Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

EMPAGLIFLOZIN 25 MG TABLET

Facility

$1,387.84

Service Code	NDC 0597-0153-37
Hospital Charge Code	171966
Hospital Revenue Code	637
Min. Negotiated Rate	$874.34
Max. Negotiated Rate	$1,249.06
Rate for Payer: Aetna Commercial	$1,179.66
Rate for Payer: Aetna New Business (MI Preferred)	$902.10
Rate for Payer: Cash Price	$1,110.27
Rate for Payer: Cofinity Commercial	$1,193.54
Rate for Payer: Cofinity Commercial	$971.49
Rate for Payer: Healthscope Commercial	$1,249.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,179.66
Rate for Payer: PHP Commercial	$1,179.66
Rate for Payer: Priority Health Cigna Priority Health	$971.49
Rate for Payer: Priority Health SBD	$874.34

EMPTY CONTAINER BOTTLE

Facility

$50.99

Service Code	NDC 0264-9757-06
Hospital Charge Code	113131
Hospital Revenue Code	250
Min. Negotiated Rate	$32.12
Max. Negotiated Rate	$45.89
Rate for Payer: Aetna Commercial	$43.34
Rate for Payer: Aetna New Business (MI Preferred)	$33.14
Rate for Payer: Cash Price	$40.79
Rate for Payer: Cofinity Commercial	$43.85
Rate for Payer: Cofinity Commercial	$35.69
Rate for Payer: Healthscope Commercial	$45.89
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$43.34
Rate for Payer: PHP Commercial	$43.34
Rate for Payer: Priority Health Cigna Priority Health	$35.69
Rate for Payer: Priority Health SBD	$32.12

EMTRICITABINE 200 MG-TENOFOVIR ALAFENAMIDE FUMARATE 25 MG TABLET

Facility

$7,944.83

Service Code	NDC 61958-2002-1
Hospital Charge Code	178497
Hospital Revenue Code	637
Min. Negotiated Rate	$5,005.24
Max. Negotiated Rate	$7,150.35
Rate for Payer: Aetna Commercial	$6,753.11
Rate for Payer: Aetna New Business (MI Preferred)	$5,164.14
Rate for Payer: Cash Price	$6,355.86
Rate for Payer: Cofinity Commercial	$5,561.38
Rate for Payer: Cofinity Commercial	$6,832.55
Rate for Payer: Healthscope Commercial	$7,150.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6,753.11
Rate for Payer: PHP Commercial	$6,753.11
Rate for Payer: Priority Health Cigna Priority Health	$5,561.38
Rate for Payer: Priority Health SBD	$5,005.24

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET

Facility

$86.26

Service Code	NDC 42385-953-30
Hospital Charge Code	39255
Hospital Revenue Code	637
Min. Negotiated Rate	$54.34
Max. Negotiated Rate	$77.63
Rate for Payer: Aetna Commercial	$73.32
Rate for Payer: Aetna New Business (MI Preferred)	$56.07
Rate for Payer: Cash Price	$69.01
Rate for Payer: Cofinity Commercial	$74.18
Rate for Payer: Cofinity Commercial	$60.38
Rate for Payer: Healthscope Commercial	$77.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$73.32
Rate for Payer: PHP Commercial	$73.32
Rate for Payer: Priority Health Cigna Priority Health	$60.38
Rate for Payer: Priority Health SBD	$54.34

EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET

Facility

$6,646.02

Service Code	NDC 61958-0701-1
Hospital Charge Code	39255
Hospital Revenue Code	637
Min. Negotiated Rate	$4,186.99
Max. Negotiated Rate	$5,981.42
Rate for Payer: Aetna Commercial	$5,649.12
Rate for Payer: Aetna New Business (MI Preferred)	$4,319.91
Rate for Payer: Cash Price	$5,316.82
Rate for Payer: Cofinity Commercial	$4,652.21
Rate for Payer: Cofinity Commercial	$5,715.58
Rate for Payer: Healthscope Commercial	$5,981.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5,649.12
Rate for Payer: PHP Commercial	$5,649.12
Rate for Payer: Priority Health Cigna Priority Health	$4,652.21
Rate for Payer: Priority Health SBD	$4,186.99

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION

Facility

$19.38

Service Code	NDC 0143-9787-10
Hospital Charge Code	9929
Hospital Revenue Code	250
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$17.44
Rate for Payer: Aetna Commercial	$16.47
Rate for Payer: Aetna New Business (MI Preferred)	$12.60
Rate for Payer: Cash Price	$15.50
Rate for Payer: Cofinity Commercial	$13.57
Rate for Payer: Cofinity Commercial	$16.67
Rate for Payer: Healthscope Commercial	$17.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.47
Rate for Payer: PHP Commercial	$16.47
Rate for Payer: Priority Health Cigna Priority Health	$13.57
Rate for Payer: Priority Health SBD	$12.21

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION

Facility

$57.56

Service Code	NDC 0143-9786-01
Hospital Charge Code	9929
Hospital Revenue Code	250
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$51.80
Rate for Payer: Aetna Commercial	$48.93
Rate for Payer: Aetna New Business (MI Preferred)	$37.41
Rate for Payer: Cash Price	$46.05
Rate for Payer: Cofinity Commercial	$40.29
Rate for Payer: Cofinity Commercial	$49.50
Rate for Payer: Healthscope Commercial	$51.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$48.93
Rate for Payer: PHP Commercial	$48.93
Rate for Payer: Priority Health Cigna Priority Health	$40.29
Rate for Payer: Priority Health SBD	$36.26

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION

Facility

$57.56

Service Code	NDC 0143-9786-10
Hospital Charge Code	9929
Hospital Revenue Code	250
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$51.80
Rate for Payer: Aetna Commercial	$48.93
Rate for Payer: Aetna New Business (MI Preferred)	$37.41
Rate for Payer: Cash Price	$46.05
Rate for Payer: Cofinity Commercial	$40.29
Rate for Payer: Cofinity Commercial	$49.50
Rate for Payer: Healthscope Commercial	$51.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$48.93
Rate for Payer: PHP Commercial	$48.93
Rate for Payer: Priority Health Cigna Priority Health	$40.29
Rate for Payer: Priority Health SBD	$36.26

ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION

Facility

$19.38

Service Code	NDC 0143-9787-01
Hospital Charge Code	9929
Hospital Revenue Code	250
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$17.44
Rate for Payer: Aetna Commercial	$16.47
Rate for Payer: Aetna New Business (MI Preferred)	$12.60
Rate for Payer: Cash Price	$15.50
Rate for Payer: Cofinity Commercial	$13.57
Rate for Payer: Cofinity Commercial	$16.67
Rate for Payer: Healthscope Commercial	$17.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.47
Rate for Payer: PHP Commercial	$16.47
Rate for Payer: Priority Health Cigna Priority Health	$13.57
Rate for Payer: Priority Health SBD	$12.21

ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND CURETTAGE)

Facility

$1,463.00

Service Code	CPT 57505
Hospital Revenue Code	360
Min. Negotiated Rate	$108.71
Max. Negotiated Rate	$1,463.00
Rate for Payer: Aetna Medicare	$743.92
Rate for Payer: Allen County Amish Medical Aid Commercial	$894.14
Rate for Payer: Amish Plain Church Group Commercial	$894.14
Rate for Payer: BCBS Complete	$410.87
Rate for Payer: BCBS MAPPO	$715.31
Rate for Payer: BCBS Trust/PPO	$439.74
Rate for Payer: BCCCP Commercial	$162.36
Rate for Payer: BCN Medicare Advantage	$715.31
Rate for Payer: Health Alliance Plan Medicare Advantage	$715.31
Rate for Payer: Mclaren Medicaid	$391.27
Rate for Payer: Mclaren Medicare	$715.31
Rate for Payer: Meridian Medicaid	$410.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$751.08
Rate for Payer: MI Amish Medical Board Commercial	$822.61
Rate for Payer: PACE Medicare	$679.54
Rate for Payer: PACE SWMI	$715.31
Rate for Payer: PHP Medicare Advantage	$715.31
Rate for Payer: Priority Health Choice Medicaid	$391.27
Rate for Payer: Priority Health Medicare	$715.31
Rate for Payer: Railroad Medicare Medicare	$715.31
Rate for Payer: UHC All Payor (Choice/PPO)	$119.58
Rate for Payer: UHC Core	$1,463.00
Rate for Payer: UHC Dual Complete DSNP	$715.31
Rate for Payer: UHC Exchange	$108.71
Rate for Payer: UHC Medicare Advantage	$736.77
Rate for Payer: VA VA	$715.31

ENDOCRINE DISORDERS WITH CC

Facility

$16,195.17

Service Code	MS-DRG 644
Min. Negotiated Rate	$7,731.92
Max. Negotiated Rate	$16,195.17
Rate for Payer: Aetna Medicare	$8,464.41
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,173.58
Rate for Payer: Amish Plain Church Group Commercial	$10,173.58
Rate for Payer: BCBS MAPPO	$8,138.86
Rate for Payer: BCBS Trust/PPO	$16,095.95
Rate for Payer: BCN Medicare Advantage	$8,138.86
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,138.86
Rate for Payer: Mclaren Medicare	$8,138.86
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,545.80
Rate for Payer: MI Amish Medical Board Commercial	$9,359.69
Rate for Payer: PACE Medicare	$7,731.92
Rate for Payer: PACE SWMI	$8,138.86
Rate for Payer: PHP Medicare Advantage	$8,138.86
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15,235.31
Rate for Payer: Priority Health Medicare	$8,138.86
Rate for Payer: Priority Health Narrow Network	$12,188.25
Rate for Payer: Railroad Medicare Medicare	$8,138.86
Rate for Payer: UHC All Payor (Choice/PPO)	$16,195.17
Rate for Payer: UHC Core	$9,937.51
Rate for Payer: UHC Dual Complete DSNP	$8,138.86
Rate for Payer: UHC Exchange	$10,643.54
Rate for Payer: UHC Medicare Advantage	$8,383.03
Rate for Payer: VA VA	$8,138.86

ENDOCRINE DISORDERS WITH MCC

Facility

$25,094.36

Service Code	MS-DRG 643
Min. Negotiated Rate	$11,723.39
Max. Negotiated Rate	$25,094.36
Rate for Payer: Aetna Medicare	$12,834.03
Rate for Payer: Allen County Amish Medical Aid Commercial	$15,425.51
Rate for Payer: Amish Plain Church Group Commercial	$15,425.51
Rate for Payer: BCBS MAPPO	$12,340.41
Rate for Payer: BCBS Trust/PPO	$23,761.83
Rate for Payer: BCN Medicare Advantage	$12,340.41
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,340.41
Rate for Payer: Mclaren Medicare	$12,340.41
Rate for Payer: Meridian Wellcare - Medicare Advantage	$12,957.43
Rate for Payer: MI Amish Medical Board Commercial	$14,191.47
Rate for Payer: PACE Medicare	$11,723.39
Rate for Payer: PACE SWMI	$12,340.41
Rate for Payer: PHP Medicare Advantage	$12,340.41
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$23,607.05
Rate for Payer: Priority Health Medicare	$12,340.41
Rate for Payer: Priority Health Narrow Network	$18,885.64
Rate for Payer: Railroad Medicare Medicare	$12,340.41
Rate for Payer: UHC All Payor (Choice/PPO)	$25,094.36
Rate for Payer: UHC Core	$15,398.14
Rate for Payer: UHC Dual Complete DSNP	$12,340.41
Rate for Payer: UHC Exchange	$16,492.13
Rate for Payer: UHC Medicare Advantage	$12,710.62
Rate for Payer: VA VA	$12,340.41

ENDOCRINE DISORDERS WITHOUT CC/MCC

Facility

$11,606.77

Service Code	MS-DRG 645
Min. Negotiated Rate	$5,673.94
Max. Negotiated Rate	$11,606.77
Rate for Payer: Aetna Medicare	$6,211.47
Rate for Payer: Allen County Amish Medical Aid Commercial	$7,465.71
Rate for Payer: Amish Plain Church Group Commercial	$7,465.71
Rate for Payer: BCBS MAPPO	$5,972.57
Rate for Payer: BCBS Trust/PPO	$9,268.89
Rate for Payer: BCN Medicare Advantage	$5,972.57
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,972.57
Rate for Payer: Mclaren Medicare	$5,972.57
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6,271.20
Rate for Payer: MI Amish Medical Board Commercial	$6,868.46
Rate for Payer: PACE Medicare	$5,673.94
Rate for Payer: PACE SWMI	$5,972.57
Rate for Payer: PHP Medicare Advantage	$5,972.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,918.85
Rate for Payer: Priority Health Medicare	$5,972.57
Rate for Payer: Priority Health Narrow Network	$8,735.08
Rate for Payer: Railroad Medicare Medicare	$5,972.57
Rate for Payer: UHC All Payor (Choice/PPO)	$11,606.77
Rate for Payer: UHC Core	$7,122.02
Rate for Payer: UHC Dual Complete DSNP	$5,972.57
Rate for Payer: UHC Exchange	$7,628.02
Rate for Payer: UHC Medicare Advantage	$6,151.75
Rate for Payer: VA VA	$5,972.57

ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC GUIDANCE

Facility

$5,532.19

Service Code	CPT 58353
Hospital Revenue Code	360
Min. Negotiated Rate	$228.23
Max. Negotiated Rate	$5,532.19
Rate for Payer: Aetna Medicare	$4,602.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$5,532.19
Rate for Payer: Amish Plain Church Group Commercial	$5,532.19
Rate for Payer: BCBS Complete	$2,542.15
Rate for Payer: BCBS MAPPO	$4,425.75
Rate for Payer: BCBS Trust/PPO	$2,010.14
Rate for Payer: BCN Medicare Advantage	$4,425.75
Rate for Payer: Health Alliance Plan Medicare Advantage	$4,425.75
Rate for Payer: Mclaren Medicaid	$2,420.89
Rate for Payer: Mclaren Medicare	$4,425.75
Rate for Payer: Meridian Medicaid	$2,542.15
Rate for Payer: Meridian Wellcare - Medicare Advantage	$4,647.04
Rate for Payer: MI Amish Medical Board Commercial	$5,089.61
Rate for Payer: PACE Medicare	$4,204.46
Rate for Payer: PACE SWMI	$4,425.75
Rate for Payer: PHP Medicare Advantage	$4,425.75
Rate for Payer: Priority Health Choice Medicaid	$2,420.89
Rate for Payer: Priority Health Medicare	$4,425.75
Rate for Payer: Railroad Medicare Medicare	$4,425.75
Rate for Payer: UHC All Payor (Choice/PPO)	$251.05
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$4,425.75
Rate for Payer: UHC Exchange	$228.23
Rate for Payer: UHC Medicare Advantage	$4,558.52
Rate for Payer: VA VA	$4,425.75

ENDOMETRIAL SAMPLING (BIOPSY) PERFORMED IN CONJUNCTION WITH COLPOSCOPY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$878.00

Service Code	CPT 58110
Hospital Revenue Code	360
Min. Negotiated Rate	$39.29
Max. Negotiated Rate	$878.00
Rate for Payer: BCBS Trust/PPO	$95.76
Rate for Payer: BCCCP Commercial	$53.05
Rate for Payer: UHC All Payor (Choice/PPO)	$43.22
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Exchange	$39.29

ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE)

Facility

$878.00

Service Code	CPT 58100
Hospital Revenue Code	360
Min. Negotiated Rate	$61.89
Max. Negotiated Rate	$878.00
Rate for Payer: Aetna Medicare	$184.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$221.64
Rate for Payer: Amish Plain Church Group Commercial	$221.64
Rate for Payer: BCBS Complete	$101.85
Rate for Payer: BCBS MAPPO	$177.31
Rate for Payer: BCBS Trust/PPO	$73.70
Rate for Payer: BCCCP Commercial	$107.56
Rate for Payer: BCN Medicare Advantage	$177.31
Rate for Payer: Health Alliance Plan Medicare Advantage	$177.31
Rate for Payer: Mclaren Medicaid	$96.99
Rate for Payer: Mclaren Medicare	$177.31
Rate for Payer: Meridian Medicaid	$101.85
Rate for Payer: Meridian Wellcare - Medicare Advantage	$186.18
Rate for Payer: MI Amish Medical Board Commercial	$203.91
Rate for Payer: PACE Medicare	$168.44
Rate for Payer: PACE SWMI	$177.31
Rate for Payer: PHP Medicare Advantage	$177.31
Rate for Payer: Priority Health Choice Medicaid	$96.99
Rate for Payer: Priority Health Medicare	$177.31
Rate for Payer: Railroad Medicare Medicare	$177.31
Rate for Payer: UHC All Payor (Choice/PPO)	$68.08
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Dual Complete DSNP	$177.31
Rate for Payer: UHC Exchange	$61.89
Rate for Payer: UHC Medicare Advantage	$182.63
Rate for Payer: VA VA	$177.31

ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE URETHRA AND/OR BLADDER NECK

Facility

$5,427.00

Service Code	CPT 51715
Hospital Revenue Code	360
Min. Negotiated Rate	$193.85
Max. Negotiated Rate	$5,427.00
Rate for Payer: Aetna Medicare	$3,226.04
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,877.45
Rate for Payer: Amish Plain Church Group Commercial	$3,877.45
Rate for Payer: BCBS Complete	$1,781.77
Rate for Payer: BCBS MAPPO	$3,101.96
Rate for Payer: BCBS Trust/PPO	$1,740.30
Rate for Payer: BCN Medicare Advantage	$3,101.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,101.96
Rate for Payer: Mclaren Medicaid	$1,696.77
Rate for Payer: Mclaren Medicare	$3,101.96
Rate for Payer: Meridian Medicaid	$1,781.77
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,257.06
Rate for Payer: MI Amish Medical Board Commercial	$3,567.25
Rate for Payer: PACE Medicare	$2,946.86
Rate for Payer: PACE SWMI	$3,101.96
Rate for Payer: PHP Medicare Advantage	$3,101.96
Rate for Payer: Priority Health Choice Medicaid	$1,696.77
Rate for Payer: Priority Health Medicare	$3,101.96
Rate for Payer: Railroad Medicare Medicare	$3,101.96
Rate for Payer: UHC All Payor (Choice/PPO)	$213.24
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$3,101.96
Rate for Payer: UHC Exchange	$193.85
Rate for Payer: UHC Medicare Advantage	$3,195.02
Rate for Payer: VA VA	$3,101.96

ENDOSCOPIC MARKER

Facility

$77.70

Service Code	NDC 9900-0000-99
Hospital Charge Code	2138700
Hospital Revenue Code	250
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$69.93
Rate for Payer: Aetna Commercial	$66.04
Rate for Payer: Aetna New Business (MI Preferred)	$50.50
Rate for Payer: Cash Price	$62.16
Rate for Payer: Cofinity Commercial	$66.82
Rate for Payer: Cofinity Commercial	$54.39
Rate for Payer: Healthscope Commercial	$69.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$66.04
Rate for Payer: PHP Commercial	$66.04
Rate for Payer: Priority Health Cigna Priority Health	$54.39
Rate for Payer: Priority Health SBD	$48.95

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC

Facility

$108,336.92

Service Code	MS-DRG 266
Min. Negotiated Rate	$43,202.05
Max. Negotiated Rate	$108,336.92
Rate for Payer: Aetna Medicare	$47,294.87
Rate for Payer: Allen County Amish Medical Aid Commercial	$56,844.80
Rate for Payer: Amish Plain Church Group Commercial	$56,844.80
Rate for Payer: BCBS MAPPO	$45,475.84
Rate for Payer: BCBS Trust/PPO	$108,336.92
Rate for Payer: BCN Medicare Advantage	$45,475.84
Rate for Payer: Health Alliance Plan Medicare Advantage	$45,475.84
Rate for Payer: Mclaren Medicare	$45,475.84
Rate for Payer: Meridian Wellcare - Medicare Advantage	$47,749.63
Rate for Payer: MI Amish Medical Board Commercial	$52,297.22
Rate for Payer: PACE Medicare	$43,202.05
Rate for Payer: PACE SWMI	$45,475.84
Rate for Payer: PHP Medicare Advantage	$45,475.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$89,631.04
Rate for Payer: Priority Health Medicare	$45,475.84
Rate for Payer: Priority Health Narrow Network	$71,704.83
Rate for Payer: Railroad Medicare Medicare	$45,475.84
Rate for Payer: UHC All Payor (Choice/PPO)	$95,278.01
Rate for Payer: UHC Core	$58,463.50
Rate for Payer: UHC Dual Complete DSNP	$45,475.84
Rate for Payer: UHC Exchange	$62,617.15
Rate for Payer: UHC Medicare Advantage	$46,840.12
Rate for Payer: VA VA	$45,475.84

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC

Facility

$90,919.04

Service Code	MS-DRG 267
Min. Negotiated Rate	$33,856.98
Max. Negotiated Rate	$90,919.04
Rate for Payer: Aetna Medicare	$37,064.49
Rate for Payer: Allen County Amish Medical Aid Commercial	$44,548.66
Rate for Payer: Amish Plain Church Group Commercial	$44,548.66
Rate for Payer: BCBS MAPPO	$35,638.93
Rate for Payer: BCBS Trust/PPO	$90,919.04
Rate for Payer: BCN Medicare Advantage	$35,638.93
Rate for Payer: Health Alliance Plan Medicare Advantage	$35,638.93
Rate for Payer: Mclaren Medicare	$35,638.93
Rate for Payer: Meridian Wellcare - Medicare Advantage	$37,420.88
Rate for Payer: MI Amish Medical Board Commercial	$40,984.77
Rate for Payer: PACE Medicare	$33,856.98
Rate for Payer: PACE SWMI	$35,638.93
Rate for Payer: PHP Medicare Advantage	$35,638.93
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$70,030.48
Rate for Payer: Priority Health Medicare	$35,638.93
Rate for Payer: Priority Health Narrow Network	$56,024.38
Rate for Payer: Railroad Medicare Medicare	$35,638.93
Rate for Payer: UHC All Payor (Choice/PPO)	$74,442.57
Rate for Payer: UHC Core	$45,678.67
Rate for Payer: UHC Dual Complete DSNP	$35,638.93
Rate for Payer: UHC Exchange	$48,924.01
Rate for Payer: UHC Medicare Advantage	$36,708.10
Rate for Payer: VA VA	$35,638.93

ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED

Facility

$8,913.25

Service Code	CPT 36475
Hospital Revenue Code	360
Min. Negotiated Rate	$266.87
Max. Negotiated Rate	$8,913.25
Rate for Payer: Aetna Medicare	$2,949.65
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,545.25
Rate for Payer: Amish Plain Church Group Commercial	$3,545.25
Rate for Payer: BCBS Complete	$1,629.11
Rate for Payer: BCBS MAPPO	$2,836.20
Rate for Payer: BCBS Trust/PPO	$1,528.16
Rate for Payer: BCN Medicare Advantage	$2,836.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,836.20
Rate for Payer: Mclaren Medicaid	$1,551.40
Rate for Payer: Mclaren Medicare	$2,836.20
Rate for Payer: Meridian Medicaid	$1,629.11
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,978.01
Rate for Payer: MI Amish Medical Board Commercial	$3,261.63
Rate for Payer: PACE Medicare	$2,694.39
Rate for Payer: PACE SWMI	$2,836.20
Rate for Payer: PHP Medicare Advantage	$2,836.20
Rate for Payer: Priority Health Choice Medicaid	$1,551.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8,913.25
Rate for Payer: Priority Health Medicare	$2,836.20
Rate for Payer: Priority Health Narrow Network	$7,130.60
Rate for Payer: Railroad Medicare Medicare	$2,836.20
Rate for Payer: UHC All Payor (Choice/PPO)	$293.56
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$2,836.20
Rate for Payer: UHC Exchange	$266.87
Rate for Payer: UHC Medicare Advantage	$2,921.29
Rate for Payer: VA VA	$2,836.20

ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$878.00

Service Code	CPT 36476
Hospital Revenue Code	360
Min. Negotiated Rate	$127.70
Max. Negotiated Rate	$878.00
Rate for Payer: BCBS Trust/PPO	$590.80
Rate for Payer: UHC All Payor (Choice/PPO)	$140.47
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Exchange	$127.70

ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION

Facility

$12,365.46

Service Code	HCPCS J9177
Hospital Charge Code	192400
Hospital Revenue Code	636
Min. Negotiated Rate	$7,790.24
Max. Negotiated Rate	$11,128.91
Rate for Payer: Aetna Commercial	$10,510.64
Rate for Payer: Aetna New Business (MI Preferred)	$8,037.55
Rate for Payer: Cash Price	$9,892.37
Rate for Payer: Cofinity Commercial	$10,634.30
Rate for Payer: Cofinity Commercial	$8,655.82
Rate for Payer: Healthscope Commercial	$11,128.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10,510.64
Rate for Payer: PHP Commercial	$10,510.64
Rate for Payer: Priority Health Cigna Priority Health	$8,655.82
Rate for Payer: Priority Health SBD	$7,790.24

ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION

Facility

$12,365.46

Service Code	HCPCS J9177
Hospital Charge Code	192400
Hospital Revenue Code	636
Min. Negotiated Rate	$19.16
Max. Negotiated Rate	$11,128.91
Rate for Payer: Aetna Commercial	$10,510.64
Rate for Payer: Aetna Medicare	$36.43
Rate for Payer: Aetna New Business (MI Preferred)	$8,037.55
Rate for Payer: Allen County Amish Medical Aid Commercial	$43.78
Rate for Payer: Amish Plain Church Group Commercial	$43.78
Rate for Payer: BCBS Complete	$20.12
Rate for Payer: BCBS MAPPO	$35.03
Rate for Payer: BCBS Trust/PPO	$103.68
Rate for Payer: BCN Medicare Advantage	$35.03
Rate for Payer: Cash Price	$9,892.37
Rate for Payer: Cash Price	$9,892.37
Rate for Payer: Cofinity Commercial	$8,655.82
Rate for Payer: Cofinity Commercial	$10,634.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$35.03
Rate for Payer: Healthscope Commercial	$11,128.91
Rate for Payer: Mclaren Medicaid	$19.16
Rate for Payer: Mclaren Medicare	$35.03
Rate for Payer: Meridian Medicaid	$20.12
Rate for Payer: Meridian Wellcare - Medicare Advantage	$36.78
Rate for Payer: MI Amish Medical Board Commercial	$40.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10,510.64
Rate for Payer: PACE Medicare	$33.28
Rate for Payer: PACE SWMI	$35.03
Rate for Payer: PHP Commercial	$10,510.64
Rate for Payer: PHP Medicare Advantage	$35.03
Rate for Payer: Priority Health Choice Medicaid	$19.16
Rate for Payer: Priority Health Cigna Priority Health	$8,655.82
Rate for Payer: Priority Health Medicare	$35.03
Rate for Payer: Priority Health SBD	$7,790.24
Rate for Payer: Railroad Medicare Medicare	$35.03
Rate for Payer: UHC Dual Complete DSNP	$35.03
Rate for Payer: UHC Medicare Advantage	$36.08
Rate for Payer: VA VA	$35.03

ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION

Facility

$18,548.19

Service Code	HCPCS J9177
Hospital Charge Code	192401
Hospital Revenue Code	636
Min. Negotiated Rate	$19.16
Max. Negotiated Rate	$16,693.37
Rate for Payer: Aetna Commercial	$15,765.96
Rate for Payer: Aetna Medicare	$36.43
Rate for Payer: Aetna New Business (MI Preferred)	$12,056.32
Rate for Payer: Allen County Amish Medical Aid Commercial	$43.78
Rate for Payer: Amish Plain Church Group Commercial	$43.78
Rate for Payer: BCBS Complete	$20.12
Rate for Payer: BCBS MAPPO	$35.03
Rate for Payer: BCBS Trust/PPO	$103.68
Rate for Payer: BCN Medicare Advantage	$35.03
Rate for Payer: Cash Price	$14,838.55
Rate for Payer: Cash Price	$14,838.55
Rate for Payer: Cofinity Commercial	$12,983.73
Rate for Payer: Cofinity Commercial	$15,951.44
Rate for Payer: Health Alliance Plan Medicare Advantage	$35.03
Rate for Payer: Healthscope Commercial	$16,693.37
Rate for Payer: Mclaren Medicaid	$19.16
Rate for Payer: Mclaren Medicare	$35.03
Rate for Payer: Meridian Medicaid	$20.12
Rate for Payer: Meridian Wellcare - Medicare Advantage	$36.78
Rate for Payer: MI Amish Medical Board Commercial	$40.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15,765.96
Rate for Payer: PACE Medicare	$33.28
Rate for Payer: PACE SWMI	$35.03
Rate for Payer: PHP Commercial	$15,765.96
Rate for Payer: PHP Medicare Advantage	$35.03
Rate for Payer: Priority Health Choice Medicaid	$19.16
Rate for Payer: Priority Health Cigna Priority Health	$12,983.73
Rate for Payer: Priority Health Medicare	$35.03
Rate for Payer: Priority Health SBD	$11,685.36
Rate for Payer: Railroad Medicare Medicare	$35.03
Rate for Payer: UHC Dual Complete DSNP	$35.03
Rate for Payer: UHC Medicare Advantage	$36.08
Rate for Payer: VA VA	$35.03

Know your out-of-pocket cost for care.

All Charges