Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PR MASTECTOMY PARTIAL W/AXILLARY LYMPHADENECTOMY

Professional

Both

$1,314.00

Service Code	HCPCS 19302
Min. Negotiated Rate	$582.77
Max. Negotiated Rate	$1,422.75
Rate for Payer: Aetna Commercial	$993.34
Rate for Payer: BCBS Complete	$611.91
Rate for Payer: BCBS Trust/PPO	$1,422.75
Rate for Payer: Cash Price	$1,051.20
Rate for Payer: Cash Price	$1,051.20
Rate for Payer: Mclaren Medicaid	$582.77
Rate for Payer: Meridian Medicaid	$611.91
Rate for Payer: Priority Health Choice Medicaid	$582.77
Rate for Payer: Priority Health Cigna Priority Health	$919.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,116.80
Rate for Payer: Priority Health Narrow Network	$1,116.80
Rate for Payer: Priority Health SBD	$1,116.80

PR MASTECTOMY SIMPLE COMPLETE

Professional

Both

$1,854.00

Service Code	HCPCS 19303
Hospital Charge Code	19303
Min. Negotiated Rate	$615.14
Max. Negotiated Rate	$1,316.25
Rate for Payer: Aetna Commercial	$1,051.23
Rate for Payer: BCBS Complete	$645.90
Rate for Payer: BCBS Trust/PPO	$1,316.25
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Mclaren Medicaid	$615.14
Rate for Payer: Meridian Medicaid	$645.90
Rate for Payer: Priority Health Choice Medicaid	$615.14
Rate for Payer: Priority Health Cigna Priority Health	$1,297.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,178.85
Rate for Payer: Priority Health Narrow Network	$1,178.85
Rate for Payer: Priority Health SBD	$1,178.85

PR MASTECTOMY SIMPLE COMPLETE

Facility

$1,854.00

Service Code	CPT 19303
Hospital Charge Code	19303
Hospital Revenue Code	960
Min. Negotiated Rate	$945.65
Max. Negotiated Rate	$17,231.52
Rate for Payer: Aetna Commercial	$1,575.90
Rate for Payer: Aetna Medicare	$6,034.52
Rate for Payer: Aetna New Business (MI Preferred)	$1,205.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,253.02
Rate for Payer: Amish Plain Church Group Commercial	$7,253.02
Rate for Payer: BCBS Complete	$3,332.91
Rate for Payer: BCBS MAPPO	$5,802.42
Rate for Payer: BCBS Trust/PPO	$4,286.03
Rate for Payer: BCN Medicare Advantage	$5,802.42
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Cofinity Commercial	$1,594.44
Rate for Payer: Cofinity Commercial	$1,297.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,802.42
Rate for Payer: Healthscope Commercial	$1,668.60
Rate for Payer: Mclaren Medicaid	$3,173.92
Rate for Payer: Mclaren Medicare	$5,802.42
Rate for Payer: Meridian Medicaid	$3,332.91
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6,092.54
Rate for Payer: MI Amish Medical Board Commercial	$6,672.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,575.90
Rate for Payer: PACE Medicare	$5,512.30
Rate for Payer: PACE SWMI	$5,802.42
Rate for Payer: PHP Commercial	$1,575.90
Rate for Payer: PHP Medicare Advantage	$5,802.42
Rate for Payer: Priority Health Choice Medicaid	$3,173.92
Rate for Payer: Priority Health Cigna Priority Health	$1,297.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17,231.52
Rate for Payer: Priority Health Medicare	$5,802.42
Rate for Payer: Priority Health Narrow Network	$13,785.22
Rate for Payer: Priority Health SBD	$1,168.02
Rate for Payer: Railroad Medicare Medicare	$5,802.42
Rate for Payer: UHC All Payor (Choice/PPO)	$1,040.22
Rate for Payer: UHC Dual Complete DSNP	$5,802.42
Rate for Payer: UHC Exchange	$945.65
Rate for Payer: UHC Medicare Advantage	$5,976.49
Rate for Payer: VA VA	$5,802.42

PR MASTECTOMY SIMPLE COMPLETE

Professional

Both

$1,854.00

Service Code	HCPCS 19303
Min. Negotiated Rate	$615.14
Max. Negotiated Rate	$1,316.25
Rate for Payer: Aetna Commercial	$1,051.23
Rate for Payer: BCBS Complete	$645.90
Rate for Payer: BCBS Trust/PPO	$1,316.25
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Mclaren Medicaid	$615.14
Rate for Payer: Meridian Medicaid	$645.90
Rate for Payer: Priority Health Choice Medicaid	$615.14
Rate for Payer: Priority Health Cigna Priority Health	$1,297.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,178.85
Rate for Payer: Priority Health Narrow Network	$1,178.85
Rate for Payer: Priority Health SBD	$1,178.85

PR MASTECTOMY SIMPLE COMPLETE

Facility

$1,854.00

Service Code	CPT 19303
Hospital Charge Code	19303
Hospital Revenue Code	960
Min. Negotiated Rate	$1,168.02
Max. Negotiated Rate	$1,668.60
Rate for Payer: Aetna Commercial	$1,575.90
Rate for Payer: Aetna New Business (MI Preferred)	$1,205.10
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Cofinity Commercial	$1,297.80
Rate for Payer: Cofinity Commercial	$1,594.44
Rate for Payer: Healthscope Commercial	$1,668.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,575.90
Rate for Payer: PHP Commercial	$1,575.90
Rate for Payer: Priority Health Cigna Priority Health	$1,297.80
Rate for Payer: Priority Health SBD	$1,168.02

PR MASTECTOMY, SUBCUTANEOUS

Facility

$1,080.00

Service Code	CPT 19304
Hospital Charge Code	19304
Hospital Revenue Code	960
Min. Negotiated Rate	$680.40
Max. Negotiated Rate	$972.00
Rate for Payer: Aetna Commercial	$918.00
Rate for Payer: Aetna New Business (MI Preferred)	$702.00
Rate for Payer: Cash Price	$864.00
Rate for Payer: Cofinity Commercial	$756.00
Rate for Payer: Cofinity Commercial	$928.80
Rate for Payer: Healthscope Commercial	$972.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$918.00
Rate for Payer: PHP Commercial	$918.00
Rate for Payer: Priority Health Cigna Priority Health	$756.00
Rate for Payer: Priority Health SBD	$680.40

PR MASTECTOMY, SUBCUTANEOUS

Professional

Both

$1,080.00

Service Code	HCPCS 19304
Hospital Charge Code	19304
Min. Negotiated Rate	$432.00
Max. Negotiated Rate	$756.00
Rate for Payer: BCBS Complete	$432.00
Rate for Payer: Cash Price	$864.00
Rate for Payer: Priority Health Cigna Priority Health	$756.00

PR MASTECTOMY, SUBCUTANEOUS

Facility

$1,080.00

Service Code	CPT 19304
Hospital Charge Code	19304
Hospital Revenue Code	960
Min. Negotiated Rate	$432.00
Max. Negotiated Rate	$972.00
Rate for Payer: Aetna Commercial	$918.00
Rate for Payer: Aetna New Business (MI Preferred)	$702.00
Rate for Payer: BCBS Complete	$432.00
Rate for Payer: Cash Price	$864.00
Rate for Payer: Cofinity Commercial	$756.00
Rate for Payer: Cofinity Commercial	$928.80
Rate for Payer: Healthscope Commercial	$972.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$918.00
Rate for Payer: PHP Commercial	$918.00
Rate for Payer: Priority Health Cigna Priority Health	$756.00
Rate for Payer: Priority Health SBD	$680.40

PR MASTECTOMY, SUBCUTANEOUS

Professional

Both

$1,080.00

Service Code	HCPCS 19304
Min. Negotiated Rate	$432.00
Max. Negotiated Rate	$756.00
Rate for Payer: BCBS Complete	$432.00
Rate for Payer: Cash Price	$864.00
Rate for Payer: Priority Health Cigna Priority Health	$756.00

PR MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN

Professional

Both

$2,004.00

Service Code	HCPCS 19307
Min. Negotiated Rate	$757.22
Max. Negotiated Rate	$18,089.98
Rate for Payer: Aetna Commercial	$1,296.93
Rate for Payer: BCBS Complete	$795.08
Rate for Payer: BCBS Trust/PPO	$18,089.98
Rate for Payer: Cash Price	$1,603.20
Rate for Payer: Cash Price	$1,603.20
Rate for Payer: Mclaren Medicaid	$757.22
Rate for Payer: Meridian Medicaid	$795.08
Rate for Payer: Priority Health Choice Medicaid	$757.22
Rate for Payer: Priority Health Cigna Priority Health	$1,402.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,453.02
Rate for Payer: Priority Health Narrow Network	$1,453.02
Rate for Payer: Priority Health SBD	$1,453.02

PR MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN

Facility

$2,004.00

Service Code	CPT 19307
Hospital Charge Code	19307
Hospital Revenue Code	960
Min. Negotiated Rate	$1,164.06
Max. Negotiated Rate	$17,231.52
Rate for Payer: Aetna Commercial	$1,703.40
Rate for Payer: Aetna Medicare	$6,034.52
Rate for Payer: Aetna New Business (MI Preferred)	$1,302.60
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,253.02
Rate for Payer: Amish Plain Church Group Commercial	$7,253.02
Rate for Payer: BCBS Complete	$3,332.91
Rate for Payer: BCBS MAPPO	$5,802.42
Rate for Payer: BCBS Trust/PPO	$3,933.18
Rate for Payer: BCN Medicare Advantage	$5,802.42
Rate for Payer: Cash Price	$1,603.20
Rate for Payer: Cash Price	$1,603.20
Rate for Payer: Cofinity Commercial	$1,723.44
Rate for Payer: Cofinity Commercial	$1,402.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,802.42
Rate for Payer: Healthscope Commercial	$1,803.60
Rate for Payer: Mclaren Medicaid	$3,173.92
Rate for Payer: Mclaren Medicare	$5,802.42
Rate for Payer: Meridian Medicaid	$3,332.91
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6,092.54
Rate for Payer: MI Amish Medical Board Commercial	$6,672.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,703.40
Rate for Payer: PACE Medicare	$5,512.30
Rate for Payer: PACE SWMI	$5,802.42
Rate for Payer: PHP Commercial	$1,703.40
Rate for Payer: PHP Medicare Advantage	$5,802.42
Rate for Payer: Priority Health Choice Medicaid	$3,173.92
Rate for Payer: Priority Health Cigna Priority Health	$1,402.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17,231.52
Rate for Payer: Priority Health Medicare	$5,802.42
Rate for Payer: Priority Health Narrow Network	$13,785.22
Rate for Payer: Priority Health SBD	$1,262.52
Rate for Payer: Railroad Medicare Medicare	$5,802.42
Rate for Payer: UHC All Payor (Choice/PPO)	$1,280.47
Rate for Payer: UHC Dual Complete DSNP	$5,802.42
Rate for Payer: UHC Exchange	$1,164.06
Rate for Payer: UHC Medicare Advantage	$5,976.49
Rate for Payer: VA VA	$5,802.42

PR MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN

Professional

Both

$2,004.00

Service Code	HCPCS 19307
Hospital Charge Code	19307
Min. Negotiated Rate	$757.22
Max. Negotiated Rate	$18,089.98
Rate for Payer: Aetna Commercial	$1,296.93
Rate for Payer: BCBS Complete	$795.08
Rate for Payer: BCBS Trust/PPO	$18,089.98
Rate for Payer: Cash Price	$1,603.20
Rate for Payer: Cash Price	$1,603.20
Rate for Payer: Mclaren Medicaid	$757.22
Rate for Payer: Meridian Medicaid	$795.08
Rate for Payer: Priority Health Choice Medicaid	$757.22
Rate for Payer: Priority Health Cigna Priority Health	$1,402.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,453.02
Rate for Payer: Priority Health Narrow Network	$1,453.02
Rate for Payer: Priority Health SBD	$1,453.02

PR MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN

Facility

$2,004.00

Service Code	CPT 19307
Hospital Charge Code	19307
Hospital Revenue Code	960
Min. Negotiated Rate	$1,262.52
Max. Negotiated Rate	$1,803.60
Rate for Payer: Aetna Commercial	$1,703.40
Rate for Payer: Aetna New Business (MI Preferred)	$1,302.60
Rate for Payer: Cash Price	$1,603.20
Rate for Payer: Cofinity Commercial	$1,402.80
Rate for Payer: Cofinity Commercial	$1,723.44
Rate for Payer: Healthscope Commercial	$1,803.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,703.40
Rate for Payer: PHP Commercial	$1,703.40
Rate for Payer: Priority Health Cigna Priority Health	$1,402.80
Rate for Payer: Priority Health SBD	$1,262.52

PR MASTOIDECTOMY COMPLETE

Professional

Both

$2,651.00

Service Code	HCPCS 69502
Min. Negotiated Rate	$606.84
Max. Negotiated Rate	$4,242.78
Rate for Payer: Aetna Commercial	$1,083.82
Rate for Payer: BCBS Complete	$637.18
Rate for Payer: BCBS Trust/PPO	$4,242.78
Rate for Payer: Cash Price	$2,120.80
Rate for Payer: Cash Price	$2,120.80
Rate for Payer: Mclaren Medicaid	$606.84
Rate for Payer: Meridian Medicaid	$637.18
Rate for Payer: Priority Health Choice Medicaid	$606.84
Rate for Payer: Priority Health Cigna Priority Health	$1,855.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,344.13
Rate for Payer: Priority Health Narrow Network	$1,344.13
Rate for Payer: Priority Health SBD	$1,344.13

PR MASTOID OBLITERATION SEPARATE PROCEDURE

Professional

Both

$3,411.00

Service Code	HCPCS 69670
Min. Negotiated Rate	$606.62
Max. Negotiated Rate	$3,570.25
Rate for Payer: Aetna Commercial	$1,073.89
Rate for Payer: BCBS Complete	$636.95
Rate for Payer: BCBS Trust/PPO	$3,570.25
Rate for Payer: Cash Price	$2,728.80
Rate for Payer: Cash Price	$2,728.80
Rate for Payer: Mclaren Medicaid	$606.62
Rate for Payer: Meridian Medicaid	$636.95
Rate for Payer: Priority Health Choice Medicaid	$606.62
Rate for Payer: Priority Health Cigna Priority Health	$2,387.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,345.07
Rate for Payer: Priority Health Narrow Network	$1,345.07
Rate for Payer: Priority Health SBD	$1,345.07

PR MASTOPEXY

Professional

Both

$1,900.00

Service Code	HCPCS 19316
Min. Negotiated Rate	$293.06
Max. Negotiated Rate	$1,330.00
Rate for Payer: Aetna Commercial	$856.33
Rate for Payer: BCBS Complete	$533.63
Rate for Payer: BCBS Trust/PPO	$293.06
Rate for Payer: Cash Price	$1,520.00
Rate for Payer: Cash Price	$1,520.00
Rate for Payer: Mclaren Medicaid	$508.22
Rate for Payer: Meridian Medicaid	$533.63
Rate for Payer: Priority Health Choice Medicaid	$508.22
Rate for Payer: Priority Health Cigna Priority Health	$1,330.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$975.39
Rate for Payer: Priority Health Narrow Network	$975.39
Rate for Payer: Priority Health SBD	$975.39

PR MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP

Facility

$798.00

Service Code	CPT 19020
Hospital Charge Code	19020
Min. Negotiated Rate	$311.72
Max. Negotiated Rate	$4,496.47
Rate for Payer: Aetna Commercial	$678.30
Rate for Payer: Aetna Medicare	$1,500.31
Rate for Payer: Aetna New Business (MI Preferred)	$518.70
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,803.26
Rate for Payer: Amish Plain Church Group Commercial	$1,803.26
Rate for Payer: BCBS Complete	$828.64
Rate for Payer: BCBS MAPPO	$1,442.61
Rate for Payer: BCBS Trust/PPO	$1,301.15
Rate for Payer: BCN Medicare Advantage	$1,442.61
Rate for Payer: Cash Price	$638.40
Rate for Payer: Cash Price	$638.40
Rate for Payer: Cofinity Commercial	$686.28
Rate for Payer: Cofinity Commercial	$558.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,442.61
Rate for Payer: Healthscope Commercial	$718.20
Rate for Payer: Mclaren Medicaid	$789.11
Rate for Payer: Mclaren Medicare	$1,442.61
Rate for Payer: Meridian Medicaid	$828.64
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,514.74
Rate for Payer: MI Amish Medical Board Commercial	$1,659.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$678.30
Rate for Payer: PACE Medicare	$1,370.48
Rate for Payer: PACE SWMI	$1,442.61
Rate for Payer: PHP Commercial	$678.30
Rate for Payer: PHP Medicare Advantage	$1,442.61
Rate for Payer: Priority Health Choice Medicaid	$789.11
Rate for Payer: Priority Health Cigna Priority Health	$558.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,496.47
Rate for Payer: Priority Health Medicare	$1,442.61
Rate for Payer: Priority Health Narrow Network	$3,597.18
Rate for Payer: Priority Health SBD	$502.74
Rate for Payer: Railroad Medicare Medicare	$1,442.61
Rate for Payer: UHC All Payor (Choice/PPO)	$342.89
Rate for Payer: UHC Dual Complete DSNP	$1,442.61
Rate for Payer: UHC Exchange	$311.72
Rate for Payer: UHC Medicare Advantage	$1,485.89
Rate for Payer: VA VA	$1,442.61

PR MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP

Professional

Both

$798.00

Service Code	HCPCS 19020
Min. Negotiated Rate	$202.78
Max. Negotiated Rate	$6,614.63
Rate for Payer: Aetna Commercial	$336.67
Rate for Payer: BCBS Complete	$212.92
Rate for Payer: BCBS Trust/PPO	$6,614.63
Rate for Payer: Cash Price	$638.40
Rate for Payer: Cash Price	$638.40
Rate for Payer: Mclaren Medicaid	$202.78
Rate for Payer: Meridian Medicaid	$212.92
Rate for Payer: Priority Health Choice Medicaid	$202.78
Rate for Payer: Priority Health Cigna Priority Health	$558.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$387.20
Rate for Payer: Priority Health Narrow Network	$387.20
Rate for Payer: Priority Health SBD	$387.20

PR MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP

Professional

Both

$798.00

Service Code	HCPCS 19020
Hospital Charge Code	19020
Min. Negotiated Rate	$202.78
Max. Negotiated Rate	$6,614.63
Rate for Payer: Aetna Commercial	$336.67
Rate for Payer: BCBS Complete	$212.92
Rate for Payer: BCBS Trust/PPO	$6,614.63
Rate for Payer: Cash Price	$638.40
Rate for Payer: Cash Price	$638.40
Rate for Payer: Mclaren Medicaid	$202.78
Rate for Payer: Meridian Medicaid	$212.92
Rate for Payer: Priority Health Choice Medicaid	$202.78
Rate for Payer: Priority Health Cigna Priority Health	$558.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$387.20
Rate for Payer: Priority Health Narrow Network	$387.20
Rate for Payer: Priority Health SBD	$387.20

PR MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP

Facility

$798.00

Service Code	CPT 19020
Hospital Charge Code	19020
Min. Negotiated Rate	$502.74
Max. Negotiated Rate	$718.20
Rate for Payer: Aetna Commercial	$678.30
Rate for Payer: Aetna New Business (MI Preferred)	$518.70
Rate for Payer: Cash Price	$638.40
Rate for Payer: Cofinity Commercial	$558.60
Rate for Payer: Cofinity Commercial	$686.28
Rate for Payer: Healthscope Commercial	$718.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$678.30
Rate for Payer: PHP Commercial	$678.30
Rate for Payer: Priority Health Cigna Priority Health	$558.60
Rate for Payer: Priority Health SBD	$502.74

PR MAST RAD W/PECTORAL MUSCLES AXILLARY LYMPH NODES

Professional

Both

$2,369.00

Service Code	HCPCS 19305
Min. Negotiated Rate	$737.62
Max. Negotiated Rate	$2,189.70
Rate for Payer: Aetna Commercial	$1,253.82
Rate for Payer: BCBS Complete	$774.50
Rate for Payer: BCBS Trust/PPO	$2,189.70
Rate for Payer: Cash Price	$1,895.20
Rate for Payer: Cash Price	$1,895.20
Rate for Payer: Mclaren Medicaid	$737.62
Rate for Payer: Meridian Medicaid	$774.50
Rate for Payer: Priority Health Choice Medicaid	$737.62
Rate for Payer: Priority Health Cigna Priority Health	$1,658.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,418.09
Rate for Payer: Priority Health Narrow Network	$1,418.09
Rate for Payer: Priority Health SBD	$1,418.09

PR MAX BREATHING CAPACITY MAXIMAL VOLUNTARY VENTJ

Professional

Both

$43.00

Service Code	HCPCS 94200
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$2,544.29
Rate for Payer: Aetna Commercial	$18.74
Rate for Payer: BCBS Complete	$17.20
Rate for Payer: BCBS Trust/PPO	$2,544.29
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cash Price	$34.40
Rate for Payer: Priority Health Cigna Priority Health	$30.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.59
Rate for Payer: Priority Health Narrow Network	$3.59
Rate for Payer: Priority Health SBD	$19.76

PR MAXILLECTOMY W/O ORBITAL EXENTERATION

Professional

Both

$3,239.00

Service Code	HCPCS 31225
Min. Negotiated Rate	$904.98
Max. Negotiated Rate	$2,505.08
Rate for Payer: Aetna Commercial	$2,328.96
Rate for Payer: BCBS Complete	$1,209.27
Rate for Payer: BCBS Trust/PPO	$904.98
Rate for Payer: Cash Price	$2,591.20
Rate for Payer: Cash Price	$2,591.20
Rate for Payer: Mclaren Medicaid	$1,151.69
Rate for Payer: Meridian Medicaid	$1,209.27
Rate for Payer: Priority Health Choice Medicaid	$1,151.69
Rate for Payer: Priority Health Cigna Priority Health	$2,267.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,505.08
Rate for Payer: Priority Health Narrow Network	$2,505.08
Rate for Payer: Priority Health SBD	$2,505.08

PR MCCD, INITIAL RATE

Professional

Both

$160.00

Service Code	HCPCS G9001
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$1,218.26
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: BCBS Complete	$64.00
Rate for Payer: BCBS Trust/PPO	$1,218.26
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Priority Health Cigna Priority Health	$112.00

PR MCCD,MAINTENANCE RATE

Professional

Both

$80.00

Service Code	HCPCS G9002
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$884.37
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: BCBS Complete	$32.00
Rate for Payer: BCBS Trust/PPO	$884.37
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00

Know your out-of-pocket cost for care.

All Charges