Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR RPR/ADVMNT TDN W/NTC SUPFCIS TDN W/FREE GRAFT EA

Professional

Both

$3,106.00

Service Code	HCPCS 26372
Min. Negotiated Rate	$588.73
Max. Negotiated Rate	$2,018.90
Rate for Payer: Aetna Commercial	$1,222.37
Rate for Payer: Aetna Medicare	$1,553.00
Rate for Payer: BCBS Complete	$618.17
Rate for Payer: BCN Commercial	$1,359.50
Rate for Payer: Cash Price	$2,484.80
Rate for Payer: Cash Price	$2,484.80
Rate for Payer: Meridian Medicaid	$618.17
Rate for Payer: Priority Health Choice Medicaid	$588.73
Rate for Payer: Priority Health Cigna Priority Health	$2,018.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,413.10
Rate for Payer: Priority Health Narrow Network	$1,413.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$985.43
Rate for Payer: UHC Exchange	$985.43
Rate for Payer: UHCCP Medicaid	$588.73

PR RPR/ADVMNT TDN W/NTC SUPFCIS TDN W/O FREE GRF EA

Professional

Both

$2,854.00

Service Code	HCPCS 26373
Min. Negotiated Rate	$250.94
Max. Negotiated Rate	$1,855.10
Rate for Payer: Aetna Commercial	$1,174.81
Rate for Payer: Aetna Medicare	$1,427.00
Rate for Payer: BCBS Complete	$594.91
Rate for Payer: BCBS Trust/PPO	$250.94
Rate for Payer: BCN Commercial	$1,309.65
Rate for Payer: Cash Price	$2,283.20
Rate for Payer: Cash Price	$2,283.20
Rate for Payer: Meridian Medicaid	$594.91
Rate for Payer: Priority Health Choice Medicaid	$566.58
Rate for Payer: Priority Health Cigna Priority Health	$1,855.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,360.18
Rate for Payer: Priority Health Narrow Network	$1,360.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$938.77
Rate for Payer: UHC Exchange	$938.77
Rate for Payer: UHCCP Medicaid	$566.58

PR RPR ANOM AORTIC ORIGIN CORONARY ART UNROOF/TLCJ

Professional

Both

$3,602.00

Service Code	HCPCS 33507
Min. Negotiated Rate	$724.30
Max. Negotiated Rate	$2,694.22
Rate for Payer: Aetna Commercial	$2,313.67
Rate for Payer: Aetna Medicare	$1,801.00
Rate for Payer: BCBS Complete	$1,136.36
Rate for Payer: BCBS Trust/PPO	$724.30
Rate for Payer: BCN Commercial	$2,466.85
Rate for Payer: Cash Price	$2,881.60
Rate for Payer: Cash Price	$2,881.60
Rate for Payer: Meridian Medicaid	$1,136.36
Rate for Payer: Priority Health Choice Medicaid	$1,082.25
Rate for Payer: Priority Health Cigna Priority Health	$2,341.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,694.22
Rate for Payer: Priority Health Narrow Network	$2,694.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,265.29
Rate for Payer: UHC Exchange	$2,265.29
Rate for Payer: UHCCP Medicaid	$1,082.25

PR RPR ANOM CORONARY ART PULM ART ORIGIN GRF W/BYP

Professional

Both

$5,041.00

Service Code	HCPCS 33504
Min. Negotiated Rate	$576.38
Max. Negotiated Rate	$3,276.65
Rate for Payer: Aetna Commercial	$1,966.00
Rate for Payer: Aetna Medicare	$2,520.50
Rate for Payer: BCBS Complete	$975.33
Rate for Payer: BCBS Trust/PPO	$576.38
Rate for Payer: BCN Commercial	$2,109.62
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Cash Price	$4,032.80
Rate for Payer: Meridian Medicaid	$975.33
Rate for Payer: Priority Health Choice Medicaid	$928.89
Rate for Payer: Priority Health Cigna Priority Health	$3,276.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,309.18
Rate for Payer: Priority Health Narrow Network	$2,309.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,903.64
Rate for Payer: UHC Exchange	$1,903.64
Rate for Payer: UHCCP Medicaid	$928.89

PR RPR ATRIAL SEPTAL DFCT SECUNDUM W/BYP W/WO PATCH

Professional

Both

$5,071.00

Service Code	HCPCS 33641
Min. Negotiated Rate	$957.28
Max. Negotiated Rate	$3,296.15
Rate for Payer: Aetna Commercial	$2,200.88
Rate for Payer: Aetna Medicare	$2,535.50
Rate for Payer: BCBS Complete	$1,083.36
Rate for Payer: BCBS Trust/PPO	$957.28
Rate for Payer: BCN Commercial	$2,349.07
Rate for Payer: Cash Price	$4,056.80
Rate for Payer: Cash Price	$4,056.80
Rate for Payer: Meridian Medicaid	$1,083.36
Rate for Payer: Priority Health Choice Medicaid	$1,031.77
Rate for Payer: Priority Health Cigna Priority Health	$3,296.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,568.72
Rate for Payer: Priority Health Narrow Network	$2,568.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,138.78
Rate for Payer: UHC Exchange	$2,138.78
Rate for Payer: UHCCP Medicaid	$1,031.77

PR RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL

Professional

Both

$1,139.00

Service Code	HCPCS 67903
Min. Negotiated Rate	$304.38
Max. Negotiated Rate	$875.71
Rate for Payer: Aetna Commercial	$624.13
Rate for Payer: Aetna Medicare	$569.50
Rate for Payer: BCBS Complete	$319.60
Rate for Payer: BCBS Trust/PPO	$714.79
Rate for Payer: BCN Commercial	$875.71
Rate for Payer: Cash Price	$911.20
Rate for Payer: Cash Price	$911.20
Rate for Payer: Meridian Medicaid	$319.60
Rate for Payer: Priority Health Choice Medicaid	$304.38
Rate for Payer: Priority Health Cigna Priority Health	$740.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$834.08
Rate for Payer: Priority Health Narrow Network	$834.08
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$528.44
Rate for Payer: UHC Exchange	$528.44
Rate for Payer: UHCCP Medicaid	$304.38

PR RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL

Professional

Both

$969.00

Service Code	HCPCS 67904
Min. Negotiated Rate	$377.01
Max. Negotiated Rate	$1,075.09
Rate for Payer: Aetna Commercial	$772.71
Rate for Payer: Aetna Medicare	$484.50
Rate for Payer: BCBS Complete	$395.86
Rate for Payer: BCBS Trust/PPO	$581.13
Rate for Payer: BCN Commercial	$1,075.09
Rate for Payer: Cash Price	$775.20
Rate for Payer: Cash Price	$775.20
Rate for Payer: Meridian Medicaid	$395.86
Rate for Payer: Priority Health Choice Medicaid	$377.01
Rate for Payer: Priority Health Cigna Priority Health	$629.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,034.70
Rate for Payer: Priority Health Narrow Network	$1,034.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$637.82
Rate for Payer: UHC Exchange	$637.82
Rate for Payer: UHCCP Medicaid	$377.01

PR RPR BLOOD VESSEL DIRECT INTRATHORACIC W/BYPASS

Professional

Both

$2,893.00

Service Code	HCPCS 35211
Min. Negotiated Rate	$877.35
Max. Negotiated Rate	$2,185.26
Rate for Payer: Aetna Commercial	$1,871.61
Rate for Payer: Aetna Medicare	$1,446.50
Rate for Payer: BCBS Complete	$921.22
Rate for Payer: BCBS Trust/PPO	$1,289.05
Rate for Payer: BCN Commercial	$1,992.34
Rate for Payer: Cash Price	$2,314.40
Rate for Payer: Cash Price	$2,314.40
Rate for Payer: Meridian Medicaid	$921.22
Rate for Payer: Priority Health Choice Medicaid	$877.35
Rate for Payer: Priority Health Cigna Priority Health	$1,880.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,185.26
Rate for Payer: Priority Health Narrow Network	$2,185.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,816.90
Rate for Payer: UHC Exchange	$1,816.90
Rate for Payer: UHCCP Medicaid	$877.35

PR RPR BLOOD VESSEL DIRECT INTRATHORACIC W/O BYPASS

Professional

Both

$5,326.00

Service Code	HCPCS 35216
Min. Negotiated Rate	$1,312.93
Max. Negotiated Rate	$3,461.90
Rate for Payer: Aetna Commercial	$2,794.95
Rate for Payer: Aetna Medicare	$2,663.00
Rate for Payer: BCBS Complete	$1,378.58
Rate for Payer: BCBS Trust/PPO	$2,159.69
Rate for Payer: BCN Commercial	$3,021.49
Rate for Payer: Cash Price	$4,260.80
Rate for Payer: Cash Price	$4,260.80
Rate for Payer: Meridian Medicaid	$1,378.58
Rate for Payer: Priority Health Choice Medicaid	$1,312.93
Rate for Payer: Priority Health Cigna Priority Health	$3,461.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,305.29
Rate for Payer: Priority Health Narrow Network	$3,305.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,616.70
Rate for Payer: UHC Exchange	$2,616.70
Rate for Payer: UHCCP Medicaid	$1,312.93

PR RPR BLOOD VESSEL VEIN GRAFT INTRATHORACIC W/BYP

Professional

Both

$6,519.00

Service Code	HCPCS 35241
Min. Negotiated Rate	$902.69
Max. Negotiated Rate	$4,237.35
Rate for Payer: Aetna Commercial	$1,926.86
Rate for Payer: Aetna Medicare	$3,259.50
Rate for Payer: BCBS Complete	$947.82
Rate for Payer: BCBS Trust/PPO	$1,986.94
Rate for Payer: BCN Commercial	$2,057.82
Rate for Payer: Cash Price	$5,215.20
Rate for Payer: Cash Price	$5,215.20
Rate for Payer: Meridian Medicaid	$947.82
Rate for Payer: Priority Health Choice Medicaid	$902.69
Rate for Payer: Priority Health Cigna Priority Health	$4,237.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,243.77
Rate for Payer: Priority Health Narrow Network	$2,243.77
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,895.20
Rate for Payer: UHC Exchange	$1,895.20
Rate for Payer: UHCCP Medicaid	$902.69

PR RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/BYP

Professional

Both

$6,744.00

Service Code	HCPCS 35271
Min. Negotiated Rate	$650.87
Max. Negotiated Rate	$4,383.60
Rate for Payer: Aetna Commercial	$1,857.88
Rate for Payer: Aetna Medicare	$3,372.00
Rate for Payer: BCBS Complete	$913.38
Rate for Payer: BCBS Trust/PPO	$650.87
Rate for Payer: BCN Commercial	$1,987.94
Rate for Payer: Cash Price	$5,395.20
Rate for Payer: Cash Price	$5,395.20
Rate for Payer: Meridian Medicaid	$913.38
Rate for Payer: Priority Health Choice Medicaid	$869.89
Rate for Payer: Priority Health Cigna Priority Health	$4,383.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,173.57
Rate for Payer: Priority Health Narrow Network	$2,173.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,822.28
Rate for Payer: UHC Exchange	$1,822.28
Rate for Payer: UHCCP Medicaid	$869.89

PR RPR BLOOD VSL GRF OTH/THN VEIN UPPER EXTREMITY

Professional

Both

$1,793.00

Service Code	HCPCS 35266
Min. Negotiated Rate	$534.11
Max. Negotiated Rate	$1,354.03
Rate for Payer: Aetna Commercial	$1,163.16
Rate for Payer: Aetna Medicare	$896.50
Rate for Payer: BCBS Complete	$571.20
Rate for Payer: BCBS Trust/PPO	$534.11
Rate for Payer: BCN Commercial	$1,232.44
Rate for Payer: Cash Price	$1,434.40
Rate for Payer: Cash Price	$1,434.40
Rate for Payer: Meridian Medicaid	$571.20
Rate for Payer: Priority Health Choice Medicaid	$544.00
Rate for Payer: Priority Health Cigna Priority Health	$1,165.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,354.03
Rate for Payer: Priority Health Narrow Network	$1,354.03
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,149.28
Rate for Payer: UHC Exchange	$1,149.28
Rate for Payer: UHCCP Medicaid	$544.00

PR RPR BLVSL W/GRF OTHER/THAN VEIN LOWER EXTREMITY

Professional

Both

$3,792.00

Service Code	HCPCS 35286
Min. Negotiated Rate	$580.64
Max. Negotiated Rate	$2,464.80
Rate for Payer: Aetna Commercial	$1,253.73
Rate for Payer: Aetna Medicare	$1,896.00
Rate for Payer: BCBS Complete	$609.67
Rate for Payer: BCBS Trust/PPO	$1,167.01
Rate for Payer: BCN Commercial	$1,329.21
Rate for Payer: Cash Price	$3,033.60
Rate for Payer: Cash Price	$3,033.60
Rate for Payer: Meridian Medicaid	$609.67
Rate for Payer: Priority Health Choice Medicaid	$580.64
Rate for Payer: Priority Health Cigna Priority Health	$2,464.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,446.56
Rate for Payer: Priority Health Narrow Network	$1,446.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,256.81
Rate for Payer: UHC Exchange	$1,256.81
Rate for Payer: UHCCP Medicaid	$580.64

PR RPR CLOACAL ANOMALY SACROPERINEAL

Professional

Both

$6,583.00

Service Code	HCPCS 46744
Min. Negotiated Rate	$741.73
Max. Negotiated Rate	$6,315.54
Rate for Payer: Aetna Commercial	$4,778.09
Rate for Payer: Aetna Medicare	$3,291.50
Rate for Payer: BCBS Complete	$2,381.65
Rate for Payer: BCBS Trust/PPO	$741.73
Rate for Payer: BCN Commercial	$5,150.66
Rate for Payer: Cash Price	$5,266.40
Rate for Payer: Cash Price	$5,266.40
Rate for Payer: Meridian Medicaid	$2,381.65
Rate for Payer: Priority Health Choice Medicaid	$2,268.24
Rate for Payer: Priority Health Cigna Priority Health	$4,278.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$6,315.54
Rate for Payer: Priority Health Narrow Network	$6,315.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,040.53
Rate for Payer: UHC Exchange	$4,040.53
Rate for Payer: UHCCP Medicaid	$2,268.24

PR RPR COLTRL LIGM MTCARPHLNGL/IPHAL JT

Professional

Both

$1,983.00

Service Code	HCPCS 26540
Min. Negotiated Rate	$400.45
Max. Negotiated Rate	$1,288.95
Rate for Payer: Aetna Commercial	$924.08
Rate for Payer: Aetna Medicare	$991.50
Rate for Payer: BCBS Complete	$474.81
Rate for Payer: BCBS Trust/PPO	$400.45
Rate for Payer: BCN Commercial	$1,041.86
Rate for Payer: Cash Price	$1,586.40
Rate for Payer: Cash Price	$1,586.40
Rate for Payer: Meridian Medicaid	$474.81
Rate for Payer: Priority Health Choice Medicaid	$452.20
Rate for Payer: Priority Health Cigna Priority Health	$1,288.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,082.86
Rate for Payer: Priority Health Narrow Network	$1,082.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$727.46
Rate for Payer: UHC Exchange	$727.46
Rate for Payer: UHCCP Medicaid	$452.20

PR RPR COMPONENT INFLATABLE PENILE PROSTHESIS

Professional

Both

$1,505.00

Service Code	HCPCS 54408
Min. Negotiated Rate	$507.58
Max. Negotiated Rate	$2,176.77
Rate for Payer: Aetna Commercial	$1,014.50
Rate for Payer: Aetna Medicare	$752.50
Rate for Payer: BCBS Complete	$532.96
Rate for Payer: BCBS Trust/PPO	$2,176.77
Rate for Payer: BCN Commercial	$1,141.06
Rate for Payer: Cash Price	$1,204.00
Rate for Payer: Cash Price	$1,204.00
Rate for Payer: Meridian Medicaid	$532.96
Rate for Payer: Priority Health Choice Medicaid	$507.58
Rate for Payer: Priority Health Cigna Priority Health	$978.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,260.13
Rate for Payer: Priority Health Narrow Network	$1,260.13
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$952.36
Rate for Payer: UHC Exchange	$952.36
Rate for Payer: UHCCP Medicaid	$507.58

PR RPR CORONARY AV/ARTERIOCAR CHMBR FSTL W/BYPASS

Professional

Both

$5,809.00

Service Code	HCPCS 33500
Min. Negotiated Rate	$426.34
Max. Negotiated Rate	$3,775.85
Rate for Payer: Aetna Commercial	$2,094.69
Rate for Payer: Aetna Medicare	$2,904.50
Rate for Payer: BCBS Complete	$1,030.35
Rate for Payer: BCBS Trust/PPO	$426.34
Rate for Payer: BCN Commercial	$2,235.70
Rate for Payer: Cash Price	$4,647.20
Rate for Payer: Cash Price	$4,647.20
Rate for Payer: Meridian Medicaid	$1,030.35
Rate for Payer: Priority Health Choice Medicaid	$981.29
Rate for Payer: Priority Health Cigna Priority Health	$3,775.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,437.36
Rate for Payer: Priority Health Narrow Network	$2,437.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,067.06
Rate for Payer: UHC Exchange	$2,067.06
Rate for Payer: UHCCP Medicaid	$981.29

PR RPR CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ SIT

Professional

Both

$852.00

Service Code	HCPCS 36576
Min. Negotiated Rate	$115.87
Max. Negotiated Rate	$1,186.03
Rate for Payer: Aetna Commercial	$245.57
Rate for Payer: Aetna Medicare	$426.00
Rate for Payer: BCBS Complete	$121.66
Rate for Payer: BCBS Trust/PPO	$1,186.03
Rate for Payer: BCN Commercial	$507.25
Rate for Payer: Cash Price	$681.60
Rate for Payer: Cash Price	$681.60
Rate for Payer: Meridian Medicaid	$121.66
Rate for Payer: Priority Health Choice Medicaid	$115.87
Rate for Payer: Priority Health Cigna Priority Health	$553.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$288.78
Rate for Payer: Priority Health Narrow Network	$288.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$246.51
Rate for Payer: UHC Exchange	$246.51
Rate for Payer: UHCCP Medicaid	$115.87

PR RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC AQT

Professional

Both

$5,993.00

Service Code	HCPCS 39540
Min. Negotiated Rate	$552.10
Max. Negotiated Rate	$3,895.45
Rate for Payer: Aetna Commercial	$887.30
Rate for Payer: Aetna Medicare	$2,996.50
Rate for Payer: BCBS Complete	$579.70
Rate for Payer: BCBS Trust/PPO	$676.75
Rate for Payer: BCN Commercial	$1,257.37
Rate for Payer: Cash Price	$4,794.40
Rate for Payer: Cash Price	$4,794.40
Rate for Payer: Meridian Medicaid	$579.70
Rate for Payer: Priority Health Choice Medicaid	$552.10
Rate for Payer: Priority Health Cigna Priority Health	$3,895.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,380.08
Rate for Payer: Priority Health Narrow Network	$1,380.08
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$983.25
Rate for Payer: UHC Exchange	$983.25
Rate for Payer: UHCCP Medicaid	$552.10

PR RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC CHRNC

Professional

Both

$1,712.00

Service Code	HCPCS 39541
Min. Negotiated Rate	$509.28
Max. Negotiated Rate	$1,482.73
Rate for Payer: Aetna Commercial	$964.34
Rate for Payer: Aetna Medicare	$856.00
Rate for Payer: BCBS Complete	$629.58
Rate for Payer: BCBS Trust/PPO	$509.28
Rate for Payer: BCN Commercial	$1,356.57
Rate for Payer: Cash Price	$1,369.60
Rate for Payer: Cash Price	$1,369.60
Rate for Payer: Meridian Medicaid	$629.58
Rate for Payer: Priority Health Choice Medicaid	$599.60
Rate for Payer: Priority Health Cigna Priority Health	$1,112.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,482.73
Rate for Payer: Priority Health Narrow Network	$1,482.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,064.14
Rate for Payer: UHC Exchange	$1,064.14
Rate for Payer: UHCCP Medicaid	$599.60

PR RPR DISLOC PERONEAL TENDON W/O FIBULAR OSTEOTOMY

Professional

Both

$1,301.00

Service Code	HCPCS 27675
Min. Negotiated Rate	$221.89
Max. Negotiated Rate	$845.65
Rate for Payer: Aetna Commercial	$654.05
Rate for Payer: Aetna Medicare	$650.50
Rate for Payer: BCBS Complete	$339.95
Rate for Payer: BCBS Trust/PPO	$221.89
Rate for Payer: BCN Commercial	$730.08
Rate for Payer: Cash Price	$1,040.80
Rate for Payer: Cash Price	$1,040.80
Rate for Payer: Meridian Medicaid	$339.95
Rate for Payer: Priority Health Choice Medicaid	$323.76
Rate for Payer: Priority Health Cigna Priority Health	$845.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$765.84
Rate for Payer: Priority Health Narrow Network	$765.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$576.12
Rate for Payer: UHC Exchange	$576.12
Rate for Payer: UHCCP Medicaid	$323.76

PR RPR DURAL/CEREBROSPINAL FLUID LEAK X REQ LAM

Professional

Both

$1,928.00

Service Code	HCPCS 63707
Min. Negotiated Rate	$618.13
Max. Negotiated Rate	$1,625.96
Rate for Payer: Aetna Commercial	$1,204.37
Rate for Payer: Aetna Medicare	$964.00
Rate for Payer: BCBS Complete	$649.04
Rate for Payer: BCBS Trust/PPO	$1,181.28
Rate for Payer: BCN Commercial	$1,528.13
Rate for Payer: Cash Price	$1,542.40
Rate for Payer: Cash Price	$1,542.40
Rate for Payer: Meridian Medicaid	$649.04
Rate for Payer: Priority Health Choice Medicaid	$618.13
Rate for Payer: Priority Health Cigna Priority Health	$1,253.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,625.96
Rate for Payer: Priority Health Narrow Network	$1,625.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,040.87
Rate for Payer: UHC Exchange	$1,040.87
Rate for Payer: UHCCP Medicaid	$618.13

PR RPR DURAL/CSF LEAK/PSEUDOMENINGOCELE W/LAM

Professional

Both

$6,028.00

Service Code	HCPCS 63709
Min. Negotiated Rate	$726.54
Max. Negotiated Rate	$3,918.20
Rate for Payer: Aetna Commercial	$1,435.43
Rate for Payer: Aetna Medicare	$3,014.00
Rate for Payer: BCBS Complete	$762.87
Rate for Payer: BCBS Trust/PPO	$1,064.00
Rate for Payer: BCN Commercial	$1,809.54
Rate for Payer: Cash Price	$4,822.40
Rate for Payer: Cash Price	$4,822.40
Rate for Payer: Meridian Medicaid	$762.87
Rate for Payer: Priority Health Choice Medicaid	$726.54
Rate for Payer: Priority Health Cigna Priority Health	$3,918.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,927.95
Rate for Payer: Priority Health Narrow Network	$1,927.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,269.52
Rate for Payer: UHC Exchange	$1,269.52
Rate for Payer: UHCCP Medicaid	$726.54

PR RPR ENCEPHALOCELE SKULL VAULT W/CRANIOPLASTY

Professional

Both

$5,844.00

Service Code	HCPCS 62120
Min. Negotiated Rate	$1,110.49
Max. Negotiated Rate	$3,798.60
Rate for Payer: Aetna Commercial	$2,715.90
Rate for Payer: Aetna Medicare	$2,922.00
Rate for Payer: BCBS Complete	$1,413.02
Rate for Payer: BCBS Trust/PPO	$1,110.49
Rate for Payer: BCN Commercial	$3,072.31
Rate for Payer: Cash Price	$4,675.20
Rate for Payer: Cash Price	$4,675.20
Rate for Payer: Meridian Medicaid	$1,413.02
Rate for Payer: Priority Health Choice Medicaid	$1,345.73
Rate for Payer: Priority Health Cigna Priority Health	$3,798.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,594.84
Rate for Payer: Priority Health Narrow Network	$3,594.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,989.30
Rate for Payer: UHC Exchange	$1,989.30
Rate for Payer: UHCCP Medicaid	$1,345.73

PR RPR EPIGASTRIC HERNIA INCARCERATED

Professional

Both

$1,488.00

Service Code	HCPCS 49572
Min. Negotiated Rate	$595.20
Max. Negotiated Rate	$967.20
Rate for Payer: Aetna Medicare	$744.00
Rate for Payer: BCBS Complete	$595.20
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Priority Health Cigna Priority Health	$967.20

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