Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

TRIHEXYPHENIDYL 2 MG TABLET

Facility

$329.00

Service Code	NDC 0591-5335-01
Hospital Charge Code	8166
Hospital Revenue Code	637
Min. Negotiated Rate	$207.27
Max. Negotiated Rate	$296.10
Rate for Payer: Aetna Commercial	$279.65
Rate for Payer: Aetna New Business (MI Preferred)	$213.85
Rate for Payer: Cash Price	$263.20
Rate for Payer: Cofinity Commercial	$230.30
Rate for Payer: Cofinity Commercial	$282.94
Rate for Payer: Healthscope Commercial	$296.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$279.65
Rate for Payer: PHP Commercial	$279.65
Rate for Payer: Priority Health Cigna Priority Health	$230.30
Rate for Payer: Priority Health SBD	$207.27

TRIHEXYPHENIDYL 2 MG TABLET

Facility

$336.05

Service Code	NDC 69452-241-20
Hospital Charge Code	8166
Hospital Revenue Code	637
Min. Negotiated Rate	$211.71
Max. Negotiated Rate	$302.44
Rate for Payer: Aetna Commercial	$285.64
Rate for Payer: Aetna New Business (MI Preferred)	$218.43
Rate for Payer: Cash Price	$268.84
Rate for Payer: Cofinity Commercial	$235.24
Rate for Payer: Cofinity Commercial	$289.00
Rate for Payer: Healthscope Commercial	$302.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$285.64
Rate for Payer: PHP Commercial	$285.64
Rate for Payer: Priority Health Cigna Priority Health	$235.24
Rate for Payer: Priority Health SBD	$211.71

TRILACICLIB 300 MG INTRAVENOUS SOLUTION

Facility

$6,833.78

Service Code	HCPCS J1448
Hospital Charge Code	196299
Hospital Revenue Code	636
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$6,150.40
Rate for Payer: Aetna Commercial	$5,808.71
Rate for Payer: Aetna Medicare	$5.41
Rate for Payer: Aetna New Business (MI Preferred)	$4,441.96
Rate for Payer: Allen County Amish Medical Aid Commercial	$6.50
Rate for Payer: Amish Plain Church Group Commercial	$6.50
Rate for Payer: BCBS Complete	$2.99
Rate for Payer: BCBS MAPPO	$5.20
Rate for Payer: BCBS Trust/PPO	$15.37
Rate for Payer: BCN Medicare Advantage	$5.20
Rate for Payer: Cash Price	$5,467.02
Rate for Payer: Cash Price	$5,467.02
Rate for Payer: Cofinity Commercial	$5,877.05
Rate for Payer: Cofinity Commercial	$4,783.65
Rate for Payer: Health Alliance Plan Medicare Advantage	$5.20
Rate for Payer: Healthscope Commercial	$6,150.40
Rate for Payer: Mclaren Medicaid	$2.84
Rate for Payer: Mclaren Medicare	$5.20
Rate for Payer: Meridian Medicaid	$2.99
Rate for Payer: Meridian Wellcare - Medicare Advantage	$5.46
Rate for Payer: MI Amish Medical Board Commercial	$5.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5,808.71
Rate for Payer: PACE Medicare	$4.94
Rate for Payer: PACE SWMI	$5.20
Rate for Payer: PHP Commercial	$5,808.71
Rate for Payer: PHP Medicare Advantage	$5.20
Rate for Payer: Priority Health Choice Medicaid	$2.84
Rate for Payer: Priority Health Cigna Priority Health	$4,783.65
Rate for Payer: Priority Health Medicare	$5.20
Rate for Payer: Priority Health SBD	$4,305.28
Rate for Payer: Railroad Medicare Medicare	$5.20
Rate for Payer: UHC Dual Complete DSNP	$5.20
Rate for Payer: UHC Medicare Advantage	$5.36
Rate for Payer: VA VA	$5.20

TRILACICLIB 300 MG INTRAVENOUS SOLUTION

Facility

$6,833.78

Service Code	HCPCS J1448
Hospital Charge Code	196299
Hospital Revenue Code	636
Min. Negotiated Rate	$4,305.28
Max. Negotiated Rate	$6,150.40
Rate for Payer: Aetna Commercial	$5,808.71
Rate for Payer: Aetna New Business (MI Preferred)	$4,441.96
Rate for Payer: Cash Price	$5,467.02
Rate for Payer: Cofinity Commercial	$4,783.65
Rate for Payer: Cofinity Commercial	$5,877.05
Rate for Payer: Healthscope Commercial	$6,150.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5,808.71
Rate for Payer: PHP Commercial	$5,808.71
Rate for Payer: Priority Health Cigna Priority Health	$4,783.65
Rate for Payer: Priority Health SBD	$4,305.28

TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION

Facility

$190.96

Service Code	HCPCS J3250
Hospital Charge Code	108755
Hospital Revenue Code	636
Min. Negotiated Rate	$120.30
Max. Negotiated Rate	$171.86
Rate for Payer: Aetna Commercial	$162.32
Rate for Payer: Aetna New Business (MI Preferred)	$124.12
Rate for Payer: Cash Price	$152.77
Rate for Payer: Cofinity Commercial	$133.67
Rate for Payer: Cofinity Commercial	$164.23
Rate for Payer: Healthscope Commercial	$171.86
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$162.32
Rate for Payer: PHP Commercial	$162.32
Rate for Payer: Priority Health Cigna Priority Health	$133.67
Rate for Payer: Priority Health SBD	$120.30

TRIMETHOPRIM 100 MG TABLET

Facility

$595.68

Service Code	NDC 51862-486-01
Hospital Charge Code	8182
Hospital Revenue Code	637
Min. Negotiated Rate	$375.28
Max. Negotiated Rate	$536.11
Rate for Payer: Aetna Commercial	$506.33
Rate for Payer: Aetna New Business (MI Preferred)	$387.19
Rate for Payer: Cash Price	$476.54
Rate for Payer: Cofinity Commercial	$416.98
Rate for Payer: Cofinity Commercial	$512.28
Rate for Payer: Healthscope Commercial	$536.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$506.33
Rate for Payer: PHP Commercial	$506.33
Rate for Payer: Priority Health Cigna Priority Health	$416.98
Rate for Payer: Priority Health SBD	$375.28

TRIMETHOPRIM 100 MG TABLET

Facility

$201.40

Service Code	NDC 43386-330-01
Hospital Charge Code	8182
Hospital Revenue Code	637
Min. Negotiated Rate	$126.88
Max. Negotiated Rate	$181.26
Rate for Payer: Aetna Commercial	$171.19
Rate for Payer: Aetna New Business (MI Preferred)	$130.91
Rate for Payer: Cash Price	$161.12
Rate for Payer: Cofinity Commercial	$140.98
Rate for Payer: Cofinity Commercial	$173.20
Rate for Payer: Healthscope Commercial	$181.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$171.19
Rate for Payer: PHP Commercial	$171.19
Rate for Payer: Priority Health Cigna Priority Health	$140.98
Rate for Payer: Priority Health SBD	$126.88

TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION

Facility

$8,768.97

Service Code	HCPCS J3315
Hospital Charge Code	31708
Hospital Revenue Code	636
Min. Negotiated Rate	$226.23
Max. Negotiated Rate	$7,892.07
Rate for Payer: Aetna Commercial	$7,453.62
Rate for Payer: Aetna Medicare	$430.13
Rate for Payer: Aetna New Business (MI Preferred)	$5,699.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$516.98
Rate for Payer: Amish Plain Church Group Commercial	$516.98
Rate for Payer: BCBS Complete	$237.56
Rate for Payer: BCBS MAPPO	$413.58
Rate for Payer: BCBS Trust/PPO	$1,224.40
Rate for Payer: BCN Medicare Advantage	$413.58
Rate for Payer: Cash Price	$7,015.18
Rate for Payer: Cash Price	$7,015.18
Rate for Payer: Cofinity Commercial	$6,138.28
Rate for Payer: Cofinity Commercial	$7,541.31
Rate for Payer: Health Alliance Plan Medicare Advantage	$413.58
Rate for Payer: Healthscope Commercial	$7,892.07
Rate for Payer: Mclaren Medicaid	$226.23
Rate for Payer: Mclaren Medicare	$413.58
Rate for Payer: Meridian Medicaid	$237.56
Rate for Payer: Meridian Wellcare - Medicare Advantage	$434.26
Rate for Payer: MI Amish Medical Board Commercial	$475.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7,453.62
Rate for Payer: PACE Medicare	$392.91
Rate for Payer: PACE SWMI	$413.58
Rate for Payer: PHP Commercial	$7,453.62
Rate for Payer: PHP Medicare Advantage	$413.58
Rate for Payer: Priority Health Choice Medicaid	$226.23
Rate for Payer: Priority Health Cigna Priority Health	$6,138.28
Rate for Payer: Priority Health Medicare	$413.58
Rate for Payer: Priority Health SBD	$5,524.45
Rate for Payer: Railroad Medicare Medicare	$413.58
Rate for Payer: UHC Dual Complete DSNP	$413.58
Rate for Payer: UHC Medicare Advantage	$425.99
Rate for Payer: VA VA	$413.58

TRIPTORELIN PAMOATE 11.25 MG IM SUSPENSION

Facility

$8,768.97

Service Code	HCPCS J3315
Hospital Charge Code	31708
Hospital Revenue Code	636
Min. Negotiated Rate	$5,524.45
Max. Negotiated Rate	$7,892.07
Rate for Payer: Aetna Commercial	$7,453.62
Rate for Payer: Aetna New Business (MI Preferred)	$5,699.83
Rate for Payer: Cash Price	$7,015.18
Rate for Payer: Cofinity Commercial	$6,138.28
Rate for Payer: Cofinity Commercial	$7,541.31
Rate for Payer: Healthscope Commercial	$7,892.07
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$7,453.62
Rate for Payer: PHP Commercial	$7,453.62
Rate for Payer: Priority Health Cigna Priority Health	$6,138.28
Rate for Payer: Priority Health SBD	$5,524.45

TRIPTORELIN PAMOATE 22.5 MG IM SUSPENSION

Facility

$14,452.20

Service Code	HCPCS J3315
Hospital Charge Code	119655
Hospital Revenue Code	636
Min. Negotiated Rate	$226.23
Max. Negotiated Rate	$13,006.98
Rate for Payer: Aetna Commercial	$12,284.37
Rate for Payer: Aetna Medicare	$430.13
Rate for Payer: Aetna New Business (MI Preferred)	$9,393.93
Rate for Payer: Allen County Amish Medical Aid Commercial	$516.98
Rate for Payer: Amish Plain Church Group Commercial	$516.98
Rate for Payer: BCBS Complete	$237.56
Rate for Payer: BCBS MAPPO	$413.58
Rate for Payer: BCBS Trust/PPO	$1,224.40
Rate for Payer: BCN Medicare Advantage	$413.58
Rate for Payer: Cash Price	$11,561.76
Rate for Payer: Cash Price	$11,561.76
Rate for Payer: Cofinity Commercial	$12,428.89
Rate for Payer: Cofinity Commercial	$10,116.54
Rate for Payer: Health Alliance Plan Medicare Advantage	$413.58
Rate for Payer: Healthscope Commercial	$13,006.98
Rate for Payer: Mclaren Medicaid	$226.23
Rate for Payer: Mclaren Medicare	$413.58
Rate for Payer: Meridian Medicaid	$237.56
Rate for Payer: Meridian Wellcare - Medicare Advantage	$434.26
Rate for Payer: MI Amish Medical Board Commercial	$475.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12,284.37
Rate for Payer: PACE Medicare	$392.91
Rate for Payer: PACE SWMI	$413.58
Rate for Payer: PHP Commercial	$12,284.37
Rate for Payer: PHP Medicare Advantage	$413.58
Rate for Payer: Priority Health Choice Medicaid	$226.23
Rate for Payer: Priority Health Cigna Priority Health	$10,116.54
Rate for Payer: Priority Health Medicare	$413.58
Rate for Payer: Priority Health SBD	$9,104.89
Rate for Payer: Railroad Medicare Medicare	$413.58
Rate for Payer: UHC Dual Complete DSNP	$413.58
Rate for Payer: UHC Medicare Advantage	$425.99
Rate for Payer: VA VA	$413.58

TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION

Facility

$2,083.20

Service Code	HCPCS J3315
Hospital Charge Code	28558
Hospital Revenue Code	636
Min. Negotiated Rate	$1,312.42
Max. Negotiated Rate	$1,874.88
Rate for Payer: Aetna Commercial	$1,770.72
Rate for Payer: Aetna New Business (MI Preferred)	$1,354.08
Rate for Payer: Cash Price	$1,666.56
Rate for Payer: Cofinity Commercial	$1,458.24
Rate for Payer: Cofinity Commercial	$1,791.55
Rate for Payer: Healthscope Commercial	$1,874.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,770.72
Rate for Payer: PHP Commercial	$1,770.72
Rate for Payer: Priority Health Cigna Priority Health	$1,458.24
Rate for Payer: Priority Health SBD	$1,312.42

TRIPTORELIN PAMOATE 3.75 MG IM SUSPENSION

Facility

$2,083.20

Service Code	HCPCS J3315
Hospital Charge Code	28558
Hospital Revenue Code	636
Min. Negotiated Rate	$226.23
Max. Negotiated Rate	$1,874.88
Rate for Payer: Aetna Commercial	$1,770.72
Rate for Payer: Aetna Medicare	$430.13
Rate for Payer: Aetna New Business (MI Preferred)	$1,354.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$516.98
Rate for Payer: Amish Plain Church Group Commercial	$516.98
Rate for Payer: BCBS Complete	$237.56
Rate for Payer: BCBS MAPPO	$413.58
Rate for Payer: BCBS Trust/PPO	$1,224.40
Rate for Payer: BCN Medicare Advantage	$413.58
Rate for Payer: Cash Price	$1,666.56
Rate for Payer: Cash Price	$1,666.56
Rate for Payer: Cofinity Commercial	$1,791.55
Rate for Payer: Cofinity Commercial	$1,458.24
Rate for Payer: Health Alliance Plan Medicare Advantage	$413.58
Rate for Payer: Healthscope Commercial	$1,874.88
Rate for Payer: Mclaren Medicaid	$226.23
Rate for Payer: Mclaren Medicare	$413.58
Rate for Payer: Meridian Medicaid	$237.56
Rate for Payer: Meridian Wellcare - Medicare Advantage	$434.26
Rate for Payer: MI Amish Medical Board Commercial	$475.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,770.72
Rate for Payer: PACE Medicare	$392.91
Rate for Payer: PACE SWMI	$413.58
Rate for Payer: PHP Commercial	$1,770.72
Rate for Payer: PHP Medicare Advantage	$413.58
Rate for Payer: Priority Health Choice Medicaid	$226.23
Rate for Payer: Priority Health Cigna Priority Health	$1,458.24
Rate for Payer: Priority Health Medicare	$413.58
Rate for Payer: Priority Health SBD	$1,312.42
Rate for Payer: Railroad Medicare Medicare	$413.58
Rate for Payer: UHC Dual Complete DSNP	$413.58
Rate for Payer: UHC Medicare Advantage	$425.99
Rate for Payer: VA VA	$413.58

TROPICAMIDE 1 % EYE DROPS

Facility

$26.20

Service Code	NDC 17478-102-12
Hospital Charge Code	8250
Hospital Revenue Code	637
Min. Negotiated Rate	$16.51
Max. Negotiated Rate	$23.58
Rate for Payer: Aetna Commercial	$22.27
Rate for Payer: Aetna New Business (MI Preferred)	$17.03
Rate for Payer: Cash Price	$20.96
Rate for Payer: Cofinity Commercial	$18.34
Rate for Payer: Cofinity Commercial	$22.53
Rate for Payer: Healthscope Commercial	$23.58
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.27
Rate for Payer: PHP Commercial	$22.27
Rate for Payer: Priority Health Cigna Priority Health	$18.34
Rate for Payer: Priority Health SBD	$16.51

TROPICAMIDE 1 % EYE DROPS

Facility

$31.08

Service Code	NDC 61314-355-01
Hospital Charge Code	8250
Hospital Revenue Code	637
Min. Negotiated Rate	$19.58
Max. Negotiated Rate	$27.97
Rate for Payer: Aetna Commercial	$26.42
Rate for Payer: Aetna New Business (MI Preferred)	$20.20
Rate for Payer: Cash Price	$24.86
Rate for Payer: Cofinity Commercial	$21.76
Rate for Payer: Cofinity Commercial	$26.73
Rate for Payer: Healthscope Commercial	$27.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$26.42
Rate for Payer: PHP Commercial	$26.42
Rate for Payer: Priority Health Cigna Priority Health	$21.76
Rate for Payer: Priority Health SBD	$19.58

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION

Facility

$232.42

Service Code	NDC 49281-752-21
Hospital Charge Code	8259
Hospital Revenue Code	250
Min. Negotiated Rate	$146.42
Max. Negotiated Rate	$209.18
Rate for Payer: Aetna Commercial	$197.56
Rate for Payer: Aetna New Business (MI Preferred)	$151.07
Rate for Payer: Cash Price	$185.94
Rate for Payer: Cofinity Commercial	$162.69
Rate for Payer: Cofinity Commercial	$199.88
Rate for Payer: Healthscope Commercial	$209.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$197.56
Rate for Payer: PHP Commercial	$197.56
Rate for Payer: Priority Health Cigna Priority Health	$162.69
Rate for Payer: Priority Health SBD	$146.42

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION

Facility

$267.99

Service Code	NDC 42023-104-01
Hospital Charge Code	8259
Hospital Revenue Code	250
Min. Negotiated Rate	$168.83
Max. Negotiated Rate	$241.19
Rate for Payer: Aetna Commercial	$227.79
Rate for Payer: Aetna New Business (MI Preferred)	$174.19
Rate for Payer: Cash Price	$214.39
Rate for Payer: Cofinity Commercial	$187.59
Rate for Payer: Cofinity Commercial	$230.47
Rate for Payer: Healthscope Commercial	$241.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$227.79
Rate for Payer: PHP Commercial	$227.79
Rate for Payer: Priority Health Cigna Priority Health	$187.59
Rate for Payer: Priority Health SBD	$168.83

TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION

Facility

$232.42

Service Code	NDC 49281-752-78
Hospital Charge Code	8259
Hospital Revenue Code	250
Min. Negotiated Rate	$146.42
Max. Negotiated Rate	$209.18
Rate for Payer: Aetna Commercial	$197.56
Rate for Payer: Aetna New Business (MI Preferred)	$151.07
Rate for Payer: Cash Price	$185.94
Rate for Payer: Cofinity Commercial	$162.69
Rate for Payer: Cofinity Commercial	$199.88
Rate for Payer: Healthscope Commercial	$209.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$197.56
Rate for Payer: PHP Commercial	$197.56
Rate for Payer: Priority Health Cigna Priority Health	$162.69
Rate for Payer: Priority Health SBD	$146.42

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION

Facility

$6,837.00

Service Code	CPT 69631
Hospital Revenue Code	360
Min. Negotiated Rate	$880.49
Max. Negotiated Rate	$6,837.00
Rate for Payer: Aetna Medicare	$5,419.21
Rate for Payer: Allen County Amish Medical Aid Commercial	$6,513.48
Rate for Payer: Amish Plain Church Group Commercial	$6,513.48
Rate for Payer: BCBS Complete	$2,993.07
Rate for Payer: BCBS MAPPO	$5,210.78
Rate for Payer: BCBS Trust/PPO	$3,362.67
Rate for Payer: BCN Medicare Advantage	$5,210.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$5,210.78
Rate for Payer: Mclaren Medicaid	$2,850.30
Rate for Payer: Mclaren Medicare	$5,210.78
Rate for Payer: Meridian Medicaid	$2,993.07
Rate for Payer: Meridian Wellcare - Medicare Advantage	$5,471.32
Rate for Payer: MI Amish Medical Board Commercial	$5,992.40
Rate for Payer: PACE Medicare	$4,950.24
Rate for Payer: PACE SWMI	$5,210.78
Rate for Payer: PHP Medicare Advantage	$5,210.78
Rate for Payer: Priority Health Choice Medicaid	$2,850.30
Rate for Payer: Priority Health Medicare	$5,210.78
Rate for Payer: Railroad Medicare Medicare	$5,210.78
Rate for Payer: UHC All Payor (Choice/PPO)	$968.54
Rate for Payer: UHC Core	$6,837.00
Rate for Payer: UHC Dual Complete DSNP	$5,210.78
Rate for Payer: UHC Exchange	$880.49
Rate for Payer: UHC Medicare Advantage	$5,367.10
Rate for Payer: VA VA	$5,210.78

TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA

Facility

$3,138.00

Service Code	CPT 69436
Hospital Revenue Code	360
Min. Negotiated Rate	$158.48
Max. Negotiated Rate	$3,138.00
Rate for Payer: Aetna Medicare	$1,411.25
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,696.21
Rate for Payer: Amish Plain Church Group Commercial	$1,696.21
Rate for Payer: BCBS Complete	$779.44
Rate for Payer: BCBS MAPPO	$1,356.97
Rate for Payer: BCBS Trust/PPO	$1,020.38
Rate for Payer: BCN Medicare Advantage	$1,356.97
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,356.97
Rate for Payer: Mclaren Medicaid	$742.26
Rate for Payer: Mclaren Medicare	$1,356.97
Rate for Payer: Meridian Medicaid	$779.44
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,424.82
Rate for Payer: MI Amish Medical Board Commercial	$1,560.52
Rate for Payer: PACE Medicare	$1,289.12
Rate for Payer: PACE SWMI	$1,356.97
Rate for Payer: PHP Medicare Advantage	$1,356.97
Rate for Payer: Priority Health Choice Medicaid	$742.26
Rate for Payer: Priority Health Medicare	$1,356.97
Rate for Payer: Railroad Medicare Medicare	$1,356.97
Rate for Payer: UHC All Payor (Choice/PPO)	$174.33
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Dual Complete DSNP	$1,356.97
Rate for Payer: UHC Exchange	$158.48
Rate for Payer: UHC Medicare Advantage	$1,397.68
Rate for Payer: VA VA	$1,356.97

ULIPRISTAL 30 MG TABLET

Facility

$123.70

Service Code	NDC 50102-911-01
Hospital Charge Code	106079
Hospital Revenue Code	637
Min. Negotiated Rate	$77.93
Max. Negotiated Rate	$111.33
Rate for Payer: Aetna Commercial	$105.14
Rate for Payer: Aetna New Business (MI Preferred)	$80.40
Rate for Payer: Cash Price	$98.96
Rate for Payer: Cofinity Commercial	$86.59
Rate for Payer: Cofinity Commercial	$106.38
Rate for Payer: Healthscope Commercial	$111.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$105.14
Rate for Payer: PHP Commercial	$105.14
Rate for Payer: Priority Health Cigna Priority Health	$86.59
Rate for Payer: Priority Health SBD	$77.93

ULIPRISTAL 30 MG TABLET

Facility

$123.70

Service Code	NDC 50102-911-01
Hospital Charge Code	106079
Hospital Revenue Code	637
Min. Negotiated Rate	$49.48
Max. Negotiated Rate	$111.33
Rate for Payer: Aetna Commercial	$105.14
Rate for Payer: Aetna New Business (MI Preferred)	$80.40
Rate for Payer: BCBS Complete	$49.48
Rate for Payer: Cash Price	$98.96
Rate for Payer: Cofinity Commercial	$106.38
Rate for Payer: Cofinity Commercial	$86.59
Rate for Payer: Healthscope Commercial	$111.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$105.14
Rate for Payer: PHP Commercial	$105.14
Rate for Payer: Priority Health Cigna Priority Health	$86.59
Rate for Payer: Priority Health SBD	$77.93

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$86,454.78

Service Code	MS-DRG 278
Min. Negotiated Rate	$30,984.82
Max. Negotiated Rate	$86,454.78
Rate for Payer: Aetna Medicare	$33,920.22
Rate for Payer: Allen County Amish Medical Aid Commercial	$40,769.50
Rate for Payer: Amish Plain Church Group Commercial	$40,769.50
Rate for Payer: BCBS MAPPO	$32,615.60
Rate for Payer: BCBS Trust/PPO	$86,454.78
Rate for Payer: BCN Medicare Advantage	$32,615.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$32,615.60
Rate for Payer: Mclaren Medicare	$32,615.60
Rate for Payer: Meridian Wellcare - Medicare Advantage	$34,246.38
Rate for Payer: MI Amish Medical Board Commercial	$37,507.94
Rate for Payer: PACE Medicare	$30,984.82
Rate for Payer: PACE SWMI	$32,615.60
Rate for Payer: PHP Medicare Advantage	$32,615.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$64,006.38
Rate for Payer: Priority Health Medicare	$32,615.60
Rate for Payer: Priority Health Narrow Network	$51,205.10
Rate for Payer: Railroad Medicare Medicare	$32,615.60
Rate for Payer: UHC All Payor (Choice/PPO)	$68,038.94
Rate for Payer: UHC Core	$41,749.34
Rate for Payer: UHC Dual Complete DSNP	$32,615.60
Rate for Payer: UHC Exchange	$44,715.51
Rate for Payer: UHC Medicare Advantage	$33,594.07
Rate for Payer: VA VA	$32,615.60

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$48,955.39

Service Code	MS-DRG 279
Min. Negotiated Rate	$22,365.64
Max. Negotiated Rate	$48,955.39
Rate for Payer: Aetna Medicare	$24,484.49
Rate for Payer: Allen County Amish Medical Aid Commercial	$29,428.48
Rate for Payer: Amish Plain Church Group Commercial	$29,428.48
Rate for Payer: BCBS MAPPO	$23,542.78
Rate for Payer: BCBS Trust/PPO	$48,955.39
Rate for Payer: BCN Medicare Advantage	$23,542.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$23,542.78
Rate for Payer: Mclaren Medicare	$23,542.78
Rate for Payer: Meridian Wellcare - Medicare Advantage	$24,719.92
Rate for Payer: MI Amish Medical Board Commercial	$27,074.20
Rate for Payer: PACE Medicare	$22,365.64
Rate for Payer: PACE SWMI	$23,542.78
Rate for Payer: PHP Medicare Advantage	$23,542.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$45,928.35
Rate for Payer: Priority Health Medicare	$23,542.78
Rate for Payer: Priority Health Narrow Network	$36,742.68
Rate for Payer: Railroad Medicare Medicare	$23,542.78
Rate for Payer: UHC All Payor (Choice/PPO)	$48,821.95
Rate for Payer: UHC Core	$29,957.62
Rate for Payer: UHC Dual Complete DSNP	$23,542.78
Rate for Payer: UHC Exchange	$32,086.02
Rate for Payer: UHC Medicare Advantage	$24,249.06
Rate for Payer: VA VA	$23,542.78

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$47,385.33

Service Code	MS-DRG 173
Min. Negotiated Rate	$21,506.34
Max. Negotiated Rate	$47,385.33
Rate for Payer: Aetna Medicare	$23,543.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$28,297.81
Rate for Payer: Amish Plain Church Group Commercial	$28,297.81
Rate for Payer: BCBS MAPPO	$22,638.25
Rate for Payer: BCBS Trust/PPO	$47,385.33
Rate for Payer: BCN Medicare Advantage	$22,638.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$22,638.25
Rate for Payer: Mclaren Medicare	$22,638.25
Rate for Payer: Meridian Wellcare - Medicare Advantage	$23,770.16
Rate for Payer: MI Amish Medical Board Commercial	$26,033.99
Rate for Payer: PACE Medicare	$21,506.34
Rate for Payer: PACE SWMI	$22,638.25
Rate for Payer: PHP Medicare Advantage	$22,638.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44,126.00
Rate for Payer: Priority Health Medicare	$22,638.25
Rate for Payer: Priority Health Narrow Network	$35,300.80
Rate for Payer: Railroad Medicare Medicare	$22,638.25
Rate for Payer: UHC All Payor (Choice/PPO)	$46,906.05
Rate for Payer: UHC Core	$28,782.00
Rate for Payer: UHC Dual Complete DSNP	$22,638.25
Rate for Payer: UHC Exchange	$30,826.88
Rate for Payer: UHC Medicare Advantage	$23,317.40
Rate for Payer: VA VA	$22,638.25

UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION

Facility

$108.71

Service Code	NDC 0173-0873-06
Hospital Charge Code	173272
Hospital Revenue Code	637
Min. Negotiated Rate	$68.49
Max. Negotiated Rate	$97.84
Rate for Payer: Aetna Commercial	$92.40
Rate for Payer: Aetna New Business (MI Preferred)	$70.66
Rate for Payer: Cash Price	$86.97
Rate for Payer: Cofinity Commercial	$76.10
Rate for Payer: Cofinity Commercial	$93.49
Rate for Payer: Healthscope Commercial	$97.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$92.40
Rate for Payer: PHP Commercial	$92.40
Rate for Payer: Priority Health Cigna Priority Health	$76.10
Rate for Payer: Priority Health SBD	$68.49

Know your out-of-pocket cost for care.

All Charges