Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PR NJX DRG CGEN C-CATHJ SLCTV CORONARY ANGRPH S&I

Professional

Both

$120.00

Service Code	HCPCS 93563
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$787.17
Rate for Payer: Aetna Commercial	$76.86
Rate for Payer: BCBS Complete	$33.77
Rate for Payer: BCBS Trust/PPO	$787.17
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Mclaren Medicaid	$32.16
Rate for Payer: Meridian Medicaid	$33.77
Rate for Payer: Priority Health Choice Medicaid	$32.16
Rate for Payer: Priority Health Cigna Priority Health	$84.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$71.88
Rate for Payer: Priority Health Narrow Network	$71.88
Rate for Payer: Priority Health SBD	$71.88

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL

Professional

Both

$332.00

Service Code	HCPCS 64490
Min. Negotiated Rate	$66.88
Max. Negotiated Rate	$232.40
Rate for Payer: Aetna Commercial	$135.62
Rate for Payer: BCBS Complete	$70.22
Rate for Payer: BCBS Trust/PPO	$140.00
Rate for Payer: Cash Price	$265.60
Rate for Payer: Cash Price	$265.60
Rate for Payer: Mclaren Medicaid	$66.88
Rate for Payer: Meridian Medicaid	$70.22
Rate for Payer: Priority Health Choice Medicaid	$66.88
Rate for Payer: Priority Health Cigna Priority Health	$232.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$175.53
Rate for Payer: Priority Health Narrow Network	$175.53
Rate for Payer: Priority Health SBD	$175.53

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL

Facility

$332.00

Service Code	CPT 64490
Hospital Charge Code	64490
Min. Negotiated Rate	$209.16
Max. Negotiated Rate	$298.80
Rate for Payer: Aetna Commercial	$282.20
Rate for Payer: Aetna New Business (MI Preferred)	$215.80
Rate for Payer: Cash Price	$265.60
Rate for Payer: Cofinity Commercial	$232.40
Rate for Payer: Cofinity Commercial	$285.52
Rate for Payer: Healthscope Commercial	$298.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$282.20
Rate for Payer: PHP Commercial	$282.20
Rate for Payer: Priority Health Cigna Priority Health	$232.40
Rate for Payer: Priority Health SBD	$209.16

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL

Facility

$332.00

Service Code	CPT 64490
Hospital Charge Code	64490
Min. Negotiated Rate	$102.82
Max. Negotiated Rate	$1,013.79
Rate for Payer: Aetna Commercial	$282.20
Rate for Payer: Aetna Medicare	$843.47
Rate for Payer: Aetna New Business (MI Preferred)	$215.80
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,013.79
Rate for Payer: Amish Plain Church Group Commercial	$1,013.79
Rate for Payer: BCBS Complete	$465.86
Rate for Payer: BCBS MAPPO	$811.03
Rate for Payer: BCBS Trust/PPO	$792.05
Rate for Payer: BCN Medicare Advantage	$811.03
Rate for Payer: Cash Price	$265.60
Rate for Payer: Cash Price	$265.60
Rate for Payer: Cofinity Commercial	$232.40
Rate for Payer: Cofinity Commercial	$285.52
Rate for Payer: Health Alliance Plan Medicare Advantage	$811.03
Rate for Payer: Healthscope Commercial	$298.80
Rate for Payer: Mclaren Medicaid	$443.63
Rate for Payer: Mclaren Medicare	$811.03
Rate for Payer: Meridian Medicaid	$465.86
Rate for Payer: Meridian Wellcare - Medicare Advantage	$851.58
Rate for Payer: MI Amish Medical Board Commercial	$932.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$282.20
Rate for Payer: PACE Medicare	$770.48
Rate for Payer: PACE SWMI	$811.03
Rate for Payer: PHP Commercial	$282.20
Rate for Payer: PHP Medicare Advantage	$811.03
Rate for Payer: Priority Health Choice Medicaid	$443.63
Rate for Payer: Priority Health Cigna Priority Health	$232.40
Rate for Payer: Priority Health Medicare	$811.03
Rate for Payer: Priority Health SBD	$209.16
Rate for Payer: Railroad Medicare Medicare	$811.03
Rate for Payer: UHC All Payor (Choice/PPO)	$113.10
Rate for Payer: UHC Dual Complete DSNP	$811.03
Rate for Payer: UHC Exchange	$102.82
Rate for Payer: UHC Medicare Advantage	$835.36
Rate for Payer: VA VA	$811.03

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL

Professional

Both

$332.00

Service Code	HCPCS 64490
Hospital Charge Code	64490
Min. Negotiated Rate	$66.88
Max. Negotiated Rate	$232.40
Rate for Payer: Aetna Commercial	$135.62
Rate for Payer: BCBS Complete	$70.22
Rate for Payer: BCBS Trust/PPO	$140.00
Rate for Payer: Cash Price	$265.60
Rate for Payer: Cash Price	$265.60
Rate for Payer: Mclaren Medicaid	$66.88
Rate for Payer: Meridian Medicaid	$70.22
Rate for Payer: Priority Health Choice Medicaid	$66.88
Rate for Payer: Priority Health Cigna Priority Health	$232.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$175.53
Rate for Payer: Priority Health Narrow Network	$175.53
Rate for Payer: Priority Health SBD	$175.53

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL

Professional

Both

$208.00

Service Code	HCPCS 64491
Hospital Charge Code	64491
Min. Negotiated Rate	$37.49
Max. Negotiated Rate	$344.45
Rate for Payer: Aetna Commercial	$77.81
Rate for Payer: BCBS Complete	$39.36
Rate for Payer: BCBS Trust/PPO	$344.45
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cash Price	$166.40
Rate for Payer: Mclaren Medicaid	$37.49
Rate for Payer: Meridian Medicaid	$39.36
Rate for Payer: Priority Health Choice Medicaid	$37.49
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$99.08
Rate for Payer: Priority Health Narrow Network	$99.08
Rate for Payer: Priority Health SBD	$99.08

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL

Facility

$208.00

Service Code	CPT 64491
Hospital Charge Code	64491
Min. Negotiated Rate	$131.04
Max. Negotiated Rate	$187.20
Rate for Payer: Aetna Commercial	$176.80
Rate for Payer: Aetna New Business (MI Preferred)	$135.20
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cofinity Commercial	$145.60
Rate for Payer: Cofinity Commercial	$178.88
Rate for Payer: Healthscope Commercial	$187.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$176.80
Rate for Payer: PHP Commercial	$176.80
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health SBD	$131.04

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL

Professional

Both

$208.00

Service Code	HCPCS 64491
Min. Negotiated Rate	$37.49
Max. Negotiated Rate	$344.45
Rate for Payer: Aetna Commercial	$77.81
Rate for Payer: BCBS Complete	$39.36
Rate for Payer: BCBS Trust/PPO	$344.45
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cash Price	$166.40
Rate for Payer: Mclaren Medicaid	$37.49
Rate for Payer: Meridian Medicaid	$39.36
Rate for Payer: Priority Health Choice Medicaid	$37.49
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$99.08
Rate for Payer: Priority Health Narrow Network	$99.08
Rate for Payer: Priority Health SBD	$99.08

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL

Facility

$208.00

Service Code	CPT 64491
Hospital Charge Code	64491
Min. Negotiated Rate	$57.63
Max. Negotiated Rate	$187.20
Rate for Payer: Aetna Commercial	$176.80
Rate for Payer: Aetna New Business (MI Preferred)	$135.20
Rate for Payer: BCBS Complete	$83.20
Rate for Payer: BCBS Trust/PPO	$186.60
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cofinity Commercial	$145.60
Rate for Payer: Cofinity Commercial	$178.88
Rate for Payer: Healthscope Commercial	$187.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$176.80
Rate for Payer: PHP Commercial	$176.80
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health SBD	$131.04
Rate for Payer: UHC All Payor (Choice/PPO)	$63.39
Rate for Payer: UHC Exchange	$57.63

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL

Professional

Both

$208.00

Service Code	HCPCS 64492
Hospital Charge Code	64492
Min. Negotiated Rate	$38.13
Max. Negotiated Rate	$216.07
Rate for Payer: Aetna Commercial	$79.05
Rate for Payer: BCBS Complete	$40.04
Rate for Payer: BCBS Trust/PPO	$216.07
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cash Price	$166.40
Rate for Payer: Mclaren Medicaid	$38.13
Rate for Payer: Meridian Medicaid	$40.04
Rate for Payer: Priority Health Choice Medicaid	$38.13
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$100.79
Rate for Payer: Priority Health Narrow Network	$100.79
Rate for Payer: Priority Health SBD	$100.79

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL

Facility

$208.00

Service Code	CPT 64492
Hospital Charge Code	64492
Min. Negotiated Rate	$58.61
Max. Negotiated Rate	$187.31
Rate for Payer: Aetna Commercial	$176.80
Rate for Payer: Aetna New Business (MI Preferred)	$135.20
Rate for Payer: BCBS Complete	$83.20
Rate for Payer: BCBS Trust/PPO	$187.31
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cofinity Commercial	$178.88
Rate for Payer: Cofinity Commercial	$145.60
Rate for Payer: Healthscope Commercial	$187.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$176.80
Rate for Payer: PHP Commercial	$176.80
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health SBD	$131.04
Rate for Payer: UHC All Payor (Choice/PPO)	$64.47
Rate for Payer: UHC Exchange	$58.61

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL

Professional

Both

$208.00

Service Code	HCPCS 64492
Min. Negotiated Rate	$38.13
Max. Negotiated Rate	$216.07
Rate for Payer: Aetna Commercial	$79.05
Rate for Payer: BCBS Complete	$40.04
Rate for Payer: BCBS Trust/PPO	$216.07
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cash Price	$166.40
Rate for Payer: Mclaren Medicaid	$38.13
Rate for Payer: Meridian Medicaid	$40.04
Rate for Payer: Priority Health Choice Medicaid	$38.13
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$100.79
Rate for Payer: Priority Health Narrow Network	$100.79
Rate for Payer: Priority Health SBD	$100.79

PR NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL

Facility

$208.00

Service Code	CPT 64492
Hospital Charge Code	64492
Min. Negotiated Rate	$131.04
Max. Negotiated Rate	$187.20
Rate for Payer: Aetna Commercial	$176.80
Rate for Payer: Aetna New Business (MI Preferred)	$135.20
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cofinity Commercial	$145.60
Rate for Payer: Cofinity Commercial	$178.88
Rate for Payer: Healthscope Commercial	$187.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$176.80
Rate for Payer: PHP Commercial	$176.80
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health SBD	$131.04

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL

Professional

Both

$237.00

Service Code	HCPCS 64493
Hospital Charge Code	64493
Min. Negotiated Rate	$57.51
Max. Negotiated Rate	$609.66
Rate for Payer: Aetna Commercial	$115.69
Rate for Payer: BCBS Complete	$60.39
Rate for Payer: BCBS Trust/PPO	$609.66
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Mclaren Medicaid	$57.51
Rate for Payer: Meridian Medicaid	$60.39
Rate for Payer: Priority Health Choice Medicaid	$57.51
Rate for Payer: Priority Health Cigna Priority Health	$165.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$151.18
Rate for Payer: Priority Health Narrow Network	$151.18
Rate for Payer: Priority Health SBD	$151.18

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL

Facility

$237.00

Service Code	CPT 64493
Hospital Charge Code	64493
Min. Negotiated Rate	$88.41
Max. Negotiated Rate	$1,013.79
Rate for Payer: Aetna Commercial	$201.45
Rate for Payer: Aetna Medicare	$843.47
Rate for Payer: Aetna New Business (MI Preferred)	$154.05
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,013.79
Rate for Payer: Amish Plain Church Group Commercial	$1,013.79
Rate for Payer: BCBS Complete	$465.86
Rate for Payer: BCBS MAPPO	$811.03
Rate for Payer: BCBS Trust/PPO	$570.17
Rate for Payer: BCN Medicare Advantage	$811.03
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cofinity Commercial	$165.90
Rate for Payer: Cofinity Commercial	$203.82
Rate for Payer: Health Alliance Plan Medicare Advantage	$811.03
Rate for Payer: Healthscope Commercial	$213.30
Rate for Payer: Mclaren Medicaid	$443.63
Rate for Payer: Mclaren Medicare	$811.03
Rate for Payer: Meridian Medicaid	$465.86
Rate for Payer: Meridian Wellcare - Medicare Advantage	$851.58
Rate for Payer: MI Amish Medical Board Commercial	$932.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$201.45
Rate for Payer: PACE Medicare	$770.48
Rate for Payer: PACE SWMI	$811.03
Rate for Payer: PHP Commercial	$201.45
Rate for Payer: PHP Medicare Advantage	$811.03
Rate for Payer: Priority Health Choice Medicaid	$443.63
Rate for Payer: Priority Health Cigna Priority Health	$165.90
Rate for Payer: Priority Health Medicare	$811.03
Rate for Payer: Priority Health SBD	$149.31
Rate for Payer: Railroad Medicare Medicare	$811.03
Rate for Payer: UHC All Payor (Choice/PPO)	$97.25
Rate for Payer: UHC Dual Complete DSNP	$811.03
Rate for Payer: UHC Exchange	$88.41
Rate for Payer: UHC Medicare Advantage	$835.36
Rate for Payer: VA VA	$811.03

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL

Facility

$237.00

Service Code	CPT 64493
Hospital Charge Code	64493
Min. Negotiated Rate	$149.31
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna Commercial	$201.45
Rate for Payer: Aetna New Business (MI Preferred)	$154.05
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cofinity Commercial	$165.90
Rate for Payer: Cofinity Commercial	$203.82
Rate for Payer: Healthscope Commercial	$213.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$201.45
Rate for Payer: PHP Commercial	$201.45
Rate for Payer: Priority Health Cigna Priority Health	$165.90
Rate for Payer: Priority Health SBD	$149.31

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL

Professional

Both

$237.00

Service Code	HCPCS 64493
Min. Negotiated Rate	$57.51
Max. Negotiated Rate	$609.66
Rate for Payer: Aetna Commercial	$115.69
Rate for Payer: BCBS Complete	$60.39
Rate for Payer: BCBS Trust/PPO	$609.66
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Mclaren Medicaid	$57.51
Rate for Payer: Meridian Medicaid	$60.39
Rate for Payer: Priority Health Choice Medicaid	$57.51
Rate for Payer: Priority Health Cigna Priority Health	$165.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$151.18
Rate for Payer: Priority Health Narrow Network	$151.18
Rate for Payer: Priority Health SBD	$151.18

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL

Facility

$164.00

Service Code	CPT 64494
Hospital Charge Code	64494
Min. Negotiated Rate	$49.44
Max. Negotiated Rate	$171.81
Rate for Payer: Aetna Commercial	$139.40
Rate for Payer: Aetna New Business (MI Preferred)	$106.60
Rate for Payer: BCBS Complete	$65.60
Rate for Payer: BCBS Trust/PPO	$171.81
Rate for Payer: Cash Price	$131.20
Rate for Payer: Cash Price	$131.20
Rate for Payer: Cofinity Commercial	$141.04
Rate for Payer: Cofinity Commercial	$114.80
Rate for Payer: Healthscope Commercial	$147.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$139.40
Rate for Payer: PHP Commercial	$139.40
Rate for Payer: Priority Health Cigna Priority Health	$114.80
Rate for Payer: Priority Health SBD	$103.32
Rate for Payer: UHC All Payor (Choice/PPO)	$54.38
Rate for Payer: UHC Exchange	$49.44

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL

Professional

Both

$164.00

Service Code	HCPCS 64494
Hospital Charge Code	64494
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$1,260.52
Rate for Payer: Aetna Commercial	$66.74
Rate for Payer: BCBS Complete	$33.77
Rate for Payer: BCBS Trust/PPO	$1,260.52
Rate for Payer: Cash Price	$131.20
Rate for Payer: Cash Price	$131.20
Rate for Payer: Mclaren Medicaid	$32.16
Rate for Payer: Meridian Medicaid	$33.77
Rate for Payer: Priority Health Choice Medicaid	$32.16
Rate for Payer: Priority Health Cigna Priority Health	$114.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$85.50
Rate for Payer: Priority Health Narrow Network	$85.50
Rate for Payer: Priority Health SBD	$85.50

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL

Facility

$164.00

Service Code	CPT 64494
Hospital Charge Code	64494
Min. Negotiated Rate	$103.32
Max. Negotiated Rate	$147.60
Rate for Payer: Aetna Commercial	$139.40
Rate for Payer: Aetna New Business (MI Preferred)	$106.60
Rate for Payer: Cash Price	$131.20
Rate for Payer: Cofinity Commercial	$114.80
Rate for Payer: Cofinity Commercial	$141.04
Rate for Payer: Healthscope Commercial	$147.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$139.40
Rate for Payer: PHP Commercial	$139.40
Rate for Payer: Priority Health Cigna Priority Health	$114.80
Rate for Payer: Priority Health SBD	$103.32

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL

Professional

Both

$164.00

Service Code	HCPCS 64494
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$1,260.52
Rate for Payer: Aetna Commercial	$66.74
Rate for Payer: BCBS Complete	$33.77
Rate for Payer: BCBS Trust/PPO	$1,260.52
Rate for Payer: Cash Price	$131.20
Rate for Payer: Cash Price	$131.20
Rate for Payer: Mclaren Medicaid	$32.16
Rate for Payer: Meridian Medicaid	$33.77
Rate for Payer: Priority Health Choice Medicaid	$32.16
Rate for Payer: Priority Health Cigna Priority Health	$114.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$85.50
Rate for Payer: Priority Health Narrow Network	$85.50
Rate for Payer: Priority Health SBD	$85.50

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL

Facility

$168.00

Service Code	CPT 64495
Hospital Charge Code	64495
Min. Negotiated Rate	$105.84
Max. Negotiated Rate	$151.20
Rate for Payer: Aetna Commercial	$142.80
Rate for Payer: Aetna New Business (MI Preferred)	$109.20
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cofinity Commercial	$117.60
Rate for Payer: Cofinity Commercial	$144.48
Rate for Payer: Healthscope Commercial	$151.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$142.80
Rate for Payer: PHP Commercial	$142.80
Rate for Payer: Priority Health Cigna Priority Health	$117.60
Rate for Payer: Priority Health SBD	$105.84

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL

Professional

Both

$168.00

Service Code	HCPCS 64495
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$184.91
Rate for Payer: Aetna Commercial	$67.57
Rate for Payer: BCBS Complete	$34.44
Rate for Payer: BCBS Trust/PPO	$184.91
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Mclaren Medicaid	$32.80
Rate for Payer: Meridian Medicaid	$34.44
Rate for Payer: Priority Health Choice Medicaid	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$117.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$86.64
Rate for Payer: Priority Health Narrow Network	$86.64
Rate for Payer: Priority Health SBD	$86.64

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL

Professional

Both

$168.00

Service Code	HCPCS 64495
Hospital Charge Code	64495
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$184.91
Rate for Payer: Aetna Commercial	$67.57
Rate for Payer: BCBS Complete	$34.44
Rate for Payer: BCBS Trust/PPO	$184.91
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Mclaren Medicaid	$32.80
Rate for Payer: Meridian Medicaid	$34.44
Rate for Payer: Priority Health Choice Medicaid	$32.80
Rate for Payer: Priority Health Cigna Priority Health	$117.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$86.64
Rate for Payer: Priority Health Narrow Network	$86.64
Rate for Payer: Priority Health SBD	$86.64

PR NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL

Facility

$168.00

Service Code	CPT 64495
Hospital Charge Code	64495
Min. Negotiated Rate	$50.43
Max. Negotiated Rate	$172.52
Rate for Payer: Aetna Commercial	$142.80
Rate for Payer: Aetna New Business (MI Preferred)	$109.20
Rate for Payer: BCBS Complete	$67.20
Rate for Payer: BCBS Trust/PPO	$172.52
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cofinity Commercial	$144.48
Rate for Payer: Cofinity Commercial	$117.60
Rate for Payer: Healthscope Commercial	$151.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$142.80
Rate for Payer: PHP Commercial	$142.80
Rate for Payer: Priority Health Cigna Priority Health	$117.60
Rate for Payer: Priority Health SBD	$105.84
Rate for Payer: UHC All Payor (Choice/PPO)	$55.47
Rate for Payer: UHC Exchange	$50.43

Know your out-of-pocket cost for care.

All Charges