Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

PR URTT/URTS XTRNL SPX PENDULOUS URETHRA

Professional

Both

$281.00

Service Code	HCPCS 53000
Min. Negotiated Rate	$112.40
Max. Negotiated Rate	$203.60
Rate for Payer: Aetna Commercial	$189.46
Rate for Payer: Aetna Medicare	$147.05
Rate for Payer: BCBS Complete	$112.40
Rate for Payer: BCBS MAPPO	$141.39
Rate for Payer: BCN Medicare Advantage	$141.39
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cofinity Commercial	$203.60
Rate for Payer: Cofinity Commercial	$189.46
Rate for Payer: Health Alliance Plan Medicare Advantage	$141.39
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$148.46
Rate for Payer: Nomi Health Commercial	$169.67
Rate for Payer: PACE SWMI	$141.39
Rate for Payer: PHP Medicare Advantage	$141.39
Rate for Payer: Priority Health Cigna Priority Health	$182.65
Rate for Payer: Priority Health Medicare	$142.80
Rate for Payer: UHC All Payor (Choice/PPO)	$141.39
Rate for Payer: UHC Dual Complete DSNP	$141.39
Rate for Payer: UHC Exchange	$141.39
Rate for Payer: UHC Medicare Advantage	$141.39

PR USE OF ECHO CONTRAST AGENT DURING STRESS ECHO

Professional

Both

$65.00

Service Code	HCPCS 93352
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$45.59
Rate for Payer: Aetna Commercial	$42.42
Rate for Payer: Aetna Medicare	$32.93
Rate for Payer: BCBS Complete	$26.00
Rate for Payer: BCBS MAPPO	$31.66
Rate for Payer: BCN Medicare Advantage	$31.66
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cofinity Commercial	$45.59
Rate for Payer: Cofinity Commercial	$42.42
Rate for Payer: Health Alliance Plan Medicare Advantage	$31.66
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$33.24
Rate for Payer: Nomi Health Commercial	$37.99
Rate for Payer: PACE SWMI	$31.66
Rate for Payer: PHP Medicare Advantage	$31.66
Rate for Payer: Priority Health Cigna Priority Health	$42.25
Rate for Payer: Priority Health Medicare	$31.98
Rate for Payer: UHC All Payor (Choice/PPO)	$31.66
Rate for Payer: UHC Dual Complete DSNP	$31.66
Rate for Payer: UHC Exchange	$31.66
Rate for Payer: UHC Medicare Advantage	$31.66

PR USE VERTICAL ELECTRODES

Professional

Both

$22.00

Service Code	HCPCS 92547
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$14.30
Rate for Payer: Aetna Commercial	$12.23
Rate for Payer: Aetna Medicare	$9.50
Rate for Payer: BCBS Complete	$8.80
Rate for Payer: BCBS MAPPO	$9.13
Rate for Payer: BCN Medicare Advantage	$9.13
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cofinity Commercial	$13.15
Rate for Payer: Cofinity Commercial	$12.23
Rate for Payer: Health Alliance Plan Medicare Advantage	$9.13
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$9.59
Rate for Payer: Nomi Health Commercial	$10.96
Rate for Payer: PACE SWMI	$9.13
Rate for Payer: PHP Medicare Advantage	$9.13
Rate for Payer: Priority Health Cigna Priority Health	$14.30
Rate for Payer: Priority Health Medicare	$9.22
Rate for Payer: UHC All Payor (Choice/PPO)	$9.13
Rate for Payer: UHC Dual Complete DSNP	$9.13
Rate for Payer: UHC Exchange	$9.13
Rate for Payer: UHC Medicare Advantage	$9.13

PR UTERINE EVACUATION & CURETTAGE HYDATIDIFORM MOLE

Professional

Both

$785.00

Service Code	HCPCS 59870
Min. Negotiated Rate	$314.00
Max. Negotiated Rate	$738.52
Rate for Payer: Aetna Commercial	$687.23
Rate for Payer: Aetna Medicare	$533.37
Rate for Payer: BCBS Complete	$314.00
Rate for Payer: BCBS MAPPO	$512.86
Rate for Payer: BCN Medicare Advantage	$512.86
Rate for Payer: Cash Price	$628.00
Rate for Payer: Cash Price	$628.00
Rate for Payer: Cofinity Commercial	$738.52
Rate for Payer: Cofinity Commercial	$687.23
Rate for Payer: Health Alliance Plan Medicare Advantage	$512.86
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$538.50
Rate for Payer: Nomi Health Commercial	$615.43
Rate for Payer: PACE SWMI	$512.86
Rate for Payer: PHP Medicare Advantage	$512.86
Rate for Payer: Priority Health Cigna Priority Health	$510.25
Rate for Payer: Priority Health Medicare	$517.99
Rate for Payer: UHC All Payor (Choice/PPO)	$512.86
Rate for Payer: UHC Dual Complete DSNP	$512.86
Rate for Payer: UHC Exchange	$512.86
Rate for Payer: UHC Medicare Advantage	$512.86

PR UTERINE SUSPENSION W/WO SHORTENING LIGAMENTS SPX

Professional

Both

$864.00

Service Code	HCPCS 58400
Min. Negotiated Rate	$345.60
Max. Negotiated Rate	$633.08
Rate for Payer: Aetna Commercial	$589.12
Rate for Payer: Aetna Medicare	$457.23
Rate for Payer: BCBS Complete	$345.60
Rate for Payer: BCBS MAPPO	$439.64
Rate for Payer: BCN Medicare Advantage	$439.64
Rate for Payer: Cash Price	$691.20
Rate for Payer: Cash Price	$691.20
Rate for Payer: Cofinity Commercial	$633.08
Rate for Payer: Cofinity Commercial	$589.12
Rate for Payer: Health Alliance Plan Medicare Advantage	$439.64
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$461.62
Rate for Payer: Nomi Health Commercial	$527.57
Rate for Payer: PACE SWMI	$439.64
Rate for Payer: PHP Medicare Advantage	$439.64
Rate for Payer: Priority Health Cigna Priority Health	$561.60
Rate for Payer: Priority Health Medicare	$444.04
Rate for Payer: UHC All Payor (Choice/PPO)	$439.64
Rate for Payer: UHC Dual Complete DSNP	$439.64
Rate for Payer: UHC Exchange	$439.64
Rate for Payer: UHC Medicare Advantage	$439.64

PR U-TUBE HEPATICOENTEROSTOMY

Professional

Both

$2,734.00

Service Code	HCPCS 47802
Min. Negotiated Rate	$1,093.60
Max. Negotiated Rate	$1,777.10
Rate for Payer: Aetna Medicare	$1,367.00
Rate for Payer: BCBS Complete	$1,093.60
Rate for Payer: Cash Price	$2,187.20
Rate for Payer: Priority Health Cigna Priority Health	$1,777.10

PR UVULECTOMY EXCISION UVULA

Professional

Both

$573.00

Service Code	HCPCS 42140
Min. Negotiated Rate	$153.68
Max. Negotiated Rate	$372.45
Rate for Payer: Aetna Commercial	$205.93
Rate for Payer: Aetna Medicare	$159.83
Rate for Payer: BCBS Complete	$229.20
Rate for Payer: BCBS MAPPO	$153.68
Rate for Payer: BCN Medicare Advantage	$153.68
Rate for Payer: Cash Price	$458.40
Rate for Payer: Cash Price	$458.40
Rate for Payer: Cofinity Commercial	$221.30
Rate for Payer: Cofinity Commercial	$205.93
Rate for Payer: Health Alliance Plan Medicare Advantage	$153.68
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$161.36
Rate for Payer: Nomi Health Commercial	$184.42
Rate for Payer: PACE SWMI	$153.68
Rate for Payer: PHP Medicare Advantage	$153.68
Rate for Payer: Priority Health Cigna Priority Health	$372.45
Rate for Payer: Priority Health Medicare	$155.22
Rate for Payer: UHC All Payor (Choice/PPO)	$153.68
Rate for Payer: UHC Dual Complete DSNP	$153.68
Rate for Payer: UHC Exchange	$153.68
Rate for Payer: UHC Medicare Advantage	$153.68

PR VAG HYST > 250 GM RMVL TUBE&/OVARY

Professional

Both

$3,124.00

Service Code	HCPCS 58291
Min. Negotiated Rate	$1,195.10
Max. Negotiated Rate	$2,030.60
Rate for Payer: Aetna Commercial	$1,601.43
Rate for Payer: Aetna Medicare	$1,242.90
Rate for Payer: BCBS Complete	$1,249.60
Rate for Payer: BCBS MAPPO	$1,195.10
Rate for Payer: BCN Medicare Advantage	$1,195.10
Rate for Payer: Cash Price	$2,499.20
Rate for Payer: Cash Price	$2,499.20
Rate for Payer: Cofinity Commercial	$1,720.94
Rate for Payer: Cofinity Commercial	$1,601.43
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,195.10
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,254.86
Rate for Payer: Nomi Health Commercial	$1,434.12
Rate for Payer: PACE SWMI	$1,195.10
Rate for Payer: PHP Medicare Advantage	$1,195.10
Rate for Payer: Priority Health Cigna Priority Health	$2,030.60
Rate for Payer: Priority Health Medicare	$1,207.05
Rate for Payer: UHC All Payor (Choice/PPO)	$1,195.10
Rate for Payer: UHC Dual Complete DSNP	$1,195.10
Rate for Payer: UHC Exchange	$1,195.10
Rate for Payer: UHC Medicare Advantage	$1,195.10

PR VAG HYST > 250 GM RMVL TUBE&/OVARY W/RPR ENTRCLE

Professional

Both

$3,457.00

Service Code	HCPCS 58292
Min. Negotiated Rate	$1,259.15
Max. Negotiated Rate	$2,247.05
Rate for Payer: Aetna Commercial	$1,687.26
Rate for Payer: Aetna Medicare	$1,309.52
Rate for Payer: BCBS Complete	$1,382.80
Rate for Payer: BCBS MAPPO	$1,259.15
Rate for Payer: BCN Medicare Advantage	$1,259.15
Rate for Payer: Cash Price	$2,765.60
Rate for Payer: Cash Price	$2,765.60
Rate for Payer: Cofinity Commercial	$1,813.18
Rate for Payer: Cofinity Commercial	$1,687.26
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,259.15
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,322.11
Rate for Payer: Nomi Health Commercial	$1,510.98
Rate for Payer: PACE SWMI	$1,259.15
Rate for Payer: PHP Medicare Advantage	$1,259.15
Rate for Payer: Priority Health Cigna Priority Health	$2,247.05
Rate for Payer: Priority Health Medicare	$1,271.74
Rate for Payer: UHC All Payor (Choice/PPO)	$1,259.15
Rate for Payer: UHC Dual Complete DSNP	$1,259.15
Rate for Payer: UHC Exchange	$1,259.15
Rate for Payer: UHC Medicare Advantage	$1,259.15

PR VAG HYST 250 GM/< W/RMVL TUBE&/OVARY

Professional

Both

$2,973.00

Service Code	HCPCS 58262
Min. Negotiated Rate	$890.83
Max. Negotiated Rate	$1,932.45
Rate for Payer: Aetna Commercial	$1,193.71
Rate for Payer: Aetna Medicare	$926.46
Rate for Payer: BCBS Complete	$1,189.20
Rate for Payer: BCBS MAPPO	$890.83
Rate for Payer: BCN Medicare Advantage	$890.83
Rate for Payer: Cash Price	$2,378.40
Rate for Payer: Cash Price	$2,378.40
Rate for Payer: Cofinity Commercial	$1,282.80
Rate for Payer: Cofinity Commercial	$1,193.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$890.83
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$935.37
Rate for Payer: Nomi Health Commercial	$1,069.00
Rate for Payer: PACE SWMI	$890.83
Rate for Payer: PHP Medicare Advantage	$890.83
Rate for Payer: Priority Health Cigna Priority Health	$1,932.45
Rate for Payer: Priority Health Medicare	$899.74
Rate for Payer: UHC All Payor (Choice/PPO)	$890.83
Rate for Payer: UHC Dual Complete DSNP	$890.83
Rate for Payer: UHC Exchange	$890.83
Rate for Payer: UHC Medicare Advantage	$890.83

PR VAG HYST 250 GM/< W/RMVL TUBE OVARY W/RPR NTRCL

Professional

Both

$3,245.00

Service Code	HCPCS 58263
Min. Negotiated Rate	$956.48
Max. Negotiated Rate	$2,109.25
Rate for Payer: Aetna Commercial	$1,281.68
Rate for Payer: Aetna Medicare	$994.74
Rate for Payer: BCBS Complete	$1,298.00
Rate for Payer: BCBS MAPPO	$956.48
Rate for Payer: BCN Medicare Advantage	$956.48
Rate for Payer: Cash Price	$2,596.00
Rate for Payer: Cash Price	$2,596.00
Rate for Payer: Cofinity Commercial	$1,377.33
Rate for Payer: Cofinity Commercial	$1,281.68
Rate for Payer: Health Alliance Plan Medicare Advantage	$956.48
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,004.30
Rate for Payer: Nomi Health Commercial	$1,147.78
Rate for Payer: PACE SWMI	$956.48
Rate for Payer: PHP Medicare Advantage	$956.48
Rate for Payer: Priority Health Cigna Priority Health	$2,109.25
Rate for Payer: Priority Health Medicare	$966.04
Rate for Payer: UHC All Payor (Choice/PPO)	$956.48
Rate for Payer: UHC Dual Complete DSNP	$956.48
Rate for Payer: UHC Exchange	$956.48
Rate for Payer: UHC Medicare Advantage	$956.48

PR VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE

Professional

Both

$3,732.00

Service Code	HCPCS 58280
Min. Negotiated Rate	$1,017.16
Max. Negotiated Rate	$2,425.80
Rate for Payer: Aetna Commercial	$1,362.99
Rate for Payer: Aetna Medicare	$1,057.85
Rate for Payer: BCBS Complete	$1,492.80
Rate for Payer: BCBS MAPPO	$1,017.16
Rate for Payer: BCN Medicare Advantage	$1,017.16
Rate for Payer: Cash Price	$2,985.60
Rate for Payer: Cash Price	$2,985.60
Rate for Payer: Cofinity Commercial	$1,464.71
Rate for Payer: Cofinity Commercial	$1,362.99
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,017.16
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,068.02
Rate for Payer: Nomi Health Commercial	$1,220.59
Rate for Payer: PACE SWMI	$1,017.16
Rate for Payer: PHP Medicare Advantage	$1,017.16
Rate for Payer: Priority Health Cigna Priority Health	$2,425.80
Rate for Payer: Priority Health Medicare	$1,027.33
Rate for Payer: UHC All Payor (Choice/PPO)	$1,017.16
Rate for Payer: UHC Dual Complete DSNP	$1,017.16
Rate for Payer: UHC Exchange	$1,017.16
Rate for Payer: UHC Medicare Advantage	$1,017.16

PR VAGINAL DELIVERY AFTER CESAREAN DELIVERY

Professional

Both

$2,145.00

Service Code	HCPCS 59612
Min. Negotiated Rate	$858.00
Max. Negotiated Rate	$1,394.25
Rate for Payer: Aetna Commercial	$1,191.25
Rate for Payer: Aetna Medicare	$924.55
Rate for Payer: BCBS Complete	$858.00
Rate for Payer: BCBS MAPPO	$888.99
Rate for Payer: BCN Medicare Advantage	$888.99
Rate for Payer: Cash Price	$1,716.00
Rate for Payer: Cash Price	$1,716.00
Rate for Payer: Cofinity Commercial	$1,280.15
Rate for Payer: Cofinity Commercial	$1,191.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$888.99
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$933.44
Rate for Payer: Nomi Health Commercial	$1,066.79
Rate for Payer: PACE SWMI	$888.99
Rate for Payer: PHP Medicare Advantage	$888.99
Rate for Payer: Priority Health Cigna Priority Health	$1,394.25
Rate for Payer: Priority Health Medicare	$897.88
Rate for Payer: UHC All Payor (Choice/PPO)	$888.99
Rate for Payer: UHC Dual Complete DSNP	$888.99
Rate for Payer: UHC Exchange	$888.99
Rate for Payer: UHC Medicare Advantage	$888.99

PR VAGINAL DELIVERY ONLY

Professional

Both

$1,970.00

Service Code	HCPCS 59409
Min. Negotiated Rate	$781.01
Max. Negotiated Rate	$1,280.50
Rate for Payer: Aetna Commercial	$1,046.55
Rate for Payer: Aetna Medicare	$812.25
Rate for Payer: BCBS Complete	$788.00
Rate for Payer: BCBS MAPPO	$781.01
Rate for Payer: BCN Medicare Advantage	$781.01
Rate for Payer: Cash Price	$1,576.00
Rate for Payer: Cash Price	$1,576.00
Rate for Payer: Cofinity Commercial	$1,124.65
Rate for Payer: Cofinity Commercial	$1,046.55
Rate for Payer: Health Alliance Plan Medicare Advantage	$781.01
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$820.06
Rate for Payer: Nomi Health Commercial	$937.21
Rate for Payer: PACE SWMI	$781.01
Rate for Payer: PHP Medicare Advantage	$781.01
Rate for Payer: Priority Health Cigna Priority Health	$1,280.50
Rate for Payer: Priority Health Medicare	$788.82
Rate for Payer: UHC All Payor (Choice/PPO)	$781.01
Rate for Payer: UHC Dual Complete DSNP	$781.01
Rate for Payer: UHC Exchange	$781.01
Rate for Payer: UHC Medicare Advantage	$781.01

PR VAGINAL DELIVERY ONLY W/POSTPARTUM CARE

Professional

Both

$2,242.00

Service Code	HCPCS 59410
Min. Negotiated Rate	$896.80
Max. Negotiated Rate	$1,518.91
Rate for Payer: Aetna Commercial	$1,413.43
Rate for Payer: Aetna Medicare	$1,096.99
Rate for Payer: BCBS Complete	$896.80
Rate for Payer: BCBS MAPPO	$1,054.80
Rate for Payer: BCN Medicare Advantage	$1,054.80
Rate for Payer: Cash Price	$1,793.60
Rate for Payer: Cash Price	$1,793.60
Rate for Payer: Cofinity Commercial	$1,518.91
Rate for Payer: Cofinity Commercial	$1,413.43
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,054.80
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,107.54
Rate for Payer: Nomi Health Commercial	$1,265.76
Rate for Payer: PACE SWMI	$1,054.80
Rate for Payer: PHP Medicare Advantage	$1,054.80
Rate for Payer: Priority Health Cigna Priority Health	$1,457.30
Rate for Payer: Priority Health Medicare	$1,065.35
Rate for Payer: UHC All Payor (Choice/PPO)	$1,054.80
Rate for Payer: UHC Dual Complete DSNP	$1,054.80
Rate for Payer: UHC Exchange	$1,054.80
Rate for Payer: UHC Medicare Advantage	$1,054.80

PR VAGINAL DELIVERY & POSTPARTUM CARE VBAC

Professional

Both

$2,417.00

Service Code	HCPCS 59614
Min. Negotiated Rate	$966.80
Max. Negotiated Rate	$1,652.04
Rate for Payer: Aetna Commercial	$1,537.32
Rate for Payer: Aetna Medicare	$1,193.14
Rate for Payer: BCBS Complete	$966.80
Rate for Payer: BCBS MAPPO	$1,147.25
Rate for Payer: BCN Medicare Advantage	$1,147.25
Rate for Payer: Cash Price	$1,933.60
Rate for Payer: Cash Price	$1,933.60
Rate for Payer: Cofinity Commercial	$1,652.04
Rate for Payer: Cofinity Commercial	$1,537.32
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,147.25
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,204.61
Rate for Payer: Nomi Health Commercial	$1,376.70
Rate for Payer: PACE SWMI	$1,147.25
Rate for Payer: PHP Medicare Advantage	$1,147.25
Rate for Payer: Priority Health Cigna Priority Health	$1,571.05
Rate for Payer: Priority Health Medicare	$1,158.72
Rate for Payer: UHC All Payor (Choice/PPO)	$1,147.25
Rate for Payer: UHC Dual Complete DSNP	$1,147.25
Rate for Payer: UHC Exchange	$1,147.25
Rate for Payer: UHC Medicare Advantage	$1,147.25

PR VAGINAL HYSTERECTOMY >250 GM RPR ENTEROCELE

Professional

Both

$2,238.00

Service Code	HCPCS 58294
Min. Negotiated Rate	$895.20
Max. Negotiated Rate	$1,684.34
Rate for Payer: Aetna Commercial	$1,567.37
Rate for Payer: Aetna Medicare	$1,216.47
Rate for Payer: BCBS Complete	$895.20
Rate for Payer: BCBS MAPPO	$1,169.68
Rate for Payer: BCN Medicare Advantage	$1,169.68
Rate for Payer: Cash Price	$1,790.40
Rate for Payer: Cash Price	$1,790.40
Rate for Payer: Cofinity Commercial	$1,684.34
Rate for Payer: Cofinity Commercial	$1,567.37
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,169.68
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,228.16
Rate for Payer: Nomi Health Commercial	$1,403.62
Rate for Payer: PACE SWMI	$1,169.68
Rate for Payer: PHP Medicare Advantage	$1,169.68
Rate for Payer: Priority Health Cigna Priority Health	$1,454.70
Rate for Payer: Priority Health Medicare	$1,181.38
Rate for Payer: UHC All Payor (Choice/PPO)	$1,169.68
Rate for Payer: UHC Dual Complete DSNP	$1,169.68
Rate for Payer: UHC Exchange	$1,169.68
Rate for Payer: UHC Medicare Advantage	$1,169.68

PR VAGINAL HYSTERECTOMY 250 GM/< W/RPR ENTEROCELE

Professional

Both

$2,757.00

Service Code	HCPCS 58270
Min. Negotiated Rate	$858.59
Max. Negotiated Rate	$1,792.05
Rate for Payer: Aetna Commercial	$1,150.51
Rate for Payer: Aetna Medicare	$892.93
Rate for Payer: BCBS Complete	$1,102.80
Rate for Payer: BCBS MAPPO	$858.59
Rate for Payer: BCN Medicare Advantage	$858.59
Rate for Payer: Cash Price	$2,205.60
Rate for Payer: Cash Price	$2,205.60
Rate for Payer: Cofinity Commercial	$1,236.37
Rate for Payer: Cofinity Commercial	$1,150.51
Rate for Payer: Health Alliance Plan Medicare Advantage	$858.59
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$901.52
Rate for Payer: Nomi Health Commercial	$1,030.31
Rate for Payer: PACE SWMI	$858.59
Rate for Payer: PHP Medicare Advantage	$858.59
Rate for Payer: Priority Health Cigna Priority Health	$1,792.05
Rate for Payer: Priority Health Medicare	$867.18
Rate for Payer: UHC All Payor (Choice/PPO)	$858.59
Rate for Payer: UHC Dual Complete DSNP	$858.59
Rate for Payer: UHC Exchange	$858.59
Rate for Payer: UHC Medicare Advantage	$858.59

PR VAGINAL HYSTERECTOMY UTERUS > 250 GM

Professional

Both

$2,917.00

Service Code	HCPCS 58290
Min. Negotiated Rate	$1,106.24
Max. Negotiated Rate	$1,896.05
Rate for Payer: Aetna Commercial	$1,482.36
Rate for Payer: Aetna Medicare	$1,150.49
Rate for Payer: BCBS Complete	$1,166.80
Rate for Payer: BCBS MAPPO	$1,106.24
Rate for Payer: BCN Medicare Advantage	$1,106.24
Rate for Payer: Cash Price	$2,333.60
Rate for Payer: Cash Price	$2,333.60
Rate for Payer: Cofinity Commercial	$1,592.99
Rate for Payer: Cofinity Commercial	$1,482.36
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,106.24
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,161.55
Rate for Payer: Nomi Health Commercial	$1,327.49
Rate for Payer: PACE SWMI	$1,106.24
Rate for Payer: PHP Medicare Advantage	$1,106.24
Rate for Payer: Priority Health Cigna Priority Health	$1,896.05
Rate for Payer: Priority Health Medicare	$1,117.30
Rate for Payer: UHC All Payor (Choice/PPO)	$1,106.24
Rate for Payer: UHC Dual Complete DSNP	$1,106.24
Rate for Payer: UHC Exchange	$1,106.24
Rate for Payer: UHC Medicare Advantage	$1,106.24

PR VAGINAL HYSTERECTOMY UTERUS 250 GM/<

Professional

Both

$2,684.00

Service Code	HCPCS 58260
Min. Negotiated Rate	$804.92
Max. Negotiated Rate	$1,744.60
Rate for Payer: Aetna Commercial	$1,078.59
Rate for Payer: Aetna Medicare	$837.12
Rate for Payer: BCBS Complete	$1,073.60
Rate for Payer: BCBS MAPPO	$804.92
Rate for Payer: BCN Medicare Advantage	$804.92
Rate for Payer: Cash Price	$2,147.20
Rate for Payer: Cash Price	$2,147.20
Rate for Payer: Cofinity Commercial	$1,159.08
Rate for Payer: Cofinity Commercial	$1,078.59
Rate for Payer: Health Alliance Plan Medicare Advantage	$804.92
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$845.17
Rate for Payer: Nomi Health Commercial	$965.90
Rate for Payer: PACE SWMI	$804.92
Rate for Payer: PHP Medicare Advantage	$804.92
Rate for Payer: Priority Health Cigna Priority Health	$1,744.60
Rate for Payer: Priority Health Medicare	$812.97
Rate for Payer: UHC All Payor (Choice/PPO)	$804.92
Rate for Payer: UHC Dual Complete DSNP	$804.92
Rate for Payer: UHC Exchange	$804.92
Rate for Payer: UHC Medicare Advantage	$804.92

PR VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY

Professional

Both

$2,416.00

Service Code	HCPCS 58275
Min. Negotiated Rate	$953.00
Max. Negotiated Rate	$1,570.40
Rate for Payer: Aetna Commercial	$1,277.02
Rate for Payer: Aetna Medicare	$991.12
Rate for Payer: BCBS Complete	$966.40
Rate for Payer: BCBS MAPPO	$953.00
Rate for Payer: BCN Medicare Advantage	$953.00
Rate for Payer: Cash Price	$1,932.80
Rate for Payer: Cash Price	$1,932.80
Rate for Payer: Cofinity Commercial	$1,372.32
Rate for Payer: Cofinity Commercial	$1,277.02
Rate for Payer: Health Alliance Plan Medicare Advantage	$953.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,000.65
Rate for Payer: Nomi Health Commercial	$1,143.60
Rate for Payer: PACE SWMI	$953.00
Rate for Payer: PHP Medicare Advantage	$953.00
Rate for Payer: Priority Health Cigna Priority Health	$1,570.40
Rate for Payer: Priority Health Medicare	$962.53
Rate for Payer: UHC All Payor (Choice/PPO)	$953.00
Rate for Payer: UHC Dual Complete DSNP	$953.00
Rate for Payer: UHC Exchange	$953.00
Rate for Payer: UHC Medicare Advantage	$953.00

PR VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL

Professional

Both

$2,025.00

Service Code	HCPCS 57110
Min. Negotiated Rate	$810.00
Max. Negotiated Rate	$1,316.25
Rate for Payer: Aetna Commercial	$1,160.33
Rate for Payer: Aetna Medicare	$900.56
Rate for Payer: BCBS Complete	$810.00
Rate for Payer: BCBS MAPPO	$865.92
Rate for Payer: BCN Medicare Advantage	$865.92
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Cofinity Commercial	$1,246.92
Rate for Payer: Cofinity Commercial	$1,160.33
Rate for Payer: Health Alliance Plan Medicare Advantage	$865.92
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$909.22
Rate for Payer: Nomi Health Commercial	$1,039.10
Rate for Payer: PACE SWMI	$865.92
Rate for Payer: PHP Medicare Advantage	$865.92
Rate for Payer: Priority Health Cigna Priority Health	$1,316.25
Rate for Payer: Priority Health Medicare	$874.58
Rate for Payer: UHC All Payor (Choice/PPO)	$865.92
Rate for Payer: UHC Dual Complete DSNP	$865.92
Rate for Payer: UHC Exchange	$865.92
Rate for Payer: UHC Medicare Advantage	$865.92

PR VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL

Professional

Both

$1,993.00

Service Code	HCPCS 57106
Min. Negotiated Rate	$510.28
Max. Negotiated Rate	$1,295.45
Rate for Payer: Aetna Commercial	$683.78
Rate for Payer: Aetna Medicare	$530.69
Rate for Payer: BCBS Complete	$797.20
Rate for Payer: BCBS MAPPO	$510.28
Rate for Payer: BCN Medicare Advantage	$510.28
Rate for Payer: Cash Price	$1,594.40
Rate for Payer: Cash Price	$1,594.40
Rate for Payer: Cofinity Commercial	$734.80
Rate for Payer: Cofinity Commercial	$683.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$510.28
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$535.79
Rate for Payer: Nomi Health Commercial	$612.34
Rate for Payer: PACE SWMI	$510.28
Rate for Payer: PHP Medicare Advantage	$510.28
Rate for Payer: Priority Health Cigna Priority Health	$1,295.45
Rate for Payer: Priority Health Medicare	$515.38
Rate for Payer: UHC All Payor (Choice/PPO)	$510.28
Rate for Payer: UHC Dual Complete DSNP	$510.28
Rate for Payer: UHC Exchange	$510.28
Rate for Payer: UHC Medicare Advantage	$510.28

PR VAGINOPLASTY INTERSEX STATE

Professional

Both

$2,533.00

Service Code	HCPCS 57335
Min. Negotiated Rate	$1,013.20
Max. Negotiated Rate	$1,646.45
Rate for Payer: Aetna Commercial	$1,511.52
Rate for Payer: Aetna Medicare	$1,173.12
Rate for Payer: BCBS Complete	$1,013.20
Rate for Payer: BCBS MAPPO	$1,128.00
Rate for Payer: BCN Medicare Advantage	$1,128.00
Rate for Payer: Cash Price	$2,026.40
Rate for Payer: Cash Price	$2,026.40
Rate for Payer: Cofinity Commercial	$1,624.32
Rate for Payer: Cofinity Commercial	$1,511.52
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,128.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,184.40
Rate for Payer: Nomi Health Commercial	$1,353.60
Rate for Payer: PACE SWMI	$1,128.00
Rate for Payer: PHP Medicare Advantage	$1,128.00
Rate for Payer: Priority Health Cigna Priority Health	$1,646.45
Rate for Payer: Priority Health Medicare	$1,139.28
Rate for Payer: UHC All Payor (Choice/PPO)	$1,128.00
Rate for Payer: UHC Dual Complete DSNP	$1,128.00
Rate for Payer: UHC Exchange	$1,128.00
Rate for Payer: UHC Medicare Advantage	$1,128.00

PR VAGNC PRTL RMVL VAG WALL W/RMVL PARAVAGINAL TISS

Professional

Both

$2,571.00

Service Code	HCPCS 57107
Min. Negotiated Rate	$1,028.40
Max. Negotiated Rate	$2,014.62
Rate for Payer: Aetna Commercial	$1,874.71
Rate for Payer: Aetna Medicare	$1,455.00
Rate for Payer: BCBS Complete	$1,028.40
Rate for Payer: BCBS MAPPO	$1,399.04
Rate for Payer: BCN Medicare Advantage	$1,399.04
Rate for Payer: Cash Price	$2,056.80
Rate for Payer: Cash Price	$2,056.80
Rate for Payer: Cofinity Commercial	$2,014.62
Rate for Payer: Cofinity Commercial	$1,874.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,399.04
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,468.99
Rate for Payer: Nomi Health Commercial	$1,678.85
Rate for Payer: PACE SWMI	$1,399.04
Rate for Payer: PHP Medicare Advantage	$1,399.04
Rate for Payer: Priority Health Cigna Priority Health	$1,671.15
Rate for Payer: Priority Health Medicare	$1,413.03
Rate for Payer: UHC All Payor (Choice/PPO)	$1,399.04
Rate for Payer: UHC Dual Complete DSNP	$1,399.04
Rate for Payer: UHC Exchange	$1,399.04
Rate for Payer: UHC Medicare Advantage	$1,399.04

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