Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING

Facility

$8,728.81

Service Code	CPT 56700
Hospital Revenue Code	360
Min. Negotiated Rate	$1,662.10
Max. Negotiated Rate	$8,728.81
Rate for Payer: Aetna Medicare	$3,224.97
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,876.16
Rate for Payer: Amish Plain Church Group Commercial	$3,876.16
Rate for Payer: BCBS Complete	$1,745.20
Rate for Payer: BCBS MAPPO	$3,100.93
Rate for Payer: BCN Medicare Advantage	$3,100.93
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,100.93
Rate for Payer: Mclaren Medicaid	$1,662.10
Rate for Payer: Mclaren Medicare	$3,100.93
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,255.98
Rate for Payer: Meridian Medicaid	$1,745.20
Rate for Payer: MI Amish Medical Board Commercial	$3,566.07
Rate for Payer: PACE Medicare	$2,945.88
Rate for Payer: PACE SWMI	$3,100.93
Rate for Payer: PHP Medicare Advantage	$3,100.93
Rate for Payer: Priority Health Choice Medicaid	$1,662.10
Rate for Payer: Priority Health Medicare	$3,100.93
Rate for Payer: Railroad Medicare Medicare	$3,100.93
Rate for Payer: UHC All Payor (Choice/PPO)	$8,728.81
Rate for Payer: UHC Dual Complete DSNP	$3,100.93
Rate for Payer: UHC Medicare Advantage	$3,100.93
Rate for Payer: UHCCP Medicaid	$1,745.82
Rate for Payer: VA VA	$3,100.93

PATELLECTOMY OR HEMIPATELLECTOMY

Facility

$19,611.80

Service Code	CPT 27350
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

PEDS ECHO LIMITED W/DEFINITY

Facility

$1,384.11

Service Code	HCPCS C8922
Hospital Charge Code	48000029
Hospital Revenue Code	480
Min. Negotiated Rate	$413.00
Max. Negotiated Rate	$2,168.96
Rate for Payer: Aetna Commercial	$1,176.49
Rate for Payer: Aetna Medicare	$801.35
Rate for Payer: Aetna New Business (MI Preferred)	$899.67
Rate for Payer: Allen County Amish Medical Aid Commercial	$963.16
Rate for Payer: Amish Plain Church Group Commercial	$963.16
Rate for Payer: BCBS Complete	$433.65
Rate for Payer: BCBS MAPPO	$770.53
Rate for Payer: BCN Medicare Advantage	$770.53
Rate for Payer: Cash Price	$1,107.29
Rate for Payer: Cash Price	$1,107.29
Rate for Payer: Cofinity Commercial	$968.88
Rate for Payer: Cofinity Commercial	$1,190.33
Rate for Payer: Cofinity Medicare Advantage	$968.88
Rate for Payer: Encore Health Key Benefits Commercial	$1,107.29
Rate for Payer: Health Alliance Plan Medicare Advantage	$770.53
Rate for Payer: Healthscope Commercial	$1,245.70
Rate for Payer: Mclaren Medicaid	$413.00
Rate for Payer: Mclaren Medicare	$770.53
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$809.06
Rate for Payer: Meridian Medicaid	$433.65
Rate for Payer: MI Amish Medical Board Commercial	$886.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,176.49
Rate for Payer: PACE Medicare	$732.00
Rate for Payer: PACE SWMI	$770.53
Rate for Payer: PHP Commercial	$1,176.49
Rate for Payer: PHP Medicare Advantage	$770.53
Rate for Payer: Priority Health Choice Medicaid	$413.00
Rate for Payer: Priority Health Cigna Priority Health	$899.67
Rate for Payer: Priority Health Medicare	$770.53
Rate for Payer: Priority Health SBD	$871.99
Rate for Payer: Railroad Medicare Medicare	$770.53
Rate for Payer: UHC All Payor (Choice/PPO)	$2,168.96
Rate for Payer: UHC Core	$1,024.24
Rate for Payer: UHC Dual Complete DSNP	$770.53
Rate for Payer: UHC Exchange	$1,024.24
Rate for Payer: UHC Medicare Advantage	$770.53
Rate for Payer: UHCCP Medicaid	$433.81
Rate for Payer: VA VA	$770.53

PEDS ECHO LIMITED W/DEFINITY

Facility

$1,384.11

Service Code	HCPCS C8922
Hospital Charge Code	48000029
Hospital Revenue Code	480
Min. Negotiated Rate	$871.99
Max. Negotiated Rate	$1,245.70
Rate for Payer: Aetna Commercial	$1,176.49
Rate for Payer: Aetna New Business (MI Preferred)	$899.67
Rate for Payer: Cash Price	$1,107.29
Rate for Payer: Cofinity Commercial	$1,190.33
Rate for Payer: Cofinity Commercial	$968.88
Rate for Payer: Cofinity Medicare Advantage	$968.88
Rate for Payer: Encore Health Key Benefits Commercial	$1,107.29
Rate for Payer: Healthscope Commercial	$1,245.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,176.49
Rate for Payer: PHP Commercial	$1,176.49
Rate for Payer: Priority Health Cigna Priority Health	$899.67
Rate for Payer: Priority Health SBD	$871.99

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION

Facility

$70.00

Service Code	NDC 52268010001
Hospital Charge Code	10839
Hospital Revenue Code	637
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.50
Rate for Payer: Aetna Medicare	$35.00
Rate for Payer: Aetna New Business (MI Preferred)	$45.50
Rate for Payer: BCBS Complete	$28.00
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$49.00
Rate for Payer: Cofinity Commercial	$60.20
Rate for Payer: Cofinity Medicare Advantage	$49.00
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.50
Rate for Payer: PHP Commercial	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$45.50
Rate for Payer: Priority Health SBD	$44.10

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION

Facility

$56.00

Service Code	NDC 43386009019
Hospital Charge Code	10839
Hospital Revenue Code	637
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna Commercial	$47.60
Rate for Payer: Aetna Medicare	$28.00
Rate for Payer: Aetna New Business (MI Preferred)	$36.40
Rate for Payer: BCBS Complete	$22.40
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cofinity Commercial	$39.20
Rate for Payer: Cofinity Commercial	$48.16
Rate for Payer: Cofinity Medicare Advantage	$39.20
Rate for Payer: Encore Health Key Benefits Commercial	$44.80
Rate for Payer: Healthscope Commercial	$50.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.60
Rate for Payer: PHP Commercial	$47.60
Rate for Payer: Priority Health Cigna Priority Health	$36.40
Rate for Payer: Priority Health SBD	$35.28

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION

Facility

$70.00

Service Code	NDC 52268010001
Hospital Charge Code	10839
Hospital Revenue Code	637
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.50
Rate for Payer: Aetna New Business (MI Preferred)	$45.50
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$49.00
Rate for Payer: Cofinity Commercial	$60.20
Rate for Payer: Cofinity Medicare Advantage	$49.00
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.50
Rate for Payer: PHP Commercial	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$45.50
Rate for Payer: Priority Health SBD	$44.10

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION

Facility

$56.00

Service Code	NDC 43386009019
Hospital Charge Code	10839
Hospital Revenue Code	637
Min. Negotiated Rate	$35.28
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna Commercial	$47.60
Rate for Payer: Aetna New Business (MI Preferred)	$36.40
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cofinity Commercial	$39.20
Rate for Payer: Cofinity Commercial	$48.16
Rate for Payer: Cofinity Medicare Advantage	$39.20
Rate for Payer: Encore Health Key Benefits Commercial	$44.80
Rate for Payer: Healthscope Commercial	$50.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.60
Rate for Payer: PHP Commercial	$47.60
Rate for Payer: Priority Health Cigna Priority Health	$36.40
Rate for Payer: Priority Health SBD	$35.28

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS

Facility

$9.52

Service Code	NDC 57896018105
Hospital Charge Code	41412
Hospital Revenue Code	637
Min. Negotiated Rate	$3.81
Max. Negotiated Rate	$8.57
Rate for Payer: Aetna Commercial	$8.09
Rate for Payer: Aetna Medicare	$4.76
Rate for Payer: Aetna New Business (MI Preferred)	$6.19
Rate for Payer: BCBS Complete	$3.81
Rate for Payer: Cash Price	$7.62
Rate for Payer: Cofinity Commercial	$8.19
Rate for Payer: Cofinity Commercial	$6.66
Rate for Payer: Cofinity Medicare Advantage	$6.66
Rate for Payer: Encore Health Key Benefits Commercial	$7.62
Rate for Payer: Healthscope Commercial	$8.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.09
Rate for Payer: PHP Commercial	$8.09
Rate for Payer: Priority Health Cigna Priority Health	$6.19
Rate for Payer: Priority Health SBD	$6.00

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS

Facility

$9.52

Service Code	NDC 57896018105
Hospital Charge Code	41412
Hospital Revenue Code	637
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$8.57
Rate for Payer: Aetna Commercial	$8.09
Rate for Payer: Aetna New Business (MI Preferred)	$6.19
Rate for Payer: Cash Price	$7.62
Rate for Payer: Cofinity Commercial	$6.66
Rate for Payer: Cofinity Commercial	$8.19
Rate for Payer: Cofinity Medicare Advantage	$6.66
Rate for Payer: Encore Health Key Benefits Commercial	$7.62
Rate for Payer: Healthscope Commercial	$8.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.09
Rate for Payer: PHP Commercial	$8.09
Rate for Payer: Priority Health Cigna Priority Health	$6.19
Rate for Payer: Priority Health SBD	$6.00

PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION

Facility

$120,400.03

Service Code	HCPCS J9266
Hospital Charge Code	12519
Hospital Revenue Code	636
Min. Negotiated Rate	$75,852.02
Max. Negotiated Rate	$108,360.03
Rate for Payer: Aetna Commercial	$102,340.03
Rate for Payer: Aetna New Business (MI Preferred)	$78,260.02
Rate for Payer: Cash Price	$96,320.02
Rate for Payer: Cofinity Commercial	$103,544.03
Rate for Payer: Cofinity Commercial	$84,280.02
Rate for Payer: Cofinity Medicare Advantage	$84,280.02
Rate for Payer: Encore Health Key Benefits Commercial	$96,320.02
Rate for Payer: Healthscope Commercial	$108,360.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$102,340.03
Rate for Payer: PHP Commercial	$102,340.03
Rate for Payer: Priority Health Cigna Priority Health	$78,260.02
Rate for Payer: Priority Health SBD	$75,852.02

PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION

Facility

$120,400.03

Service Code	HCPCS J9266
Hospital Charge Code	12519
Hospital Revenue Code	636
Min. Negotiated Rate	$15,235.30
Max. Negotiated Rate	$108,360.03
Rate for Payer: Aetna Commercial	$102,340.03
Rate for Payer: Aetna Medicare	$29,561.02
Rate for Payer: Aetna New Business (MI Preferred)	$78,260.02
Rate for Payer: Allen County Amish Medical Aid Commercial	$35,530.07
Rate for Payer: Amish Plain Church Group Commercial	$35,530.07
Rate for Payer: BCBS Complete	$15,997.06
Rate for Payer: BCBS MAPPO	$28,424.06
Rate for Payer: BCN Medicare Advantage	$28,424.06
Rate for Payer: Cash Price	$96,320.02
Rate for Payer: Cash Price	$96,320.02
Rate for Payer: Cofinity Commercial	$84,280.02
Rate for Payer: Cofinity Commercial	$103,544.03
Rate for Payer: Cofinity Medicare Advantage	$84,280.02
Rate for Payer: Encore Health Key Benefits Commercial	$96,320.02
Rate for Payer: Health Alliance Plan Medicare Advantage	$28,424.06
Rate for Payer: Healthscope Commercial	$108,360.03
Rate for Payer: Mclaren Medicaid	$15,235.30
Rate for Payer: Mclaren Medicare	$28,424.06
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$29,845.26
Rate for Payer: Meridian Medicaid	$15,997.06
Rate for Payer: MI Amish Medical Board Commercial	$32,687.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$102,340.03
Rate for Payer: PACE Medicare	$27,002.86
Rate for Payer: PACE SWMI	$28,424.06
Rate for Payer: PHP Commercial	$102,340.03
Rate for Payer: PHP Medicare Advantage	$28,424.06
Rate for Payer: Priority Health Choice Medicaid	$15,235.30
Rate for Payer: Priority Health Cigna Priority Health	$78,260.02
Rate for Payer: Priority Health Medicare	$28,424.06
Rate for Payer: Priority Health SBD	$75,852.02
Rate for Payer: Railroad Medicare Medicare	$28,424.06
Rate for Payer: UHC All Payor (Choice/PPO)	$80,010.89
Rate for Payer: UHC Dual Complete DSNP	$28,424.06
Rate for Payer: UHC Medicare Advantage	$28,424.06
Rate for Payer: UHCCP Medicaid	$16,002.75
Rate for Payer: VA VA	$28,424.06

PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR

Facility

$11,749.74

Service Code	HCPCS J2506
Hospital Charge Code	173747
Hospital Revenue Code	636
Min. Negotiated Rate	$7,402.34
Max. Negotiated Rate	$10,574.77
Rate for Payer: Aetna Commercial	$9,987.28
Rate for Payer: Aetna New Business (MI Preferred)	$7,637.33
Rate for Payer: Cash Price	$9,399.79
Rate for Payer: Cofinity Commercial	$10,104.78
Rate for Payer: Cofinity Commercial	$8,224.82
Rate for Payer: Cofinity Medicare Advantage	$8,224.82
Rate for Payer: Encore Health Key Benefits Commercial	$9,399.79
Rate for Payer: Healthscope Commercial	$10,574.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9,987.28
Rate for Payer: PHP Commercial	$9,987.28
Rate for Payer: Priority Health Cigna Priority Health	$7,637.33
Rate for Payer: Priority Health SBD	$7,402.34

PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR

Facility

$11,749.74

Service Code	HCPCS J2506
Hospital Charge Code	173747
Hospital Revenue Code	636
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$10,574.77
Rate for Payer: Aetna Commercial	$9,987.28
Rate for Payer: Aetna Medicare	$92.91
Rate for Payer: Aetna New Business (MI Preferred)	$7,637.33
Rate for Payer: Allen County Amish Medical Aid Commercial	$111.67
Rate for Payer: Amish Plain Church Group Commercial	$111.67
Rate for Payer: BCBS Complete	$50.28
Rate for Payer: BCBS MAPPO	$89.34
Rate for Payer: BCN Medicare Advantage	$89.34
Rate for Payer: Cash Price	$9,399.79
Rate for Payer: Cash Price	$9,399.79
Rate for Payer: Cofinity Commercial	$10,104.78
Rate for Payer: Cofinity Commercial	$8,224.82
Rate for Payer: Cofinity Medicare Advantage	$8,224.82
Rate for Payer: Encore Health Key Benefits Commercial	$9,399.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$89.34
Rate for Payer: Healthscope Commercial	$10,574.77
Rate for Payer: Mclaren Medicaid	$47.89
Rate for Payer: Mclaren Medicare	$89.34
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$93.81
Rate for Payer: Meridian Medicaid	$50.28
Rate for Payer: MI Amish Medical Board Commercial	$102.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9,987.28
Rate for Payer: PACE Medicare	$84.87
Rate for Payer: PACE SWMI	$89.34
Rate for Payer: PHP Commercial	$9,987.28
Rate for Payer: PHP Medicare Advantage	$89.34
Rate for Payer: Priority Health Choice Medicaid	$47.89
Rate for Payer: Priority Health Cigna Priority Health	$7,637.33
Rate for Payer: Priority Health Medicare	$89.34
Rate for Payer: Priority Health SBD	$7,402.34
Rate for Payer: Railroad Medicare Medicare	$89.34
Rate for Payer: UHC All Payor (Choice/PPO)	$251.48
Rate for Payer: UHC Dual Complete DSNP	$89.34
Rate for Payer: UHC Medicare Advantage	$89.34
Rate for Payer: UHCCP Medicaid	$50.30
Rate for Payer: VA VA	$89.34

PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$9,392.27

Service Code	HCPCS J2506
Hospital Charge Code	32267
Hospital Revenue Code	636
Min. Negotiated Rate	$5,917.13
Max. Negotiated Rate	$8,453.04
Rate for Payer: Aetna Commercial	$7,983.43
Rate for Payer: Aetna New Business (MI Preferred)	$6,104.98
Rate for Payer: Cash Price	$7,513.82
Rate for Payer: Cofinity Commercial	$6,574.59
Rate for Payer: Cofinity Commercial	$8,077.35
Rate for Payer: Cofinity Medicare Advantage	$6,574.59
Rate for Payer: Encore Health Key Benefits Commercial	$7,513.82
Rate for Payer: Healthscope Commercial	$8,453.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,983.43
Rate for Payer: PHP Commercial	$7,983.43
Rate for Payer: Priority Health Cigna Priority Health	$6,104.98
Rate for Payer: Priority Health SBD	$5,917.13

PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$9,392.27

Service Code	HCPCS J2506
Hospital Charge Code	32267
Hospital Revenue Code	636
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$8,453.04
Rate for Payer: Aetna Commercial	$7,983.43
Rate for Payer: Aetna Medicare	$92.91
Rate for Payer: Aetna New Business (MI Preferred)	$6,104.98
Rate for Payer: Allen County Amish Medical Aid Commercial	$111.67
Rate for Payer: Amish Plain Church Group Commercial	$111.67
Rate for Payer: BCBS Complete	$50.28
Rate for Payer: BCBS MAPPO	$89.34
Rate for Payer: BCN Medicare Advantage	$89.34
Rate for Payer: Cash Price	$7,513.82
Rate for Payer: Cash Price	$7,513.82
Rate for Payer: Cofinity Commercial	$8,077.35
Rate for Payer: Cofinity Commercial	$6,574.59
Rate for Payer: Cofinity Medicare Advantage	$6,574.59
Rate for Payer: Encore Health Key Benefits Commercial	$7,513.82
Rate for Payer: Health Alliance Plan Medicare Advantage	$89.34
Rate for Payer: Healthscope Commercial	$8,453.04
Rate for Payer: Mclaren Medicaid	$47.89
Rate for Payer: Mclaren Medicare	$89.34
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$93.81
Rate for Payer: Meridian Medicaid	$50.28
Rate for Payer: MI Amish Medical Board Commercial	$102.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,983.43
Rate for Payer: PACE Medicare	$84.87
Rate for Payer: PACE SWMI	$89.34
Rate for Payer: PHP Commercial	$7,983.43
Rate for Payer: PHP Medicare Advantage	$89.34
Rate for Payer: Priority Health Choice Medicaid	$47.89
Rate for Payer: Priority Health Cigna Priority Health	$6,104.98
Rate for Payer: Priority Health Medicare	$89.34
Rate for Payer: Priority Health SBD	$5,917.13
Rate for Payer: Railroad Medicare Medicare	$89.34
Rate for Payer: UHC All Payor (Choice/PPO)	$251.48
Rate for Payer: UHC Dual Complete DSNP	$89.34
Rate for Payer: UHC Medicare Advantage	$89.34
Rate for Payer: UHCCP Medicaid	$50.30
Rate for Payer: VA VA	$89.34

PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$5,301.28

Service Code	HCPCS Q5122
Hospital Charge Code	195654
Hospital Revenue Code	636
Min. Negotiated Rate	$70.30
Max. Negotiated Rate	$4,771.15
Rate for Payer: Aetna Commercial	$4,506.09
Rate for Payer: Aetna Medicare	$136.41
Rate for Payer: Aetna New Business (MI Preferred)	$3,445.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$163.95
Rate for Payer: Amish Plain Church Group Commercial	$163.95
Rate for Payer: BCBS Complete	$73.82
Rate for Payer: BCBS MAPPO	$131.16
Rate for Payer: BCN Medicare Advantage	$131.16
Rate for Payer: Cash Price	$4,241.02
Rate for Payer: Cash Price	$4,241.02
Rate for Payer: Cofinity Commercial	$3,710.90
Rate for Payer: Cofinity Commercial	$4,559.10
Rate for Payer: Cofinity Medicare Advantage	$3,710.90
Rate for Payer: Encore Health Key Benefits Commercial	$4,241.02
Rate for Payer: Health Alliance Plan Medicare Advantage	$131.16
Rate for Payer: Healthscope Commercial	$4,771.15
Rate for Payer: Mclaren Medicaid	$70.30
Rate for Payer: Mclaren Medicare	$131.16
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$137.72
Rate for Payer: Meridian Medicaid	$73.82
Rate for Payer: MI Amish Medical Board Commercial	$150.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,506.09
Rate for Payer: PACE Medicare	$124.60
Rate for Payer: PACE SWMI	$131.16
Rate for Payer: PHP Commercial	$4,506.09
Rate for Payer: PHP Medicare Advantage	$131.16
Rate for Payer: Priority Health Choice Medicaid	$70.30
Rate for Payer: Priority Health Cigna Priority Health	$3,445.83
Rate for Payer: Priority Health Medicare	$131.16
Rate for Payer: Priority Health SBD	$3,339.81
Rate for Payer: Railroad Medicare Medicare	$131.16
Rate for Payer: UHC All Payor (Choice/PPO)	$369.20
Rate for Payer: UHC Dual Complete DSNP	$131.16
Rate for Payer: UHC Medicare Advantage	$131.16
Rate for Payer: UHCCP Medicaid	$73.84
Rate for Payer: VA VA	$131.16

PEGFILGRASTIM-APGF 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$5,301.28

Service Code	HCPCS Q5122
Hospital Charge Code	195654
Hospital Revenue Code	636
Min. Negotiated Rate	$3,339.81
Max. Negotiated Rate	$4,771.15
Rate for Payer: Aetna Commercial	$4,506.09
Rate for Payer: Aetna New Business (MI Preferred)	$3,445.83
Rate for Payer: Cash Price	$4,241.02
Rate for Payer: Cofinity Commercial	$3,710.90
Rate for Payer: Cofinity Commercial	$4,559.10
Rate for Payer: Cofinity Medicare Advantage	$3,710.90
Rate for Payer: Encore Health Key Benefits Commercial	$4,241.02
Rate for Payer: Healthscope Commercial	$4,771.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,506.09
Rate for Payer: PHP Commercial	$4,506.09
Rate for Payer: Priority Health Cigna Priority Health	$3,445.83
Rate for Payer: Priority Health SBD	$3,339.81

PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$6,368.78

Service Code	HCPCS Q5120
Hospital Charge Code	192102
Hospital Revenue Code	636
Min. Negotiated Rate	$4,012.33
Max. Negotiated Rate	$5,731.90
Rate for Payer: Aetna Commercial	$5,413.46
Rate for Payer: Aetna New Business (MI Preferred)	$4,139.71
Rate for Payer: Cash Price	$5,095.02
Rate for Payer: Cofinity Commercial	$4,458.15
Rate for Payer: Cofinity Commercial	$5,477.15
Rate for Payer: Cofinity Medicare Advantage	$4,458.15
Rate for Payer: Encore Health Key Benefits Commercial	$5,095.02
Rate for Payer: Healthscope Commercial	$5,731.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,413.46
Rate for Payer: PHP Commercial	$5,413.46
Rate for Payer: Priority Health Cigna Priority Health	$4,139.71
Rate for Payer: Priority Health SBD	$4,012.33

PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$6,368.78

Service Code	HCPCS Q5120
Hospital Charge Code	192102
Hospital Revenue Code	636
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$5,731.90
Rate for Payer: Aetna Commercial	$5,413.46
Rate for Payer: Aetna Medicare	$31.53
Rate for Payer: Aetna New Business (MI Preferred)	$4,139.71
Rate for Payer: Allen County Amish Medical Aid Commercial	$37.90
Rate for Payer: Amish Plain Church Group Commercial	$37.90
Rate for Payer: BCBS Complete	$17.06
Rate for Payer: BCBS MAPPO	$30.32
Rate for Payer: BCN Medicare Advantage	$30.32
Rate for Payer: Cash Price	$5,095.02
Rate for Payer: Cash Price	$5,095.02
Rate for Payer: Cofinity Commercial	$5,477.15
Rate for Payer: Cofinity Commercial	$4,458.15
Rate for Payer: Cofinity Medicare Advantage	$4,458.15
Rate for Payer: Encore Health Key Benefits Commercial	$5,095.02
Rate for Payer: Health Alliance Plan Medicare Advantage	$30.32
Rate for Payer: Healthscope Commercial	$5,731.90
Rate for Payer: Mclaren Medicaid	$16.25
Rate for Payer: Mclaren Medicare	$30.32
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$31.84
Rate for Payer: Meridian Medicaid	$17.06
Rate for Payer: MI Amish Medical Board Commercial	$34.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,413.46
Rate for Payer: PACE Medicare	$28.80
Rate for Payer: PACE SWMI	$30.32
Rate for Payer: PHP Commercial	$5,413.46
Rate for Payer: PHP Medicare Advantage	$30.32
Rate for Payer: Priority Health Choice Medicaid	$16.25
Rate for Payer: Priority Health Cigna Priority Health	$4,139.71
Rate for Payer: Priority Health Medicare	$30.32
Rate for Payer: Priority Health SBD	$4,012.33
Rate for Payer: Railroad Medicare Medicare	$30.32
Rate for Payer: UHC All Payor (Choice/PPO)	$85.35
Rate for Payer: UHC Dual Complete DSNP	$30.32
Rate for Payer: UHC Medicare Advantage	$30.32
Rate for Payer: UHCCP Medicaid	$17.07
Rate for Payer: VA VA	$30.32

PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR

Facility

$8,837.40

Service Code	NDC 70114013001
Hospital Charge Code	206387
Hospital Revenue Code	636
Min. Negotiated Rate	$3,534.96
Max. Negotiated Rate	$7,953.66
Rate for Payer: Aetna Commercial	$7,511.79
Rate for Payer: Aetna Medicare	$4,418.70
Rate for Payer: Aetna New Business (MI Preferred)	$5,744.31
Rate for Payer: BCBS Complete	$3,534.96
Rate for Payer: Cash Price	$7,069.92
Rate for Payer: Cofinity Commercial	$6,186.18
Rate for Payer: Cofinity Commercial	$7,600.16
Rate for Payer: Cofinity Medicare Advantage	$6,186.18
Rate for Payer: Encore Health Key Benefits Commercial	$7,069.92
Rate for Payer: Healthscope Commercial	$7,953.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,511.79
Rate for Payer: PHP Commercial	$7,511.79
Rate for Payer: Priority Health Cigna Priority Health	$5,744.31
Rate for Payer: Priority Health SBD	$5,567.56

PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR

Facility

$8,837.40

Service Code	NDC 70114013001
Hospital Charge Code	206387
Hospital Revenue Code	636
Min. Negotiated Rate	$5,567.56
Max. Negotiated Rate	$7,953.66
Rate for Payer: Aetna Commercial	$7,511.79
Rate for Payer: Aetna New Business (MI Preferred)	$5,744.31
Rate for Payer: Cash Price	$7,069.92
Rate for Payer: Cofinity Commercial	$6,186.18
Rate for Payer: Cofinity Commercial	$7,600.16
Rate for Payer: Cofinity Medicare Advantage	$6,186.18
Rate for Payer: Encore Health Key Benefits Commercial	$7,069.92
Rate for Payer: Healthscope Commercial	$7,953.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,511.79
Rate for Payer: PHP Commercial	$7,511.79
Rate for Payer: Priority Health Cigna Priority Health	$5,744.31
Rate for Payer: Priority Health SBD	$5,567.56

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS AUTO-INJECTOR

Facility

$5,304.00

Service Code	HCPCS Q5111
Hospital Charge Code	203866
Hospital Revenue Code	636
Min. Negotiated Rate	$3,341.52
Max. Negotiated Rate	$4,773.60
Rate for Payer: Aetna Commercial	$4,508.40
Rate for Payer: Aetna New Business (MI Preferred)	$3,447.60
Rate for Payer: Cash Price	$4,243.20
Rate for Payer: Cofinity Commercial	$3,712.80
Rate for Payer: Cofinity Commercial	$4,561.44
Rate for Payer: Cofinity Medicare Advantage	$3,712.80
Rate for Payer: Encore Health Key Benefits Commercial	$4,243.20
Rate for Payer: Healthscope Commercial	$4,773.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,508.40
Rate for Payer: PHP Commercial	$4,508.40
Rate for Payer: Priority Health Cigna Priority Health	$3,447.60
Rate for Payer: Priority Health SBD	$3,341.52

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS AUTO-INJECTOR

Facility

$5,304.00

Service Code	HCPCS Q5111
Hospital Charge Code	203866
Hospital Revenue Code	636
Min. Negotiated Rate	$56.99
Max. Negotiated Rate	$4,773.60
Rate for Payer: Aetna Commercial	$4,508.40
Rate for Payer: Aetna Medicare	$110.58
Rate for Payer: Aetna New Business (MI Preferred)	$3,447.60
Rate for Payer: Allen County Amish Medical Aid Commercial	$132.91
Rate for Payer: Amish Plain Church Group Commercial	$132.91
Rate for Payer: BCBS Complete	$59.84
Rate for Payer: BCBS MAPPO	$106.33
Rate for Payer: BCN Medicare Advantage	$106.33
Rate for Payer: Cash Price	$4,243.20
Rate for Payer: Cash Price	$4,243.20
Rate for Payer: Cofinity Commercial	$3,712.80
Rate for Payer: Cofinity Commercial	$4,561.44
Rate for Payer: Cofinity Medicare Advantage	$3,712.80
Rate for Payer: Encore Health Key Benefits Commercial	$4,243.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$106.33
Rate for Payer: Healthscope Commercial	$4,773.60
Rate for Payer: Mclaren Medicaid	$56.99
Rate for Payer: Mclaren Medicare	$106.33
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$111.65
Rate for Payer: Meridian Medicaid	$59.84
Rate for Payer: MI Amish Medical Board Commercial	$122.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,508.40
Rate for Payer: PACE Medicare	$101.01
Rate for Payer: PACE SWMI	$106.33
Rate for Payer: PHP Commercial	$4,508.40
Rate for Payer: PHP Medicare Advantage	$106.33
Rate for Payer: Priority Health Choice Medicaid	$56.99
Rate for Payer: Priority Health Cigna Priority Health	$3,447.60
Rate for Payer: Priority Health Medicare	$106.33
Rate for Payer: Priority Health SBD	$3,341.52
Rate for Payer: Railroad Medicare Medicare	$106.33
Rate for Payer: UHC All Payor (Choice/PPO)	$299.31
Rate for Payer: UHC Dual Complete DSNP	$106.33
Rate for Payer: UHC Medicare Advantage	$106.33
Rate for Payer: UHCCP Medicaid	$59.86
Rate for Payer: VA VA	$106.33

PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE

Facility

$5,304.00

Service Code	HCPCS Q5111
Hospital Charge Code	189200
Hospital Revenue Code	636
Min. Negotiated Rate	$3,341.52
Max. Negotiated Rate	$4,773.60
Rate for Payer: Aetna Commercial	$4,508.40
Rate for Payer: Aetna New Business (MI Preferred)	$3,447.60
Rate for Payer: Cash Price	$4,243.20
Rate for Payer: Cofinity Commercial	$3,712.80
Rate for Payer: Cofinity Commercial	$4,561.44
Rate for Payer: Cofinity Medicare Advantage	$3,712.80
Rate for Payer: Encore Health Key Benefits Commercial	$4,243.20
Rate for Payer: Healthscope Commercial	$4,773.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,508.40
Rate for Payer: PHP Commercial	$4,508.40
Rate for Payer: Priority Health Cigna Priority Health	$3,447.60
Rate for Payer: Priority Health SBD	$3,341.52

Know your out-of-pocket cost for care.

All Charges