
Rate for Payer: UHC All Payor (Choice/PPO)	$19,611.80
Rate for Payer: UHC Dual Complete DSNP	$6,967.14
Rate for Payer: UHC Medicare Advantage	$6,967.14
Rate for Payer: UHCCP Medicaid	$3,922.50
Rate for Payer: VA VA	$6,967.14

ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR

Facility

$19,611.80

Service Code	CPT 29827
Hospital Revenue Code	360
Min. Negotiated Rate	$3,734.39
Max. Negotiated Rate	$19,611.80
Rate for Payer: Aetna Medicare	$7,245.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,708.92
Rate for Payer: Amish Plain Church Group Commercial	$8,708.92
Rate for Payer: BCBS Complete	$3,921.11
Rate for Payer: BCBS MAPPO	$6,967.14
Rate for Payer: BCN Medicare Advantage	$6,967.14
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,967.14
Rate for Payer: Mclaren Medicaid	$3,734.39
Rate for Payer: Mclaren Medicare	$6,967.14
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,315.50
Rate for Payer: Meridian Medicaid	$3,921.11
Rate for Payer: MI Amish Medical Board Commercial	$8,012.21
Rate for Payer: PACE Medicare	$6,618.78
Rate for Payer: PACE SWMI	$6,967.14
Rate for Payer: PHP Medicare Advantage	$6,967.14
Rate for Payer: Priority Health Choice Medicaid	$3,734.39
Rate for Payer: Priority Health Medicare	$6,967.14
Rate for Payer: Railroad Medicare Medicare	$6,967.14
Rate for Payer: UHC All Payor (Choice/PPO)	$19,611.80
Rate for Payer: UHC Dual Complete DSNP	$6,967.14
Rate for Payer: UHC Medicare Advantage	$6,967.14
Rate for Payer: UHCCP Medicaid	$3,922.50
Rate for Payer: VA VA	$6,967.14

ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY

Facility

$8,907.47

Service Code	CPT 23044
Hospital Revenue Code	360
Min. Negotiated Rate	$1,696.12
Max. Negotiated Rate	$8,907.47
Rate for Payer: Aetna Medicare	$3,290.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,955.50
Rate for Payer: Amish Plain Church Group Commercial	$3,955.50
Rate for Payer: BCBS Complete	$1,780.92
Rate for Payer: BCBS MAPPO	$3,164.40
Rate for Payer: BCN Medicare Advantage	$3,164.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,164.40
Rate for Payer: Mclaren Medicaid	$1,696.12
Rate for Payer: Mclaren Medicare	$3,164.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,322.62
Rate for Payer: Meridian Medicaid	$1,780.92
Rate for Payer: MI Amish Medical Board Commercial	$3,639.06
Rate for Payer: PACE Medicare	$3,006.18
Rate for Payer: PACE SWMI	$3,164.40
Rate for Payer: PHP Medicare Advantage	$3,164.40
Rate for Payer: Priority Health Choice Medicaid	$1,696.12
Rate for Payer: Priority Health Medicare	$3,164.40
Rate for Payer: Railroad Medicare Medicare	$3,164.40
Rate for Payer: UHC All Payor (Choice/PPO)	$8,907.47
Rate for Payer: UHC Dual Complete DSNP	$3,164.40
Rate for Payer: UHC Medicare Advantage	$3,164.40
Rate for Payer: UHCCP Medicaid	$1,781.56
Rate for Payer: VA VA	$3,164.40

ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY

Facility

$8,907.47

Service Code	CPT 27610
Hospital Revenue Code	360
Min. Negotiated Rate	$1,696.12
Max. Negotiated Rate	$8,907.47
Rate for Payer: Aetna Medicare	$3,290.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,955.50
Rate for Payer: Amish Plain Church Group Commercial	$3,955.50
Rate for Payer: BCBS Complete	$1,780.92
Rate for Payer: BCBS MAPPO	$3,164.40
Rate for Payer: BCN Medicare Advantage	$3,164.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,164.40
Rate for Payer: Mclaren Medicaid	$1,696.12
Rate for Payer: Mclaren Medicare	$3,164.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,322.62
Rate for Payer: Meridian Medicaid	$1,780.92
Rate for Payer: MI Amish Medical Board Commercial	$3,639.06
Rate for Payer: PACE Medicare	$3,006.18
Rate for Payer: PACE SWMI	$3,164.40
Rate for Payer: PHP Medicare Advantage	$3,164.40
Rate for Payer: Priority Health Choice Medicaid	$1,696.12
Rate for Payer: Priority Health Medicare	$3,164.40
Rate for Payer: Railroad Medicare Medicare	$3,164.40
Rate for Payer: UHC All Payor (Choice/PPO)	$8,907.47
Rate for Payer: UHC Dual Complete DSNP	$3,164.40
Rate for Payer: UHC Medicare Advantage	$3,164.40
Rate for Payer: UHCCP Medicaid	$1,781.56
Rate for Payer: VA VA	$3,164.40

ARTHROTOMY, ELBOW, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY

Facility

$8,907.47

Service Code	CPT 24000
Hospital Revenue Code	360
Min. Negotiated Rate	$1,696.12
Max. Negotiated Rate	$8,907.47
Rate for Payer: Aetna Medicare	$3,290.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,955.50
Rate for Payer: Amish Plain Church Group Commercial	$3,955.50
Rate for Payer: BCBS Complete	$1,780.92
Rate for Payer: BCBS MAPPO	$3,164.40
Rate for Payer: BCN Medicare Advantage	$3,164.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,164.40
Rate for Payer: Mclaren Medicaid	$1,696.12
Rate for Payer: Mclaren Medicare	$3,164.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,322.62
Rate for Payer: Meridian Medicaid	$1,780.92
Rate for Payer: MI Amish Medical Board Commercial	$3,639.06
Rate for Payer: PACE Medicare	$3,006.18
Rate for Payer: PACE SWMI	$3,164.40
Rate for Payer: PHP Medicare Advantage	$3,164.40
Rate for Payer: Priority Health Choice Medicaid	$1,696.12
Rate for Payer: Priority Health Medicare	$3,164.40
Rate for Payer: Railroad Medicare Medicare	$3,164.40
Rate for Payer: UHC All Payor (Choice/PPO)	$8,907.47
Rate for Payer: UHC Dual Complete DSNP	$3,164.40
Rate for Payer: UHC Medicare Advantage	$3,164.40
Rate for Payer: UHCCP Medicaid	$1,781.56
Rate for Payer: VA VA	$3,164.40

ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY

Facility

$8,907.47

Service Code	CPT 23040
Hospital Revenue Code	360
Min. Negotiated Rate	$1,696.12
Max. Negotiated Rate	$8,907.47
Rate for Payer: Aetna Medicare	$3,290.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,955.50
Rate for Payer: Amish Plain Church Group Commercial	$3,955.50
Rate for Payer: BCBS Complete	$1,780.92
Rate for Payer: BCBS MAPPO	$3,164.40
Rate for Payer: BCN Medicare Advantage	$3,164.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,164.40
Rate for Payer: Mclaren Medicaid	$1,696.12
Rate for Payer: Mclaren Medicare	$3,164.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,322.62
Rate for Payer: Meridian Medicaid	$1,780.92
Rate for Payer: MI Amish Medical Board Commercial	$3,639.06
Rate for Payer: PACE Medicare	$3,006.18
Rate for Payer: PACE SWMI	$3,164.40
Rate for Payer: PHP Medicare Advantage	$3,164.40
Rate for Payer: Priority Health Choice Medicaid	$1,696.12
Rate for Payer: Priority Health Medicare	$3,164.40
Rate for Payer: Railroad Medicare Medicare	$3,164.40
Rate for Payer: UHC All Payor (Choice/PPO)	$8,907.47
Rate for Payer: UHC Dual Complete DSNP	$3,164.40
Rate for Payer: UHC Medicare Advantage	$3,164.40
Rate for Payer: UHCCP Medicaid	$1,781.56
Rate for Payer: VA VA	$3,164.40

ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOINT EXPLORATION, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY

Facility

$19,611.80

Service Code	CPT 23107
Hospital Revenue Code	360
Min. Negotiated Rate	$3,734.39
Max. Negotiated Rate	$19,611.80
Rate for Payer: Aetna Medicare	$7,245.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,708.92
Rate for Payer: Amish Plain Church Group Commercial	$8,708.92
Rate for Payer: BCBS Complete	$3,921.11
Rate for Payer: BCBS MAPPO	$6,967.14
Rate for Payer: BCN Medicare Advantage	$6,967.14
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,967.14
Rate for Payer: Mclaren Medicaid	$3,734.39
Rate for Payer: Mclaren Medicare	$6,967.14
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,315.50
Rate for Payer: Meridian Medicaid	$3,921.11
Rate for Payer: MI Amish Medical Board Commercial	$8,012.21
Rate for Payer: PACE Medicare	$6,618.78
Rate for Payer: PACE SWMI	$6,967.14
Rate for Payer: PHP Medicare Advantage	$6,967.14
Rate for Payer: Priority Health Choice Medicaid	$3,734.39
Rate for Payer: Priority Health Medicare	$6,967.14
Rate for Payer: Railroad Medicare Medicare	$6,967.14
Rate for Payer: UHC All Payor (Choice/PPO)	$19,611.80
Rate for Payer: UHC Dual Complete DSNP	$6,967.14
Rate for Payer: UHC Medicare Advantage	$6,967.14
Rate for Payer: UHCCP Medicaid	$3,922.50
Rate for Payer: VA VA	$6,967.14

ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR

Facility

$8,907.47

Service Code	CPT 27334
Hospital Revenue Code	360
Min. Negotiated Rate	$1,696.12
Max. Negotiated Rate	$8,907.47
Rate for Payer: Aetna Medicare	$3,290.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,955.50
Rate for Payer: Amish Plain Church Group Commercial	$3,955.50
Rate for Payer: BCBS Complete	$1,780.92
Rate for Payer: BCBS MAPPO	$3,164.40
Rate for Payer: BCN Medicare Advantage	$3,164.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,164.40
Rate for Payer: Mclaren Medicaid	$1,696.12
Rate for Payer: Mclaren Medicare	$3,164.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,322.62
Rate for Payer: Meridian Medicaid	$1,780.92
Rate for Payer: MI Amish Medical Board Commercial	$3,639.06
Rate for Payer: PACE Medicare	$3,006.18
Rate for Payer: PACE SWMI	$3,164.40
Rate for Payer: PHP Medicare Advantage	$3,164.40
Rate for Payer: Priority Health Choice Medicaid	$1,696.12
Rate for Payer: Priority Health Medicare	$3,164.40
Rate for Payer: Railroad Medicare Medicare	$3,164.40
Rate for Payer: UHC All Payor (Choice/PPO)	$8,907.47
Rate for Payer: UHC Dual Complete DSNP	$3,164.40
Rate for Payer: UHC Medicare Advantage	$3,164.40
Rate for Payer: UHCCP Medicaid	$1,781.56
Rate for Payer: VA VA	$3,164.40

ARTIFICIAL TEARS EYE DROPS WRAPPER

Facility

$58.14

Service Code	NDC 00536132594
Hospital Charge Code	301578
Hospital Revenue Code	637
Min. Negotiated Rate	$23.26
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna Medicare	$29.07
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: BCBS Complete	$23.26
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Cofinity Medicare Advantage	$40.70
Rate for Payer: Encore Health Key Benefits Commercial	$46.51
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$37.79
Rate for Payer: Priority Health SBD	$36.63

ARTIFICIAL TEARS EYE DROPS WRAPPER

Facility

$81.36

Service Code	NDC 00536138694
Hospital Charge Code	301578
Hospital Revenue Code	637
Min. Negotiated Rate	$32.54
Max. Negotiated Rate	$73.22
Rate for Payer: Aetna Commercial	$69.16
Rate for Payer: Aetna Medicare	$40.68
Rate for Payer: Aetna New Business (MI Preferred)	$52.88
Rate for Payer: BCBS Complete	$32.54
Rate for Payer: Cash Price	$65.09
Rate for Payer: Cofinity Commercial	$56.95
Rate for Payer: Cofinity Commercial	$69.97
Rate for Payer: Cofinity Medicare Advantage	$56.95
Rate for Payer: Encore Health Key Benefits Commercial	$65.09
Rate for Payer: Healthscope Commercial	$73.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.16
Rate for Payer: PHP Commercial	$69.16
Rate for Payer: Priority Health Cigna Priority Health	$52.88
Rate for Payer: Priority Health SBD	$51.26

ARTIFICIAL TEARS EYE DROPS WRAPPER

Facility

$58.14

Service Code	NDC 00536132594
Hospital Charge Code	301578
Hospital Revenue Code	637
Min. Negotiated Rate	$36.63
Max. Negotiated Rate	$52.33
Rate for Payer: Aetna Commercial	$49.42
Rate for Payer: Aetna New Business (MI Preferred)	$37.79
Rate for Payer: Cash Price	$46.51
Rate for Payer: Cofinity Commercial	$40.70
Rate for Payer: Cofinity Commercial	$50.00
Rate for Payer: Cofinity Medicare Advantage	$40.70
Rate for Payer: Encore Health Key Benefits Commercial	$46.51
Rate for Payer: Healthscope Commercial	$52.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.42
Rate for Payer: PHP Commercial	$49.42
Rate for Payer: Priority Health Cigna Priority Health	$37.79
Rate for Payer: Priority Health SBD	$36.63

ARTIFICIAL TEARS EYE DROPS WRAPPER

Facility

$81.36

Service Code	NDC 00536138694
Hospital Charge Code	301578
Hospital Revenue Code	637
Min. Negotiated Rate	$51.26
Max. Negotiated Rate	$73.22
Rate for Payer: Aetna Commercial	$69.16
Rate for Payer: Aetna New Business (MI Preferred)	$52.88
Rate for Payer: Cash Price	$65.09
Rate for Payer: Cofinity Commercial	$56.95
Rate for Payer: Cofinity Commercial	$69.97
Rate for Payer: Cofinity Medicare Advantage	$56.95
Rate for Payer: Encore Health Key Benefits Commercial	$65.09
Rate for Payer: Healthscope Commercial	$73.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.16
Rate for Payer: PHP Commercial	$69.16
Rate for Payer: Priority Health Cigna Priority Health	$52.88
Rate for Payer: Priority Health SBD	$51.26

ASCORBIC ACID (VITAMIN C) 500 MG TABLET

Facility

$110.45

Service Code	NDC 79854030035
Hospital Charge Code	664
Hospital Revenue Code	637
Min. Negotiated Rate	$69.58
Max. Negotiated Rate	$99.41
Rate for Payer: Aetna Commercial	$93.88
Rate for Payer: Aetna New Business (MI Preferred)	$71.79
Rate for Payer: Cash Price	$88.36
Rate for Payer: Cofinity Commercial	$77.31
Rate for Payer: Cofinity Commercial	$94.99
Rate for Payer: Cofinity Medicare Advantage	$77.31
Rate for Payer: Encore Health Key Benefits Commercial	$88.36
Rate for Payer: Healthscope Commercial	$99.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.88
Rate for Payer: PHP Commercial	$93.88
Rate for Payer: Priority Health Cigna Priority Health	$71.79
Rate for Payer: Priority Health SBD	$69.58

ASCORBIC ACID (VITAMIN C) 500 MG TABLET

Facility

$70.50

Service Code	NDC 11845005171
Hospital Charge Code	664
Hospital Revenue Code	637
Min. Negotiated Rate	$44.41
Max. Negotiated Rate	$63.45
Rate for Payer: Aetna Commercial	$59.92
Rate for Payer: Aetna New Business (MI Preferred)	$45.83
Rate for Payer: Cash Price	$56.40
Rate for Payer: Cofinity Commercial	$49.35
Rate for Payer: Cofinity Commercial	$60.63
Rate for Payer: Cofinity Medicare Advantage	$49.35
Rate for Payer: Encore Health Key Benefits Commercial	$56.40
Rate for Payer: Healthscope Commercial	$63.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.92
Rate for Payer: PHP Commercial	$59.92
Rate for Payer: Priority Health Cigna Priority Health	$45.83
Rate for Payer: Priority Health SBD	$44.41

ASCORBIC ACID (VITAMIN C) 500 MG TABLET

Facility

$129.25

Service Code	NDC 79854030105
Hospital Charge Code	664
Hospital Revenue Code	637
Min. Negotiated Rate	$81.43
Max. Negotiated Rate	$116.33
Rate for Payer: Aetna Commercial	$109.86
Rate for Payer: Aetna New Business (MI Preferred)	$84.01
Rate for Payer: Cash Price	$103.40
Rate for Payer: Cofinity Commercial	$111.16
Rate for Payer: Cofinity Commercial	$90.47
Rate for Payer: Cofinity Medicare Advantage	$90.47
Rate for Payer: Encore Health Key Benefits Commercial	$103.40
Rate for Payer: Healthscope Commercial	$116.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$109.86
Rate for Payer: PHP Commercial	$109.86
Rate for Payer: Priority Health Cigna Priority Health	$84.01
Rate for Payer: Priority Health SBD	$81.43

ASCORBIC ACID (VITAMIN C) 500 MG TABLET

Facility

$183.30

Service Code	NDC 00904052372
Hospital Charge Code	664
Hospital Revenue Code	637
Min. Negotiated Rate	$115.48
Max. Negotiated Rate	$164.97
Rate for Payer: Aetna Commercial	$155.81
Rate for Payer: Aetna New Business (MI Preferred)	$119.14
Rate for Payer: Cash Price	$146.64
Rate for Payer: Cofinity Commercial	$128.31
Rate for Payer: Cofinity Commercial	$157.64
Rate for Payer: Cofinity Medicare Advantage	$128.31
Rate for Payer: Encore Health Key Benefits Commercial	$146.64
Rate for Payer: Healthscope Commercial	$164.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.81
Rate for Payer: PHP Commercial	$155.81
Rate for Payer: Priority Health Cigna Priority Health	$119.14
Rate for Payer: Priority Health SBD	$115.48

ASCORBIC ACID (VITAMIN C) 500 MG TABLET

Facility

$183.30

Service Code	NDC 00904052372
Hospital Charge Code	664
Hospital Revenue Code	637
Min. Negotiated Rate	$73.32
Max. Negotiated Rate	$164.97
Rate for Payer: Aetna Commercial	$155.81
Rate for Payer: Aetna Medicare	$91.65
Rate for Payer: Aetna New Business (MI Preferred)	$119.14
Rate for Payer: BCBS Complete	$73.32
Rate for Payer: Cash Price	$146.64
Rate for Payer: Cofinity Commercial	$128.31
Rate for Payer: Cofinity Commercial	$157.64
Rate for Payer: Cofinity Medicare Advantage	$128.31
Rate for Payer: Encore Health Key Benefits Commercial	$146.64
Rate for Payer: Healthscope Commercial	$164.97
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.81
Rate for Payer: PHP Commercial	$155.81
Rate for Payer: Priority Health Cigna Priority Health	$119.14
Rate for Payer: Priority Health SBD	$115.48

ASCORBIC ACID (VITAMIN C) 500 MG TABLET

Facility

$70.50

Service Code	NDC 00904052361
Hospital Charge Code	664
Hospital Revenue Code	637
Min. Negotiated Rate	$28.20
Max. Negotiated Rate	$63.45
Rate for Payer: Aetna Commercial	$59.92
Rate for Payer: Aetna Medicare	$35.25
Rate for Payer: Aetna New Business (MI Preferred)	$45.83
Rate for Payer: BCBS Complete	$28.20
Rate for Payer: Cash Price	$56.40
Rate for Payer: Cofinity Commercial	$49.35
Rate for Payer: Cofinity Commercial	$60.63
Rate for Payer: Cofinity Medicare Advantage	$49.35
Rate for Payer: Encore Health Key Benefits Commercial	$56.40
Rate for Payer: Healthscope Commercial	$63.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.92
Rate for Payer: PHP Commercial	$59.92
Rate for Payer: Priority Health Cigna Priority Health	$45.83
Rate for Payer: Priority Health SBD	$44.41

ASCORBIC ACID (VITAMIN C) 500 MG TABLET

Facility

$129.25

Service Code	NDC 79854030105
Hospital Charge Code	664
Hospital Revenue Code	637
Min. Negotiated Rate	$51.70
Max. Negotiated Rate	$116.33
Rate for Payer: Aetna Commercial	$109.86
Rate for Payer: Aetna Medicare	$64.62
Rate for Payer: Aetna New Business (MI Preferred)	$84.01
Rate for Payer: BCBS Complete	$51.70
Rate for Payer: Cash Price	$103.40
Rate for Payer: Cofinity Commercial	$111.16
Rate for Payer: Cofinity Commercial	$90.47
Rate for Payer: Cofinity Medicare Advantage	$90.47
Rate for Payer: Encore Health Key Benefits Commercial	$103.40
Rate for Payer: Healthscope Commercial	$116.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$109.86
Rate for Payer: PHP Commercial	$109.86
Rate for Payer: Priority Health Cigna Priority Health	$84.01
Rate for Payer: Priority Health SBD	$81.43

ASCORBIC ACID (VITAMIN C) 500 MG TABLET

Facility

$110.45

Service Code	NDC 79854030035
Hospital Charge Code	664
Hospital Revenue Code	637
Min. Negotiated Rate	$44.18
Max. Negotiated Rate	$99.41
Rate for Payer: Aetna Commercial	$93.88
Rate for Payer: Aetna Medicare	$55.23
Rate for Payer: Aetna New Business (MI Preferred)	$71.79
Rate for Payer: BCBS Complete	$44.18
Rate for Payer: Cash Price	$88.36
Rate for Payer: Cofinity Commercial	$77.31
Rate for Payer: Cofinity Commercial	$94.99
Rate for Payer: Cofinity Medicare Advantage	$77.31
Rate for Payer: Encore Health Key Benefits Commercial	$88.36
Rate for Payer: Healthscope Commercial	$99.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.88
Rate for Payer: PHP Commercial	$93.88
Rate for Payer: Priority Health Cigna Priority Health	$71.79
Rate for Payer: Priority Health SBD	$69.58

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