Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED

Facility

$19,004.38

Service Code	CPT 31253
Hospital Revenue Code	360
Min. Negotiated Rate	$3,618.72
Max. Negotiated Rate	$19,004.38
Rate for Payer: Aetna Medicare	$7,021.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,439.19
Rate for Payer: Amish Plain Church Group Commercial	$8,439.19
Rate for Payer: BCBS Complete	$3,799.66
Rate for Payer: BCBS MAPPO	$6,751.35
Rate for Payer: BCN Medicare Advantage	$6,751.35
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,751.35
Rate for Payer: Mclaren Medicaid	$3,618.72
Rate for Payer: Mclaren Medicare	$6,751.35
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,088.92
Rate for Payer: Meridian Medicaid	$3,799.66
Rate for Payer: MI Amish Medical Board Commercial	$7,764.05
Rate for Payer: PACE Medicare	$6,413.78
Rate for Payer: PACE SWMI	$6,751.35
Rate for Payer: PHP Medicare Advantage	$6,751.35
Rate for Payer: Priority Health Choice Medicaid	$3,618.72
Rate for Payer: Priority Health Medicare	$6,751.35
Rate for Payer: Railroad Medicare Medicare	$6,751.35
Rate for Payer: UHC All Payor (Choice/PPO)	$19,004.38
Rate for Payer: UHC Dual Complete DSNP	$6,751.35
Rate for Payer: UHC Medicare Advantage	$6,751.35
Rate for Payer: UHCCP Medicaid	$3,801.01
Rate for Payer: VA VA	$6,751.35

NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY

Facility

$19,004.38

Service Code	CPT 31257
Hospital Revenue Code	360
Min. Negotiated Rate	$3,618.72
Max. Negotiated Rate	$19,004.38
Rate for Payer: Aetna Medicare	$7,021.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,439.19
Rate for Payer: Amish Plain Church Group Commercial	$8,439.19
Rate for Payer: BCBS Complete	$3,799.66
Rate for Payer: BCBS MAPPO	$6,751.35
Rate for Payer: BCN Medicare Advantage	$6,751.35
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,751.35
Rate for Payer: Mclaren Medicaid	$3,618.72
Rate for Payer: Mclaren Medicare	$6,751.35
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,088.92
Rate for Payer: Meridian Medicaid	$3,799.66
Rate for Payer: MI Amish Medical Board Commercial	$7,764.05
Rate for Payer: PACE Medicare	$6,413.78
Rate for Payer: PACE SWMI	$6,751.35
Rate for Payer: PHP Medicare Advantage	$6,751.35
Rate for Payer: Priority Health Choice Medicaid	$3,618.72
Rate for Payer: Priority Health Medicare	$6,751.35
Rate for Payer: Railroad Medicare Medicare	$6,751.35
Rate for Payer: UHC All Payor (Choice/PPO)	$19,004.38
Rate for Payer: UHC Dual Complete DSNP	$6,751.35
Rate for Payer: UHC Medicare Advantage	$6,751.35
Rate for Payer: UHCCP Medicaid	$3,801.01
Rate for Payer: VA VA	$6,751.35

NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS

Facility

$19,004.38

Service Code	CPT 31259
Hospital Revenue Code	360
Min. Negotiated Rate	$3,618.72
Max. Negotiated Rate	$19,004.38
Rate for Payer: Aetna Medicare	$7,021.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,439.19
Rate for Payer: Amish Plain Church Group Commercial	$8,439.19
Rate for Payer: BCBS Complete	$3,799.66
Rate for Payer: BCBS MAPPO	$6,751.35
Rate for Payer: BCN Medicare Advantage	$6,751.35
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,751.35
Rate for Payer: Mclaren Medicaid	$3,618.72
Rate for Payer: Mclaren Medicare	$6,751.35
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,088.92
Rate for Payer: Meridian Medicaid	$3,799.66
Rate for Payer: MI Amish Medical Board Commercial	$7,764.05
Rate for Payer: PACE Medicare	$6,413.78
Rate for Payer: PACE SWMI	$6,751.35
Rate for Payer: PHP Medicare Advantage	$6,751.35
Rate for Payer: Priority Health Choice Medicaid	$3,618.72
Rate for Payer: Priority Health Medicare	$6,751.35
Rate for Payer: Railroad Medicare Medicare	$6,751.35
Rate for Payer: UHC All Payor (Choice/PPO)	$19,004.38
Rate for Payer: UHC Dual Complete DSNP	$6,751.35
Rate for Payer: UHC Medicare Advantage	$6,751.35
Rate for Payer: UHCCP Medicaid	$3,801.01
Rate for Payer: VA VA	$6,751.35

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED

Facility

$19,004.38

Service Code	CPT 31276
Hospital Revenue Code	360
Min. Negotiated Rate	$3,618.72
Max. Negotiated Rate	$19,004.38
Rate for Payer: Aetna Medicare	$7,021.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,439.19
Rate for Payer: Amish Plain Church Group Commercial	$8,439.19
Rate for Payer: BCBS Complete	$3,799.66
Rate for Payer: BCBS MAPPO	$6,751.35
Rate for Payer: BCN Medicare Advantage	$6,751.35
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,751.35
Rate for Payer: Mclaren Medicaid	$3,618.72
Rate for Payer: Mclaren Medicare	$6,751.35
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,088.92
Rate for Payer: Meridian Medicaid	$3,799.66
Rate for Payer: MI Amish Medical Board Commercial	$7,764.05
Rate for Payer: PACE Medicare	$6,413.78
Rate for Payer: PACE SWMI	$6,751.35
Rate for Payer: PHP Medicare Advantage	$6,751.35
Rate for Payer: Priority Health Choice Medicaid	$3,618.72
Rate for Payer: Priority Health Medicare	$6,751.35
Rate for Payer: Railroad Medicare Medicare	$6,751.35
Rate for Payer: UHC All Payor (Choice/PPO)	$19,004.38
Rate for Payer: UHC Dual Complete DSNP	$6,751.35
Rate for Payer: UHC Medicare Advantage	$6,751.35
Rate for Payer: UHCCP Medicaid	$3,801.01
Rate for Payer: VA VA	$6,751.35

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;

Facility

$10,121.85

Service Code	CPT 31256
Hospital Revenue Code	360
Min. Negotiated Rate	$1,927.35
Max. Negotiated Rate	$10,121.85
Rate for Payer: Aetna Medicare	$3,739.64
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,494.76
Rate for Payer: Amish Plain Church Group Commercial	$4,494.76
Rate for Payer: BCBS Complete	$2,023.72
Rate for Payer: BCBS MAPPO	$3,595.81
Rate for Payer: BCN Medicare Advantage	$3,595.81
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,595.81
Rate for Payer: Mclaren Medicaid	$1,927.35
Rate for Payer: Mclaren Medicare	$3,595.81
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,775.60
Rate for Payer: Meridian Medicaid	$2,023.72
Rate for Payer: MI Amish Medical Board Commercial	$4,135.18
Rate for Payer: PACE Medicare	$3,416.02
Rate for Payer: PACE SWMI	$3,595.81
Rate for Payer: PHP Medicare Advantage	$3,595.81
Rate for Payer: Priority Health Choice Medicaid	$1,927.35
Rate for Payer: Priority Health Medicare	$3,595.81
Rate for Payer: Railroad Medicare Medicare	$3,595.81
Rate for Payer: UHC All Payor (Choice/PPO)	$10,121.85
Rate for Payer: UHC Dual Complete DSNP	$3,595.81
Rate for Payer: UHC Medicare Advantage	$3,595.81
Rate for Payer: UHCCP Medicaid	$2,024.44
Rate for Payer: VA VA	$3,595.81

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS

Facility

$19,004.38

Service Code	CPT 31267
Hospital Revenue Code	360
Min. Negotiated Rate	$3,618.72
Max. Negotiated Rate	$19,004.38
Rate for Payer: Aetna Medicare	$7,021.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,439.19
Rate for Payer: Amish Plain Church Group Commercial	$8,439.19
Rate for Payer: BCBS Complete	$3,799.66
Rate for Payer: BCBS MAPPO	$6,751.35
Rate for Payer: BCN Medicare Advantage	$6,751.35
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,751.35
Rate for Payer: Mclaren Medicaid	$3,618.72
Rate for Payer: Mclaren Medicare	$6,751.35
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,088.92
Rate for Payer: Meridian Medicaid	$3,799.66
Rate for Payer: MI Amish Medical Board Commercial	$7,764.05
Rate for Payer: PACE Medicare	$6,413.78
Rate for Payer: PACE SWMI	$6,751.35
Rate for Payer: PHP Medicare Advantage	$6,751.35
Rate for Payer: Priority Health Choice Medicaid	$3,618.72
Rate for Payer: Priority Health Medicare	$6,751.35
Rate for Payer: Railroad Medicare Medicare	$6,751.35
Rate for Payer: UHC All Payor (Choice/PPO)	$19,004.38
Rate for Payer: UHC Dual Complete DSNP	$6,751.35
Rate for Payer: UHC Medicare Advantage	$6,751.35
Rate for Payer: UHCCP Medicaid	$3,801.01
Rate for Payer: VA VA	$6,751.35

NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY;

Facility

$19,004.38

Service Code	CPT 31287
Hospital Revenue Code	360
Min. Negotiated Rate	$3,618.72
Max. Negotiated Rate	$19,004.38
Rate for Payer: Aetna Medicare	$7,021.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,439.19
Rate for Payer: Amish Plain Church Group Commercial	$8,439.19
Rate for Payer: BCBS Complete	$3,799.66
Rate for Payer: BCBS MAPPO	$6,751.35
Rate for Payer: BCN Medicare Advantage	$6,751.35
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,751.35
Rate for Payer: Mclaren Medicaid	$3,618.72
Rate for Payer: Mclaren Medicare	$6,751.35
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7,088.92
Rate for Payer: Meridian Medicaid	$3,799.66
Rate for Payer: MI Amish Medical Board Commercial	$7,764.05
Rate for Payer: PACE Medicare	$6,413.78
Rate for Payer: PACE SWMI	$6,751.35
Rate for Payer: PHP Medicare Advantage	$6,751.35
Rate for Payer: Priority Health Choice Medicaid	$3,618.72
Rate for Payer: Priority Health Medicare	$6,751.35
Rate for Payer: Railroad Medicare Medicare	$6,751.35
Rate for Payer: UHC All Payor (Choice/PPO)	$19,004.38
Rate for Payer: UHC Dual Complete DSNP	$6,751.35
Rate for Payer: UHC Medicare Advantage	$6,751.35
Rate for Payer: UHCCP Medicaid	$3,801.01
Rate for Payer: VA VA	$6,751.35

NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); BILATERAL

Facility

$16,240.34

Service Code	CPT 69706
Hospital Revenue Code	360
Min. Negotiated Rate	$3,092.41
Max. Negotiated Rate	$16,240.34
Rate for Payer: Aetna Medicare	$6,000.20
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,211.77
Rate for Payer: Amish Plain Church Group Commercial	$7,211.77
Rate for Payer: BCBS Complete	$3,247.03
Rate for Payer: BCBS MAPPO	$5,769.42
Rate for Payer: BCN Medicare Advantage	$5,769.42
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,769.42
Rate for Payer: Mclaren Medicaid	$3,092.41
Rate for Payer: Mclaren Medicare	$5,769.42
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,057.89
Rate for Payer: Meridian Medicaid	$3,247.03
Rate for Payer: MI Amish Medical Board Commercial	$6,634.83
Rate for Payer: PACE Medicare	$5,480.95
Rate for Payer: PACE SWMI	$5,769.42
Rate for Payer: PHP Medicare Advantage	$5,769.42
Rate for Payer: Priority Health Choice Medicaid	$3,092.41
Rate for Payer: Priority Health Medicare	$5,769.42
Rate for Payer: Railroad Medicare Medicare	$5,769.42
Rate for Payer: UHC All Payor (Choice/PPO)	$16,240.34
Rate for Payer: UHC Dual Complete DSNP	$5,769.42
Rate for Payer: UHC Medicare Advantage	$5,769.42
Rate for Payer: UHCCP Medicaid	$3,248.18
Rate for Payer: VA VA	$5,769.42

NASOPHARYNGOSCOPY, SURGICAL, WITH DILATION OF EUSTACHIAN TUBE (IE, BALLOON DILATION); UNILATERAL

Facility

$16,240.34

Service Code	CPT 69705
Hospital Revenue Code	360
Min. Negotiated Rate	$3,092.41
Max. Negotiated Rate	$16,240.34
Rate for Payer: Aetna Medicare	$6,000.20
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,211.77
Rate for Payer: Amish Plain Church Group Commercial	$7,211.77
Rate for Payer: BCBS Complete	$3,247.03
Rate for Payer: BCBS MAPPO	$5,769.42
Rate for Payer: BCN Medicare Advantage	$5,769.42
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,769.42
Rate for Payer: Mclaren Medicaid	$3,092.41
Rate for Payer: Mclaren Medicare	$5,769.42
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6,057.89
Rate for Payer: Meridian Medicaid	$3,247.03
Rate for Payer: MI Amish Medical Board Commercial	$6,634.83
Rate for Payer: PACE Medicare	$5,480.95
Rate for Payer: PACE SWMI	$5,769.42
Rate for Payer: PHP Medicare Advantage	$5,769.42
Rate for Payer: Priority Health Choice Medicaid	$3,092.41
Rate for Payer: Priority Health Medicare	$5,769.42
Rate for Payer: Railroad Medicare Medicare	$5,769.42
Rate for Payer: UHC All Payor (Choice/PPO)	$16,240.34
Rate for Payer: UHC Dual Complete DSNP	$5,769.42
Rate for Payer: UHC Medicare Advantage	$5,769.42
Rate for Payer: UHCCP Medicaid	$3,248.18
Rate for Payer: VA VA	$5,769.42

NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION

Facility

$22,198.06

Service Code	HCPCS J2323
Hospital Charge Code	40120
Hospital Revenue Code	636
Min. Negotiated Rate	$13,984.78
Max. Negotiated Rate	$19,978.25
Rate for Payer: Aetna Commercial	$18,868.35
Rate for Payer: Aetna New Business (MI Preferred)	$14,428.74
Rate for Payer: Cash Price	$17,758.45
Rate for Payer: Cofinity Commercial	$15,538.64
Rate for Payer: Cofinity Commercial	$19,090.33
Rate for Payer: Cofinity Medicare Advantage	$15,538.64
Rate for Payer: Encore Health Key Benefits Commercial	$17,758.45
Rate for Payer: Healthscope Commercial	$19,978.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18,868.35
Rate for Payer: PHP Commercial	$18,868.35
Rate for Payer: Priority Health Cigna Priority Health	$14,428.74
Rate for Payer: Priority Health SBD	$13,984.78

NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION

Facility

$22,198.06

Service Code	HCPCS J2323
Hospital Charge Code	40120
Hospital Revenue Code	636
Min. Negotiated Rate	$12.86
Max. Negotiated Rate	$19,978.25
Rate for Payer: Aetna Commercial	$18,868.35
Rate for Payer: Aetna Medicare	$24.96
Rate for Payer: Aetna New Business (MI Preferred)	$14,428.74
Rate for Payer: Allen County Amish Medical Aid Commercial	$30.00
Rate for Payer: Amish Plain Church Group Commercial	$30.00
Rate for Payer: BCBS Complete	$13.51
Rate for Payer: BCBS MAPPO	$24.00
Rate for Payer: BCN Medicare Advantage	$24.00
Rate for Payer: Cash Price	$17,758.45
Rate for Payer: Cash Price	$17,758.45
Rate for Payer: Cofinity Commercial	$15,538.64
Rate for Payer: Cofinity Commercial	$19,090.33
Rate for Payer: Cofinity Medicare Advantage	$15,538.64
Rate for Payer: Encore Health Key Benefits Commercial	$17,758.45
Rate for Payer: Health Alliance Plan Medicare Advantage	$24.00
Rate for Payer: Healthscope Commercial	$19,978.25
Rate for Payer: Mclaren Medicaid	$12.86
Rate for Payer: Mclaren Medicare	$24.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$25.20
Rate for Payer: Meridian Medicaid	$13.51
Rate for Payer: MI Amish Medical Board Commercial	$27.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18,868.35
Rate for Payer: PACE Medicare	$22.80
Rate for Payer: PACE SWMI	$24.00
Rate for Payer: PHP Commercial	$18,868.35
Rate for Payer: PHP Medicare Advantage	$24.00
Rate for Payer: Priority Health Choice Medicaid	$12.86
Rate for Payer: Priority Health Cigna Priority Health	$14,428.74
Rate for Payer: Priority Health Medicare	$24.00
Rate for Payer: Priority Health SBD	$13,984.78
Rate for Payer: Railroad Medicare Medicare	$24.00
Rate for Payer: UHC All Payor (Choice/PPO)	$67.56
Rate for Payer: UHC Dual Complete DSNP	$24.00
Rate for Payer: UHC Medicare Advantage	$24.00
Rate for Payer: UHCCP Medicaid	$13.51
Rate for Payer: VA VA	$24.00

NECITUMUMAB 800 MG/50 ML (16 MG/ML) INTRAVENOUS SOLUTION

Facility

$19,440.58

Service Code	HCPCS J9295
Hospital Charge Code	176602
Hospital Revenue Code	636
Min. Negotiated Rate	$12,247.57
Max. Negotiated Rate	$17,496.52
Rate for Payer: Aetna Commercial	$16,524.49
Rate for Payer: Aetna New Business (MI Preferred)	$12,636.38
Rate for Payer: Cash Price	$15,552.46
Rate for Payer: Cofinity Commercial	$13,608.41
Rate for Payer: Cofinity Commercial	$16,718.90
Rate for Payer: Cofinity Medicare Advantage	$13,608.41
Rate for Payer: Encore Health Key Benefits Commercial	$15,552.46
Rate for Payer: Healthscope Commercial	$17,496.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16,524.49
Rate for Payer: PHP Commercial	$16,524.49
Rate for Payer: Priority Health Cigna Priority Health	$12,636.38
Rate for Payer: Priority Health SBD	$12,247.57

NECITUMUMAB 800 MG/50 ML (16 MG/ML) INTRAVENOUS SOLUTION

Facility

$19,440.58

Service Code	HCPCS J9295
Hospital Charge Code	176602
Hospital Revenue Code	636
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$17,496.52
Rate for Payer: Aetna Commercial	$16,524.49
Rate for Payer: Aetna Medicare	$5.96
Rate for Payer: Aetna New Business (MI Preferred)	$12,636.38
Rate for Payer: Allen County Amish Medical Aid Commercial	$7.16
Rate for Payer: Amish Plain Church Group Commercial	$7.16
Rate for Payer: BCBS Complete	$3.22
Rate for Payer: BCBS MAPPO	$5.73
Rate for Payer: BCN Medicare Advantage	$5.73
Rate for Payer: Cash Price	$15,552.46
Rate for Payer: Cash Price	$15,552.46
Rate for Payer: Cofinity Commercial	$16,718.90
Rate for Payer: Cofinity Commercial	$13,608.41
Rate for Payer: Cofinity Medicare Advantage	$13,608.41
Rate for Payer: Encore Health Key Benefits Commercial	$15,552.46
Rate for Payer: Health Alliance Plan Medicare Advantage	$5.73
Rate for Payer: Healthscope Commercial	$17,496.52
Rate for Payer: Mclaren Medicaid	$3.07
Rate for Payer: Mclaren Medicare	$5.73
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$6.02
Rate for Payer: Meridian Medicaid	$3.22
Rate for Payer: MI Amish Medical Board Commercial	$6.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16,524.49
Rate for Payer: PACE Medicare	$5.44
Rate for Payer: PACE SWMI	$5.73
Rate for Payer: PHP Commercial	$16,524.49
Rate for Payer: PHP Medicare Advantage	$5.73
Rate for Payer: Priority Health Choice Medicaid	$3.07
Rate for Payer: Priority Health Cigna Priority Health	$12,636.38
Rate for Payer: Priority Health Medicare	$5.73
Rate for Payer: Priority Health SBD	$12,247.57
Rate for Payer: Railroad Medicare Medicare	$5.73
Rate for Payer: UHC All Payor (Choice/PPO)	$16.13
Rate for Payer: UHC Dual Complete DSNP	$5.73
Rate for Payer: UHC Medicare Advantage	$5.73
Rate for Payer: UHCCP Medicaid	$3.23
Rate for Payer: VA VA	$5.73

NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS

Facility

$1,096.83

Service Code	CPT 97607
Hospital Revenue Code	360
Min. Negotiated Rate	$208.85
Max. Negotiated Rate	$1,096.83
Rate for Payer: Aetna Medicare	$405.24
Rate for Payer: Allen County Amish Medical Aid Commercial	$487.06
Rate for Payer: Amish Plain Church Group Commercial	$487.06
Rate for Payer: BCBS Complete	$219.30
Rate for Payer: BCBS MAPPO	$389.65
Rate for Payer: BCN Medicare Advantage	$389.65
Rate for Payer: Health Alliance Plan Medicare Advantage	$389.65
Rate for Payer: Mclaren Medicaid	$208.85
Rate for Payer: Mclaren Medicare	$389.65
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$409.13
Rate for Payer: Meridian Medicaid	$219.30
Rate for Payer: MI Amish Medical Board Commercial	$448.10
Rate for Payer: PACE Medicare	$370.17
Rate for Payer: PACE SWMI	$389.65
Rate for Payer: PHP Medicare Advantage	$389.65
Rate for Payer: Priority Health Choice Medicaid	$208.85
Rate for Payer: Priority Health Medicare	$389.65
Rate for Payer: Railroad Medicare Medicare	$389.65
Rate for Payer: UHC All Payor (Choice/PPO)	$1,096.83
Rate for Payer: UHC Dual Complete DSNP	$389.65
Rate for Payer: UHC Medicare Advantage	$389.65
Rate for Payer: UHCCP Medicaid	$219.37
Rate for Payer: VA VA	$389.65

NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS

Facility

$545.50

Service Code	CPT 97605
Hospital Revenue Code	360
Min. Negotiated Rate	$103.87
Max. Negotiated Rate	$545.50
Rate for Payer: Aetna Medicare	$201.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$242.24
Rate for Payer: Amish Plain Church Group Commercial	$242.24
Rate for Payer: BCBS Complete	$109.07
Rate for Payer: BCBS MAPPO	$193.79
Rate for Payer: BCN Medicare Advantage	$193.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$193.79
Rate for Payer: Mclaren Medicaid	$103.87
Rate for Payer: Mclaren Medicare	$193.79
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$203.48
Rate for Payer: Meridian Medicaid	$109.07
Rate for Payer: MI Amish Medical Board Commercial	$222.86
Rate for Payer: PACE Medicare	$184.10
Rate for Payer: PACE SWMI	$193.79
Rate for Payer: PHP Medicare Advantage	$193.79
Rate for Payer: Priority Health Choice Medicaid	$103.87
Rate for Payer: Priority Health Medicare	$193.79
Rate for Payer: Railroad Medicare Medicare	$193.79
Rate for Payer: UHC All Payor (Choice/PPO)	$545.50
Rate for Payer: UHC Dual Complete DSNP	$193.79
Rate for Payer: UHC Medicare Advantage	$193.79
Rate for Payer: UHCCP Medicaid	$109.10
Rate for Payer: VA VA	$193.79

NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS

Facility

$166.15

Service Code	NDC 24208079062
Hospital Charge Code	5474
Hospital Revenue Code	637
Min. Negotiated Rate	$66.46
Max. Negotiated Rate	$149.53
Rate for Payer: Aetna Commercial	$141.23
Rate for Payer: Aetna Medicare	$83.08
Rate for Payer: Aetna New Business (MI Preferred)	$108.00
Rate for Payer: BCBS Complete	$66.46
Rate for Payer: Cash Price	$132.92
Rate for Payer: Cofinity Commercial	$116.31
Rate for Payer: Cofinity Commercial	$142.89
Rate for Payer: Cofinity Medicare Advantage	$116.31
Rate for Payer: Encore Health Key Benefits Commercial	$132.92
Rate for Payer: Healthscope Commercial	$149.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$141.23
Rate for Payer: PHP Commercial	$141.23
Rate for Payer: Priority Health Cigna Priority Health	$108.00
Rate for Payer: Priority Health SBD	$104.67

NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS

Facility

$166.15

Service Code	NDC 24208079062
Hospital Charge Code	5474
Hospital Revenue Code	637
Min. Negotiated Rate	$104.67
Max. Negotiated Rate	$149.53
Rate for Payer: Aetna Commercial	$141.23
Rate for Payer: Aetna New Business (MI Preferred)	$108.00
Rate for Payer: Cash Price	$132.92
Rate for Payer: Cofinity Commercial	$116.31
Rate for Payer: Cofinity Commercial	$142.89
Rate for Payer: Cofinity Medicare Advantage	$116.31
Rate for Payer: Encore Health Key Benefits Commercial	$132.92
Rate for Payer: Healthscope Commercial	$149.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$141.23
Rate for Payer: PHP Commercial	$141.23
Rate for Payer: Priority Health Cigna Priority Health	$108.00
Rate for Payer: Priority Health SBD	$104.67

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT

Facility

$46.73

Service Code	NDC 24208079535
Hospital Charge Code	19495
Hospital Revenue Code	637
Min. Negotiated Rate	$18.69
Max. Negotiated Rate	$42.06
Rate for Payer: Aetna Commercial	$39.72
Rate for Payer: Aetna Medicare	$23.36
Rate for Payer: Aetna New Business (MI Preferred)	$30.37
Rate for Payer: BCBS Complete	$18.69
Rate for Payer: Cash Price	$37.38
Rate for Payer: Cofinity Commercial	$32.71
Rate for Payer: Cofinity Commercial	$40.19
Rate for Payer: Cofinity Medicare Advantage	$32.71
Rate for Payer: Encore Health Key Benefits Commercial	$37.38
Rate for Payer: Healthscope Commercial	$42.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$39.72
Rate for Payer: PHP Commercial	$39.72
Rate for Payer: Priority Health Cigna Priority Health	$30.37
Rate for Payer: Priority Health SBD	$29.44

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT

Facility

$58.60

Service Code	NDC 61314063136
Hospital Charge Code	19495
Hospital Revenue Code	637
Min. Negotiated Rate	$36.92
Max. Negotiated Rate	$52.74
Rate for Payer: Aetna Commercial	$49.81
Rate for Payer: Aetna New Business (MI Preferred)	$38.09
Rate for Payer: Cash Price	$46.88
Rate for Payer: Cofinity Commercial	$41.02
Rate for Payer: Cofinity Commercial	$50.40
Rate for Payer: Cofinity Medicare Advantage	$41.02
Rate for Payer: Encore Health Key Benefits Commercial	$46.88
Rate for Payer: Healthscope Commercial	$52.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.81
Rate for Payer: PHP Commercial	$49.81
Rate for Payer: Priority Health Cigna Priority Health	$38.09
Rate for Payer: Priority Health SBD	$36.92

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT

Facility

$58.60

Service Code	NDC 61314063136
Hospital Charge Code	19495
Hospital Revenue Code	637
Min. Negotiated Rate	$23.44
Max. Negotiated Rate	$52.74
Rate for Payer: Aetna Commercial	$49.81
Rate for Payer: Aetna Medicare	$29.30
Rate for Payer: Aetna New Business (MI Preferred)	$38.09
Rate for Payer: BCBS Complete	$23.44
Rate for Payer: Cash Price	$46.88
Rate for Payer: Cofinity Commercial	$41.02
Rate for Payer: Cofinity Commercial	$50.40
Rate for Payer: Cofinity Medicare Advantage	$41.02
Rate for Payer: Encore Health Key Benefits Commercial	$46.88
Rate for Payer: Healthscope Commercial	$52.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.81
Rate for Payer: PHP Commercial	$49.81
Rate for Payer: Priority Health Cigna Priority Health	$38.09
Rate for Payer: Priority Health SBD	$36.92

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT

Facility

$46.73

Service Code	NDC 24208079535
Hospital Charge Code	19495
Hospital Revenue Code	637
Min. Negotiated Rate	$29.44
Max. Negotiated Rate	$42.06
Rate for Payer: Aetna Commercial	$39.72
Rate for Payer: Aetna New Business (MI Preferred)	$30.37
Rate for Payer: Cash Price	$37.38
Rate for Payer: Cofinity Commercial	$32.71
Rate for Payer: Cofinity Commercial	$40.19
Rate for Payer: Cofinity Medicare Advantage	$32.71
Rate for Payer: Encore Health Key Benefits Commercial	$37.38
Rate for Payer: Healthscope Commercial	$42.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$39.72
Rate for Payer: PHP Commercial	$39.72
Rate for Payer: Priority Health Cigna Priority Health	$30.37
Rate for Payer: Priority Health SBD	$29.44

NEOMYCIN 500 MG TABLET

Facility

$6.06

Service Code	NDC 39822031007
Hospital Charge Code	5472
Hospital Revenue Code	637
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$5.45
Rate for Payer: Aetna Commercial	$5.15
Rate for Payer: Aetna Medicare	$3.03
Rate for Payer: Aetna New Business (MI Preferred)	$3.94
Rate for Payer: BCBS Complete	$2.42
Rate for Payer: Cash Price	$4.85
Rate for Payer: Cofinity Commercial	$4.24
Rate for Payer: Cofinity Commercial	$5.21
Rate for Payer: Cofinity Medicare Advantage	$4.24
Rate for Payer: Encore Health Key Benefits Commercial	$4.85
Rate for Payer: Healthscope Commercial	$5.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.15
Rate for Payer: PHP Commercial	$5.15
Rate for Payer: Priority Health Cigna Priority Health	$3.94
Rate for Payer: Priority Health SBD	$3.82

NEOMYCIN 500 MG TABLET

Facility

$605.76

Service Code	NDC 39822031005
Hospital Charge Code	5472
Hospital Revenue Code	637
Min. Negotiated Rate	$381.63
Max. Negotiated Rate	$545.18
Rate for Payer: Aetna Commercial	$514.90
Rate for Payer: Aetna New Business (MI Preferred)	$393.74
Rate for Payer: Cash Price	$484.61
Rate for Payer: Cofinity Commercial	$424.03
Rate for Payer: Cofinity Commercial	$520.95
Rate for Payer: Cofinity Medicare Advantage	$424.03
Rate for Payer: Encore Health Key Benefits Commercial	$484.61
Rate for Payer: Healthscope Commercial	$545.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$514.90
Rate for Payer: PHP Commercial	$514.90
Rate for Payer: Priority Health Cigna Priority Health	$393.74
Rate for Payer: Priority Health SBD	$381.63

NEOMYCIN 500 MG TABLET

Facility

$454.56

Service Code	NDC 50383056510
Hospital Charge Code	5472
Hospital Revenue Code	637
Min. Negotiated Rate	$286.37
Max. Negotiated Rate	$409.10
Rate for Payer: Aetna Commercial	$386.38
Rate for Payer: Aetna New Business (MI Preferred)	$295.46
Rate for Payer: Cash Price	$363.65
Rate for Payer: Cofinity Commercial	$318.19
Rate for Payer: Cofinity Commercial	$390.92
Rate for Payer: Cofinity Medicare Advantage	$318.19
Rate for Payer: Encore Health Key Benefits Commercial	$363.65
Rate for Payer: Healthscope Commercial	$409.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$386.38
Rate for Payer: PHP Commercial	$386.38
Rate for Payer: Priority Health Cigna Priority Health	$295.46
Rate for Payer: Priority Health SBD	$286.37

NEOMYCIN 500 MG TABLET

Facility

$605.76

Service Code	NDC 39822031005
Hospital Charge Code	5472
Hospital Revenue Code	637
Min. Negotiated Rate	$242.30
Max. Negotiated Rate	$545.18
Rate for Payer: Aetna Commercial	$514.90
Rate for Payer: Aetna Medicare	$302.88
Rate for Payer: Aetna New Business (MI Preferred)	$393.74
Rate for Payer: BCBS Complete	$242.30
Rate for Payer: Cash Price	$484.61
Rate for Payer: Cofinity Commercial	$424.03
Rate for Payer: Cofinity Commercial	$520.95
Rate for Payer: Cofinity Medicare Advantage	$424.03
Rate for Payer: Encore Health Key Benefits Commercial	$484.61
Rate for Payer: Healthscope Commercial	$545.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$514.90
Rate for Payer: PHP Commercial	$514.90
Rate for Payer: Priority Health Cigna Priority Health	$393.74
Rate for Payer: Priority Health SBD	$381.63

Know your out-of-pocket cost for care.

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