Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR EVASC RPR DPLMNT ILIO-ILIAC NDGFT RPT

Professional

Both

$3,899.00

Service Code	HCPCS 34708
Min. Negotiated Rate	$1,134.44
Max. Negotiated Rate	$2,827.72
Rate for Payer: Aetna Commercial	$2,493.77
Rate for Payer: Aetna Medicare	$1,949.50
Rate for Payer: BCBS Complete	$1,191.16
Rate for Payer: BCBS Trust/PPO	$1,929.88
Rate for Payer: BCN Commercial	$2,587.55
Rate for Payer: Cash Price	$3,119.20
Rate for Payer: Cash Price	$3,119.20
Rate for Payer: Meridian Medicaid	$1,191.16
Rate for Payer: Priority Health Choice Medicaid	$1,134.44
Rate for Payer: Priority Health Cigna Priority Health	$2,534.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,827.72
Rate for Payer: Priority Health Narrow Network	$2,827.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,482.36
Rate for Payer: UHC Exchange	$2,482.36
Rate for Payer: UHCCP Medicaid	$1,134.44

PR EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH

Professional

Both

$8,245.00

Service Code	HCPCS 33880
Min. Negotiated Rate	$649.81
Max. Negotiated Rate	$5,359.25
Rate for Payer: Aetna Commercial	$2,407.28
Rate for Payer: Aetna Medicare	$4,122.50
Rate for Payer: BCBS Complete	$1,169.24
Rate for Payer: BCBS Trust/PPO	$649.81
Rate for Payer: BCN Commercial	$2,552.85
Rate for Payer: Cash Price	$6,596.00
Rate for Payer: Cash Price	$6,596.00
Rate for Payer: Meridian Medicaid	$1,169.24
Rate for Payer: Priority Health Choice Medicaid	$1,113.56
Rate for Payer: Priority Health Cigna Priority Health	$5,359.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,779.31
Rate for Payer: Priority Health Narrow Network	$2,779.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,428.45
Rate for Payer: UHC Exchange	$2,428.45
Rate for Payer: UHCCP Medicaid	$1,113.56

PR EVASC RPR DTA EXP COVERAGE W/O ART ORIGIN

Professional

Both

$5,504.00

Service Code	HCPCS 33881
Min. Negotiated Rate	$924.53
Max. Negotiated Rate	$3,577.60
Rate for Payer: Aetna Commercial	$2,063.09
Rate for Payer: Aetna Medicare	$2,752.00
Rate for Payer: BCBS Complete	$1,004.41
Rate for Payer: BCBS Trust/PPO	$924.53
Rate for Payer: BCN Commercial	$2,187.32
Rate for Payer: Cash Price	$4,403.20
Rate for Payer: Cash Price	$4,403.20
Rate for Payer: Meridian Medicaid	$1,004.41
Rate for Payer: Priority Health Choice Medicaid	$956.58
Rate for Payer: Priority Health Cigna Priority Health	$3,577.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,387.37
Rate for Payer: Priority Health Narrow Network	$2,387.37
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,085.23
Rate for Payer: UHC Exchange	$2,085.23
Rate for Payer: UHCCP Medicaid	$956.58

PR EVASC RPR ILAC ART BIFUR ENDGRFT CATHJ RS&I UNI

Professional

Both

$959.00

Service Code	HCPCS 0254T
Min. Negotiated Rate	$383.60
Max. Negotiated Rate	$623.35
Rate for Payer: Aetna Medicare	$479.50
Rate for Payer: BCBS Complete	$383.60
Rate for Payer: Cash Price	$767.20
Rate for Payer: Priority Health Cigna Priority Health	$623.35

PR EVASC RPR ILIAC ART N/A A-ILIAC ART NDGFT UNI

Professional

Both

$2,162.00

Service Code	HCPCS 34718
Min. Negotiated Rate	$770.63
Max. Negotiated Rate	$1,924.14
Rate for Payer: Aetna Commercial	$1,652.85
Rate for Payer: Aetna Medicare	$1,081.00
Rate for Payer: BCBS Complete	$809.16
Rate for Payer: BCBS Trust/PPO	$1,579.62
Rate for Payer: BCN Commercial	$1,758.75
Rate for Payer: Cash Price	$1,729.60
Rate for Payer: Cash Price	$1,729.60
Rate for Payer: Meridian Medicaid	$809.16
Rate for Payer: Priority Health Choice Medicaid	$770.63
Rate for Payer: Priority Health Cigna Priority Health	$1,405.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,924.14
Rate for Payer: Priority Health Narrow Network	$1,924.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,672.88
Rate for Payer: UHC Exchange	$1,672.88
Rate for Payer: UHCCP Medicaid	$770.63

PR EVASC RPR ILIAC ART TM OF A-ILIAC ART NDGFT UNI

Professional

Both

$809.00

Service Code	HCPCS 34717
Min. Negotiated Rate	$274.77
Max. Negotiated Rate	$1,145.35
Rate for Payer: Aetna Commercial	$594.51
Rate for Payer: Aetna Medicare	$404.50
Rate for Payer: BCBS Complete	$288.51
Rate for Payer: BCBS Trust/PPO	$1,145.35
Rate for Payer: BCN Commercial	$629.42
Rate for Payer: Cash Price	$647.20
Rate for Payer: Cash Price	$647.20
Rate for Payer: Meridian Medicaid	$288.51
Rate for Payer: Priority Health Choice Medicaid	$274.77
Rate for Payer: Priority Health Cigna Priority Health	$525.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$686.58
Rate for Payer: Priority Health Narrow Network	$686.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$601.11
Rate for Payer: UHC Exchange	$601.11
Rate for Payer: UHCCP Medicaid	$274.77

PR EVASC TEMP BALLOON ARTL OCCLUSION HEAD/NECK

Professional

Both

$3,336.00

Service Code	HCPCS 61623
Min. Negotiated Rate	$124.15
Max. Negotiated Rate	$2,168.40
Rate for Payer: Aetna Commercial	$737.47
Rate for Payer: Aetna Medicare	$1,668.00
Rate for Payer: BCBS Complete	$386.91
Rate for Payer: BCBS Trust/PPO	$124.15
Rate for Payer: BCN Commercial	$838.57
Rate for Payer: Cash Price	$2,668.80
Rate for Payer: Cash Price	$2,668.80
Rate for Payer: Meridian Medicaid	$386.91
Rate for Payer: Priority Health Choice Medicaid	$368.49
Rate for Payer: Priority Health Cigna Priority Health	$2,168.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$980.47
Rate for Payer: Priority Health Narrow Network	$980.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$675.28
Rate for Payer: UHC Exchange	$675.28
Rate for Payer: UHCCP Medicaid	$368.49

PR EWHO RIGID W/O JNTS CF

Professional

Both

$699.00

Service Code	HCPCS L3763
Min. Negotiated Rate	$279.60
Max. Negotiated Rate	$646.68
Rate for Payer: Aetna Commercial	$410.20
Rate for Payer: Aetna Medicare	$349.50
Rate for Payer: BCBS Complete	$279.60
Rate for Payer: BCN Commercial	$646.68
Rate for Payer: Cash Price	$559.20
Rate for Payer: Cash Price	$559.20
Rate for Payer: Priority Health Cigna Priority Health	$454.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$370.01
Rate for Payer: UHC Exchange	$370.01

PR EWHO W/JOINT(S) CF

Professional

Both

$731.00

Service Code	HCPCS L3764
Min. Negotiated Rate	$292.40
Max. Negotiated Rate	$676.76
Rate for Payer: Aetna Commercial	$429.28
Rate for Payer: Aetna Medicare	$365.50
Rate for Payer: BCBS Complete	$292.40
Rate for Payer: BCN Commercial	$676.76
Rate for Payer: Cash Price	$584.80
Rate for Payer: Cash Price	$584.80
Rate for Payer: Priority Health Cigna Priority Health	$475.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$387.22
Rate for Payer: UHC Exchange	$387.22

PR EXC 1/> SMALL/LARGE LESIONS INTESTINE ENTEROTOM

Professional

Both

$2,379.00

Service Code	HCPCS 44110
Min. Negotiated Rate	$545.71
Max. Negotiated Rate	$1,643.01
Rate for Payer: Aetna Commercial	$1,141.78
Rate for Payer: Aetna Medicare	$1,189.50
Rate for Payer: BCBS Complete	$573.00
Rate for Payer: BCBS Trust/PPO	$1,643.01
Rate for Payer: BCN Commercial	$1,234.88
Rate for Payer: Cash Price	$1,903.20
Rate for Payer: Cash Price	$1,903.20
Rate for Payer: Meridian Medicaid	$573.00
Rate for Payer: Priority Health Choice Medicaid	$545.71
Rate for Payer: Priority Health Cigna Priority Health	$1,546.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,523.10
Rate for Payer: Priority Health Narrow Network	$1,523.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,022.59
Rate for Payer: UHC Exchange	$1,022.59
Rate for Payer: UHCCP Medicaid	$545.71

PR EXC 1/> SM/LG LESIONS INTESTNE MULT ENTEROTOMIE

Professional

Both

$3,605.00

Service Code	HCPCS 44111
Min. Negotiated Rate	$266.79
Max. Negotiated Rate	$2,343.25
Rate for Payer: Aetna Commercial	$1,314.35
Rate for Payer: Aetna Medicare	$1,802.50
Rate for Payer: BCBS Complete	$659.32
Rate for Payer: BCBS Trust/PPO	$266.79
Rate for Payer: BCN Commercial	$1,435.25
Rate for Payer: Cash Price	$2,884.00
Rate for Payer: Cash Price	$2,884.00
Rate for Payer: Meridian Medicaid	$659.32
Rate for Payer: Priority Health Choice Medicaid	$627.92
Rate for Payer: Priority Health Cigna Priority Health	$2,343.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,748.62
Rate for Payer: Priority Health Narrow Network	$1,748.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,190.55
Rate for Payer: UHC Exchange	$1,190.55
Rate for Payer: UHCCP Medicaid	$627.92

PR EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/<

Facility

$224.00

Service Code	CPT 11440
Hospital Charge Code	11440
Hospital Revenue Code	521
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$224.00
Rate for Payer: Aetna Commercial	$201.60
Rate for Payer: ASR ASR	$217.28
Rate for Payer: ASR Commercial	$217.28
Rate for Payer: BCBS Trust/PPO	$182.54
Rate for Payer: BCN Commercial	$173.67
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cofinity Commercial	$210.56
Rate for Payer: Encore Health Key Benefits Commercial	$179.20
Rate for Payer: Healthscope Commercial	$224.00
Rate for Payer: Healthscope Whirlpool	$217.28
Rate for Payer: Mclaren Commercial	$201.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$190.40
Rate for Payer: Nomi Health Commercial	$183.68
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$197.12

PR EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/<

Facility

$224.00

Service Code	CPT 11440
Hospital Charge Code	11440
Hospital Revenue Code	521
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$1,068.51
Rate for Payer: Aetna Commercial	$201.60
Rate for Payer: Aetna Medicare	$689.36
Rate for Payer: Allen County Amish Medical Aid Commercial	$861.70
Rate for Payer: Amish Plain Church Group Commercial	$861.70
Rate for Payer: ASR ASR	$217.28
Rate for Payer: ASR Commercial	$217.28
Rate for Payer: BCBS Complete	$387.97
Rate for Payer: BCBS MAPPO	$689.36
Rate for Payer: BCBS Trust/PPO	$183.43
Rate for Payer: BCN Commercial	$173.67
Rate for Payer: BCN Medicare Advantage	$689.36
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cofinity Commercial	$210.56
Rate for Payer: Encore Health Key Benefits Commercial	$179.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$689.36
Rate for Payer: Healthscope Commercial	$224.00
Rate for Payer: Healthscope Whirlpool	$217.28
Rate for Payer: Humana Choice PPO Medicare	$689.36
Rate for Payer: Mclaren Commercial	$201.60
Rate for Payer: Mclaren Medicaid	$369.50
Rate for Payer: Mclaren Medicare	$689.36
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$723.83
Rate for Payer: Meridian Medicaid	$387.97
Rate for Payer: MI Amish Medical Board Commercial	$792.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$190.40
Rate for Payer: Nomi Health Commercial	$183.68
Rate for Payer: PACE Medicare	$654.89
Rate for Payer: PACE SWMI	$689.36
Rate for Payer: PHP Commercial	$758.30
Rate for Payer: PHP Medicaid	$369.50
Rate for Payer: PHP Medicare Advantage	$689.36
Rate for Payer: Priority Health Choice Medicaid	$369.50
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$196.27
Rate for Payer: Priority Health Medicare	$689.36
Rate for Payer: Priority Health Narrow Network	$157.02
Rate for Payer: Railroad Medicare Medicare	$689.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$197.12
Rate for Payer: UHC Dual Complete DSNP	$689.36
Rate for Payer: UHC Exchange	$1,068.51
Rate for Payer: UHC Medicare Advantage	$689.36
Rate for Payer: UHCCP DNSP	$689.36
Rate for Payer: UHCCP Medicaid	$369.50
Rate for Payer: VA VA	$689.36

PR EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/<

Professional

Both

$224.00

Service Code	HCPCS 11440
Hospital Charge Code	11440
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$169.24
Rate for Payer: Aetna Commercial	$109.82
Rate for Payer: Aetna Medicare	$112.00
Rate for Payer: BCBS Complete	$72.91
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: BCN Commercial	$169.24
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Meridian Medicaid	$72.91
Rate for Payer: Priority Health Choice Medicaid	$69.44
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$146.29
Rate for Payer: Priority Health Narrow Network	$146.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$102.09
Rate for Payer: UHC Exchange	$102.09
Rate for Payer: UHCCP Medicaid	$69.44

PR EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/<

Professional

Both

$224.00

Service Code	HCPCS 11440
Min. Negotiated Rate	$28.95
Max. Negotiated Rate	$169.24
Rate for Payer: Aetna Commercial	$109.82
Rate for Payer: Aetna Medicare	$112.00
Rate for Payer: BCBS Complete	$72.91
Rate for Payer: BCBS Trust/PPO	$28.95
Rate for Payer: BCN Commercial	$169.24
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Meridian Medicaid	$72.91
Rate for Payer: Priority Health Choice Medicaid	$69.44
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$146.29
Rate for Payer: Priority Health Narrow Network	$146.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$102.09
Rate for Payer: UHC Exchange	$102.09
Rate for Payer: UHCCP Medicaid	$69.44

PR EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M > 4.0CM

Professional

Both

$826.00

Service Code	HCPCS 11446
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$536.90
Rate for Payer: Aetna Commercial	$345.75
Rate for Payer: Aetna Medicare	$413.00
Rate for Payer: BCBS Complete	$215.83
Rate for Payer: BCBS Trust/PPO	$150.00
Rate for Payer: BCN Commercial	$449.99
Rate for Payer: Cash Price	$660.80
Rate for Payer: Cash Price	$660.80
Rate for Payer: Meridian Medicaid	$215.83
Rate for Payer: Priority Health Choice Medicaid	$205.55
Rate for Payer: Priority Health Cigna Priority Health	$536.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$430.30
Rate for Payer: Priority Health Narrow Network	$430.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$337.27
Rate for Payer: UHC Exchange	$337.27
Rate for Payer: UHCCP Medicaid	$205.55

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/<

Professional

Both

$203.00

Service Code	HCPCS 11420
Min. Negotiated Rate	$53.46
Max. Negotiated Rate	$150.39
Rate for Payer: Aetna Commercial	$87.38
Rate for Payer: Aetna Medicare	$101.50
Rate for Payer: BCBS Complete	$56.13
Rate for Payer: BCBS Trust/PPO	$100.72
Rate for Payer: BCN Commercial	$150.39
Rate for Payer: Cash Price	$162.40
Rate for Payer: Cash Price	$162.40
Rate for Payer: Meridian Medicaid	$56.13
Rate for Payer: Priority Health Choice Medicaid	$53.46
Rate for Payer: Priority Health Cigna Priority Health	$131.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$111.97
Rate for Payer: Priority Health Narrow Network	$111.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$83.58
Rate for Payer: UHC Exchange	$83.58
Rate for Payer: UHCCP Medicaid	$53.46

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM

Professional

Both

$261.00

Service Code	HCPCS 11421
Min. Negotiated Rate	$70.50
Max. Negotiated Rate	$338.18
Rate for Payer: Aetna Commercial	$116.28
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS Complete	$74.02
Rate for Payer: BCBS Trust/PPO	$338.18
Rate for Payer: BCN Commercial	$188.87
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Meridian Medicaid	$74.02
Rate for Payer: Priority Health Choice Medicaid	$70.50
Rate for Payer: Priority Health Cigna Priority Health	$169.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$148.55
Rate for Payer: Priority Health Narrow Network	$148.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$114.26
Rate for Payer: UHC Exchange	$114.26
Rate for Payer: UHCCP Medicaid	$70.50

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM

Facility

$261.00

Service Code	CPT 11421
Hospital Charge Code	11421
Hospital Revenue Code	521
Min. Negotiated Rate	$169.65
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$234.90
Rate for Payer: ASR ASR	$253.17
Rate for Payer: ASR Commercial	$253.17
Rate for Payer: BCBS Trust/PPO	$212.69
Rate for Payer: BCN Commercial	$202.35
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cofinity Commercial	$245.34
Rate for Payer: Encore Health Key Benefits Commercial	$208.80
Rate for Payer: Healthscope Commercial	$261.00
Rate for Payer: Healthscope Whirlpool	$253.17
Rate for Payer: Mclaren Commercial	$234.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.85
Rate for Payer: Nomi Health Commercial	$214.02
Rate for Payer: Priority Health Cigna Priority Health	$169.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$229.68

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM

Facility

$261.00

Service Code	CPT 11421
Hospital Charge Code	11421
Hospital Revenue Code	521
Min. Negotiated Rate	$169.65
Max. Negotiated Rate	$1,068.51
Rate for Payer: Aetna Commercial	$234.90
Rate for Payer: Aetna Medicare	$689.36
Rate for Payer: Allen County Amish Medical Aid Commercial	$861.70
Rate for Payer: Amish Plain Church Group Commercial	$861.70
Rate for Payer: ASR ASR	$253.17
Rate for Payer: ASR Commercial	$253.17
Rate for Payer: BCBS Complete	$387.97
Rate for Payer: BCBS MAPPO	$689.36
Rate for Payer: BCBS Trust/PPO	$213.73
Rate for Payer: BCN Commercial	$202.35
Rate for Payer: BCN Medicare Advantage	$689.36
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cofinity Commercial	$245.34
Rate for Payer: Encore Health Key Benefits Commercial	$208.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$689.36
Rate for Payer: Healthscope Commercial	$261.00
Rate for Payer: Healthscope Whirlpool	$253.17
Rate for Payer: Humana Choice PPO Medicare	$689.36
Rate for Payer: Mclaren Commercial	$234.90
Rate for Payer: Mclaren Medicaid	$369.50
Rate for Payer: Mclaren Medicare	$689.36
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$723.83
Rate for Payer: Meridian Medicaid	$387.97
Rate for Payer: MI Amish Medical Board Commercial	$792.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.85
Rate for Payer: Nomi Health Commercial	$214.02
Rate for Payer: PACE Medicare	$654.89
Rate for Payer: PACE SWMI	$689.36
Rate for Payer: PHP Commercial	$758.30
Rate for Payer: PHP Medicaid	$369.50
Rate for Payer: PHP Medicare Advantage	$689.36
Rate for Payer: Priority Health Choice Medicaid	$369.50
Rate for Payer: Priority Health Cigna Priority Health	$169.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$228.69
Rate for Payer: Priority Health Medicare	$689.36
Rate for Payer: Priority Health Narrow Network	$182.96
Rate for Payer: Railroad Medicare Medicare	$689.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$229.68
Rate for Payer: UHC Dual Complete DSNP	$689.36
Rate for Payer: UHC Exchange	$1,068.51
Rate for Payer: UHC Medicare Advantage	$689.36
Rate for Payer: UHCCP DNSP	$689.36
Rate for Payer: UHCCP Medicaid	$369.50
Rate for Payer: VA VA	$689.36

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM

Professional

Both

$261.00

Service Code	HCPCS 11421
Hospital Charge Code	11421
Min. Negotiated Rate	$70.50
Max. Negotiated Rate	$338.18
Rate for Payer: Aetna Commercial	$116.28
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS Complete	$74.02
Rate for Payer: BCBS Trust/PPO	$338.18
Rate for Payer: BCN Commercial	$188.87
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Meridian Medicaid	$74.02
Rate for Payer: Priority Health Choice Medicaid	$70.50
Rate for Payer: Priority Health Cigna Priority Health	$169.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$148.55
Rate for Payer: Priority Health Narrow Network	$148.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$114.26
Rate for Payer: UHC Exchange	$114.26
Rate for Payer: UHCCP Medicaid	$70.50

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM

Professional

Both

$291.00

Service Code	HCPCS 11422
Hospital Charge Code	11422
Min. Negotiated Rate	$32.57
Max. Negotiated Rate	$211.65
Rate for Payer: Aetna Commercial	$143.70
Rate for Payer: Aetna Medicare	$145.50
Rate for Payer: BCBS Complete	$92.82
Rate for Payer: BCBS Trust/PPO	$32.57
Rate for Payer: BCN Commercial	$211.65
Rate for Payer: Cash Price	$232.80
Rate for Payer: Cash Price	$232.80
Rate for Payer: Meridian Medicaid	$92.82
Rate for Payer: Priority Health Choice Medicaid	$88.40
Rate for Payer: Priority Health Cigna Priority Health	$189.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$185.12
Rate for Payer: Priority Health Narrow Network	$185.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$137.74
Rate for Payer: UHC Exchange	$137.74
Rate for Payer: UHCCP Medicaid	$88.40

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM

Facility

$291.00

Service Code	CPT 11422
Hospital Charge Code	11422
Hospital Revenue Code	521
Min. Negotiated Rate	$189.15
Max. Negotiated Rate	$2,460.59
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: Aetna Medicare	$1,587.48
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,984.35
Rate for Payer: Amish Plain Church Group Commercial	$1,984.35
Rate for Payer: ASR ASR	$282.27
Rate for Payer: ASR Commercial	$282.27
Rate for Payer: BCBS Complete	$893.43
Rate for Payer: BCBS MAPPO	$1,587.48
Rate for Payer: BCBS Trust/PPO	$238.30
Rate for Payer: BCN Commercial	$225.61
Rate for Payer: BCN Medicare Advantage	$1,587.48
Rate for Payer: Cash Price	$232.80
Rate for Payer: Cash Price	$232.80
Rate for Payer: Cofinity Commercial	$273.54
Rate for Payer: Encore Health Key Benefits Commercial	$232.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,587.48
Rate for Payer: Healthscope Commercial	$291.00
Rate for Payer: Healthscope Whirlpool	$282.27
Rate for Payer: Humana Choice PPO Medicare	$1,587.48
Rate for Payer: Mclaren Commercial	$261.90
Rate for Payer: Mclaren Medicaid	$850.89
Rate for Payer: Mclaren Medicare	$1,587.48
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,666.85
Rate for Payer: Meridian Medicaid	$893.43
Rate for Payer: MI Amish Medical Board Commercial	$1,825.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$247.35
Rate for Payer: Nomi Health Commercial	$238.62
Rate for Payer: PACE Medicare	$1,508.11
Rate for Payer: PACE SWMI	$1,587.48
Rate for Payer: PHP Commercial	$1,746.23
Rate for Payer: PHP Medicaid	$850.89
Rate for Payer: PHP Medicare Advantage	$1,587.48
Rate for Payer: Priority Health Choice Medicaid	$850.89
Rate for Payer: Priority Health Cigna Priority Health	$189.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$254.97
Rate for Payer: Priority Health Medicare	$1,587.48
Rate for Payer: Priority Health Narrow Network	$203.99
Rate for Payer: Railroad Medicare Medicare	$1,587.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$256.08
Rate for Payer: UHC Dual Complete DSNP	$1,587.48
Rate for Payer: UHC Exchange	$2,460.59
Rate for Payer: UHC Medicare Advantage	$1,587.48
Rate for Payer: UHCCP DNSP	$1,587.48
Rate for Payer: UHCCP Medicaid	$850.89
Rate for Payer: VA VA	$1,587.48

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM

Facility

$291.00

Service Code	CPT 11422
Hospital Charge Code	11422
Hospital Revenue Code	521
Min. Negotiated Rate	$189.15
Max. Negotiated Rate	$291.00
Rate for Payer: Aetna Commercial	$261.90
Rate for Payer: ASR ASR	$282.27
Rate for Payer: ASR Commercial	$282.27
Rate for Payer: BCBS Trust/PPO	$237.14
Rate for Payer: BCN Commercial	$225.61
Rate for Payer: Cash Price	$232.80
Rate for Payer: Cofinity Commercial	$273.54
Rate for Payer: Encore Health Key Benefits Commercial	$232.80
Rate for Payer: Healthscope Commercial	$291.00
Rate for Payer: Healthscope Whirlpool	$282.27
Rate for Payer: Mclaren Commercial	$261.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$247.35
Rate for Payer: Nomi Health Commercial	$238.62
Rate for Payer: Priority Health Cigna Priority Health	$189.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$256.08

PR EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 1.1-2.0CM

Professional

Both

$291.00

Service Code	HCPCS 11422
Min. Negotiated Rate	$32.57
Max. Negotiated Rate	$211.65
Rate for Payer: Aetna Commercial	$143.70
Rate for Payer: Aetna Medicare	$145.50
Rate for Payer: BCBS Complete	$92.82
Rate for Payer: BCBS Trust/PPO	$32.57
Rate for Payer: BCN Commercial	$211.65
Rate for Payer: Cash Price	$232.80
Rate for Payer: Cash Price	$232.80
Rate for Payer: Meridian Medicaid	$92.82
Rate for Payer: Priority Health Choice Medicaid	$88.40
Rate for Payer: Priority Health Cigna Priority Health	$189.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$185.12
Rate for Payer: Priority Health Narrow Network	$185.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$137.74
Rate for Payer: UHC Exchange	$137.74
Rate for Payer: UHCCP Medicaid	$88.40

Know your out-of-pocket cost for care.

All Charges