Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

PR REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH

Professional

Both

$1,753.00

Service Code	HCPCS 26420
Min. Negotiated Rate	$66.57
Max. Negotiated Rate	$1,227.10
Rate for Payer: Aetna Commercial	$986.20
Rate for Payer: BCBS Complete	$505.00
Rate for Payer: BCBS Trust/PPO	$66.57
Rate for Payer: Cash Price	$1,402.40
Rate for Payer: Cash Price	$1,402.40
Rate for Payer: Mclaren Medicaid	$480.95
Rate for Payer: Meridian Medicaid	$505.00
Rate for Payer: Priority Health Choice Medicaid	$480.95
Rate for Payer: Priority Health Cigna Priority Health	$1,227.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,155.09
Rate for Payer: Priority Health Narrow Network	$1,155.09
Rate for Payer: Priority Health SBD	$1,155.09

PR REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH

Professional

Both

$1,283.00

Service Code	HCPCS 26418
Min. Negotiated Rate	$132.08
Max. Negotiated Rate	$972.79
Rate for Payer: Aetna Commercial	$816.06
Rate for Payer: BCBS Complete	$425.83
Rate for Payer: BCBS Trust/PPO	$132.08
Rate for Payer: Cash Price	$1,026.40
Rate for Payer: Cash Price	$1,026.40
Rate for Payer: Mclaren Medicaid	$405.55
Rate for Payer: Meridian Medicaid	$425.83
Rate for Payer: Priority Health Choice Medicaid	$405.55
Rate for Payer: Priority Health Cigna Priority Health	$898.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$972.79
Rate for Payer: Priority Health Narrow Network	$972.79
Rate for Payer: Priority Health SBD	$972.79

PR REPAIR EXTENSOR TENDON HAND W/GRAFT EACH

Professional

Both

$1,895.00

Service Code	HCPCS 26412
Min. Negotiated Rate	$77.66
Max. Negotiated Rate	$1,326.50
Rate for Payer: Aetna Commercial	$950.15
Rate for Payer: BCBS Complete	$486.66
Rate for Payer: BCBS Trust/PPO	$77.66
Rate for Payer: Cash Price	$1,516.00
Rate for Payer: Cash Price	$1,516.00
Rate for Payer: Mclaren Medicaid	$463.49
Rate for Payer: Meridian Medicaid	$486.66
Rate for Payer: Priority Health Choice Medicaid	$463.49
Rate for Payer: Priority Health Cigna Priority Health	$1,326.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,115.78
Rate for Payer: Priority Health Narrow Network	$1,115.78
Rate for Payer: Priority Health SBD	$1,115.78

PR REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH

Professional

Both

$1,232.00

Service Code	HCPCS 26410
Min. Negotiated Rate	$154.79
Max. Negotiated Rate	$937.55
Rate for Payer: Aetna Commercial	$793.05
Rate for Payer: BCBS Complete	$409.50
Rate for Payer: BCBS Trust/PPO	$154.79
Rate for Payer: Cash Price	$985.60
Rate for Payer: Cash Price	$985.60
Rate for Payer: Mclaren Medicaid	$390.00
Rate for Payer: Meridian Medicaid	$409.50
Rate for Payer: Priority Health Choice Medicaid	$390.00
Rate for Payer: Priority Health Cigna Priority Health	$862.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$937.55
Rate for Payer: Priority Health Narrow Network	$937.55
Rate for Payer: Priority Health SBD	$937.55

PR REPAIR FASCIAL DEFECT LEG

Professional

Both

$907.00

Service Code	HCPCS 27656
Min. Negotiated Rate	$221.09
Max. Negotiated Rate	$1,234.11
Rate for Payer: Aetna Commercial	$468.22
Rate for Payer: BCBS Complete	$232.14
Rate for Payer: BCBS Trust/PPO	$1,234.11
Rate for Payer: Cash Price	$725.60
Rate for Payer: Cash Price	$725.60
Rate for Payer: Mclaren Medicaid	$221.09
Rate for Payer: Meridian Medicaid	$232.14
Rate for Payer: Priority Health Choice Medicaid	$221.09
Rate for Payer: Priority Health Cigna Priority Health	$634.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$531.59
Rate for Payer: Priority Health Narrow Network	$531.59
Rate for Payer: Priority Health SBD	$531.59

PR REPAIR FIBULA NONUNION/MALUNION W/INT FIXATION

Professional

Both

$3,954.00

Service Code	HCPCS 27726
Min. Negotiated Rate	$614.51
Max. Negotiated Rate	$2,767.80
Rate for Payer: Aetna Commercial	$1,282.82
Rate for Payer: BCBS Complete	$645.24
Rate for Payer: BCBS Trust/PPO	$746.49
Rate for Payer: Cash Price	$3,163.20
Rate for Payer: Cash Price	$3,163.20
Rate for Payer: Mclaren Medicaid	$614.51
Rate for Payer: Meridian Medicaid	$645.24
Rate for Payer: Priority Health Choice Medicaid	$614.51
Rate for Payer: Priority Health Cigna Priority Health	$2,767.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,466.59
Rate for Payer: Priority Health Narrow Network	$1,466.59
Rate for Payer: Priority Health SBD	$1,466.59

PR REPAIR FIRST ABDOMINAL WALL HERNIA

Professional

Both

$2,065.00

Service Code	HCPCS 49560
Min. Negotiated Rate	$826.00
Max. Negotiated Rate	$1,445.50
Rate for Payer: BCBS Complete	$826.00
Rate for Payer: Cash Price	$1,652.00
Rate for Payer: Priority Health Cigna Priority Health	$1,445.50

PR REPAIR FISTULA OROMAXILLARY

Professional

Both

$1,454.00

Service Code	HCPCS 30580
Min. Negotiated Rate	$294.79
Max. Negotiated Rate	$1,017.80
Rate for Payer: Aetna Commercial	$589.31
Rate for Payer: BCBS Complete	$309.53
Rate for Payer: BCBS Trust/PPO	$804.60
Rate for Payer: Cash Price	$1,163.20
Rate for Payer: Cash Price	$1,163.20
Rate for Payer: Mclaren Medicaid	$294.79
Rate for Payer: Meridian Medicaid	$309.53
Rate for Payer: Priority Health Choice Medicaid	$294.79
Rate for Payer: Priority Health Cigna Priority Health	$1,017.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$637.15
Rate for Payer: Priority Health Narrow Network	$637.15
Rate for Payer: Priority Health SBD	$637.15

PR REPAIR FLEXOR TENDON LEG PRIMARY W/O GRAFT EACH

Professional

Both

$1,275.00

Service Code	HCPCS 27658
Min. Negotiated Rate	$212.38
Max. Negotiated Rate	$892.50
Rate for Payer: Aetna Commercial	$490.73
Rate for Payer: BCBS Complete	$251.38
Rate for Payer: BCBS Trust/PPO	$212.38
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Cash Price	$1,020.00
Rate for Payer: Mclaren Medicaid	$239.41
Rate for Payer: Meridian Medicaid	$251.38
Rate for Payer: Priority Health Choice Medicaid	$239.41
Rate for Payer: Priority Health Cigna Priority Health	$892.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$567.34
Rate for Payer: Priority Health Narrow Network	$567.34
Rate for Payer: Priority Health SBD	$567.34

PR REPAIR INCOMPLETE CIRCUMCISION

Professional

Both

$401.00

Service Code	HCPCS 54163
Min. Negotiated Rate	$140.79
Max. Negotiated Rate	$452.22
Rate for Payer: Aetna Commercial	$277.43
Rate for Payer: BCBS Complete	$147.83
Rate for Payer: BCBS Trust/PPO	$452.22
Rate for Payer: Cash Price	$320.80
Rate for Payer: Cash Price	$320.80
Rate for Payer: Mclaren Medicaid	$140.79
Rate for Payer: Meridian Medicaid	$147.83
Rate for Payer: Priority Health Choice Medicaid	$140.79
Rate for Payer: Priority Health Cigna Priority Health	$280.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$350.70
Rate for Payer: Priority Health Narrow Network	$350.70
Rate for Payer: Priority Health SBD	$350.70

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM

Professional

Both

$997.00

Service Code	HCPCS 12055
Min. Negotiated Rate	$192.77
Max. Negotiated Rate	$697.90
Rate for Payer: Aetna Commercial	$322.34
Rate for Payer: BCBS Complete	$202.41
Rate for Payer: BCBS Trust/PPO	$364.91
Rate for Payer: Cash Price	$797.60
Rate for Payer: Cash Price	$797.60
Rate for Payer: Mclaren Medicaid	$192.77
Rate for Payer: Meridian Medicaid	$202.41
Rate for Payer: Priority Health Choice Medicaid	$192.77
Rate for Payer: Priority Health Cigna Priority Health	$697.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$367.47
Rate for Payer: Priority Health Narrow Network	$367.47
Rate for Payer: Priority Health SBD	$367.47

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<

Professional

Both

$436.00

Service Code	HCPCS 12051
Min. Negotiated Rate	$108.20
Max. Negotiated Rate	$305.20
Rate for Payer: Aetna Commercial	$180.03
Rate for Payer: BCBS Complete	$113.61
Rate for Payer: BCBS Trust/PPO	$212.16
Rate for Payer: Cash Price	$348.80
Rate for Payer: Cash Price	$348.80
Rate for Payer: Mclaren Medicaid	$108.20
Rate for Payer: Meridian Medicaid	$113.61
Rate for Payer: Priority Health Choice Medicaid	$108.20
Rate for Payer: Priority Health Cigna Priority Health	$305.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$207.16
Rate for Payer: Priority Health Narrow Network	$207.16
Rate for Payer: Priority Health SBD	$207.16

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<

Facility

$436.00

Service Code	CPT 12051
Hospital Charge Code	12051
Hospital Revenue Code	521
Min. Negotiated Rate	$137.63
Max. Negotiated Rate	$1,118.65
Rate for Payer: Aetna Commercial	$370.60
Rate for Payer: Aetna Medicare	$368.99
Rate for Payer: Aetna New Business (MI Preferred)	$283.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$443.50
Rate for Payer: Amish Plain Church Group Commercial	$443.50
Rate for Payer: BCBS Complete	$203.80
Rate for Payer: BCBS MAPPO	$354.80
Rate for Payer: BCBS Trust/PPO	$137.63
Rate for Payer: BCN Medicare Advantage	$354.80
Rate for Payer: Cash Price	$348.80
Rate for Payer: Cash Price	$348.80
Rate for Payer: Cofinity Commercial	$305.20
Rate for Payer: Cofinity Commercial	$374.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$354.80
Rate for Payer: Healthscope Commercial	$392.40
Rate for Payer: Mclaren Medicaid	$194.08
Rate for Payer: Mclaren Medicare	$354.80
Rate for Payer: Meridian Medicaid	$203.80
Rate for Payer: Meridian Wellcare - Medicare Advantage	$372.54
Rate for Payer: MI Amish Medical Board Commercial	$408.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$370.60
Rate for Payer: PACE Medicare	$337.06
Rate for Payer: PACE SWMI	$354.80
Rate for Payer: PHP Commercial	$370.60
Rate for Payer: PHP Medicare Advantage	$354.80
Rate for Payer: Priority Health Choice Medicaid	$194.08
Rate for Payer: Priority Health Cigna Priority Health	$305.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,118.65
Rate for Payer: Priority Health Medicare	$354.80
Rate for Payer: Priority Health Narrow Network	$894.92
Rate for Payer: Priority Health SBD	$274.68
Rate for Payer: Railroad Medicare Medicare	$354.80
Rate for Payer: UHC All Payor (Choice/PPO)	$182.97
Rate for Payer: UHC Dual Complete DSNP	$354.80
Rate for Payer: UHC Exchange	$166.34
Rate for Payer: UHC Medicare Advantage	$365.44
Rate for Payer: VA VA	$354.80

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<

Facility

$436.00

Service Code	CPT 12051
Hospital Charge Code	12051
Hospital Revenue Code	521
Min. Negotiated Rate	$274.68
Max. Negotiated Rate	$392.40
Rate for Payer: Aetna Commercial	$370.60
Rate for Payer: Aetna New Business (MI Preferred)	$283.40
Rate for Payer: Cash Price	$348.80
Rate for Payer: Cofinity Commercial	$305.20
Rate for Payer: Cofinity Commercial	$374.96
Rate for Payer: Healthscope Commercial	$392.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$370.60
Rate for Payer: PHP Commercial	$370.60
Rate for Payer: Priority Health Cigna Priority Health	$305.20
Rate for Payer: Priority Health SBD	$274.68

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<

Professional

Both

$436.00

Service Code	HCPCS 12051
Hospital Charge Code	12051
Min. Negotiated Rate	$108.20
Max. Negotiated Rate	$305.20
Rate for Payer: Aetna Commercial	$180.03
Rate for Payer: BCBS Complete	$113.61
Rate for Payer: BCBS Trust/PPO	$212.16
Rate for Payer: Cash Price	$348.80
Rate for Payer: Cash Price	$348.80
Rate for Payer: Mclaren Medicaid	$108.20
Rate for Payer: Meridian Medicaid	$113.61
Rate for Payer: Priority Health Choice Medicaid	$108.20
Rate for Payer: Priority Health Cigna Priority Health	$305.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$207.16
Rate for Payer: Priority Health Narrow Network	$207.16
Rate for Payer: Priority Health SBD	$207.16

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM

Facility

$549.00

Service Code	CPT 12052
Hospital Charge Code	12052
Hospital Revenue Code	521
Min. Negotiated Rate	$345.87
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna Commercial	$466.65
Rate for Payer: Aetna New Business (MI Preferred)	$356.85
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cofinity Commercial	$384.30
Rate for Payer: Cofinity Commercial	$472.14
Rate for Payer: Healthscope Commercial	$494.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$466.65
Rate for Payer: PHP Commercial	$466.65
Rate for Payer: Priority Health Cigna Priority Health	$384.30
Rate for Payer: Priority Health SBD	$345.87

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM

Professional

Both

$549.00

Service Code	HCPCS 12052
Min. Negotiated Rate	$127.16
Max. Negotiated Rate	$384.30
Rate for Payer: Aetna Commercial	$213.15
Rate for Payer: BCBS Complete	$133.52
Rate for Payer: BCBS Trust/PPO	$212.16
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cash Price	$439.20
Rate for Payer: Mclaren Medicaid	$127.16
Rate for Payer: Meridian Medicaid	$133.52
Rate for Payer: Priority Health Choice Medicaid	$127.16
Rate for Payer: Priority Health Cigna Priority Health	$384.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$243.74
Rate for Payer: Priority Health Narrow Network	$243.74
Rate for Payer: Priority Health SBD	$243.74

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM

Facility

$549.00

Service Code	CPT 12052
Hospital Charge Code	12052
Hospital Revenue Code	521
Min. Negotiated Rate	$194.08
Max. Negotiated Rate	$1,118.65
Rate for Payer: Aetna Commercial	$466.65
Rate for Payer: Aetna Medicare	$368.99
Rate for Payer: Aetna New Business (MI Preferred)	$356.85
Rate for Payer: Allen County Amish Medical Aid Commercial	$443.50
Rate for Payer: Amish Plain Church Group Commercial	$443.50
Rate for Payer: BCBS Complete	$203.80
Rate for Payer: BCBS MAPPO	$354.80
Rate for Payer: BCBS Trust/PPO	$248.53
Rate for Payer: BCN Medicare Advantage	$354.80
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cofinity Commercial	$472.14
Rate for Payer: Cofinity Commercial	$384.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$354.80
Rate for Payer: Healthscope Commercial	$494.10
Rate for Payer: Mclaren Medicaid	$194.08
Rate for Payer: Mclaren Medicare	$354.80
Rate for Payer: Meridian Medicaid	$203.80
Rate for Payer: Meridian Wellcare - Medicare Advantage	$372.54
Rate for Payer: MI Amish Medical Board Commercial	$408.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$466.65
Rate for Payer: PACE Medicare	$337.06
Rate for Payer: PACE SWMI	$354.80
Rate for Payer: PHP Commercial	$466.65
Rate for Payer: PHP Medicare Advantage	$354.80
Rate for Payer: Priority Health Choice Medicaid	$194.08
Rate for Payer: Priority Health Cigna Priority Health	$384.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,118.65
Rate for Payer: Priority Health Medicare	$354.80
Rate for Payer: Priority Health Narrow Network	$894.92
Rate for Payer: Priority Health SBD	$345.87
Rate for Payer: Railroad Medicare Medicare	$354.80
Rate for Payer: UHC All Payor (Choice/PPO)	$215.03
Rate for Payer: UHC Dual Complete DSNP	$354.80
Rate for Payer: UHC Exchange	$195.48
Rate for Payer: UHC Medicare Advantage	$365.44
Rate for Payer: VA VA	$354.80

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM

Professional

Both

$549.00

Service Code	HCPCS 12052
Hospital Charge Code	12052
Min. Negotiated Rate	$127.16
Max. Negotiated Rate	$384.30
Rate for Payer: Aetna Commercial	$213.15
Rate for Payer: BCBS Complete	$133.52
Rate for Payer: BCBS Trust/PPO	$212.16
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cash Price	$439.20
Rate for Payer: Mclaren Medicaid	$127.16
Rate for Payer: Meridian Medicaid	$133.52
Rate for Payer: Priority Health Choice Medicaid	$127.16
Rate for Payer: Priority Health Cigna Priority Health	$384.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$243.74
Rate for Payer: Priority Health Narrow Network	$243.74
Rate for Payer: Priority Health SBD	$243.74

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM

Facility

$622.00

Service Code	CPT 12053
Hospital Charge Code	12053
Hospital Revenue Code	521
Min. Negotiated Rate	$391.86
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna Commercial	$528.70
Rate for Payer: Aetna New Business (MI Preferred)	$404.30
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cofinity Commercial	$435.40
Rate for Payer: Cofinity Commercial	$534.92
Rate for Payer: Healthscope Commercial	$559.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$528.70
Rate for Payer: PHP Commercial	$528.70
Rate for Payer: Priority Health Cigna Priority Health	$435.40
Rate for Payer: Priority Health SBD	$391.86

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM

Facility

$622.00

Service Code	CPT 12053
Hospital Charge Code	12053
Hospital Revenue Code	521
Min. Negotiated Rate	$116.67
Max. Negotiated Rate	$1,118.65
Rate for Payer: Aetna Commercial	$528.70
Rate for Payer: Aetna Medicare	$368.99
Rate for Payer: Aetna New Business (MI Preferred)	$404.30
Rate for Payer: Allen County Amish Medical Aid Commercial	$443.50
Rate for Payer: Amish Plain Church Group Commercial	$443.50
Rate for Payer: BCBS Complete	$203.80
Rate for Payer: BCBS MAPPO	$354.80
Rate for Payer: BCBS Trust/PPO	$116.67
Rate for Payer: BCN Medicare Advantage	$354.80
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cofinity Commercial	$435.40
Rate for Payer: Cofinity Commercial	$534.92
Rate for Payer: Health Alliance Plan Medicare Advantage	$354.80
Rate for Payer: Healthscope Commercial	$559.80
Rate for Payer: Mclaren Medicaid	$194.08
Rate for Payer: Mclaren Medicare	$354.80
Rate for Payer: Meridian Medicaid	$203.80
Rate for Payer: Meridian Wellcare - Medicare Advantage	$372.54
Rate for Payer: MI Amish Medical Board Commercial	$408.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$528.70
Rate for Payer: PACE Medicare	$337.06
Rate for Payer: PACE SWMI	$354.80
Rate for Payer: PHP Commercial	$528.70
Rate for Payer: PHP Medicare Advantage	$354.80
Rate for Payer: Priority Health Choice Medicaid	$194.08
Rate for Payer: Priority Health Cigna Priority Health	$435.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,118.65
Rate for Payer: Priority Health Medicare	$354.80
Rate for Payer: Priority Health Narrow Network	$894.92
Rate for Payer: Priority Health SBD	$391.86
Rate for Payer: Railroad Medicare Medicare	$354.80
Rate for Payer: UHC All Payor (Choice/PPO)	$231.96
Rate for Payer: UHC Dual Complete DSNP	$354.80
Rate for Payer: UHC Exchange	$210.87
Rate for Payer: UHC Medicare Advantage	$365.44
Rate for Payer: VA VA	$354.80

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM

Professional

Both

$622.00

Service Code	HCPCS 12053
Hospital Charge Code	12053
Min. Negotiated Rate	$137.17
Max. Negotiated Rate	$435.40
Rate for Payer: Aetna Commercial	$230.84
Rate for Payer: BCBS Complete	$144.03
Rate for Payer: BCBS Trust/PPO	$212.16
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cash Price	$497.60
Rate for Payer: Mclaren Medicaid	$137.17
Rate for Payer: Meridian Medicaid	$144.03
Rate for Payer: Priority Health Choice Medicaid	$137.17
Rate for Payer: Priority Health Cigna Priority Health	$435.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$263.07
Rate for Payer: Priority Health Narrow Network	$263.07
Rate for Payer: Priority Health SBD	$263.07

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM

Professional

Both

$622.00

Service Code	HCPCS 12053
Min. Negotiated Rate	$137.17
Max. Negotiated Rate	$435.40
Rate for Payer: Aetna Commercial	$230.84
Rate for Payer: BCBS Complete	$144.03
Rate for Payer: BCBS Trust/PPO	$212.16
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cash Price	$497.60
Rate for Payer: Mclaren Medicaid	$137.17
Rate for Payer: Meridian Medicaid	$144.03
Rate for Payer: Priority Health Choice Medicaid	$137.17
Rate for Payer: Priority Health Cigna Priority Health	$435.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$263.07
Rate for Payer: Priority Health Narrow Network	$263.07
Rate for Payer: Priority Health SBD	$263.07

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM

Facility

$780.00

Service Code	CPT 12054
Hospital Charge Code	12054
Hospital Revenue Code	521
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$1,118.65
Rate for Payer: Aetna Commercial	$663.00
Rate for Payer: Aetna Medicare	$368.99
Rate for Payer: Aetna New Business (MI Preferred)	$507.00
Rate for Payer: Allen County Amish Medical Aid Commercial	$443.50
Rate for Payer: Amish Plain Church Group Commercial	$443.50
Rate for Payer: BCBS Complete	$203.80
Rate for Payer: BCBS MAPPO	$354.80
Rate for Payer: BCBS Trust/PPO	$169.15
Rate for Payer: BCN Medicare Advantage	$354.80
Rate for Payer: Cash Price	$624.00
Rate for Payer: Cash Price	$624.00
Rate for Payer: Cofinity Commercial	$670.80
Rate for Payer: Cofinity Commercial	$546.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$354.80
Rate for Payer: Healthscope Commercial	$702.00
Rate for Payer: Mclaren Medicaid	$194.08
Rate for Payer: Mclaren Medicare	$354.80
Rate for Payer: Meridian Medicaid	$203.80
Rate for Payer: Meridian Wellcare - Medicare Advantage	$372.54
Rate for Payer: MI Amish Medical Board Commercial	$408.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$663.00
Rate for Payer: PACE Medicare	$337.06
Rate for Payer: PACE SWMI	$354.80
Rate for Payer: PHP Commercial	$663.00
Rate for Payer: PHP Medicare Advantage	$354.80
Rate for Payer: Priority Health Choice Medicaid	$194.08
Rate for Payer: Priority Health Cigna Priority Health	$546.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,118.65
Rate for Payer: Priority Health Medicare	$354.80
Rate for Payer: Priority Health Narrow Network	$894.92
Rate for Payer: Priority Health SBD	$491.40
Rate for Payer: Railroad Medicare Medicare	$354.80
Rate for Payer: UHC All Payor (Choice/PPO)	$237.36
Rate for Payer: UHC Dual Complete DSNP	$354.80
Rate for Payer: UHC Exchange	$215.78
Rate for Payer: UHC Medicare Advantage	$365.44
Rate for Payer: VA VA	$354.80

PR REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM

Professional

Both

$780.00

Service Code	HCPCS 12054
Min. Negotiated Rate	$140.37
Max. Negotiated Rate	$546.00
Rate for Payer: Aetna Commercial	$235.75
Rate for Payer: BCBS Complete	$147.39
Rate for Payer: BCBS Trust/PPO	$212.16
Rate for Payer: Cash Price	$624.00
Rate for Payer: Cash Price	$624.00
Rate for Payer: Mclaren Medicaid	$140.37
Rate for Payer: Meridian Medicaid	$147.39
Rate for Payer: Priority Health Choice Medicaid	$140.37
Rate for Payer: Priority Health Cigna Priority Health	$546.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$268.82
Rate for Payer: Priority Health Narrow Network	$268.82
Rate for Payer: Priority Health SBD	$268.82

Know your out-of-pocket cost for care.

All Charges