Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC POLARCATH

Facility

$6,937.70

Service Code	HCPCS C1725
Hospital Charge Code	27200064
Hospital Revenue Code	272
Min. Negotiated Rate	$4,370.75
Max. Negotiated Rate	$6,243.93
Rate for Payer: Aetna Commercial	$5,897.04
Rate for Payer: Aetna New Business (MI Preferred)	$4,509.50
Rate for Payer: Cash Price	$5,550.16
Rate for Payer: Cofinity Commercial	$4,856.39
Rate for Payer: Cofinity Commercial	$5,966.42
Rate for Payer: Healthscope Commercial	$6,243.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$5,897.04
Rate for Payer: PHP Commercial	$5,897.04
Rate for Payer: Priority Health Cigna Priority Health	$4,856.39
Rate for Payer: Priority Health SBD	$4,370.75

HC POLARCATH N.O. CARTRIDGE

Facility

$268.79

Hospital Charge Code	27200148
Hospital Revenue Code	272
Min. Negotiated Rate	$107.52
Max. Negotiated Rate	$241.91
Rate for Payer: Aetna Commercial	$228.47
Rate for Payer: Aetna New Business (MI Preferred)	$174.71
Rate for Payer: BCBS Complete	$107.52
Rate for Payer: Cash Price	$215.03
Rate for Payer: Cofinity Commercial	$188.15
Rate for Payer: Cofinity Commercial	$231.16
Rate for Payer: Healthscope Commercial	$241.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$228.47
Rate for Payer: PHP Commercial	$228.47
Rate for Payer: Priority Health Cigna Priority Health	$188.15
Rate for Payer: Priority Health SBD	$169.34

HC POLARCATH N.O. CARTRIDGE

Facility

$268.79

Hospital Charge Code	27200148
Hospital Revenue Code	272
Min. Negotiated Rate	$169.34
Max. Negotiated Rate	$241.91
Rate for Payer: Aetna Commercial	$228.47
Rate for Payer: Aetna New Business (MI Preferred)	$174.71
Rate for Payer: Cash Price	$215.03
Rate for Payer: Cofinity Commercial	$188.15
Rate for Payer: Cofinity Commercial	$231.16
Rate for Payer: Healthscope Commercial	$241.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$228.47
Rate for Payer: PHP Commercial	$228.47
Rate for Payer: Priority Health Cigna Priority Health	$188.15
Rate for Payer: Priority Health SBD	$169.34

HC POLIOVIRUS VACCINE, INACTIVATED (IPV) SUBQ/IM

Facility

$42.64

Service Code	CPT 90713
Hospital Charge Code	63600082
Hospital Revenue Code	636
Min. Negotiated Rate	$26.86
Max. Negotiated Rate	$38.38
Rate for Payer: Aetna Commercial	$36.24
Rate for Payer: Aetna New Business (MI Preferred)	$27.72
Rate for Payer: Cash Price	$34.11
Rate for Payer: Cofinity Commercial	$29.85
Rate for Payer: Cofinity Commercial	$36.67
Rate for Payer: Healthscope Commercial	$38.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$36.24
Rate for Payer: PHP Commercial	$36.24
Rate for Payer: Priority Health Cigna Priority Health	$29.85
Rate for Payer: Priority Health SBD	$26.86

HC POLIOVIRUS VACCINE, INACTIVATED (IPV) SUBQ/IM

Facility

$42.64

Service Code	CPT 90713
Hospital Charge Code	63600082
Hospital Revenue Code	636
Min. Negotiated Rate	$17.06
Max. Negotiated Rate	$116.63
Rate for Payer: Aetna Commercial	$36.24
Rate for Payer: Aetna New Business (MI Preferred)	$27.72
Rate for Payer: BCBS Complete	$17.06
Rate for Payer: BCBS Trust/PPO	$116.63
Rate for Payer: Cash Price	$34.11
Rate for Payer: Cash Price	$34.11
Rate for Payer: Cofinity Commercial	$29.85
Rate for Payer: Cofinity Commercial	$36.67
Rate for Payer: Healthscope Commercial	$38.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$36.24
Rate for Payer: PHP Commercial	$36.24
Rate for Payer: Priority Health Cigna Priority Health	$29.85
Rate for Payer: Priority Health SBD	$26.86

HC POLYPECTOMY

Facility

$482.14

Hospital Charge Code	36000080
Hospital Revenue Code	360
Min. Negotiated Rate	$303.75
Max. Negotiated Rate	$433.93
Rate for Payer: Aetna Commercial	$409.82
Rate for Payer: Aetna New Business (MI Preferred)	$313.39
Rate for Payer: Cash Price	$385.71
Rate for Payer: Cofinity Commercial	$337.50
Rate for Payer: Cofinity Commercial	$414.64
Rate for Payer: Healthscope Commercial	$433.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$409.82
Rate for Payer: PHP Commercial	$409.82
Rate for Payer: Priority Health Cigna Priority Health	$337.50
Rate for Payer: Priority Health SBD	$303.75

HC POLYPECTOMY

Facility

$482.14

Hospital Charge Code	36000080
Hospital Revenue Code	360
Min. Negotiated Rate	$192.86
Max. Negotiated Rate	$433.93
Rate for Payer: Aetna Commercial	$409.82
Rate for Payer: Aetna New Business (MI Preferred)	$313.39
Rate for Payer: BCBS Complete	$192.86
Rate for Payer: Cash Price	$385.71
Rate for Payer: Cofinity Commercial	$337.50
Rate for Payer: Cofinity Commercial	$414.64
Rate for Payer: Healthscope Commercial	$433.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$409.82
Rate for Payer: PHP Commercial	$409.82
Rate for Payer: Priority Health Cigna Priority Health	$337.50
Rate for Payer: Priority Health SBD	$303.75

HC POLYPECTOMY ADDL 45 MIN OR MORE

Facility

$179.15

Hospital Charge Code	36000004
Hospital Revenue Code	360
Min. Negotiated Rate	$112.86
Max. Negotiated Rate	$161.24
Rate for Payer: Aetna Commercial	$152.28
Rate for Payer: Aetna New Business (MI Preferred)	$116.45
Rate for Payer: Cash Price	$143.32
Rate for Payer: Cofinity Commercial	$125.40
Rate for Payer: Cofinity Commercial	$154.07
Rate for Payer: Healthscope Commercial	$161.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$152.28
Rate for Payer: PHP Commercial	$152.28
Rate for Payer: Priority Health Cigna Priority Health	$125.40
Rate for Payer: Priority Health SBD	$112.86

HC POLYPECTOMY ADDL 45 MIN OR MORE

Facility

$179.15

Hospital Charge Code	36000004
Hospital Revenue Code	360
Min. Negotiated Rate	$71.66
Max. Negotiated Rate	$161.24
Rate for Payer: Aetna Commercial	$152.28
Rate for Payer: Aetna New Business (MI Preferred)	$116.45
Rate for Payer: BCBS Complete	$71.66
Rate for Payer: Cash Price	$143.32
Rate for Payer: Cofinity Commercial	$125.40
Rate for Payer: Cofinity Commercial	$154.07
Rate for Payer: Healthscope Commercial	$161.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$152.28
Rate for Payer: PHP Commercial	$152.28
Rate for Payer: Priority Health Cigna Priority Health	$125.40
Rate for Payer: Priority Health SBD	$112.86

HC PORPHYRIN URINE QUANTITATIVE

Facility

$32.64

Service Code	CPT 84120
Hospital Charge Code	30100395
Hospital Revenue Code	301
Min. Negotiated Rate	$8.05
Max. Negotiated Rate	$29.38
Rate for Payer: Aetna Commercial	$27.74
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: Aetna New Business (MI Preferred)	$21.22
Rate for Payer: Allen County Amish Medical Aid Commercial	$18.39
Rate for Payer: Amish Plain Church Group Commercial	$18.39
Rate for Payer: BCBS Complete	$8.45
Rate for Payer: BCBS MAPPO	$14.71
Rate for Payer: BCBS Trust/PPO	$11.52
Rate for Payer: BCN Medicare Advantage	$14.71
Rate for Payer: Cash Price	$26.11
Rate for Payer: Cash Price	$26.11
Rate for Payer: Cofinity Commercial	$22.85
Rate for Payer: Cofinity Commercial	$28.07
Rate for Payer: Health Alliance Plan Medicare Advantage	$14.71
Rate for Payer: Healthscope Commercial	$29.38
Rate for Payer: Mclaren Medicaid	$8.05
Rate for Payer: Mclaren Medicare	$14.71
Rate for Payer: Meridian Medicaid	$8.45
Rate for Payer: Meridian Wellcare - Medicare Advantage	$15.45
Rate for Payer: MI Amish Medical Board Commercial	$16.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$27.74
Rate for Payer: PACE Medicare	$13.97
Rate for Payer: PACE SWMI	$14.71
Rate for Payer: PHP Commercial	$27.74
Rate for Payer: PHP Medicare Advantage	$14.71
Rate for Payer: Priority Health Choice Medicaid	$8.05
Rate for Payer: Priority Health Cigna Priority Health	$22.85
Rate for Payer: Priority Health Medicare	$14.71
Rate for Payer: Priority Health SBD	$20.56
Rate for Payer: Railroad Medicare Medicare	$14.71
Rate for Payer: UHC All Payor (Choice/PPO)	$17.65
Rate for Payer: UHC Core	$25.00
Rate for Payer: UHC Dual Complete DSNP	$14.71
Rate for Payer: UHC Exchange	$14.71
Rate for Payer: UHC Medicare Advantage	$15.15
Rate for Payer: VA VA	$14.71

HC PORPHYRIN URINE QUANTITATIVE

Facility

$32.64

Service Code	CPT 84120
Hospital Charge Code	30100395
Hospital Revenue Code	301
Min. Negotiated Rate	$20.56
Max. Negotiated Rate	$29.38
Rate for Payer: Aetna Commercial	$27.74
Rate for Payer: Aetna New Business (MI Preferred)	$21.22
Rate for Payer: Cash Price	$26.11
Rate for Payer: Cofinity Commercial	$22.85
Rate for Payer: Cofinity Commercial	$28.07
Rate for Payer: Healthscope Commercial	$29.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$27.74
Rate for Payer: PHP Commercial	$27.74
Rate for Payer: Priority Health Cigna Priority Health	$22.85
Rate for Payer: Priority Health SBD	$20.56

HC PORPHYRIN URINE QUANTITATIVE C

Facility

$31.00

Service Code	CPT 84110
Hospital Charge Code	30100394
Hospital Revenue Code	301
Min. Negotiated Rate	$19.53
Max. Negotiated Rate	$27.90
Rate for Payer: Aetna Commercial	$26.35
Rate for Payer: Aetna New Business (MI Preferred)	$20.15
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cofinity Commercial	$21.70
Rate for Payer: Cofinity Commercial	$26.66
Rate for Payer: Healthscope Commercial	$27.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$26.35
Rate for Payer: PHP Commercial	$26.35
Rate for Payer: Priority Health Cigna Priority Health	$21.70
Rate for Payer: Priority Health SBD	$19.53

HC PORPHYRIN URINE QUANTITATIVE C

Facility

$31.00

Service Code	CPT 84110
Hospital Charge Code	30100394
Hospital Revenue Code	301
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$27.90
Rate for Payer: Aetna Commercial	$26.35
Rate for Payer: Aetna Medicare	$8.78
Rate for Payer: Aetna New Business (MI Preferred)	$20.15
Rate for Payer: Allen County Amish Medical Aid Commercial	$10.55
Rate for Payer: Amish Plain Church Group Commercial	$10.55
Rate for Payer: BCBS Complete	$4.85
Rate for Payer: BCBS MAPPO	$8.44
Rate for Payer: BCBS Trust/PPO	$6.61
Rate for Payer: BCN Medicare Advantage	$8.44
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cofinity Commercial	$21.70
Rate for Payer: Cofinity Commercial	$26.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$8.44
Rate for Payer: Healthscope Commercial	$27.90
Rate for Payer: Mclaren Medicaid	$4.62
Rate for Payer: Mclaren Medicare	$8.44
Rate for Payer: Meridian Medicaid	$4.85
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8.86
Rate for Payer: MI Amish Medical Board Commercial	$9.71
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$26.35
Rate for Payer: PACE Medicare	$8.02
Rate for Payer: PACE SWMI	$8.44
Rate for Payer: PHP Commercial	$26.35
Rate for Payer: PHP Medicare Advantage	$8.44
Rate for Payer: Priority Health Choice Medicaid	$4.62
Rate for Payer: Priority Health Cigna Priority Health	$21.70
Rate for Payer: Priority Health Medicare	$8.44
Rate for Payer: Priority Health SBD	$19.53
Rate for Payer: Railroad Medicare Medicare	$8.44
Rate for Payer: UHC All Payor (Choice/PPO)	$10.13
Rate for Payer: UHC Core	$14.35
Rate for Payer: UHC Dual Complete DSNP	$8.44
Rate for Payer: UHC Exchange	$8.44
Rate for Payer: UHC Medicare Advantage	$8.69
Rate for Payer: VA VA	$8.44

HC PORTAL FILMS

Facility

$262.14

Service Code	CPT 77417
Hospital Charge Code	33300023
Hospital Revenue Code	333
Min. Negotiated Rate	$165.15
Max. Negotiated Rate	$235.93
Rate for Payer: Aetna Commercial	$222.82
Rate for Payer: Aetna Commercial	$180.20
Rate for Payer: Aetna New Business (MI Preferred)	$170.39
Rate for Payer: Aetna New Business (MI Preferred)	$137.80
Rate for Payer: Cash Price	$209.71
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cofinity Commercial	$182.32
Rate for Payer: Cofinity Commercial	$225.44
Rate for Payer: Cofinity Commercial	$148.40
Rate for Payer: Cofinity Commercial	$183.50
Rate for Payer: Healthscope Commercial	$190.80
Rate for Payer: Healthscope Commercial	$235.93
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$222.82
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$180.20
Rate for Payer: PHP Commercial	$180.20
Rate for Payer: PHP Commercial	$222.82
Rate for Payer: Priority Health Cigna Priority Health	$148.40
Rate for Payer: Priority Health Cigna Priority Health	$183.50
Rate for Payer: Priority Health SBD	$133.56
Rate for Payer: Priority Health SBD	$165.15

HC PORTAL FILMS

Facility

$262.14

Service Code	CPT 77417
Hospital Charge Code	33300023
Hospital Revenue Code	333
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$235.93
Rate for Payer: Aetna Commercial	$222.82
Rate for Payer: Aetna Commercial	$180.20
Rate for Payer: Aetna New Business (MI Preferred)	$137.80
Rate for Payer: Aetna New Business (MI Preferred)	$170.39
Rate for Payer: BCBS Complete	$104.86
Rate for Payer: BCBS Complete	$84.80
Rate for Payer: BCBS Trust/PPO	$22.62
Rate for Payer: BCBS Trust/PPO	$22.62
Rate for Payer: Cash Price	$209.71
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cash Price	$209.71
Rate for Payer: Cofinity Commercial	$148.40
Rate for Payer: Cofinity Commercial	$182.32
Rate for Payer: Cofinity Commercial	$183.50
Rate for Payer: Cofinity Commercial	$225.44
Rate for Payer: Healthscope Commercial	$235.93
Rate for Payer: Healthscope Commercial	$190.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$180.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$222.82
Rate for Payer: PHP Commercial	$222.82
Rate for Payer: PHP Commercial	$180.20
Rate for Payer: Priority Health Cigna Priority Health	$148.40
Rate for Payer: Priority Health Cigna Priority Health	$183.50
Rate for Payer: Priority Health SBD	$165.15
Rate for Payer: Priority Health SBD	$133.56
Rate for Payer: UHC All Payor (Choice/PPO)	$16.20
Rate for Payer: UHC All Payor (Choice/PPO)	$16.20
Rate for Payer: UHC Exchange	$14.73
Rate for Payer: UHC Exchange	$14.73

HC PORT PLAN, TOTAL BODY

Facility

$527.00

Service Code	CPT 77321
Hospital Charge Code	33300031
Hospital Revenue Code	333
Min. Negotiated Rate	$332.01
Max. Negotiated Rate	$474.30
Rate for Payer: Aetna Commercial	$447.95
Rate for Payer: Aetna Commercial	$461.24
Rate for Payer: Aetna New Business (MI Preferred)	$342.55
Rate for Payer: Aetna New Business (MI Preferred)	$352.72
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cash Price	$434.11
Rate for Payer: Cofinity Commercial	$368.90
Rate for Payer: Cofinity Commercial	$379.85
Rate for Payer: Cofinity Commercial	$466.67
Rate for Payer: Cofinity Commercial	$453.22
Rate for Payer: Healthscope Commercial	$474.30
Rate for Payer: Healthscope Commercial	$488.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$461.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$447.95
Rate for Payer: PHP Commercial	$447.95
Rate for Payer: PHP Commercial	$461.24
Rate for Payer: Priority Health Cigna Priority Health	$379.85
Rate for Payer: Priority Health Cigna Priority Health	$368.90
Rate for Payer: Priority Health SBD	$332.01
Rate for Payer: Priority Health SBD	$341.86

HC PORT PLAN, TOTAL BODY

Facility

$527.00

Service Code	CPT 77321
Hospital Charge Code	33300031
Hospital Revenue Code	333
Min. Negotiated Rate	$72.26
Max. Negotiated Rate	$474.30
Rate for Payer: Aetna Commercial	$447.95
Rate for Payer: Aetna Commercial	$461.24
Rate for Payer: Aetna Medicare	$341.92
Rate for Payer: Aetna Medicare	$341.92
Rate for Payer: Aetna New Business (MI Preferred)	$342.55
Rate for Payer: Aetna New Business (MI Preferred)	$352.72
Rate for Payer: Allen County Amish Medical Aid Commercial	$410.96
Rate for Payer: Allen County Amish Medical Aid Commercial	$410.96
Rate for Payer: Amish Plain Church Group Commercial	$410.96
Rate for Payer: Amish Plain Church Group Commercial	$410.96
Rate for Payer: BCBS Complete	$188.85
Rate for Payer: BCBS Complete	$188.85
Rate for Payer: BCBS MAPPO	$328.77
Rate for Payer: BCBS MAPPO	$328.77
Rate for Payer: BCBS Trust/PPO	$72.26
Rate for Payer: BCBS Trust/PPO	$72.26
Rate for Payer: BCN Medicare Advantage	$328.77
Rate for Payer: BCN Medicare Advantage	$328.77
Rate for Payer: Cash Price	$434.11
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cash Price	$434.11
Rate for Payer: Cofinity Commercial	$368.90
Rate for Payer: Cofinity Commercial	$453.22
Rate for Payer: Cofinity Commercial	$466.67
Rate for Payer: Cofinity Commercial	$379.85
Rate for Payer: Health Alliance Plan Medicare Advantage	$328.77
Rate for Payer: Health Alliance Plan Medicare Advantage	$328.77
Rate for Payer: Healthscope Commercial	$488.38
Rate for Payer: Healthscope Commercial	$474.30
Rate for Payer: Mclaren Medicaid	$179.84
Rate for Payer: Mclaren Medicaid	$179.84
Rate for Payer: Mclaren Medicare	$328.77
Rate for Payer: Mclaren Medicare	$328.77
Rate for Payer: Meridian Medicaid	$188.85
Rate for Payer: Meridian Medicaid	$188.85
Rate for Payer: Meridian Wellcare - Medicare Advantage	$345.21
Rate for Payer: Meridian Wellcare - Medicare Advantage	$345.21
Rate for Payer: MI Amish Medical Board Commercial	$378.09
Rate for Payer: MI Amish Medical Board Commercial	$378.09
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$447.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$461.24
Rate for Payer: PACE Medicare	$312.33
Rate for Payer: PACE Medicare	$312.33
Rate for Payer: PACE SWMI	$328.77
Rate for Payer: PACE SWMI	$328.77
Rate for Payer: PHP Commercial	$447.95
Rate for Payer: PHP Commercial	$461.24
Rate for Payer: PHP Medicare Advantage	$328.77
Rate for Payer: PHP Medicare Advantage	$328.77
Rate for Payer: Priority Health Choice Medicaid	$179.84
Rate for Payer: Priority Health Choice Medicaid	$179.84
Rate for Payer: Priority Health Cigna Priority Health	$379.85
Rate for Payer: Priority Health Cigna Priority Health	$368.90
Rate for Payer: Priority Health Medicare	$328.77
Rate for Payer: Priority Health Medicare	$328.77
Rate for Payer: Priority Health SBD	$332.01
Rate for Payer: Priority Health SBD	$341.86
Rate for Payer: Railroad Medicare Medicare	$328.77
Rate for Payer: Railroad Medicare Medicare	$328.77
Rate for Payer: UHC All Payor (Choice/PPO)	$101.94
Rate for Payer: UHC All Payor (Choice/PPO)	$101.94
Rate for Payer: UHC Dual Complete DSNP	$328.77
Rate for Payer: UHC Dual Complete DSNP	$328.77
Rate for Payer: UHC Exchange	$92.67
Rate for Payer: UHC Exchange	$92.67
Rate for Payer: UHC Medicare Advantage	$338.63
Rate for Payer: UHC Medicare Advantage	$338.63
Rate for Payer: VA VA	$328.77
Rate for Payer: VA VA	$328.77

HC POST MASTECTOMY SLEEVE A

Facility

$68.00

Service Code	HCPCS L8010
Hospital Charge Code	96000049
Hospital Revenue Code	270
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$61.20
Rate for Payer: Aetna Commercial	$57.80
Rate for Payer: Aetna New Business (MI Preferred)	$44.20
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cofinity Commercial	$47.60
Rate for Payer: Cofinity Commercial	$58.48
Rate for Payer: Healthscope Commercial	$61.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.80
Rate for Payer: PHP Commercial	$57.80
Rate for Payer: Priority Health Cigna Priority Health	$47.60
Rate for Payer: Priority Health SBD	$42.84

HC POST MASTECTOMY SLEEVE A

Facility

$68.00

Service Code	HCPCS L8010
Hospital Charge Code	96000049
Hospital Revenue Code	270
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$148.19
Rate for Payer: Aetna Commercial	$57.80
Rate for Payer: Aetna New Business (MI Preferred)	$44.20
Rate for Payer: BCBS Complete	$27.20
Rate for Payer: BCBS Trust/PPO	$148.19
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cofinity Commercial	$47.60
Rate for Payer: Cofinity Commercial	$58.48
Rate for Payer: Healthscope Commercial	$61.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.80
Rate for Payer: PHP Commercial	$57.80
Rate for Payer: Priority Health Cigna Priority Health	$47.60
Rate for Payer: Priority Health SBD	$42.84

HC POST MASTECTOMY SLEEVE B

Facility

$80.00

Service Code	HCPCS L8010
Hospital Charge Code	96000050
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.00
Rate for Payer: Aetna New Business (MI Preferred)	$52.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cofinity Commercial	$56.00
Rate for Payer: Cofinity Commercial	$68.80
Rate for Payer: Healthscope Commercial	$72.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$68.00
Rate for Payer: PHP Commercial	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: Priority Health SBD	$50.40

HC POST MASTECTOMY SLEEVE B

Facility

$80.00

Service Code	HCPCS L8010
Hospital Charge Code	96000050
Hospital Revenue Code	270
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$148.19
Rate for Payer: Aetna Commercial	$68.00
Rate for Payer: Aetna New Business (MI Preferred)	$52.00
Rate for Payer: BCBS Complete	$32.00
Rate for Payer: BCBS Trust/PPO	$148.19
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cofinity Commercial	$56.00
Rate for Payer: Cofinity Commercial	$68.80
Rate for Payer: Healthscope Commercial	$72.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$68.00
Rate for Payer: PHP Commercial	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: Priority Health SBD	$50.40

HC POST MASTECTOMY SLEEVE C

Facility

$216.00

Service Code	HCPCS L8010
Hospital Charge Code	96000051
Hospital Revenue Code	270
Min. Negotiated Rate	$86.40
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna Commercial	$183.60
Rate for Payer: Aetna New Business (MI Preferred)	$140.40
Rate for Payer: BCBS Complete	$86.40
Rate for Payer: BCBS Trust/PPO	$148.19
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cofinity Commercial	$185.76
Rate for Payer: Cofinity Commercial	$151.20
Rate for Payer: Healthscope Commercial	$194.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$183.60
Rate for Payer: PHP Commercial	$183.60
Rate for Payer: Priority Health Cigna Priority Health	$151.20
Rate for Payer: Priority Health SBD	$136.08

HC POST MASTECTOMY SLEEVE C

Facility

$216.00

Service Code	HCPCS L8010
Hospital Charge Code	96000051
Hospital Revenue Code	270
Min. Negotiated Rate	$136.08
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna Commercial	$183.60
Rate for Payer: Aetna New Business (MI Preferred)	$140.40
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cofinity Commercial	$151.20
Rate for Payer: Cofinity Commercial	$185.76
Rate for Payer: Healthscope Commercial	$194.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$183.60
Rate for Payer: PHP Commercial	$183.60
Rate for Payer: Priority Health Cigna Priority Health	$151.20
Rate for Payer: Priority Health SBD	$136.08

HC POST MASTECTOMY SLEEVE D

Facility

$246.00

Service Code	HCPCS L8010
Hospital Charge Code	96000052
Hospital Revenue Code	270
Min. Negotiated Rate	$154.98
Max. Negotiated Rate	$221.40
Rate for Payer: Aetna Commercial	$209.10
Rate for Payer: Aetna New Business (MI Preferred)	$159.90
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cofinity Commercial	$172.20
Rate for Payer: Cofinity Commercial	$211.56
Rate for Payer: Healthscope Commercial	$221.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$209.10
Rate for Payer: PHP Commercial	$209.10
Rate for Payer: Priority Health Cigna Priority Health	$172.20
Rate for Payer: Priority Health SBD	$154.98

HC POST MASTECTOMY SLEEVE D

Facility

$246.00

Service Code	HCPCS L8010
Hospital Charge Code	96000052
Hospital Revenue Code	270
Min. Negotiated Rate	$98.40
Max. Negotiated Rate	$221.40
Rate for Payer: Aetna Commercial	$209.10
Rate for Payer: Aetna New Business (MI Preferred)	$159.90
Rate for Payer: BCBS Complete	$98.40
Rate for Payer: BCBS Trust/PPO	$148.19
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cofinity Commercial	$172.20
Rate for Payer: Cofinity Commercial	$211.56
Rate for Payer: Healthscope Commercial	$221.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$209.10
Rate for Payer: PHP Commercial	$209.10
Rate for Payer: Priority Health Cigna Priority Health	$172.20
Rate for Payer: Priority Health SBD	$154.98

Know your out-of-pocket cost for care.

All Charges