Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF

Professional

Both

$1,430.00

Service Code	HCPCS 26433
Min. Negotiated Rate	$362.10
Max. Negotiated Rate	$1,072.50
Rate for Payer: Aetna Commercial	$753.27
Rate for Payer: Aetna Medicare	$715.00
Rate for Payer: BCBS Complete	$380.20
Rate for Payer: BCN Commercial	$860.51
Rate for Payer: Cash Price	$1,144.00
Rate for Payer: Cash Price	$1,144.00
Rate for Payer: Mclaren Medicaid	$362.10
Rate for Payer: Meridian Medicaid	$380.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,072.50
Rate for Payer: Priority Health Choice Medicaid	$362.10
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$919.87
Rate for Payer: Priority Health Narrow/Tiered Network	$919.87
Rate for Payer: UHC Medicaid	$362.10
Rate for Payer: UHCCP Medicaid	$362.10

PR REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH

Professional

Both

$1,842.00

Service Code	HCPCS 26420
Min. Negotiated Rate	$457.95
Max. Negotiated Rate	$1,381.50
Rate for Payer: Aetna Commercial	$986.20
Rate for Payer: Aetna Medicare	$921.00
Rate for Payer: BCBS Complete	$480.85
Rate for Payer: BCN Commercial	$1,114.98
Rate for Payer: Cash Price	$1,473.60
Rate for Payer: Cash Price	$1,473.60
Rate for Payer: Mclaren Medicaid	$457.95
Rate for Payer: Meridian Medicaid	$480.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,381.50
Rate for Payer: Priority Health Choice Medicaid	$457.95
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,191.88
Rate for Payer: Priority Health Narrow/Tiered Network	$1,191.88
Rate for Payer: UHC Medicaid	$457.95
Rate for Payer: UHCCP Medicaid	$457.95

PR REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH

Professional

Both

$1,348.00

Service Code	HCPCS 26418
Min. Negotiated Rate	$400.23
Max. Negotiated Rate	$1,011.00
Rate for Payer: Aetna Commercial	$816.06
Rate for Payer: Aetna Medicare	$674.00
Rate for Payer: BCBS Complete	$420.24
Rate for Payer: BCN Commercial	$940.68
Rate for Payer: Cash Price	$1,078.40
Rate for Payer: Cash Price	$1,078.40
Rate for Payer: Mclaren Medicaid	$400.23
Rate for Payer: Meridian Medicaid	$420.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,011.00
Rate for Payer: Priority Health Choice Medicaid	$400.23
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,005.57
Rate for Payer: Priority Health Narrow/Tiered Network	$1,005.57
Rate for Payer: UHC Medicaid	$400.23
Rate for Payer: UHCCP Medicaid	$400.23

PR REPAIR EXTENSOR TENDON HAND W/GRAFT EACH

Professional

Both

$1,991.00

Service Code	HCPCS 26412
Min. Negotiated Rate	$443.47
Max. Negotiated Rate	$1,493.25
Rate for Payer: Aetna Commercial	$950.15
Rate for Payer: Aetna Medicare	$995.50
Rate for Payer: BCBS Complete	$465.64
Rate for Payer: BCN Commercial	$1,076.14
Rate for Payer: Cash Price	$1,592.80
Rate for Payer: Cash Price	$1,592.80
Rate for Payer: Mclaren Medicaid	$443.47
Rate for Payer: Meridian Medicaid	$465.64
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,493.25
Rate for Payer: Priority Health Choice Medicaid	$443.47
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,150.36
Rate for Payer: Priority Health Narrow/Tiered Network	$1,150.36
Rate for Payer: UHC Medicaid	$443.47
Rate for Payer: UHCCP Medicaid	$443.47

PR REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH

Professional

Both

$1,295.00

Service Code	HCPCS 26410
Min. Negotiated Rate	$381.70
Max. Negotiated Rate	$971.25
Rate for Payer: Aetna Commercial	$793.05
Rate for Payer: Aetna Medicare	$647.50
Rate for Payer: BCBS Complete	$400.79
Rate for Payer: BCN Commercial	$904.83
Rate for Payer: Cash Price	$1,036.00
Rate for Payer: Cash Price	$1,036.00
Rate for Payer: Mclaren Medicaid	$381.70
Rate for Payer: Meridian Medicaid	$400.79
Rate for Payer: Opus (Opus Packaging Group) HMA	$971.25
Rate for Payer: Priority Health Choice Medicaid	$381.70
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$967.25
Rate for Payer: Priority Health Narrow/Tiered Network	$967.25
Rate for Payer: UHC Medicaid	$381.70
Rate for Payer: UHCCP Medicaid	$381.70

PR REPAIR FASCIAL DEFECT LEG

Professional

Both

$953.00

Service Code	HCPCS 27656
Min. Negotiated Rate	$204.69
Max. Negotiated Rate	$714.75
Rate for Payer: Aetna Commercial	$468.22
Rate for Payer: Aetna Medicare	$476.50
Rate for Payer: BCBS Complete	$214.92
Rate for Payer: BCN Commercial	$516.41
Rate for Payer: Cash Price	$762.40
Rate for Payer: Cash Price	$762.40
Rate for Payer: Mclaren Medicaid	$204.69
Rate for Payer: Meridian Medicaid	$214.92
Rate for Payer: Opus (Opus Packaging Group) HMA	$714.75
Rate for Payer: Priority Health Choice Medicaid	$204.69
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$552.02
Rate for Payer: Priority Health Narrow/Tiered Network	$552.02
Rate for Payer: UHC Medicaid	$204.69
Rate for Payer: UHCCP Medicaid	$204.69

PR REPAIR FIBULA NONUNION/MALUNION W/INT FIXATION

Professional

Both

$4,154.00

Service Code	HCPCS 27726
Min. Negotiated Rate	$558.06
Max. Negotiated Rate	$3,115.50
Rate for Payer: Aetna Commercial	$1,282.82
Rate for Payer: Aetna Medicare	$2,077.00
Rate for Payer: BCBS Complete	$585.96
Rate for Payer: BCN Commercial	$1,452.61
Rate for Payer: Cash Price	$3,323.20
Rate for Payer: Cash Price	$3,323.20
Rate for Payer: Mclaren Medicaid	$558.06
Rate for Payer: Meridian Medicaid	$585.96
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,115.50
Rate for Payer: Priority Health Choice Medicaid	$558.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$1,552.80
Rate for Payer: Priority Health Narrow/Tiered Network	$1,552.80
Rate for Payer: UHC Medicaid	$558.06
Rate for Payer: UHCCP Medicaid	$558.06

PR REPAIR FIRST ABDOMINAL WALL HERNIA

Professional

Both

$2,169.00

Service Code	HCPCS 49560
Min. Negotiated Rate	$867.60
Max. Negotiated Rate	$1,626.75
Rate for Payer: Aetna Medicare	$1,084.50
Rate for Payer: BCBS Complete	$867.60
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,626.75

PR REPAIR FISTULA OROMAXILLARY

Professional

Both

$1,527.00

Service Code	HCPCS 30580
Min. Negotiated Rate	$267.74
Max. Negotiated Rate	$1,145.25
Rate for Payer: Aetna Commercial	$589.31
Rate for Payer: Aetna Medicare	$763.50
Rate for Payer: BCBS Complete	$281.13
Rate for Payer: BCN Commercial	$700.17
Rate for Payer: Cash Price	$1,221.60
Rate for Payer: Cash Price	$1,221.60
Rate for Payer: Mclaren Medicaid	$267.74
Rate for Payer: Meridian Medicaid	$281.13
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,145.25
Rate for Payer: Priority Health Choice Medicaid	$267.74
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$659.34
Rate for Payer: Priority Health Narrow/Tiered Network	$659.34
Rate for Payer: UHC Medicaid	$267.74
Rate for Payer: UHCCP Medicaid	$267.74

PR REPAIR FLEXOR TENDON LEG PRIMARY W/O GRAFT EACH

Professional

Both

$1,340.00

Service Code	HCPCS 27658
Min. Negotiated Rate	$227.70
Max. Negotiated Rate	$1,005.00
Rate for Payer: Aetna Commercial	$490.73
Rate for Payer: Aetna Medicare	$670.00
Rate for Payer: BCBS Complete	$239.09
Rate for Payer: BCN Commercial	$566.70
Rate for Payer: Cash Price	$1,072.00
Rate for Payer: Cash Price	$1,072.00
Rate for Payer: Mclaren Medicaid	$227.70
Rate for Payer: Meridian Medicaid	$239.09
Rate for Payer: Opus (Opus Packaging Group) HMA	$1,005.00
Rate for Payer: Priority Health Choice Medicaid	$227.70
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$605.78
Rate for Payer: Priority Health Narrow/Tiered Network	$605.78
Rate for Payer: UHC Medicaid	$227.70
Rate for Payer: UHCCP Medicaid	$227.70

PR REPAIR INCOMPLETE CIRCUMCISION

Professional

Both

$421.00

Service Code	HCPCS 54163
Min. Negotiated Rate	$132.06
Max. Negotiated Rate	$361.28
Rate for Payer: Aetna Commercial	$277.43
Rate for Payer: Aetna Medicare	$210.50
Rate for Payer: BCBS Complete	$138.66
Rate for Payer: BCN Commercial	$331.65
Rate for Payer: Cash Price	$336.80
Rate for Payer: Cash Price	$336.80
Rate for Payer: Mclaren Medicaid	$132.06
Rate for Payer: Meridian Medicaid	$138.66
Rate for Payer: Opus (Opus Packaging Group) HMA	$315.75
Rate for Payer: Priority Health Choice Medicaid	$132.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$361.28
Rate for Payer: Priority Health Narrow/Tiered Network	$361.28
Rate for Payer: UHC Medicaid	$132.06
Rate for Payer: UHCCP Medicaid	$132.06

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

Professional

Both

$1,048.00

Service Code	HCPCS 12055
Min. Negotiated Rate	$187.65
Max. Negotiated Rate	$786.00
Rate for Payer: Aetna Commercial	$322.34
Rate for Payer: Aetna Medicare	$524.00
Rate for Payer: BCBS Complete	$197.03
Rate for Payer: BCN Commercial	$452.66
Rate for Payer: Cash Price	$838.40
Rate for Payer: Cash Price	$838.40
Rate for Payer: Mclaren Medicaid	$187.65
Rate for Payer: Meridian Medicaid	$197.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$786.00
Rate for Payer: Priority Health Choice Medicaid	$187.65
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$414.31
Rate for Payer: Priority Health Narrow/Tiered Network	$414.31
Rate for Payer: UHC Medicaid	$187.65
Rate for Payer: UHCCP Medicaid	$187.65

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

Facility

$458.00

Service Code	CPT 12051
Hospital Charge Code	12051
Hospital Revenue Code	521
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$412.20
Rate for Payer: Aetna Commercial	$389.30
Rate for Payer: Aetna Medicare	$119.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$143.12
Rate for Payer: Amish Plain Church Group Commercial	$143.12
Rate for Payer: BCBS Complete	$84.78
Rate for Payer: BCBS MAPPO	$114.50
Rate for Payer: BCBS Trust/PPO	$376.52
Rate for Payer: BCN Commercial	$376.52
Rate for Payer: BCN Medicare Advantage	$114.50
Rate for Payer: Cash Price	$366.40
Rate for Payer: Cofinity Commercial	$393.88
Rate for Payer: Encore Health Key Benefits Commercial	$366.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$114.50
Rate for Payer: Healthscope Commercial	$412.20
Rate for Payer: Lakeland Regional Health Systems Commercial	$343.50
Rate for Payer: Mclaren Medicaid	$80.75
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$120.22
Rate for Payer: Meridian Medicaid	$84.78
Rate for Payer: MI Amish Medical Board Commercial	$131.68
Rate for Payer: Molina Medicare/Medicaid	$125.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$389.30
Rate for Payer: Nomi Health Commercial	$375.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$343.50
Rate for Payer: PACE Senior Care Partners	$108.78
Rate for Payer: PACE SWMI	$114.50
Rate for Payer: PHP Commercial	$389.30
Rate for Payer: PHP Medicare Advantage	$114.50
Rate for Payer: Priority Health Choice Medicaid	$80.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$398.46
Rate for Payer: Priority Health Medicare	$115.64
Rate for Payer: Priority Health Narrow/Tiered Network	$318.77
Rate for Payer: Railroad Medicare Medicare	$114.50
Rate for Payer: UHC Core	$382.43
Rate for Payer: UHC Exchange	$114.50
Rate for Payer: UHC Medicaid	$80.75
Rate for Payer: UHC Medicare Advantage	$114.50
Rate for Payer: UHCCP Medicaid	$80.75
Rate for Payer: VA VA	$114.50
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$343.50

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

Professional

Both

$458.00

Service Code	HCPCS 12051
Min. Negotiated Rate	$95.21
Max. Negotiated Rate	$343.50
Rate for Payer: Aetna Commercial	$180.03
Rate for Payer: Aetna Medicare	$229.00
Rate for Payer: BCBS Complete	$99.97
Rate for Payer: BCN Commercial	$253.97
Rate for Payer: Cash Price	$366.40
Rate for Payer: Cash Price	$366.40
Rate for Payer: Mclaren Medicaid	$95.21
Rate for Payer: Meridian Medicaid	$99.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$343.50
Rate for Payer: Priority Health Choice Medicaid	$95.21
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$232.45
Rate for Payer: Priority Health Narrow/Tiered Network	$232.45
Rate for Payer: UHC Medicaid	$95.21
Rate for Payer: UHCCP Medicaid	$95.21

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

Facility

$458.00

Service Code	CPT 12051
Hospital Charge Code	12051
Hospital Revenue Code	521
Min. Negotiated Rate	$318.77
Max. Negotiated Rate	$412.20
Rate for Payer: Aetna Commercial	$389.30
Rate for Payer: BCBS Trust/PPO	$378.26
Rate for Payer: BCN Commercial	$378.26
Rate for Payer: Cash Price	$366.40
Rate for Payer: Cofinity Commercial	$393.88
Rate for Payer: Encore Health Key Benefits Commercial	$366.40
Rate for Payer: Healthscope Commercial	$412.20
Rate for Payer: Lakeland Regional Health Systems Commercial	$343.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$389.30
Rate for Payer: Nomi Health Commercial	$375.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$343.50
Rate for Payer: PHP Commercial	$389.30
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$398.46
Rate for Payer: Priority Health Narrow/Tiered Network	$318.77
Rate for Payer: UHC Core	$382.43
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$343.50

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

Professional

Both

$458.00

Service Code	HCPCS 12051
Hospital Charge Code	12051
Min. Negotiated Rate	$95.21
Max. Negotiated Rate	$343.50
Rate for Payer: Aetna Commercial	$180.03
Rate for Payer: Aetna Medicare	$229.00
Rate for Payer: BCBS Complete	$99.97
Rate for Payer: BCN Commercial	$253.97
Rate for Payer: Cash Price	$366.40
Rate for Payer: Cash Price	$366.40
Rate for Payer: Mclaren Medicaid	$95.21
Rate for Payer: Meridian Medicaid	$99.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$343.50
Rate for Payer: Priority Health Choice Medicaid	$95.21
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$232.45
Rate for Payer: Priority Health Narrow/Tiered Network	$232.45
Rate for Payer: UHC Medicaid	$95.21
Rate for Payer: UHCCP Medicaid	$95.21

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

Facility

$577.00

Service Code	CPT 12052
Hospital Charge Code	12052
Hospital Revenue Code	521
Min. Negotiated Rate	$401.59
Max. Negotiated Rate	$519.30
Rate for Payer: Aetna Commercial	$490.45
Rate for Payer: BCBS Trust/PPO	$476.54
Rate for Payer: BCN Commercial	$476.54
Rate for Payer: Cash Price	$461.60
Rate for Payer: Cofinity Commercial	$496.22
Rate for Payer: Encore Health Key Benefits Commercial	$461.60
Rate for Payer: Healthscope Commercial	$519.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$432.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$490.45
Rate for Payer: Nomi Health Commercial	$473.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$432.75
Rate for Payer: PHP Commercial	$490.45
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$501.99
Rate for Payer: Priority Health Narrow/Tiered Network	$401.59
Rate for Payer: UHC Core	$481.80
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$432.75

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

Professional

Both

$577.00

Service Code	HCPCS 12052
Hospital Charge Code	12052
Min. Negotiated Rate	$110.12
Max. Negotiated Rate	$432.75
Rate for Payer: Aetna Commercial	$213.15
Rate for Payer: Aetna Medicare	$288.50
Rate for Payer: BCBS Complete	$115.63
Rate for Payer: BCN Commercial	$299.79
Rate for Payer: Cash Price	$461.60
Rate for Payer: Cash Price	$461.60
Rate for Payer: Mclaren Medicaid	$110.12
Rate for Payer: Meridian Medicaid	$115.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$432.75
Rate for Payer: Priority Health Choice Medicaid	$110.12
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$274.39
Rate for Payer: Priority Health Narrow/Tiered Network	$274.39
Rate for Payer: UHC Medicaid	$110.12
Rate for Payer: UHCCP Medicaid	$110.12

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

Facility

$577.00

Service Code	CPT 12052
Hospital Charge Code	12052
Hospital Revenue Code	521
Min. Negotiated Rate	$101.73
Max. Negotiated Rate	$519.30
Rate for Payer: Aetna Commercial	$490.45
Rate for Payer: Aetna Medicare	$150.02
Rate for Payer: Allen County Amish Medical Aid Commercial	$180.31
Rate for Payer: Amish Plain Church Group Commercial	$180.31
Rate for Payer: BCBS Complete	$106.80
Rate for Payer: BCBS MAPPO	$144.25
Rate for Payer: BCBS Trust/PPO	$474.35
Rate for Payer: BCN Commercial	$474.35
Rate for Payer: BCN Medicare Advantage	$144.25
Rate for Payer: Cash Price	$461.60
Rate for Payer: Cofinity Commercial	$496.22
Rate for Payer: Encore Health Key Benefits Commercial	$461.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$144.25
Rate for Payer: Healthscope Commercial	$519.30
Rate for Payer: Lakeland Regional Health Systems Commercial	$432.75
Rate for Payer: Mclaren Medicaid	$101.73
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$151.46
Rate for Payer: Meridian Medicaid	$106.80
Rate for Payer: MI Amish Medical Board Commercial	$165.89
Rate for Payer: Molina Medicare/Medicaid	$158.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$490.45
Rate for Payer: Nomi Health Commercial	$473.14
Rate for Payer: Opus (Opus Packaging Group) HMA	$432.75
Rate for Payer: PACE Senior Care Partners	$137.04
Rate for Payer: PACE SWMI	$144.25
Rate for Payer: PHP Commercial	$490.45
Rate for Payer: PHP Medicare Advantage	$144.25
Rate for Payer: Priority Health Choice Medicaid	$101.73
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$501.99
Rate for Payer: Priority Health Medicare	$145.69
Rate for Payer: Priority Health Narrow/Tiered Network	$401.59
Rate for Payer: Railroad Medicare Medicare	$144.25
Rate for Payer: UHC Core	$481.80
Rate for Payer: UHC Exchange	$144.25
Rate for Payer: UHC Medicaid	$101.73
Rate for Payer: UHC Medicare Advantage	$144.25
Rate for Payer: UHCCP Medicaid	$101.73
Rate for Payer: VA VA	$144.25
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$432.75

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

Professional

Both

$577.00

Service Code	HCPCS 12052
Min. Negotiated Rate	$110.12
Max. Negotiated Rate	$432.75
Rate for Payer: Aetna Commercial	$213.15
Rate for Payer: Aetna Medicare	$288.50
Rate for Payer: BCBS Complete	$115.63
Rate for Payer: BCN Commercial	$299.79
Rate for Payer: Cash Price	$461.60
Rate for Payer: Cash Price	$461.60
Rate for Payer: Mclaren Medicaid	$110.12
Rate for Payer: Meridian Medicaid	$115.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$432.75
Rate for Payer: Priority Health Choice Medicaid	$110.12
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$274.39
Rate for Payer: Priority Health Narrow/Tiered Network	$274.39
Rate for Payer: UHC Medicaid	$110.12
Rate for Payer: UHCCP Medicaid	$110.12

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

Professional

Both

$653.00

Service Code	HCPCS 12053
Min. Negotiated Rate	$119.28
Max. Negotiated Rate	$489.75
Rate for Payer: Aetna Commercial	$230.84
Rate for Payer: Aetna Medicare	$326.50
Rate for Payer: BCBS Complete	$125.24
Rate for Payer: BCN Commercial	$323.19
Rate for Payer: Cash Price	$522.40
Rate for Payer: Cash Price	$522.40
Rate for Payer: Mclaren Medicaid	$119.28
Rate for Payer: Meridian Medicaid	$125.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$489.75
Rate for Payer: Priority Health Choice Medicaid	$119.28
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$295.80
Rate for Payer: Priority Health Narrow/Tiered Network	$295.80
Rate for Payer: UHC Medicaid	$119.28
Rate for Payer: UHCCP Medicaid	$119.28

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

Facility

$653.00

Service Code	CPT 12053
Hospital Charge Code	12053
Hospital Revenue Code	521
Min. Negotiated Rate	$454.49
Max. Negotiated Rate	$587.70
Rate for Payer: Aetna Commercial	$555.05
Rate for Payer: BCBS Trust/PPO	$539.31
Rate for Payer: BCN Commercial	$539.31
Rate for Payer: Cash Price	$522.40
Rate for Payer: Cofinity Commercial	$561.58
Rate for Payer: Encore Health Key Benefits Commercial	$522.40
Rate for Payer: Healthscope Commercial	$587.70
Rate for Payer: Lakeland Regional Health Systems Commercial	$489.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$555.05
Rate for Payer: Nomi Health Commercial	$535.46
Rate for Payer: Opus (Opus Packaging Group) HMA	$489.75
Rate for Payer: PHP Commercial	$555.05
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$568.11
Rate for Payer: Priority Health Narrow/Tiered Network	$454.49
Rate for Payer: UHC Core	$545.25
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$489.75

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

Professional

Both

$653.00

Service Code	HCPCS 12053
Hospital Charge Code	12053
Min. Negotiated Rate	$119.28
Max. Negotiated Rate	$489.75
Rate for Payer: Aetna Commercial	$230.84
Rate for Payer: Aetna Medicare	$326.50
Rate for Payer: BCBS Complete	$125.24
Rate for Payer: BCN Commercial	$323.19
Rate for Payer: Cash Price	$522.40
Rate for Payer: Cash Price	$522.40
Rate for Payer: Mclaren Medicaid	$119.28
Rate for Payer: Meridian Medicaid	$125.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$489.75
Rate for Payer: Priority Health Choice Medicaid	$119.28
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$295.80
Rate for Payer: Priority Health Narrow/Tiered Network	$295.80
Rate for Payer: UHC Medicaid	$119.28
Rate for Payer: UHCCP Medicaid	$119.28

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

Facility

$653.00

Service Code	CPT 12053
Hospital Charge Code	12053
Hospital Revenue Code	521
Min. Negotiated Rate	$115.12
Max. Negotiated Rate	$587.70
Rate for Payer: Aetna Commercial	$555.05
Rate for Payer: Aetna Medicare	$169.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$204.06
Rate for Payer: Amish Plain Church Group Commercial	$204.06
Rate for Payer: BCBS Complete	$120.87
Rate for Payer: BCBS MAPPO	$163.25
Rate for Payer: BCBS Trust/PPO	$536.83
Rate for Payer: BCN Commercial	$536.83
Rate for Payer: BCN Medicare Advantage	$163.25
Rate for Payer: Cash Price	$522.40
Rate for Payer: Cofinity Commercial	$561.58
Rate for Payer: Encore Health Key Benefits Commercial	$522.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$163.25
Rate for Payer: Healthscope Commercial	$587.70
Rate for Payer: Lakeland Regional Health Systems Commercial	$489.75
Rate for Payer: Mclaren Medicaid	$115.12
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$171.41
Rate for Payer: Meridian Medicaid	$120.87
Rate for Payer: MI Amish Medical Board Commercial	$187.74
Rate for Payer: Molina Medicare/Medicaid	$179.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$555.05
Rate for Payer: Nomi Health Commercial	$535.46
Rate for Payer: Opus (Opus Packaging Group) HMA	$489.75
Rate for Payer: PACE Senior Care Partners	$155.09
Rate for Payer: PACE SWMI	$163.25
Rate for Payer: PHP Commercial	$555.05
Rate for Payer: PHP Medicare Advantage	$163.25
Rate for Payer: Priority Health Choice Medicaid	$115.12
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$568.11
Rate for Payer: Priority Health Medicare	$164.88
Rate for Payer: Priority Health Narrow/Tiered Network	$454.49
Rate for Payer: Railroad Medicare Medicare	$163.25
Rate for Payer: UHC Core	$545.25
Rate for Payer: UHC Exchange	$163.25
Rate for Payer: UHC Medicaid	$115.12
Rate for Payer: UHC Medicare Advantage	$163.25
Rate for Payer: UHCCP Medicaid	$115.12
Rate for Payer: VA VA	$163.25
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$489.75

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

Facility

$820.00

Service Code	CPT 12054
Hospital Charge Code	12054
Hospital Revenue Code	521
Min. Negotiated Rate	$570.72
Max. Negotiated Rate	$738.00
Rate for Payer: Aetna Commercial	$697.00
Rate for Payer: BCBS Trust/PPO	$677.24
Rate for Payer: BCN Commercial	$677.24
Rate for Payer: Cash Price	$656.00
Rate for Payer: Cofinity Commercial	$705.20
Rate for Payer: Encore Health Key Benefits Commercial	$656.00
Rate for Payer: Healthscope Commercial	$738.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$615.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$697.00
Rate for Payer: Nomi Health Commercial	$672.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$615.00
Rate for Payer: PHP Commercial	$697.00
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO	$713.40
Rate for Payer: Priority Health Narrow/Tiered Network	$570.72
Rate for Payer: UHC Core	$684.70
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$615.00

Know your out-of-pocket cost for care.

All Charges