Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION

Facility

$78.33

Service Code	NDC 65219-052-29
Hospital Charge Code	6451
Hospital Revenue Code	250
Min. Negotiated Rate	$34.47
Max. Negotiated Rate	$70.50
Rate for Payer: Aetna American Axle	$50.91
Rate for Payer: Aetna Commercial	$66.58
Rate for Payer: Aetna New Business (MI Preferred)	$50.91
Rate for Payer: Cash Price	$62.66
Rate for Payer: Cofinity Commercial	$54.83
Rate for Payer: Cofinity Commercial	$67.36
Rate for Payer: Encore Health Key Benefits Commercial	$62.66
Rate for Payer: Healthscope Commercial	$70.50
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$54.83
Rate for Payer: Lakeland Regional Health Systems Commercial	$58.75
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$66.58
Rate for Payer: PHP Commercial	$66.58
Rate for Payer: Priority Health Cigna Priority Health	$54.83
Rate for Payer: Priority Health SBD	$49.35
Rate for Payer: UMR Bronson Commercial	$34.47
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$58.75

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION

Facility

$759.80

Service Code	NDC 65219-056-09
Hospital Charge Code	6451
Hospital Revenue Code	250
Min. Negotiated Rate	$334.31
Max. Negotiated Rate	$683.82
Rate for Payer: Aetna American Axle	$493.87
Rate for Payer: Aetna Commercial	$645.83
Rate for Payer: Aetna New Business (MI Preferred)	$493.87
Rate for Payer: Cash Price	$607.84
Rate for Payer: Cofinity Commercial	$531.86
Rate for Payer: Cofinity Commercial	$653.43
Rate for Payer: Encore Health Key Benefits Commercial	$607.84
Rate for Payer: Healthscope Commercial	$683.82
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$531.86
Rate for Payer: Lakeland Regional Health Systems Commercial	$569.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$645.83
Rate for Payer: PHP Commercial	$645.83
Rate for Payer: Priority Health Cigna Priority Health	$531.86
Rate for Payer: Priority Health SBD	$478.67
Rate for Payer: UMR Bronson Commercial	$334.31
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$569.85

POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION (TPN COMPONENT)

Facility

$777.74

Service Code	NDC 9900-0019-21
Hospital Charge Code	301289
Hospital Revenue Code	250
Min. Negotiated Rate	$342.21
Max. Negotiated Rate	$699.97
Rate for Payer: Aetna American Axle	$505.53
Rate for Payer: Aetna Commercial	$661.08
Rate for Payer: Aetna New Business (MI Preferred)	$505.53
Rate for Payer: Cash Price	$622.19
Rate for Payer: Cofinity Commercial	$544.42
Rate for Payer: Cofinity Commercial	$668.86
Rate for Payer: Encore Health Key Benefits Commercial	$622.19
Rate for Payer: Healthscope Commercial	$699.97
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$544.42
Rate for Payer: Lakeland Regional Health Systems Commercial	$583.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$661.08
Rate for Payer: PHP Commercial	$661.08
Rate for Payer: Priority Health Cigna Priority Health	$544.42
Rate for Payer: Priority Health SBD	$489.98
Rate for Payer: UMR Bronson Commercial	$342.21
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$583.30

POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB

Facility

$109.98

Service Code	NDC 1650004108
Hospital Charge Code	174294
Hospital Revenue Code	637
Min. Negotiated Rate	$48.39
Max. Negotiated Rate	$98.98
Rate for Payer: Aetna American Axle	$71.49
Rate for Payer: Aetna Commercial	$93.48
Rate for Payer: Aetna New Business (MI Preferred)	$71.49
Rate for Payer: Cash Price	$87.98
Rate for Payer: Cofinity Commercial	$76.99
Rate for Payer: Cofinity Commercial	$94.58
Rate for Payer: Encore Health Key Benefits Commercial	$87.98
Rate for Payer: Healthscope Commercial	$98.98
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$76.99
Rate for Payer: Lakeland Regional Health Systems Commercial	$82.48
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$93.48
Rate for Payer: PHP Commercial	$93.48
Rate for Payer: Priority Health Cigna Priority Health	$76.99
Rate for Payer: Priority Health SBD	$69.29
Rate for Payer: UMR Bronson Commercial	$48.39
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$82.48

POT BICARB 344 MG-SOD BICARB 1,050 MG-CITRIC ACID 1,000 MG EFFERV TAB

Facility

$148.05

Service Code	NDC 1650056675
Hospital Charge Code	174294
Hospital Revenue Code	637
Min. Negotiated Rate	$65.14
Max. Negotiated Rate	$133.24
Rate for Payer: Aetna American Axle	$96.23
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.24
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$103.64
Rate for Payer: Lakeland Regional Health Systems Commercial	$111.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$103.64
Rate for Payer: Priority Health SBD	$93.27
Rate for Payer: UMR Bronson Commercial	$65.14
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$111.04

POVIDONE (BULK) K-30 POWDER

Facility

$630.00

Service Code	NDC 51552-1323-5
Hospital Charge Code	23281
Hospital Revenue Code	637
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$567.00
Rate for Payer: Aetna American Axle	$409.50
Rate for Payer: Aetna Commercial	$535.50
Rate for Payer: Aetna New Business (MI Preferred)	$409.50
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cofinity Commercial	$441.00
Rate for Payer: Cofinity Commercial	$541.80
Rate for Payer: Encore Health Key Benefits Commercial	$504.00
Rate for Payer: Healthscope Commercial	$567.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$441.00
Rate for Payer: Lakeland Regional Health Systems Commercial	$472.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$535.50
Rate for Payer: PHP Commercial	$535.50
Rate for Payer: Priority Health Cigna Priority Health	$441.00
Rate for Payer: Priority Health SBD	$396.90
Rate for Payer: UMR Bronson Commercial	$277.20
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$472.50

POVIDONE-IODINE 0.3 % VAGINAL SOLUTION

Facility

$16.03

Service Code	NDC 4160808743
Hospital Charge Code	12799
Hospital Revenue Code	637
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$14.43
Rate for Payer: Aetna American Axle	$10.42
Rate for Payer: Aetna Commercial	$13.63
Rate for Payer: Aetna New Business (MI Preferred)	$10.42
Rate for Payer: Cash Price	$12.82
Rate for Payer: Cofinity Commercial	$11.22
Rate for Payer: Cofinity Commercial	$13.79
Rate for Payer: Encore Health Key Benefits Commercial	$12.82
Rate for Payer: Healthscope Commercial	$14.43
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$11.22
Rate for Payer: Lakeland Regional Health Systems Commercial	$12.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.63
Rate for Payer: PHP Commercial	$13.63
Rate for Payer: Priority Health Cigna Priority Health	$11.22
Rate for Payer: Priority Health SBD	$10.10
Rate for Payer: UMR Bronson Commercial	$7.05
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$12.02

POVIDONE-IODINE 10 % TOPICAL SOLUTION

Facility

$21.29

Service Code	NDC 0395-2325-16
Hospital Charge Code	6458
Hospital Revenue Code	637
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$19.16
Rate for Payer: Aetna American Axle	$13.84
Rate for Payer: Aetna Commercial	$18.10
Rate for Payer: Aetna New Business (MI Preferred)	$13.84
Rate for Payer: Cash Price	$17.03
Rate for Payer: Cofinity Commercial	$14.90
Rate for Payer: Cofinity Commercial	$18.31
Rate for Payer: Encore Health Key Benefits Commercial	$17.03
Rate for Payer: Healthscope Commercial	$19.16
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$14.90
Rate for Payer: Lakeland Regional Health Systems Commercial	$15.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$18.10
Rate for Payer: PHP Commercial	$18.10
Rate for Payer: Priority Health Cigna Priority Health	$14.90
Rate for Payer: Priority Health SBD	$13.41
Rate for Payer: UMR Bronson Commercial	$9.37
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$15.97

POVIDONE-IODINE 10 % TOPICAL SOLUTION

Facility

$17.07

Service Code	NDC 67618-150-09
Hospital Charge Code	6458
Hospital Revenue Code	637
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$15.36
Rate for Payer: Aetna American Axle	$11.10
Rate for Payer: Aetna Commercial	$14.51
Rate for Payer: Aetna New Business (MI Preferred)	$11.10
Rate for Payer: Cash Price	$13.66
Rate for Payer: Cofinity Commercial	$11.95
Rate for Payer: Cofinity Commercial	$14.68
Rate for Payer: Encore Health Key Benefits Commercial	$13.66
Rate for Payer: Healthscope Commercial	$15.36
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$11.95
Rate for Payer: Lakeland Regional Health Systems Commercial	$12.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.51
Rate for Payer: PHP Commercial	$14.51
Rate for Payer: Priority Health Cigna Priority Health	$11.95
Rate for Payer: Priority Health SBD	$10.75
Rate for Payer: UMR Bronson Commercial	$7.51
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$12.80

POVIDONE-IODINE 10 % TOPICAL SOLUTION

Facility

$14.87

Service Code	NDC 0904-1103-09
Hospital Charge Code	6458
Hospital Revenue Code	637
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$13.38
Rate for Payer: Aetna American Axle	$9.67
Rate for Payer: Aetna Commercial	$12.64
Rate for Payer: Aetna New Business (MI Preferred)	$9.67
Rate for Payer: Cash Price	$11.90
Rate for Payer: Cofinity Commercial	$10.41
Rate for Payer: Cofinity Commercial	$12.79
Rate for Payer: Encore Health Key Benefits Commercial	$11.90
Rate for Payer: Healthscope Commercial	$13.38
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$10.41
Rate for Payer: Lakeland Regional Health Systems Commercial	$11.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.64
Rate for Payer: PHP Commercial	$12.64
Rate for Payer: Priority Health Cigna Priority Health	$10.41
Rate for Payer: Priority Health SBD	$9.37
Rate for Payer: UMR Bronson Commercial	$6.54
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$11.15

POVIDONE-IODINE 10 % TOPICAL SOLUTION

Facility

$14.94

Service Code	NDC 52380-1905-8
Hospital Charge Code	6458
Hospital Revenue Code	637
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$13.45
Rate for Payer: Aetna American Axle	$9.71
Rate for Payer: Aetna Commercial	$12.70
Rate for Payer: Aetna New Business (MI Preferred)	$9.71
Rate for Payer: Cash Price	$11.95
Rate for Payer: Cofinity Commercial	$10.46
Rate for Payer: Cofinity Commercial	$12.85
Rate for Payer: Encore Health Key Benefits Commercial	$11.95
Rate for Payer: Healthscope Commercial	$13.45
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$10.46
Rate for Payer: Lakeland Regional Health Systems Commercial	$11.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.70
Rate for Payer: PHP Commercial	$12.70
Rate for Payer: Priority Health Cigna Priority Health	$10.46
Rate for Payer: Priority Health SBD	$9.41
Rate for Payer: UMR Bronson Commercial	$6.57
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$11.20

POVIDONE-IODINE 5 % EYE SOLUTION

Facility

$31.82

Service Code	NDC 0065-0411-30
Hospital Charge Code	19791
Hospital Revenue Code	637
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$28.64
Rate for Payer: Aetna American Axle	$20.68
Rate for Payer: Aetna Commercial	$27.05
Rate for Payer: Aetna New Business (MI Preferred)	$20.68
Rate for Payer: Cash Price	$25.46
Rate for Payer: Cofinity Commercial	$22.27
Rate for Payer: Cofinity Commercial	$27.37
Rate for Payer: Encore Health Key Benefits Commercial	$25.46
Rate for Payer: Healthscope Commercial	$28.64
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$22.27
Rate for Payer: Lakeland Regional Health Systems Commercial	$23.86
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$27.05
Rate for Payer: PHP Commercial	$27.05
Rate for Payer: Priority Health Cigna Priority Health	$22.27
Rate for Payer: Priority Health SBD	$20.05
Rate for Payer: UMR Bronson Commercial	$14.00
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$23.86

POVIDONE-IODINE 5 % EYE SOLUTION

Facility

$3.54

Service Code	NDC 9900-0003-95
Hospital Charge Code	19791
Hospital Revenue Code	637
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$3.19
Rate for Payer: Aetna American Axle	$2.30
Rate for Payer: Aetna Commercial	$3.01
Rate for Payer: Aetna New Business (MI Preferred)	$2.30
Rate for Payer: Cash Price	$2.83
Rate for Payer: Cofinity Commercial	$2.48
Rate for Payer: Cofinity Commercial	$3.04
Rate for Payer: Encore Health Key Benefits Commercial	$2.83
Rate for Payer: Healthscope Commercial	$3.19
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$2.48
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.66
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.01
Rate for Payer: PHP Commercial	$3.01
Rate for Payer: Priority Health Cigna Priority Health	$2.48
Rate for Payer: Priority Health SBD	$2.23
Rate for Payer: UMR Bronson Commercial	$1.56
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.66

PR 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR

Professional

Both

$2,057.00

Service Code	HCPCS 54332
Min. Negotiated Rate	$640.92
Max. Negotiated Rate	$2,967.99
Rate for Payer: Aetna Commercial	$1,298.52
Rate for Payer: BCBS Complete	$672.97
Rate for Payer: BCBS Trust/PPO	$2,967.99
Rate for Payer: Cash Price	$1,645.60
Rate for Payer: Cash Price	$1,645.60
Rate for Payer: Meridian Medicaid	$672.97
Rate for Payer: Priority Health Choice Medicaid	$640.92
Rate for Payer: Priority Health Cigna Priority Health	$1,439.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,606.49
Rate for Payer: Priority Health Narrow Network	$1,606.49
Rate for Payer: Priority Health SBD	$1,606.49
Rate for Payer: UMR Bronson Commercial	$946.22

PR 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS

Professional

Both

$1,739.00

Service Code	HCPCS 54326
Min. Negotiated Rate	$598.53
Max. Negotiated Rate	$2,714.41
Rate for Payer: Aetna Commercial	$1,210.28
Rate for Payer: BCBS Complete	$628.46
Rate for Payer: BCBS Trust/PPO	$2,714.41
Rate for Payer: Cash Price	$1,391.20
Rate for Payer: Cash Price	$1,391.20
Rate for Payer: Meridian Medicaid	$628.46
Rate for Payer: Priority Health Choice Medicaid	$598.53
Rate for Payer: Priority Health Cigna Priority Health	$1,217.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,500.04
Rate for Payer: Priority Health Narrow Network	$1,500.04
Rate for Payer: Priority Health SBD	$1,500.04
Rate for Payer: UMR Bronson Commercial	$799.94

PR 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT

Professional

Both

$4,902.00

Service Code	HCPCS 54322
Min. Negotiated Rate	$362.41
Max. Negotiated Rate	$3,431.40
Rate for Payer: Aetna Commercial	$1,003.62
Rate for Payer: BCBS Complete	$521.56
Rate for Payer: BCBS Trust/PPO	$362.41
Rate for Payer: Cash Price	$3,921.60
Rate for Payer: Cash Price	$3,921.60
Rate for Payer: Meridian Medicaid	$521.56
Rate for Payer: Priority Health Choice Medicaid	$496.72
Rate for Payer: Priority Health Cigna Priority Health	$3,431.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,245.52
Rate for Payer: Priority Health Narrow Network	$1,245.52
Rate for Payer: Priority Health SBD	$1,245.52
Rate for Payer: UMR Bronson Commercial	$2,254.92

PR 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS

Professional

Both

$1,972.94

Service Code	HCPCS 54324
Min. Negotiated Rate	$517.21
Max. Negotiated Rate	$1,540.55
Rate for Payer: Aetna Commercial	$1,242.77
Rate for Payer: BCBS Complete	$645.46
Rate for Payer: BCBS Trust/PPO	$517.21
Rate for Payer: Cash Price	$1,578.35
Rate for Payer: Cash Price	$1,578.35
Rate for Payer: Meridian Medicaid	$645.46
Rate for Payer: Priority Health Choice Medicaid	$614.72
Rate for Payer: Priority Health Cigna Priority Health	$1,381.06
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,540.55
Rate for Payer: Priority Health Narrow Network	$1,540.55
Rate for Payer: Priority Health SBD	$1,540.55
Rate for Payer: UMR Bronson Commercial	$907.55

PR 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB

Professional

Both

$155.00

Service Code	HCPCS 99460
Min. Negotiated Rate	$58.58
Max. Negotiated Rate	$190.72
Rate for Payer: Aetna Commercial	$94.30
Rate for Payer: BCBS Complete	$61.51
Rate for Payer: BCBS Trust/PPO	$190.72
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cash Price	$124.00
Rate for Payer: Meridian Medicaid	$61.51
Rate for Payer: Priority Health Choice Medicaid	$58.58
Rate for Payer: Priority Health Cigna Priority Health	$108.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$117.36
Rate for Payer: Priority Health Narrow Network	$117.36
Rate for Payer: Priority Health SBD	$117.36
Rate for Payer: UMR Bronson Commercial	$71.30

PR 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT

Professional

Both

$169.00

Service Code	HCPCS 99463
Min. Negotiated Rate	$68.37
Max. Negotiated Rate	$1,537.35
Rate for Payer: Aetna Commercial	$108.47
Rate for Payer: BCBS Complete	$71.79
Rate for Payer: BCBS Trust/PPO	$1,537.35
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Meridian Medicaid	$71.79
Rate for Payer: Priority Health Choice Medicaid	$68.37
Rate for Payer: Priority Health Cigna Priority Health	$118.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$137.92
Rate for Payer: Priority Health Narrow Network	$137.92
Rate for Payer: Priority Health SBD	$137.92
Rate for Payer: UMR Bronson Commercial	$77.74

PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES

Professional

Both

$346.00

Service Code	HCPCS 99223
Min. Negotiated Rate	$109.48
Max. Negotiated Rate	$1,363.01
Rate for Payer: Aetna Commercial	$197.06
Rate for Payer: BCBS Complete	$114.95
Rate for Payer: BCBS Trust/PPO	$1,363.01
Rate for Payer: Cash Price	$276.80
Rate for Payer: Cash Price	$276.80
Rate for Payer: Meridian Medicaid	$114.95
Rate for Payer: Priority Health Choice Medicaid	$109.48
Rate for Payer: Priority Health Cigna Priority Health	$242.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$219.73
Rate for Payer: Priority Health Narrow Network	$219.73
Rate for Payer: Priority Health SBD	$219.73
Rate for Payer: UMR Bronson Commercial	$159.16

PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES

Professional

Both

$236.00

Service Code	HCPCS 99222
Min. Negotiated Rate	$82.64
Max. Negotiated Rate	$2,113.20
Rate for Payer: Aetna Commercial	$133.90
Rate for Payer: BCBS Complete	$86.77
Rate for Payer: BCBS Trust/PPO	$2,113.20
Rate for Payer: Cash Price	$188.80
Rate for Payer: Cash Price	$188.80
Rate for Payer: Meridian Medicaid	$86.77
Rate for Payer: Priority Health Choice Medicaid	$82.64
Rate for Payer: Priority Health Cigna Priority Health	$165.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$164.91
Rate for Payer: Priority Health Narrow Network	$164.91
Rate for Payer: Priority Health SBD	$164.91
Rate for Payer: UMR Bronson Commercial	$108.56

PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES

Professional

Both

$174.00

Service Code	HCPCS 99221
Min. Negotiated Rate	$52.40
Max. Negotiated Rate	$1,817.88
Rate for Payer: Aetna Commercial	$99.61
Rate for Payer: BCBS Complete	$55.02
Rate for Payer: BCBS Trust/PPO	$1,817.88
Rate for Payer: Cash Price	$139.20
Rate for Payer: Cash Price	$139.20
Rate for Payer: Meridian Medicaid	$55.02
Rate for Payer: Priority Health Choice Medicaid	$52.40
Rate for Payer: Priority Health Cigna Priority Health	$121.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$105.36
Rate for Payer: Priority Health Narrow Network	$105.36
Rate for Payer: Priority Health SBD	$105.36
Rate for Payer: UMR Bronson Commercial	$80.04

PR 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/<

Professional

Both

$1,642.00

Service Code	HCPCS 99468
Min. Negotiated Rate	$127.77
Max. Negotiated Rate	$1,149.40
Rate for Payer: Aetna Commercial	$902.56
Rate for Payer: BCBS Complete	$881.36
Rate for Payer: BCBS Trust/PPO	$127.77
Rate for Payer: Cash Price	$1,313.60
Rate for Payer: Cash Price	$1,313.60
Rate for Payer: Meridian Medicaid	$881.36
Rate for Payer: Priority Health Choice Medicaid	$839.39
Rate for Payer: Priority Health Cigna Priority Health	$1,149.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,131.19
Rate for Payer: Priority Health Narrow Network	$1,131.19
Rate for Payer: Priority Health SBD	$1,131.19
Rate for Payer: UMR Bronson Commercial	$755.32

PR 1ST PSYCHIATRIC COLLAB CARE MGMT 1ST 70 MINS

Professional

Both

$309.00

Service Code	HCPCS 99492
Min. Negotiated Rate	$59.43
Max. Negotiated Rate	$1,323.39
Rate for Payer: Aetna Commercial	$92.57
Rate for Payer: BCBS Complete	$62.40
Rate for Payer: BCBS Trust/PPO	$1,323.39
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cash Price	$247.20
Rate for Payer: Meridian Medicaid	$62.40
Rate for Payer: Priority Health Choice Medicaid	$59.43
Rate for Payer: Priority Health Cigna Priority Health	$216.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$172.40
Rate for Payer: Priority Health Narrow Network	$172.40
Rate for Payer: Priority Health SBD	$172.40
Rate for Payer: UMR Bronson Commercial	$142.14

PR 1ST/SBSQ PSYCH COLLAB CARE MGMT EA ADDL 30 MINS

Professional

Both

$126.00

Service Code	HCPCS 99494
Min. Negotiated Rate	$25.99
Max. Negotiated Rate	$984.75
Rate for Payer: Aetna Commercial	$40.26
Rate for Payer: BCBS Complete	$27.29
Rate for Payer: BCBS Trust/PPO	$984.75
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Meridian Medicaid	$27.29
Rate for Payer: Priority Health Choice Medicaid	$25.99
Rate for Payer: Priority Health Cigna Priority Health	$88.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$82.71
Rate for Payer: Priority Health Narrow Network	$82.71
Rate for Payer: Priority Health SBD	$82.71
Rate for Payer: UMR Bronson Commercial	$57.96

Know your out-of-pocket cost for care.

All Charges