Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR MONALISA TOUCH, SERIES, UP TO 7 VISITS, LICHEN SCLEROSUS

Professional

Both

$2,142.00

Service Code	HCPCS 00560
Hospital Revenue Code	990
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,392.30
Rate for Payer: Aetna Medicare	$1,071.00
Rate for Payer: BCBS Complete	$856.80
Rate for Payer: Cash Price	$1,713.60
Rate for Payer: Priority Health Cigna Priority Health	$1,392.30

PR MONOVISC INJ PER DOSE

Professional

Both

$941.00

Service Code	HCPCS J7327
Min. Negotiated Rate	$376.40
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$735.80
Rate for Payer: Aetna Medicare	$470.50
Rate for Payer: BCBS Complete	$376.40
Rate for Payer: BCBS Trust/PPO	$727.84
Rate for Payer: BCN Commercial	$800.00
Rate for Payer: Cash Price	$752.80
Rate for Payer: Cash Price	$752.80
Rate for Payer: Priority Health Cigna Priority Health	$611.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$651.85
Rate for Payer: UHC Exchange	$651.85

PR MORPHINE SULFATE INJECTION

Professional

Both

$8.00

Service Code	HCPCS J2270
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$5.20
Rate for Payer: Aetna Commercial	$4.80
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: BCBS Trust/PPO	$0.09
Rate for Payer: BCN Commercial	$0.06
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.24
Rate for Payer: UHC Exchange	$3.24

PR MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB

Professional

Both

$138.00

Service Code	HCPCS 95905
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1,790.41
Rate for Payer: Aetna Commercial	$49.71
Rate for Payer: Aetna Medicare	$69.00
Rate for Payer: BCBS Complete	$1.78
Rate for Payer: BCBS Trust/PPO	$1,790.41
Rate for Payer: BCN Commercial	$50.33
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Meridian Medicaid	$1.78
Rate for Payer: Priority Health Choice Medicaid	$1.70
Rate for Payer: Priority Health Cigna Priority Health	$89.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.61
Rate for Payer: Priority Health Narrow Network	$3.61
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$78.38
Rate for Payer: UHC Exchange	$78.38
Rate for Payer: UHCCP Medicaid	$1.70

PR MPSV4 VACCINE GROUPS ACYW-135 SUBQ USE

Professional

Both

$129.00

Service Code	HCPCS 90733
Min. Negotiated Rate	$51.60
Max. Negotiated Rate	$177.18
Rate for Payer: Aetna Commercial	$125.50
Rate for Payer: Aetna Medicare	$64.50
Rate for Payer: BCBS Complete	$51.60
Rate for Payer: BCBS Trust/PPO	$125.49
Rate for Payer: BCN Commercial	$123.17
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Priority Health Cigna Priority Health	$83.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$177.18
Rate for Payer: UHC Exchange	$177.18

PR MULTIPLE FAM GROUP BHV TX GDN PHYS/QHP EA 15 MIN

Professional

Both

$61.00

Service Code	HCPCS 97157
Min. Negotiated Rate	$20.79
Max. Negotiated Rate	$997.43
Rate for Payer: Aetna Commercial	$20.79
Rate for Payer: Aetna Medicare	$30.50
Rate for Payer: BCBS Complete	$24.40
Rate for Payer: BCBS Trust/PPO	$997.43
Rate for Payer: BCN Commercial	$23.79
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Priority Health Cigna Priority Health	$39.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27.60
Rate for Payer: Priority Health Narrow Network	$27.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$23.09
Rate for Payer: UHC Exchange	$23.09

PR MULTIPLE FAMILY GROUP PSYCHOTHERAPY

Professional

Both

$92.00

Service Code	HCPCS 90849
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$59.80
Rate for Payer: Aetna Commercial	$46.80
Rate for Payer: Aetna Medicare	$46.00
Rate for Payer: BCBS Complete	$36.80
Rate for Payer: BCBS Trust/PPO	$58.11
Rate for Payer: BCN Commercial	$53.75
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cash Price	$73.60
Rate for Payer: Priority Health Cigna Priority Health	$59.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$38.14
Rate for Payer: Priority Health Narrow Network	$38.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$31.50
Rate for Payer: UHC Exchange	$31.50

PR MUSCLE-SKIN FLAP,HEAD/NECK

Professional

Both

$3,247.00

Service Code	HCPCS 15732
Min. Negotiated Rate	$1,298.80
Max. Negotiated Rate	$2,110.55
Rate for Payer: Aetna Medicare	$1,623.50
Rate for Payer: BCBS Complete	$1,298.80
Rate for Payer: Cash Price	$2,597.60
Rate for Payer: Priority Health Cigna Priority Health	$2,110.55

PR MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE

Professional

Both

$1,140.00

Service Code	HCPCS 24301
Min. Negotiated Rate	$114.64
Max. Negotiated Rate	$1,161.22
Rate for Payer: Aetna Commercial	$1,002.27
Rate for Payer: Aetna Medicare	$570.00
Rate for Payer: BCBS Complete	$514.62
Rate for Payer: BCBS Trust/PPO	$114.64
Rate for Payer: BCN Commercial	$1,109.30
Rate for Payer: Cash Price	$912.00
Rate for Payer: Cash Price	$912.00
Rate for Payer: Meridian Medicaid	$514.62
Rate for Payer: Priority Health Choice Medicaid	$490.11
Rate for Payer: Priority Health Cigna Priority Health	$741.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,161.22
Rate for Payer: Priority Health Narrow Network	$1,161.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$859.30
Rate for Payer: UHC Exchange	$859.30
Rate for Payer: UHCCP Medicaid	$490.11

PR MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE

Professional

Both

$3,065.00

Service Code	HCPCS 23397
Min. Negotiated Rate	$78.96
Max. Negotiated Rate	$1,992.25
Rate for Payer: Aetna Commercial	$1,512.60
Rate for Payer: Aetna Medicare	$1,532.50
Rate for Payer: BCBS Complete	$773.61
Rate for Payer: BCBS Trust/PPO	$78.96
Rate for Payer: BCN Commercial	$1,668.35
Rate for Payer: Cash Price	$2,452.00
Rate for Payer: Cash Price	$2,452.00
Rate for Payer: Meridian Medicaid	$773.61
Rate for Payer: Priority Health Choice Medicaid	$736.77
Rate for Payer: Priority Health Cigna Priority Health	$1,992.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,753.02
Rate for Payer: Priority Health Narrow Network	$1,753.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,321.15
Rate for Payer: UHC Exchange	$1,321.15
Rate for Payer: UHCCP Medicaid	$736.77

PR MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE

Professional

Both

$3,414.00

Service Code	HCPCS 23395
Min. Negotiated Rate	$61.98
Max. Negotiated Rate	$2,219.10
Rate for Payer: Aetna Commercial	$1,710.89
Rate for Payer: Aetna Medicare	$1,707.00
Rate for Payer: BCBS Complete	$874.02
Rate for Payer: BCBS Trust/PPO	$61.98
Rate for Payer: BCN Commercial	$1,875.55
Rate for Payer: Cash Price	$2,731.20
Rate for Payer: Cash Price	$2,731.20
Rate for Payer: Meridian Medicaid	$874.02
Rate for Payer: Priority Health Choice Medicaid	$832.40
Rate for Payer: Priority Health Cigna Priority Health	$2,219.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,972.34
Rate for Payer: Priority Health Narrow Network	$1,972.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,481.48
Rate for Payer: UHC Exchange	$1,481.48
Rate for Payer: UHCCP Medicaid	$832.40

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR

Professional

Both

$2,475.00

Service Code	HCPCS 15738
Min. Negotiated Rate	$75.69
Max. Negotiated Rate	$1,850.62
Rate for Payer: Aetna Commercial	$1,391.76
Rate for Payer: Aetna Medicare	$1,237.50
Rate for Payer: BCBS Complete	$852.56
Rate for Payer: BCBS Trust/PPO	$75.69
Rate for Payer: BCN Commercial	$1,850.62
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Meridian Medicaid	$852.56
Rate for Payer: Priority Health Choice Medicaid	$811.96
Rate for Payer: Priority Health Cigna Priority Health	$1,608.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,715.31
Rate for Payer: Priority Health Narrow Network	$1,715.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,342.02
Rate for Payer: UHC Exchange	$1,342.02
Rate for Payer: UHCCP Medicaid	$811.96

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Facility

$4,600.00

Service Code	CPT 15734
Hospital Charge Code	15734
Min. Negotiated Rate	$2,990.00
Max. Negotiated Rate	$4,600.00
Rate for Payer: Aetna Commercial	$4,140.00
Rate for Payer: ASR ASR	$4,462.00
Rate for Payer: ASR Commercial	$4,462.00
Rate for Payer: BCBS Trust/PPO	$3,748.54
Rate for Payer: BCN Commercial	$3,566.38
Rate for Payer: Cash Price	$3,680.00
Rate for Payer: Cofinity Commercial	$4,324.00
Rate for Payer: Encore Health Key Benefits Commercial	$3,680.00
Rate for Payer: Healthscope Commercial	$4,600.00
Rate for Payer: Healthscope Whirlpool	$4,462.00
Rate for Payer: Mclaren Commercial	$4,140.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,910.00
Rate for Payer: Nomi Health Commercial	$3,772.00
Rate for Payer: Priority Health Cigna Priority Health	$2,990.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,048.00

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Professional

Both

$4,600.00

Service Code	HCPCS 15734
Hospital Charge Code	15734
Min. Negotiated Rate	$75.69
Max. Negotiated Rate	$2,990.00
Rate for Payer: Aetna Commercial	$1,635.70
Rate for Payer: Aetna Medicare	$2,300.00
Rate for Payer: BCBS Complete	$1,013.81
Rate for Payer: BCBS Trust/PPO	$75.69
Rate for Payer: BCN Commercial	$2,188.30
Rate for Payer: Cash Price	$3,680.00
Rate for Payer: Cash Price	$3,680.00
Rate for Payer: Meridian Medicaid	$1,013.81
Rate for Payer: Priority Health Choice Medicaid	$965.53
Rate for Payer: Priority Health Cigna Priority Health	$2,990.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,032.28
Rate for Payer: Priority Health Narrow Network	$2,032.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,436.80
Rate for Payer: UHC Exchange	$1,436.80
Rate for Payer: UHCCP Medicaid	$965.53

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Facility

$4,600.00

Service Code	CPT 15734
Hospital Charge Code	15734
Min. Negotiated Rate	$1,922.61
Max. Negotiated Rate	$5,559.77
Rate for Payer: Aetna Commercial	$4,140.00
Rate for Payer: Aetna Medicare	$3,586.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,483.69
Rate for Payer: Amish Plain Church Group Commercial	$4,483.69
Rate for Payer: ASR ASR	$4,462.00
Rate for Payer: ASR Commercial	$4,462.00
Rate for Payer: BCBS Complete	$2,018.74
Rate for Payer: BCBS MAPPO	$3,586.95
Rate for Payer: BCBS Trust/PPO	$3,766.94
Rate for Payer: BCN Commercial	$3,566.38
Rate for Payer: BCN Medicare Advantage	$3,586.95
Rate for Payer: Cash Price	$3,680.00
Rate for Payer: Cash Price	$3,680.00
Rate for Payer: Cofinity Commercial	$4,324.00
Rate for Payer: Encore Health Key Benefits Commercial	$3,680.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,586.95
Rate for Payer: Healthscope Commercial	$4,600.00
Rate for Payer: Healthscope Whirlpool	$4,462.00
Rate for Payer: Humana Choice PPO Medicare	$3,586.95
Rate for Payer: Mclaren Commercial	$4,140.00
Rate for Payer: Mclaren Medicaid	$1,922.61
Rate for Payer: Mclaren Medicare	$3,586.95
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,766.30
Rate for Payer: Meridian Medicaid	$2,018.74
Rate for Payer: MI Amish Medical Board Commercial	$4,124.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,910.00
Rate for Payer: Nomi Health Commercial	$3,772.00
Rate for Payer: PACE Medicare	$3,407.60
Rate for Payer: PACE SWMI	$3,586.95
Rate for Payer: PHP Commercial	$3,945.64
Rate for Payer: PHP Medicaid	$1,922.61
Rate for Payer: PHP Medicare Advantage	$3,586.95
Rate for Payer: Priority Health Choice Medicaid	$1,922.61
Rate for Payer: Priority Health Cigna Priority Health	$2,990.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,030.52
Rate for Payer: Priority Health Medicare	$3,586.95
Rate for Payer: Priority Health Narrow Network	$3,224.60
Rate for Payer: Railroad Medicare Medicare	$3,586.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,048.00
Rate for Payer: UHC Dual Complete DSNP	$3,586.95
Rate for Payer: UHC Exchange	$5,559.77
Rate for Payer: UHC Medicare Advantage	$3,586.95
Rate for Payer: UHCCP DNSP	$3,586.95
Rate for Payer: UHCCP Medicaid	$1,922.61
Rate for Payer: VA VA	$3,586.95

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK

Professional

Both

$4,600.00

Service Code	HCPCS 15734
Min. Negotiated Rate	$75.69
Max. Negotiated Rate	$2,990.00
Rate for Payer: Aetna Commercial	$1,635.70
Rate for Payer: Aetna Medicare	$2,300.00
Rate for Payer: BCBS Complete	$1,013.81
Rate for Payer: BCBS Trust/PPO	$75.69
Rate for Payer: BCN Commercial	$2,188.30
Rate for Payer: Cash Price	$3,680.00
Rate for Payer: Cash Price	$3,680.00
Rate for Payer: Meridian Medicaid	$1,013.81
Rate for Payer: Priority Health Choice Medicaid	$965.53
Rate for Payer: Priority Health Cigna Priority Health	$2,990.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,032.28
Rate for Payer: Priority Health Narrow Network	$2,032.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,436.80
Rate for Payer: UHC Exchange	$1,436.80
Rate for Payer: UHCCP Medicaid	$965.53

PR MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR

Professional

Both

$2,306.00

Service Code	HCPCS 15736
Min. Negotiated Rate	$783.41
Max. Negotiated Rate	$1,774.39
Rate for Payer: Aetna Commercial	$1,317.66
Rate for Payer: Aetna Medicare	$1,153.00
Rate for Payer: BCBS Complete	$822.58
Rate for Payer: BCBS Trust/PPO	$1,648.76
Rate for Payer: BCN Commercial	$1,774.39
Rate for Payer: Cash Price	$1,844.80
Rate for Payer: Cash Price	$1,844.80
Rate for Payer: Meridian Medicaid	$822.58
Rate for Payer: Priority Health Choice Medicaid	$783.41
Rate for Payer: Priority Health Cigna Priority Health	$1,498.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,651.19
Rate for Payer: Priority Health Narrow Network	$1,651.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,229.24
Rate for Payer: UHC Exchange	$1,229.24
Rate for Payer: UHCCP Medicaid	$783.41

PR MUSC MYOQ/FSCQ FLAP HEAD&NECK W/NAMED VASC PEDCL

Professional

Both

$3,162.00

Service Code	HCPCS 15733
Min. Negotiated Rate	$660.94
Max. Negotiated Rate	$2,055.30
Rate for Payer: Aetna Commercial	$1,117.11
Rate for Payer: Aetna Medicare	$1,581.00
Rate for Payer: BCBS Complete	$693.99
Rate for Payer: BCBS Trust/PPO	$1,152.77
Rate for Payer: BCN Commercial	$1,502.19
Rate for Payer: Cash Price	$2,529.60
Rate for Payer: Cash Price	$2,529.60
Rate for Payer: Meridian Medicaid	$693.99
Rate for Payer: Priority Health Choice Medicaid	$660.94
Rate for Payer: Priority Health Cigna Priority Health	$2,055.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,392.93
Rate for Payer: Priority Health Narrow Network	$1,392.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,211.87
Rate for Payer: UHC Exchange	$1,211.87
Rate for Payer: UHCCP Medicaid	$660.94

PR MYOCARDIAL RESECTION

Professional

Both

$6,268.00

Service Code	HCPCS 33542
Min. Negotiated Rate	$841.58
Max. Negotiated Rate	$4,097.18
Rate for Payer: Aetna Commercial	$3,532.04
Rate for Payer: Aetna Medicare	$3,134.00
Rate for Payer: BCBS Complete	$1,734.63
Rate for Payer: BCBS Trust/PPO	$841.58
Rate for Payer: BCN Commercial	$3,754.51
Rate for Payer: Cash Price	$5,014.40
Rate for Payer: Cash Price	$5,014.40
Rate for Payer: Meridian Medicaid	$1,734.63
Rate for Payer: Priority Health Choice Medicaid	$1,652.03
Rate for Payer: Priority Health Cigna Priority Health	$4,074.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,097.18
Rate for Payer: Priority Health Narrow Network	$4,097.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,426.11
Rate for Payer: UHC Exchange	$3,426.11
Rate for Payer: UHCCP Medicaid	$1,652.03

PR MYOMECTOMY 1-4 MYOMAS 250 GM/< VAGINAL APPR

Professional

Both

$1,961.00

Service Code	HCPCS 58145
Min. Negotiated Rate	$361.04
Max. Negotiated Rate	$1,274.65
Rate for Payer: Aetna Commercial	$676.97
Rate for Payer: Aetna Medicare	$980.50
Rate for Payer: BCBS Complete	$379.09
Rate for Payer: BCBS Trust/PPO	$876.45
Rate for Payer: BCN Commercial	$834.66
Rate for Payer: Cash Price	$1,568.80
Rate for Payer: Cash Price	$1,568.80
Rate for Payer: Meridian Medicaid	$379.09
Rate for Payer: Priority Health Choice Medicaid	$361.04
Rate for Payer: Priority Health Cigna Priority Health	$1,274.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$854.19
Rate for Payer: Priority Health Narrow Network	$854.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$619.24
Rate for Payer: UHC Exchange	$619.24
Rate for Payer: UHCCP Medicaid	$361.04

PR MYOMECTOMY 1-4 MYOMAS W/250 GM/< ABDOMINAL APPR

Professional

Both

$3,033.00

Service Code	HCPCS 58140
Min. Negotiated Rate	$590.22
Max. Negotiated Rate	$1,971.45
Rate for Payer: Aetna Commercial	$1,116.00
Rate for Payer: Aetna Medicare	$1,516.50
Rate for Payer: BCBS Complete	$619.73
Rate for Payer: BCBS Trust/PPO	$737.51
Rate for Payer: BCN Commercial	$1,370.25
Rate for Payer: Cash Price	$2,426.40
Rate for Payer: Cash Price	$2,426.40
Rate for Payer: Meridian Medicaid	$619.73
Rate for Payer: Priority Health Choice Medicaid	$590.22
Rate for Payer: Priority Health Cigna Priority Health	$1,971.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,378.02
Rate for Payer: Priority Health Narrow Network	$1,378.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,048.89
Rate for Payer: UHC Exchange	$1,048.89
Rate for Payer: UHCCP Medicaid	$590.22

PR MYOMECTOMY 5/> MYOMAS &/>250 GM ABDOMINA

Professional

Both

$2,215.00

Service Code	HCPCS 58146
Min. Negotiated Rate	$738.90
Max. Negotiated Rate	$2,587.61
Rate for Payer: Aetna Commercial	$1,387.27
Rate for Payer: Aetna Medicare	$1,107.50
Rate for Payer: BCBS Complete	$775.84
Rate for Payer: BCBS Trust/PPO	$2,587.61
Rate for Payer: BCN Commercial	$1,692.78
Rate for Payer: Cash Price	$1,772.00
Rate for Payer: Cash Price	$1,772.00
Rate for Payer: Meridian Medicaid	$775.84
Rate for Payer: Priority Health Choice Medicaid	$738.90
Rate for Payer: Priority Health Cigna Priority Health	$1,439.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,723.76
Rate for Payer: Priority Health Narrow Network	$1,723.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,328.27
Rate for Payer: UHC Exchange	$1,328.27
Rate for Payer: UHCCP Medicaid	$738.90

PR MYRINGOPLASTY

Professional

Both

$1,167.00

Service Code	HCPCS 69620
Min. Negotiated Rate	$319.71
Max. Negotiated Rate	$1,611.84
Rate for Payer: Aetna Commercial	$551.61
Rate for Payer: Aetna Medicare	$583.50
Rate for Payer: BCBS Complete	$335.70
Rate for Payer: BCBS Trust/PPO	$1,611.84
Rate for Payer: BCN Commercial	$1,099.04
Rate for Payer: Cash Price	$933.60
Rate for Payer: Cash Price	$933.60
Rate for Payer: Meridian Medicaid	$335.70
Rate for Payer: Priority Health Choice Medicaid	$319.71
Rate for Payer: Priority Health Cigna Priority Health	$758.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$728.10
Rate for Payer: Priority Health Narrow Network	$728.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$537.18
Rate for Payer: UHC Exchange	$537.18
Rate for Payer: UHCCP Medicaid	$319.71

PR MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ

Professional

Both

$317.00

Service Code	HCPCS 69420
Min. Negotiated Rate	$78.17
Max. Negotiated Rate	$2,402.18
Rate for Payer: Aetna Commercial	$133.05
Rate for Payer: Aetna Medicare	$158.50
Rate for Payer: BCBS Complete	$82.08
Rate for Payer: BCBS Trust/PPO	$2,402.18
Rate for Payer: BCN Commercial	$282.46
Rate for Payer: Cash Price	$253.60
Rate for Payer: Cash Price	$253.60
Rate for Payer: Meridian Medicaid	$82.08
Rate for Payer: Priority Health Choice Medicaid	$78.17
Rate for Payer: Priority Health Cigna Priority Health	$206.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$178.01
Rate for Payer: Priority Health Narrow Network	$178.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$131.79
Rate for Payer: UHC Exchange	$131.79
Rate for Payer: UHCCP Medicaid	$78.17

PR MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ ANES

Professional

Both

$472.00

Service Code	HCPCS 69421
Min. Negotiated Rate	$97.77
Max. Negotiated Rate	$306.80
Rate for Payer: Aetna Commercial	$167.15
Rate for Payer: Aetna Medicare	$236.00
Rate for Payer: BCBS Complete	$102.66
Rate for Payer: BCBS Trust/PPO	$178.04
Rate for Payer: BCN Commercial	$223.81
Rate for Payer: Cash Price	$377.60
Rate for Payer: Cash Price	$377.60
Rate for Payer: Meridian Medicaid	$102.66
Rate for Payer: Priority Health Choice Medicaid	$97.77
Rate for Payer: Priority Health Cigna Priority Health	$306.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$223.25
Rate for Payer: Priority Health Narrow Network	$223.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$165.69
Rate for Payer: UHC Exchange	$165.69
Rate for Payer: UHCCP Medicaid	$97.77

Know your out-of-pocket cost for care.

All Charges