Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ALCOHOL/SUBSTANCE SCREEN & INTERVEN 15-30 MIN

Professional

Both

$54.00

Service Code	HCPCS 99408
Min. Negotiated Rate	$20.24
Max. Negotiated Rate	$1,099.92
Rate for Payer: Aetna Commercial	$33.63
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS Complete	$21.25
Rate for Payer: BCBS Trust/PPO	$1,099.92
Rate for Payer: BCN Commercial	$50.33
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Meridian Medicaid	$21.25
Rate for Payer: Priority Health Choice Medicaid	$20.24
Rate for Payer: Priority Health Cigna Priority Health	$35.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$42.18
Rate for Payer: Priority Health Narrow Network	$42.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.65
Rate for Payer: UHC Exchange	$36.65
Rate for Payer: UHCCP Medicaid	$20.24

PR ALCOHOL/SUBSTANCE SCREEN & INTERVENTION >30 MIN

Professional

Both

$104.00

Service Code	HCPCS 99409
Min. Negotiated Rate	$40.04
Max. Negotiated Rate	$1,109.43
Rate for Payer: Aetna Commercial	$67.61
Rate for Payer: Aetna Medicare	$52.00
Rate for Payer: BCBS Complete	$42.04
Rate for Payer: BCBS Trust/PPO	$1,109.43
Rate for Payer: BCN Commercial	$96.27
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Meridian Medicaid	$42.04
Rate for Payer: Priority Health Choice Medicaid	$40.04
Rate for Payer: Priority Health Cigna Priority Health	$67.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$84.36
Rate for Payer: Priority Health Narrow Network	$84.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$73.32
Rate for Payer: UHC Exchange	$73.32
Rate for Payer: UHCCP Medicaid	$40.04

PR ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED

Professional

Both

$489.00

Service Code	HCPCS 20930
Min. Negotiated Rate	$135.79
Max. Negotiated Rate	$11,952.59
Rate for Payer: Aetna Commercial	$155.86
Rate for Payer: Aetna Medicare	$244.50
Rate for Payer: BCBS Complete	$195.60
Rate for Payer: BCBS Trust/PPO	$11,952.59
Rate for Payer: BCN Commercial	$135.79
Rate for Payer: Cash Price	$391.20
Rate for Payer: Cash Price	$391.20
Rate for Payer: Priority Health Cigna Priority Health	$317.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$178.11
Rate for Payer: Priority Health Narrow Network	$178.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$141.42
Rate for Payer: UHC Exchange	$141.42

PR ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL

Professional

Both

$446.00

Service Code	HCPCS 20931
Min. Negotiated Rate	$70.93
Max. Negotiated Rate	$29,358.48
Rate for Payer: Aetna Commercial	$148.79
Rate for Payer: Aetna Medicare	$223.00
Rate for Payer: BCBS Complete	$74.48
Rate for Payer: BCBS Trust/PPO	$29,358.48
Rate for Payer: BCN Commercial	$177.03
Rate for Payer: Cash Price	$356.80
Rate for Payer: Cash Price	$356.80
Rate for Payer: Meridian Medicaid	$74.48
Rate for Payer: Priority Health Choice Medicaid	$70.93
Rate for Payer: Priority Health Cigna Priority Health	$289.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$167.93
Rate for Payer: Priority Health Narrow Network	$167.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$134.21
Rate for Payer: UHC Exchange	$134.21
Rate for Payer: UHCCP Medicaid	$70.93

PR ALTEPLASE RECOMBINANT

Professional

Both

$91.00

Service Code	HCPCS J2997
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$91.64
Rate for Payer: Aetna Commercial	$91.64
Rate for Payer: Aetna Medicare	$45.50
Rate for Payer: BCBS Complete	$36.40
Rate for Payer: BCBS Trust/PPO	$88.53
Rate for Payer: BCN Commercial	$87.12
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cash Price	$72.80
Rate for Payer: Priority Health Cigna Priority Health	$59.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$91.34
Rate for Payer: UHC Exchange	$91.34

PR AMBULATORY BP MNTR W/SW 24 HR+ REC SCAN ALYS I&R

Professional

Both

$257.00

Service Code	HCPCS 93784
Min. Negotiated Rate	$37.78
Max. Negotiated Rate	$167.05
Rate for Payer: Aetna Commercial	$49.46
Rate for Payer: Aetna Medicare	$128.50
Rate for Payer: BCBS Complete	$102.80
Rate for Payer: BCBS Trust/PPO	$37.78
Rate for Payer: BCN Commercial	$66.46
Rate for Payer: Cash Price	$205.60
Rate for Payer: Cash Price	$205.60
Rate for Payer: Priority Health Cigna Priority Health	$167.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$64.98
Rate for Payer: Priority Health Narrow Network	$64.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$67.00
Rate for Payer: UHC Exchange	$67.00

PR AMBULATORY BP MNTR W/SW 24 HR+ REVIEW W/I&R

Professional

Both

$36.00

Service Code	HCPCS 93790
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$31.84
Rate for Payer: Aetna Commercial	$20.22
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS Complete	$14.40
Rate for Payer: BCBS Trust/PPO	$31.84
Rate for Payer: BCN Commercial	$25.90
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Priority Health Cigna Priority Health	$23.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24.95
Rate for Payer: Priority Health Narrow Network	$24.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.35
Rate for Payer: UHC Exchange	$20.35

PR AMBULATORY EEG MONITORING

Professional

Both

$584.00

Service Code	HCPCS 95950
Min. Negotiated Rate	$233.60
Max. Negotiated Rate	$379.60
Rate for Payer: Aetna Medicare	$292.00
Rate for Payer: BCBS Complete	$233.60
Rate for Payer: Cash Price	$467.20
Rate for Payer: Priority Health Cigna Priority Health	$379.60

PR AMINOLEVULINIC ACID HCL TOP

Professional

Both

$177.00

Service Code	HCPCS J7308
Min. Negotiated Rate	$70.80
Max. Negotiated Rate	$404.09
Rate for Payer: Aetna Commercial	$404.09
Rate for Payer: Aetna Medicare	$88.50
Rate for Payer: BCBS Complete	$70.80
Rate for Payer: BCBS Trust/PPO	$399.72
Rate for Payer: BCN Commercial	$388.57
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Priority Health Cigna Priority Health	$115.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$395.24
Rate for Payer: UHC Exchange	$395.24

PRAMIPEXOLE 0.125 MG TABLET

Facility

$112.10

Service Code	NDC 13668009190
Hospital Charge Code	21287
Hospital Revenue Code	637
Min. Negotiated Rate	$72.86
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$100.89
Rate for Payer: ASR ASR	$108.74
Rate for Payer: ASR Commercial	$108.74
Rate for Payer: BCBS Trust/PPO	$91.35
Rate for Payer: BCN Commercial	$86.91
Rate for Payer: Cash Price	$89.68
Rate for Payer: Cofinity Commercial	$105.37
Rate for Payer: Encore Health Key Benefits Commercial	$89.68
Rate for Payer: Healthscope Commercial	$112.10
Rate for Payer: Healthscope Whirlpool	$108.74
Rate for Payer: Mclaren Commercial	$100.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$95.28
Rate for Payer: Nomi Health Commercial	$91.92
Rate for Payer: Priority Health Cigna Priority Health	$72.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$98.65

PRAMIPEXOLE 0.125 MG TABLET

Facility

$112.10

Service Code	NDC 13668009190
Hospital Charge Code	21287
Hospital Revenue Code	637
Min. Negotiated Rate	$44.84
Max. Negotiated Rate	$112.10
Rate for Payer: Aetna Commercial	$100.89
Rate for Payer: Aetna Medicare	$56.05
Rate for Payer: ASR ASR	$108.74
Rate for Payer: ASR Commercial	$108.74
Rate for Payer: BCBS Complete	$44.84
Rate for Payer: BCBS Trust/PPO	$91.80
Rate for Payer: BCN Commercial	$86.91
Rate for Payer: Cash Price	$89.68
Rate for Payer: Cofinity Commercial	$105.37
Rate for Payer: Encore Health Key Benefits Commercial	$89.68
Rate for Payer: Healthscope Commercial	$112.10
Rate for Payer: Healthscope Whirlpool	$108.74
Rate for Payer: Mclaren Commercial	$100.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$95.28
Rate for Payer: Nomi Health Commercial	$91.92
Rate for Payer: Priority Health Cigna Priority Health	$72.86
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$98.22
Rate for Payer: Priority Health Narrow Network	$78.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$98.65

PRAMIPEXOLE 0.25 MG TABLET

Facility

$444.15

Service Code	NDC 00904670461
Hospital Charge Code	21290
Hospital Revenue Code	637
Min. Negotiated Rate	$177.66
Max. Negotiated Rate	$444.15
Rate for Payer: Aetna Commercial	$399.74
Rate for Payer: Aetna Medicare	$222.08
Rate for Payer: ASR ASR	$430.83
Rate for Payer: ASR Commercial	$430.83
Rate for Payer: BCBS Complete	$177.66
Rate for Payer: BCBS Trust/PPO	$363.71
Rate for Payer: BCN Commercial	$344.35
Rate for Payer: Cash Price	$355.32
Rate for Payer: Cofinity Commercial	$417.50
Rate for Payer: Encore Health Key Benefits Commercial	$355.32
Rate for Payer: Healthscope Commercial	$444.15
Rate for Payer: Healthscope Whirlpool	$430.83
Rate for Payer: Mclaren Commercial	$399.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$377.53
Rate for Payer: Nomi Health Commercial	$364.20
Rate for Payer: Priority Health Cigna Priority Health	$288.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$389.16
Rate for Payer: Priority Health Narrow Network	$311.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$390.85

PRAMIPEXOLE 0.25 MG TABLET

Facility

$109.98

Service Code	NDC 13668009290
Hospital Charge Code	21290
Hospital Revenue Code	637
Min. Negotiated Rate	$43.99
Max. Negotiated Rate	$109.98
Rate for Payer: Aetna Commercial	$98.98
Rate for Payer: Aetna Medicare	$54.99
Rate for Payer: ASR ASR	$106.68
Rate for Payer: ASR Commercial	$106.68
Rate for Payer: BCBS Complete	$43.99
Rate for Payer: BCBS Trust/PPO	$90.06
Rate for Payer: BCN Commercial	$85.27
Rate for Payer: Cash Price	$87.98
Rate for Payer: Cofinity Commercial	$103.38
Rate for Payer: Encore Health Key Benefits Commercial	$87.98
Rate for Payer: Healthscope Commercial	$109.98
Rate for Payer: Healthscope Whirlpool	$106.68
Rate for Payer: Mclaren Commercial	$98.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.48
Rate for Payer: Nomi Health Commercial	$90.18
Rate for Payer: Priority Health Cigna Priority Health	$71.49
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$96.36
Rate for Payer: Priority Health Narrow Network	$77.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$96.78

PRAMIPEXOLE 0.25 MG TABLET

Facility

$444.15

Service Code	NDC 00904670461
Hospital Charge Code	21290
Hospital Revenue Code	637
Min. Negotiated Rate	$288.70
Max. Negotiated Rate	$444.15
Rate for Payer: Aetna Commercial	$399.74
Rate for Payer: ASR ASR	$430.83
Rate for Payer: ASR Commercial	$430.83
Rate for Payer: BCBS Trust/PPO	$361.94
Rate for Payer: BCN Commercial	$344.35
Rate for Payer: Cash Price	$355.32
Rate for Payer: Cofinity Commercial	$417.50
Rate for Payer: Encore Health Key Benefits Commercial	$355.32
Rate for Payer: Healthscope Commercial	$444.15
Rate for Payer: Healthscope Whirlpool	$430.83
Rate for Payer: Mclaren Commercial	$399.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$377.53
Rate for Payer: Nomi Health Commercial	$364.20
Rate for Payer: Priority Health Cigna Priority Health	$288.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$390.85

PRAMIPEXOLE 0.25 MG TABLET

Facility

$109.98

Service Code	NDC 13668009290
Hospital Charge Code	21290
Hospital Revenue Code	637
Min. Negotiated Rate	$71.49
Max. Negotiated Rate	$109.98
Rate for Payer: Aetna Commercial	$98.98
Rate for Payer: ASR ASR	$106.68
Rate for Payer: ASR Commercial	$106.68
Rate for Payer: BCBS Trust/PPO	$89.62
Rate for Payer: BCN Commercial	$85.27
Rate for Payer: Cash Price	$87.98
Rate for Payer: Cofinity Commercial	$103.38
Rate for Payer: Encore Health Key Benefits Commercial	$87.98
Rate for Payer: Healthscope Commercial	$109.98
Rate for Payer: Healthscope Whirlpool	$106.68
Rate for Payer: Mclaren Commercial	$98.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.48
Rate for Payer: Nomi Health Commercial	$90.18
Rate for Payer: Priority Health Cigna Priority Health	$71.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$96.78

PR AMNIOCENTESIS DIAGNOSIC

Professional

Both

$240.00

Service Code	HCPCS 59000
Min. Negotiated Rate	$51.55
Max. Negotiated Rate	$570.04
Rate for Payer: Aetna Commercial	$86.80
Rate for Payer: Aetna Medicare	$120.00
Rate for Payer: BCBS Complete	$54.13
Rate for Payer: BCBS Trust/PPO	$570.04
Rate for Payer: BCN Commercial	$172.01
Rate for Payer: Cash Price	$192.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Meridian Medicaid	$54.13
Rate for Payer: Priority Health Choice Medicaid	$51.55
Rate for Payer: Priority Health Cigna Priority Health	$156.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$113.18
Rate for Payer: Priority Health Narrow Network	$113.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$92.82
Rate for Payer: UHC Exchange	$92.82
Rate for Payer: UHCCP Medicaid	$51.55

PR AMNIOCENTESIS THER AMNIOTIC FLUID RDCTJ US GUID

Professional

Both

$418.00

Service Code	HCPCS 59001
Min. Negotiated Rate	$113.74
Max. Negotiated Rate	$523.55
Rate for Payer: Aetna Commercial	$194.91
Rate for Payer: Aetna Medicare	$209.00
Rate for Payer: BCBS Complete	$119.43
Rate for Payer: BCBS Trust/PPO	$523.55
Rate for Payer: BCN Commercial	$259.98
Rate for Payer: Cash Price	$334.40
Rate for Payer: Cash Price	$334.40
Rate for Payer: Meridian Medicaid	$119.43
Rate for Payer: Priority Health Choice Medicaid	$113.74
Rate for Payer: Priority Health Cigna Priority Health	$271.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$249.18
Rate for Payer: Priority Health Narrow Network	$249.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$211.21
Rate for Payer: UHC Exchange	$211.21
Rate for Payer: UHCCP Medicaid	$113.74

PR AMP ARM THRU HUMERUS SECONDARY CLSR/SCAR REVJ

Professional

Both

$1,591.00

Service Code	HCPCS 24925
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$1,034.15
Rate for Payer: Aetna Commercial	$758.37
Rate for Payer: Aetna Medicare	$795.50
Rate for Payer: BCBS Complete	$393.40
Rate for Payer: BCBS Trust/PPO	$140.00
Rate for Payer: BCN Commercial	$842.97
Rate for Payer: Cash Price	$1,272.80
Rate for Payer: Cash Price	$1,272.80
Rate for Payer: Meridian Medicaid	$393.40
Rate for Payer: Priority Health Choice Medicaid	$374.67
Rate for Payer: Priority Health Cigna Priority Health	$1,034.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$886.44
Rate for Payer: Priority Health Narrow Network	$886.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$634.73
Rate for Payer: UHC Exchange	$634.73
Rate for Payer: UHCCP Medicaid	$374.67

PR AMP F/ARM THRU RADIUS&ULNA SEC CLOSURE/SCAR RE

Professional

Both

$1,616.00

Service Code	HCPCS 25907
Min. Negotiated Rate	$206.57
Max. Negotiated Rate	$1,050.40
Rate for Payer: Aetna Commercial	$820.99
Rate for Payer: Aetna Medicare	$808.00
Rate for Payer: BCBS Complete	$423.82
Rate for Payer: BCBS Trust/PPO	$206.57
Rate for Payer: BCN Commercial	$908.45
Rate for Payer: Cash Price	$1,292.80
Rate for Payer: Cash Price	$1,292.80
Rate for Payer: Meridian Medicaid	$423.82
Rate for Payer: Priority Health Choice Medicaid	$403.64
Rate for Payer: Priority Health Cigna Priority Health	$1,050.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$956.15
Rate for Payer: Priority Health Narrow Network	$956.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$728.59
Rate for Payer: UHC Exchange	$728.59
Rate for Payer: UHCCP Medicaid	$403.64

PR AMP FOREARM THRU RADIUS & ULNA OPEN CIRCULAR

Professional

Both

$1,920.00

Service Code	HCPCS 25905
Min. Negotiated Rate	$173.28
Max. Negotiated Rate	$1,248.00
Rate for Payer: Aetna Commercial	$938.09
Rate for Payer: Aetna Medicare	$960.00
Rate for Payer: BCBS Complete	$481.97
Rate for Payer: BCBS Trust/PPO	$173.28
Rate for Payer: BCN Commercial	$1,035.02
Rate for Payer: Cash Price	$1,536.00
Rate for Payer: Cash Price	$1,536.00
Rate for Payer: Meridian Medicaid	$481.97
Rate for Payer: Priority Health Choice Medicaid	$459.02
Rate for Payer: Priority Health Cigna Priority Health	$1,248.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,087.95
Rate for Payer: Priority Health Narrow Network	$1,087.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$833.60
Rate for Payer: UHC Exchange	$833.60
Rate for Payer: UHCCP Medicaid	$459.02

PR AMP FOREARM THRU RADIUS&ULNA RE-AMPUTATION

Professional

Both

$1,237.00

Service Code	HCPCS 25909
Min. Negotiated Rate	$304.30
Max. Negotiated Rate	$1,061.99
Rate for Payer: Aetna Commercial	$915.24
Rate for Payer: Aetna Medicare	$618.50
Rate for Payer: BCBS Complete	$471.45
Rate for Payer: BCBS Trust/PPO	$304.30
Rate for Payer: BCN Commercial	$1,012.05
Rate for Payer: Cash Price	$989.60
Rate for Payer: Cash Price	$989.60
Rate for Payer: Meridian Medicaid	$471.45
Rate for Payer: Priority Health Choice Medicaid	$449.00
Rate for Payer: Priority Health Cigna Priority Health	$804.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,061.99
Rate for Payer: Priority Health Narrow Network	$1,061.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$816.31
Rate for Payer: UHC Exchange	$816.31
Rate for Payer: UHCCP Medicaid	$449.00

PR AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP

Professional

Both

$2,200.00

Service Code	HCPCS 26952
Min. Negotiated Rate	$285.28
Max. Negotiated Rate	$1,430.00
Rate for Payer: Aetna Commercial	$900.77
Rate for Payer: Aetna Medicare	$1,100.00
Rate for Payer: BCBS Complete	$464.74
Rate for Payer: BCBS Trust/PPO	$285.28
Rate for Payer: BCN Commercial	$1,018.41
Rate for Payer: Cash Price	$1,760.00
Rate for Payer: Cash Price	$1,760.00
Rate for Payer: Meridian Medicaid	$464.74
Rate for Payer: Priority Health Choice Medicaid	$442.61
Rate for Payer: Priority Health Cigna Priority Health	$1,430.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,058.43
Rate for Payer: Priority Health Narrow Network	$1,058.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$715.02
Rate for Payer: UHC Exchange	$715.02
Rate for Payer: UHCCP Medicaid	$442.61

PR AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR

Professional

Both

$1,650.00

Service Code	HCPCS 26951
Min. Negotiated Rate	$455.61
Max. Negotiated Rate	$4,383.83
Rate for Payer: Aetna Commercial	$916.42
Rate for Payer: Aetna Medicare	$825.00
Rate for Payer: BCBS Complete	$478.39
Rate for Payer: BCBS Trust/PPO	$4,383.83
Rate for Payer: BCN Commercial	$1,042.35
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Meridian Medicaid	$478.39
Rate for Payer: Priority Health Choice Medicaid	$455.61
Rate for Payer: Priority Health Cigna Priority Health	$1,072.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,088.96
Rate for Payer: Priority Health Narrow Network	$1,088.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$697.84
Rate for Payer: UHC Exchange	$697.84
Rate for Payer: UHCCP Medicaid	$455.61

PR AMPICILLIN 500 MG INJ

Professional

Both

$20.00

Service Code	HCPCS J0290
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$1.04
Rate for Payer: Aetna Medicare	$10.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS Trust/PPO	$0.17
Rate for Payer: BCN Commercial	$0.15
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Priority Health Cigna Priority Health	$13.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$0.88
Rate for Payer: UHC Exchange	$0.88

PR AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION

Professional

Both

$1,993.00

Service Code	HCPCS 27886
Min. Negotiated Rate	$416.63
Max. Negotiated Rate	$1,295.45
Rate for Payer: Aetna Commercial	$873.61
Rate for Payer: Aetna Medicare	$996.50
Rate for Payer: BCBS Complete	$437.46
Rate for Payer: BCBS Trust/PPO	$527.77
Rate for Payer: BCN Commercial	$944.61
Rate for Payer: Cash Price	$1,594.40
Rate for Payer: Cash Price	$1,594.40
Rate for Payer: Meridian Medicaid	$437.46
Rate for Payer: Priority Health Choice Medicaid	$416.63
Rate for Payer: Priority Health Cigna Priority Health	$1,295.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$990.76
Rate for Payer: Priority Health Narrow Network	$990.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$788.89
Rate for Payer: UHC Exchange	$788.89
Rate for Payer: UHCCP Medicaid	$416.63

Know your out-of-pocket cost for care.

All Charges