Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC PERIPHERAL DIAGNOSTIC CATHETER

Facility

$278.26

Hospital Charge Code	27200145
Hospital Revenue Code	272
Min. Negotiated Rate	$175.30
Max. Negotiated Rate	$250.43
Rate for Payer: Aetna Commercial	$236.52
Rate for Payer: Aetna New Business (MI Preferred)	$180.87
Rate for Payer: Cash Price	$222.61
Rate for Payer: Cofinity Commercial	$194.78
Rate for Payer: Cofinity Commercial	$239.30
Rate for Payer: Healthscope Commercial	$250.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$236.52
Rate for Payer: PHP Commercial	$236.52
Rate for Payer: Priority Health Cigna Priority Health	$194.78
Rate for Payer: Priority Health SBD	$175.30

HC PERIPHERAL DIAGNOSTIC CATHETER

Facility

$278.26

Hospital Charge Code	27200145
Hospital Revenue Code	272
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$250.43
Rate for Payer: Aetna Commercial	$236.52
Rate for Payer: Aetna New Business (MI Preferred)	$180.87
Rate for Payer: BCBS Complete	$111.30
Rate for Payer: Cash Price	$222.61
Rate for Payer: Cofinity Commercial	$194.78
Rate for Payer: Cofinity Commercial	$239.30
Rate for Payer: Healthscope Commercial	$250.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$236.52
Rate for Payer: PHP Commercial	$236.52
Rate for Payer: Priority Health Cigna Priority Health	$194.78
Rate for Payer: Priority Health SBD	$175.30

HC PERIPHERAL INTRODUCER

Facility

$670.87

Hospital Charge Code	27200146
Hospital Revenue Code	272
Min. Negotiated Rate	$422.65
Max. Negotiated Rate	$603.78
Rate for Payer: Aetna Commercial	$570.24
Rate for Payer: Aetna New Business (MI Preferred)	$436.07
Rate for Payer: Cash Price	$536.70
Rate for Payer: Cofinity Commercial	$469.61
Rate for Payer: Cofinity Commercial	$576.95
Rate for Payer: Healthscope Commercial	$603.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$570.24
Rate for Payer: PHP Commercial	$570.24
Rate for Payer: Priority Health Cigna Priority Health	$469.61
Rate for Payer: Priority Health SBD	$422.65

HC PERIPHERAL INTRODUCER

Facility

$670.87

Hospital Charge Code	27200146
Hospital Revenue Code	272
Min. Negotiated Rate	$268.35
Max. Negotiated Rate	$603.78
Rate for Payer: Aetna Commercial	$570.24
Rate for Payer: Aetna New Business (MI Preferred)	$436.07
Rate for Payer: BCBS Complete	$268.35
Rate for Payer: Cash Price	$536.70
Rate for Payer: Cofinity Commercial	$469.61
Rate for Payer: Cofinity Commercial	$576.95
Rate for Payer: Healthscope Commercial	$603.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$570.24
Rate for Payer: PHP Commercial	$570.24
Rate for Payer: Priority Health Cigna Priority Health	$469.61
Rate for Payer: Priority Health SBD	$422.65

HC PERITONEAL DIALYSIS

Facility

$938.26

Service Code	CPT 90945
Hospital Charge Code	83000001
Hospital Revenue Code	881
Min. Negotiated Rate	$83.17
Max. Negotiated Rate	$844.43
Rate for Payer: Aetna Commercial	$797.52
Rate for Payer: Aetna Medicare	$409.86
Rate for Payer: Aetna New Business (MI Preferred)	$609.87
Rate for Payer: Allen County Amish Medical Aid Commercial	$492.62
Rate for Payer: Amish Plain Church Group Commercial	$492.62
Rate for Payer: BCBS Complete	$226.37
Rate for Payer: BCBS MAPPO	$394.10
Rate for Payer: BCN Medicare Advantage	$394.10
Rate for Payer: Cash Price	$750.61
Rate for Payer: Cash Price	$750.61
Rate for Payer: Cofinity Commercial	$656.78
Rate for Payer: Cofinity Commercial	$806.90
Rate for Payer: Health Alliance Plan Medicare Advantage	$394.10
Rate for Payer: Healthscope Commercial	$844.43
Rate for Payer: Mclaren Medicaid	$215.57
Rate for Payer: Mclaren Medicare	$394.10
Rate for Payer: Meridian Medicaid	$226.37
Rate for Payer: Meridian Wellcare - Medicare Advantage	$413.80
Rate for Payer: MI Amish Medical Board Commercial	$453.22
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$797.52
Rate for Payer: PACE Medicare	$374.40
Rate for Payer: PACE SWMI	$394.10
Rate for Payer: PHP Commercial	$797.52
Rate for Payer: PHP Medicare Advantage	$394.10
Rate for Payer: Priority Health Choice Medicaid	$215.57
Rate for Payer: Priority Health Cigna Priority Health	$656.78
Rate for Payer: Priority Health Medicare	$394.10
Rate for Payer: Priority Health SBD	$591.10
Rate for Payer: Railroad Medicare Medicare	$394.10
Rate for Payer: UHC All Payor (Choice/PPO)	$91.49
Rate for Payer: UHC Dual Complete DSNP	$394.10
Rate for Payer: UHC Exchange	$83.17
Rate for Payer: UHC Medicare Advantage	$405.92
Rate for Payer: VA VA	$394.10

HC PERITONEAL DIALYSIS

Facility

$938.26

Service Code	CPT 90945
Hospital Charge Code	83000001
Hospital Revenue Code	881
Min. Negotiated Rate	$591.10
Max. Negotiated Rate	$844.43
Rate for Payer: Aetna Commercial	$797.52
Rate for Payer: Aetna New Business (MI Preferred)	$609.87
Rate for Payer: Cash Price	$750.61
Rate for Payer: Cofinity Commercial	$656.78
Rate for Payer: Cofinity Commercial	$806.90
Rate for Payer: Healthscope Commercial	$844.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$797.52
Rate for Payer: PHP Commercial	$797.52
Rate for Payer: Priority Health Cigna Priority Health	$656.78
Rate for Payer: Priority Health SBD	$591.10

HC PERITONEAL LVG TRAY

Facility

$693.53

Hospital Charge Code	27000135
Hospital Revenue Code	270
Min. Negotiated Rate	$436.92
Max. Negotiated Rate	$624.18
Rate for Payer: Aetna Commercial	$589.50
Rate for Payer: Aetna New Business (MI Preferred)	$450.79
Rate for Payer: Cash Price	$554.82
Rate for Payer: Cofinity Commercial	$485.47
Rate for Payer: Cofinity Commercial	$596.44
Rate for Payer: Healthscope Commercial	$624.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$589.50
Rate for Payer: PHP Commercial	$589.50
Rate for Payer: Priority Health Cigna Priority Health	$485.47
Rate for Payer: Priority Health SBD	$436.92

HC PERITONEAL LVG TRAY

Facility

$693.53

Hospital Charge Code	27000135
Hospital Revenue Code	270
Min. Negotiated Rate	$277.41
Max. Negotiated Rate	$624.18
Rate for Payer: Aetna Commercial	$589.50
Rate for Payer: Aetna New Business (MI Preferred)	$450.79
Rate for Payer: BCBS Complete	$277.41
Rate for Payer: Cash Price	$554.82
Rate for Payer: Cofinity Commercial	$485.47
Rate for Payer: Cofinity Commercial	$596.44
Rate for Payer: Healthscope Commercial	$624.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$589.50
Rate for Payer: PHP Commercial	$589.50
Rate for Payer: Priority Health Cigna Priority Health	$485.47
Rate for Payer: Priority Health SBD	$436.92

HC PERITONEOGRAM

Facility

$557.52

Service Code	CPT 74190
Hospital Charge Code	32000294
Hospital Revenue Code	320
Min. Negotiated Rate	$268.51
Max. Negotiated Rate	$613.60
Rate for Payer: Aetna Commercial	$473.89
Rate for Payer: Aetna Medicare	$510.52
Rate for Payer: Aetna New Business (MI Preferred)	$362.39
Rate for Payer: Allen County Amish Medical Aid Commercial	$613.60
Rate for Payer: Amish Plain Church Group Commercial	$613.60
Rate for Payer: BCBS Complete	$281.96
Rate for Payer: BCBS MAPPO	$490.88
Rate for Payer: BCBS Trust/PPO	$525.32
Rate for Payer: BCN Medicare Advantage	$490.88
Rate for Payer: Cash Price	$446.02
Rate for Payer: Cash Price	$446.02
Rate for Payer: Cofinity Commercial	$390.26
Rate for Payer: Cofinity Commercial	$479.47
Rate for Payer: Health Alliance Plan Medicare Advantage	$490.88
Rate for Payer: Healthscope Commercial	$501.77
Rate for Payer: Mclaren Medicaid	$268.51
Rate for Payer: Mclaren Medicare	$490.88
Rate for Payer: Meridian Medicaid	$281.96
Rate for Payer: Meridian Wellcare - Medicare Advantage	$515.42
Rate for Payer: MI Amish Medical Board Commercial	$564.51
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$473.89
Rate for Payer: PACE Medicare	$466.34
Rate for Payer: PACE SWMI	$490.88
Rate for Payer: PHP Commercial	$473.89
Rate for Payer: PHP Medicare Advantage	$490.88
Rate for Payer: Priority Health Choice Medicaid	$268.51
Rate for Payer: Priority Health Cigna Priority Health	$390.26
Rate for Payer: Priority Health Medicare	$490.88
Rate for Payer: Priority Health SBD	$351.24
Rate for Payer: Railroad Medicare Medicare	$490.88
Rate for Payer: UHC Dual Complete DSNP	$490.88
Rate for Payer: UHC Medicare Advantage	$505.61
Rate for Payer: VA VA	$490.88

HC PERITONEOGRAM

Facility

$557.52

Service Code	CPT 74190
Hospital Charge Code	32000294
Hospital Revenue Code	320
Min. Negotiated Rate	$351.24
Max. Negotiated Rate	$501.77
Rate for Payer: Aetna Commercial	$473.89
Rate for Payer: Aetna New Business (MI Preferred)	$362.39
Rate for Payer: Cash Price	$446.02
Rate for Payer: Cofinity Commercial	$390.26
Rate for Payer: Cofinity Commercial	$479.47
Rate for Payer: Healthscope Commercial	$501.77
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$473.89
Rate for Payer: PHP Commercial	$473.89
Rate for Payer: Priority Health Cigna Priority Health	$390.26
Rate for Payer: Priority Health SBD	$351.24

HC PERMANENT PACEMAKER INTRODUCER

Facility

$242.23

Service Code	HCPCS C1892
Hospital Charge Code	27200062
Hospital Revenue Code	272
Min. Negotiated Rate	$96.89
Max. Negotiated Rate	$218.01
Rate for Payer: Aetna Commercial	$205.90
Rate for Payer: Aetna New Business (MI Preferred)	$157.45
Rate for Payer: BCBS Complete	$96.89
Rate for Payer: Cash Price	$193.78
Rate for Payer: Cofinity Commercial	$169.56
Rate for Payer: Cofinity Commercial	$208.32
Rate for Payer: Healthscope Commercial	$218.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$205.90
Rate for Payer: PHP Commercial	$205.90
Rate for Payer: Priority Health Cigna Priority Health	$169.56
Rate for Payer: Priority Health SBD	$152.60

HC PERMANENT PACEMAKER INTRODUCER

Facility

$242.23

Service Code	HCPCS C1892
Hospital Charge Code	27200062
Hospital Revenue Code	272
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.01
Rate for Payer: Aetna Commercial	$205.90
Rate for Payer: Aetna New Business (MI Preferred)	$157.45
Rate for Payer: Cash Price	$193.78
Rate for Payer: Cofinity Commercial	$169.56
Rate for Payer: Cofinity Commercial	$208.32
Rate for Payer: Healthscope Commercial	$218.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$205.90
Rate for Payer: PHP Commercial	$205.90
Rate for Payer: Priority Health Cigna Priority Health	$169.56
Rate for Payer: Priority Health SBD	$152.60

HC PERMANENT PACEMAKER PACK

Facility

$330.12

Hospital Charge Code	62200010
Hospital Revenue Code	270
Min. Negotiated Rate	$132.05
Max. Negotiated Rate	$297.11
Rate for Payer: Aetna Commercial	$280.60
Rate for Payer: Aetna New Business (MI Preferred)	$214.58
Rate for Payer: BCBS Complete	$132.05
Rate for Payer: Cash Price	$264.10
Rate for Payer: Cofinity Commercial	$283.90
Rate for Payer: Cofinity Commercial	$231.08
Rate for Payer: Healthscope Commercial	$297.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$280.60
Rate for Payer: PHP Commercial	$280.60
Rate for Payer: Priority Health Cigna Priority Health	$231.08
Rate for Payer: Priority Health SBD	$207.98

HC PERMANENT PACEMAKER PACK

Facility

$330.12

Hospital Charge Code	62200010
Hospital Revenue Code	270
Min. Negotiated Rate	$207.98
Max. Negotiated Rate	$297.11
Rate for Payer: Aetna Commercial	$280.60
Rate for Payer: Aetna New Business (MI Preferred)	$214.58
Rate for Payer: Cash Price	$264.10
Rate for Payer: Cofinity Commercial	$231.08
Rate for Payer: Cofinity Commercial	$283.90
Rate for Payer: Healthscope Commercial	$297.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$280.60
Rate for Payer: PHP Commercial	$280.60
Rate for Payer: Priority Health Cigna Priority Health	$231.08
Rate for Payer: Priority Health SBD	$207.98

HC PERNICIOUS ANEMIA EVALUATION

Facility

$45.90

Service Code	CPT 82607
Hospital Charge Code	30100186
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$41.31
Rate for Payer: Aetna Commercial	$39.02
Rate for Payer: Aetna Medicare	$15.68
Rate for Payer: Aetna New Business (MI Preferred)	$29.84
Rate for Payer: Allen County Amish Medical Aid Commercial	$18.85
Rate for Payer: Amish Plain Church Group Commercial	$18.85
Rate for Payer: BCBS Complete	$8.66
Rate for Payer: BCBS MAPPO	$15.08
Rate for Payer: BCBS Trust/PPO	$11.81
Rate for Payer: BCN Medicare Advantage	$15.08
Rate for Payer: Cash Price	$36.72
Rate for Payer: Cash Price	$36.72
Rate for Payer: Cofinity Commercial	$32.13
Rate for Payer: Cofinity Commercial	$39.47
Rate for Payer: Health Alliance Plan Medicare Advantage	$15.08
Rate for Payer: Healthscope Commercial	$41.31
Rate for Payer: Mclaren Medicaid	$8.25
Rate for Payer: Mclaren Medicare	$15.08
Rate for Payer: Meridian Medicaid	$8.66
Rate for Payer: Meridian Wellcare - Medicare Advantage	$15.83
Rate for Payer: MI Amish Medical Board Commercial	$17.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$39.02
Rate for Payer: PACE Medicare	$14.33
Rate for Payer: PACE SWMI	$15.08
Rate for Payer: PHP Commercial	$39.02
Rate for Payer: PHP Medicare Advantage	$15.08
Rate for Payer: Priority Health Choice Medicaid	$8.25
Rate for Payer: Priority Health Cigna Priority Health	$32.13
Rate for Payer: Priority Health Medicare	$15.08
Rate for Payer: Priority Health SBD	$28.92
Rate for Payer: Railroad Medicare Medicare	$15.08
Rate for Payer: UHC All Payor (Choice/PPO)	$18.10
Rate for Payer: UHC Core	$25.62
Rate for Payer: UHC Dual Complete DSNP	$15.08
Rate for Payer: UHC Exchange	$15.08
Rate for Payer: UHC Medicare Advantage	$15.53
Rate for Payer: VA VA	$15.08

HC PERNICIOUS ANEMIA EVALUATION

Facility

$45.90

Service Code	CPT 82607
Hospital Charge Code	30100186
Hospital Revenue Code	301
Min. Negotiated Rate	$28.92
Max. Negotiated Rate	$41.31
Rate for Payer: Aetna Commercial	$39.02
Rate for Payer: Aetna New Business (MI Preferred)	$29.84
Rate for Payer: Cash Price	$36.72
Rate for Payer: Cofinity Commercial	$32.13
Rate for Payer: Cofinity Commercial	$39.47
Rate for Payer: Healthscope Commercial	$41.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$39.02
Rate for Payer: PHP Commercial	$39.02
Rate for Payer: Priority Health Cigna Priority Health	$32.13
Rate for Payer: Priority Health SBD	$28.92

HC PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY

Facility

$1,734.00

Service Code	CPT 33017
Hospital Charge Code	36100616
Hospital Revenue Code	361
Min. Negotiated Rate	$1,092.42
Max. Negotiated Rate	$1,560.60
Rate for Payer: Aetna Commercial	$1,473.90
Rate for Payer: Aetna New Business (MI Preferred)	$1,127.10
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Cofinity Commercial	$1,213.80
Rate for Payer: Cofinity Commercial	$1,491.24
Rate for Payer: Healthscope Commercial	$1,560.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,473.90
Rate for Payer: PHP Commercial	$1,473.90
Rate for Payer: Priority Health Cigna Priority Health	$1,213.80
Rate for Payer: Priority Health SBD	$1,092.42

HC PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY

Facility

$1,734.00

Service Code	CPT 33017
Hospital Charge Code	36100616
Hospital Revenue Code	361
Min. Negotiated Rate	$237.40
Max. Negotiated Rate	$3,138.00
Rate for Payer: Aetna Commercial	$1,473.90
Rate for Payer: Aetna New Business (MI Preferred)	$1,127.10
Rate for Payer: BCBS Complete	$693.60
Rate for Payer: BCBS Trust/PPO	$485.93
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Cofinity Commercial	$1,491.24
Rate for Payer: Cofinity Commercial	$1,213.80
Rate for Payer: Healthscope Commercial	$1,560.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,473.90
Rate for Payer: PHP Commercial	$1,473.90
Rate for Payer: Priority Health Cigna Priority Health	$1,213.80
Rate for Payer: Priority Health SBD	$1,092.42
Rate for Payer: UHC All Payor (Choice/PPO)	$261.14
Rate for Payer: UHC Core	$3,138.00
Rate for Payer: UHC Exchange	$237.40

HC PERQ REPLACE GTUBE NOT REQ REV GSTRST TRACT

Facility

$434.34

Service Code	CPT 43762
Hospital Charge Code	76100320
Hospital Revenue Code	761
Min. Negotiated Rate	$273.63
Max. Negotiated Rate	$390.91
Rate for Payer: Aetna Commercial	$369.19
Rate for Payer: Aetna New Business (MI Preferred)	$282.32
Rate for Payer: Cash Price	$347.47
Rate for Payer: Cofinity Commercial	$304.04
Rate for Payer: Cofinity Commercial	$373.53
Rate for Payer: Healthscope Commercial	$390.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$369.19
Rate for Payer: PHP Commercial	$369.19
Rate for Payer: Priority Health Cigna Priority Health	$304.04
Rate for Payer: Priority Health SBD	$273.63

HC PERQ REPLACE GTUBE NOT REQ REV GSTRST TRACT

Facility

$434.34

Service Code	CPT 43762
Hospital Charge Code	76100320
Hospital Revenue Code	761
Min. Negotiated Rate	$36.35
Max. Negotiated Rate	$390.91
Rate for Payer: Aetna Commercial	$369.19
Rate for Payer: Aetna Medicare	$228.71
Rate for Payer: Aetna New Business (MI Preferred)	$282.32
Rate for Payer: Allen County Amish Medical Aid Commercial	$274.89
Rate for Payer: Amish Plain Church Group Commercial	$274.89
Rate for Payer: BCBS Complete	$126.32
Rate for Payer: BCBS MAPPO	$219.91
Rate for Payer: BCBS Trust/PPO	$242.60
Rate for Payer: BCN Medicare Advantage	$219.91
Rate for Payer: Cash Price	$347.47
Rate for Payer: Cash Price	$347.47
Rate for Payer: Cofinity Commercial	$373.53
Rate for Payer: Cofinity Commercial	$304.04
Rate for Payer: Health Alliance Plan Medicare Advantage	$219.91
Rate for Payer: Healthscope Commercial	$390.91
Rate for Payer: Mclaren Medicaid	$120.29
Rate for Payer: Mclaren Medicare	$219.91
Rate for Payer: Meridian Medicaid	$126.32
Rate for Payer: Meridian Wellcare - Medicare Advantage	$230.91
Rate for Payer: MI Amish Medical Board Commercial	$252.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$369.19
Rate for Payer: PACE Medicare	$208.91
Rate for Payer: PACE SWMI	$219.91
Rate for Payer: PHP Commercial	$369.19
Rate for Payer: PHP Medicare Advantage	$219.91
Rate for Payer: Priority Health Choice Medicaid	$120.29
Rate for Payer: Priority Health Cigna Priority Health	$304.04
Rate for Payer: Priority Health Medicare	$219.91
Rate for Payer: Priority Health SBD	$273.63
Rate for Payer: Railroad Medicare Medicare	$219.91
Rate for Payer: UHC All Payor (Choice/PPO)	$39.98
Rate for Payer: UHC Dual Complete DSNP	$219.91
Rate for Payer: UHC Exchange	$36.35
Rate for Payer: UHC Medicare Advantage	$226.51
Rate for Payer: VA VA	$219.91

HC PERQ TRLUML CORONRY LITHOTRIPSY

Facility

$433.65

Service Code	CPT 92972
Hospital Charge Code	48000402
Hospital Revenue Code	480
Min. Negotiated Rate	$273.20
Max. Negotiated Rate	$390.28
Rate for Payer: Aetna Commercial	$368.60
Rate for Payer: Aetna New Business (MI Preferred)	$281.87
Rate for Payer: Cash Price	$346.92
Rate for Payer: Cofinity Commercial	$303.56
Rate for Payer: Cofinity Commercial	$372.94
Rate for Payer: Healthscope Commercial	$390.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$368.60
Rate for Payer: PHP Commercial	$368.60
Rate for Payer: Priority Health Cigna Priority Health	$303.56
Rate for Payer: Priority Health SBD	$273.20

HC PERQ TRLUML CORONRY LITHOTRIPSY

Facility

$433.65

Service Code	CPT 92972
Hospital Charge Code	48000402
Hospital Revenue Code	480
Min. Negotiated Rate	$140.15
Max. Negotiated Rate	$390.28
Rate for Payer: Aetna Commercial	$368.60
Rate for Payer: Aetna New Business (MI Preferred)	$281.87
Rate for Payer: BCBS Complete	$173.46
Rate for Payer: Cash Price	$346.92
Rate for Payer: Cash Price	$346.92
Rate for Payer: Cofinity Commercial	$372.94
Rate for Payer: Cofinity Commercial	$303.56
Rate for Payer: Healthscope Commercial	$390.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$368.60
Rate for Payer: PHP Commercial	$368.60
Rate for Payer: Priority Health Cigna Priority Health	$303.56
Rate for Payer: Priority Health SBD	$273.20
Rate for Payer: UHC All Payor (Choice/PPO)	$154.16
Rate for Payer: UHC Exchange	$140.15

HC PESSARY NON RUBBER ANY TYPE

Facility

$84.15

Service Code	HCPCS A4562
Hospital Charge Code	27200305
Hospital Revenue Code	272
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$196.77
Rate for Payer: Aetna Commercial	$71.53
Rate for Payer: Aetna New Business (MI Preferred)	$54.70
Rate for Payer: BCBS Complete	$33.66
Rate for Payer: BCBS Trust/PPO	$196.77
Rate for Payer: Cash Price	$67.32
Rate for Payer: Cash Price	$67.32
Rate for Payer: Cofinity Commercial	$58.90
Rate for Payer: Cofinity Commercial	$72.37
Rate for Payer: Healthscope Commercial	$75.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$71.53
Rate for Payer: PHP Commercial	$71.53
Rate for Payer: Priority Health Cigna Priority Health	$58.90
Rate for Payer: Priority Health SBD	$53.01
Rate for Payer: UHC All Payor (Choice/PPO)	$99.29
Rate for Payer: UHC Exchange	$82.74

HC PESSARY NON RUBBER ANY TYPE

Facility

$84.15

Service Code	HCPCS A4562
Hospital Charge Code	27200305
Hospital Revenue Code	272
Min. Negotiated Rate	$53.01
Max. Negotiated Rate	$75.74
Rate for Payer: Aetna Commercial	$71.53
Rate for Payer: Aetna New Business (MI Preferred)	$54.70
Rate for Payer: Cash Price	$67.32
Rate for Payer: Cofinity Commercial	$58.90
Rate for Payer: Cofinity Commercial	$72.37
Rate for Payer: Healthscope Commercial	$75.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$71.53
Rate for Payer: PHP Commercial	$71.53
Rate for Payer: Priority Health Cigna Priority Health	$58.90
Rate for Payer: Priority Health SBD	$53.01

HC PESSARY RUBBER ANY TYPE

Facility

$192.78

Service Code	CPT A4561
Hospital Charge Code	27200345
Hospital Revenue Code	272
Min. Negotiated Rate	$121.45
Max. Negotiated Rate	$173.50
Rate for Payer: Aetna Commercial	$163.86
Rate for Payer: Aetna New Business (MI Preferred)	$125.31
Rate for Payer: Cash Price	$154.22
Rate for Payer: Cofinity Commercial	$134.95
Rate for Payer: Cofinity Commercial	$165.79
Rate for Payer: Healthscope Commercial	$173.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$163.86
Rate for Payer: PHP Commercial	$163.86
Rate for Payer: Priority Health Cigna Priority Health	$134.95
Rate for Payer: Priority Health SBD	$121.45

Know your out-of-pocket cost for care.

All Charges