Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC ENZYME HISTOCHEMISTRY

Facility

$162.00

Service Code	CPT 88319
Hospital Charge Code	31200006
Hospital Revenue Code	312
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna Commercial	$145.80
Rate for Payer: ASR ASR	$157.14
Rate for Payer: BCBS Trust/PPO	$125.60
Rate for Payer: BCN Commercial	$125.60
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cofinity Commercial	$152.28
Rate for Payer: Encore Health Key Benefits Commercial	$129.60
Rate for Payer: Healthscope Commercial	$162.00
Rate for Payer: Healthscope Whirlpool	$157.14
Rate for Payer: Mclaren Commercial	$145.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$137.70
Rate for Payer: Priority Health Cigna Priority Health	$113.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$142.56

HC ENZYME HISTOCHEMISTRY

Facility

$162.00

Service Code	CPT 88319
Hospital Charge Code	31200006
Hospital Revenue Code	312
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$955.41
Rate for Payer: Aetna Commercial	$145.80
Rate for Payer: Aetna Medicare	$764.33
Rate for Payer: Allen County Amish Medical Aid Commercial	$955.41
Rate for Payer: Amish Plain Church Group Commercial	$955.41
Rate for Payer: ASR ASR	$157.14
Rate for Payer: BCBS Complete	$439.03
Rate for Payer: BCBS MAPPO	$764.33
Rate for Payer: BCBS Trust/PPO	$125.60
Rate for Payer: BCN Commercial	$125.60
Rate for Payer: BCN Medicare Advantage	$764.33
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cofinity Commercial	$152.28
Rate for Payer: Encore Health Key Benefits Commercial	$129.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$764.33
Rate for Payer: Healthscope Commercial	$162.00
Rate for Payer: Healthscope Whirlpool	$157.14
Rate for Payer: Humana Choice PPO Medicare	$764.33
Rate for Payer: Mclaren Commercial	$145.80
Rate for Payer: Mclaren Medicaid	$418.09
Rate for Payer: Mclaren Medicare	$764.33
Rate for Payer: Meridian Medicaid	$439.03
Rate for Payer: Meridian Wellcare - Medicare Advantage	$802.55
Rate for Payer: MI Amish Medical Board Commercial	$878.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$137.70
Rate for Payer: PACE Medicare	$726.11
Rate for Payer: PACE SWMI	$764.33
Rate for Payer: PHP Commercial	$840.76
Rate for Payer: PHP Medicaid	$418.09
Rate for Payer: PHP Medicare Advantage	$764.33
Rate for Payer: Priority Health Choice Medicaid	$418.09
Rate for Payer: Priority Health Cigna Priority Health	$113.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$147.42
Rate for Payer: Priority Health Medicare	$764.33
Rate for Payer: Priority Health Narrow Network	$115.02
Rate for Payer: Railroad Medicare Medicare	$764.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$142.56
Rate for Payer: UHC Medicare Advantage	$787.26
Rate for Payer: VA VA	$764.33

HC EOSINOPHIL NASAL SMEAR

Facility

$45.40

Service Code	CPT 89190
Hospital Charge Code	30000003
Hospital Revenue Code	300
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$45.40
Rate for Payer: Aetna Commercial	$40.86
Rate for Payer: Aetna Medicare	$5.79
Rate for Payer: Allen County Amish Medical Aid Commercial	$7.24
Rate for Payer: Amish Plain Church Group Commercial	$7.24
Rate for Payer: ASR ASR	$44.04
Rate for Payer: BCBS Complete	$3.33
Rate for Payer: BCBS MAPPO	$5.79
Rate for Payer: BCBS Trust/PPO	$35.20
Rate for Payer: BCN Commercial	$35.20
Rate for Payer: BCN Medicare Advantage	$5.79
Rate for Payer: Cash Price	$36.32
Rate for Payer: Cash Price	$36.32
Rate for Payer: Cofinity Commercial	$42.68
Rate for Payer: Encore Health Key Benefits Commercial	$36.32
Rate for Payer: Health Alliance Plan Medicare Advantage	$5.79
Rate for Payer: Healthscope Commercial	$45.40
Rate for Payer: Healthscope Whirlpool	$44.04
Rate for Payer: Humana Choice PPO Medicare	$5.79
Rate for Payer: Mclaren Commercial	$40.86
Rate for Payer: Mclaren Medicaid	$3.17
Rate for Payer: Mclaren Medicare	$5.79
Rate for Payer: Meridian Medicaid	$3.33
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6.08
Rate for Payer: MI Amish Medical Board Commercial	$6.66
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.59
Rate for Payer: PACE Medicare	$5.50
Rate for Payer: PACE SWMI	$5.79
Rate for Payer: PHP Commercial	$6.37
Rate for Payer: PHP Medicaid	$3.17
Rate for Payer: PHP Medicare Advantage	$5.79
Rate for Payer: Priority Health Choice Medicaid	$3.17
Rate for Payer: Priority Health Cigna Priority Health	$31.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.95
Rate for Payer: Priority Health Medicare	$5.79
Rate for Payer: Priority Health Narrow Network	$14.36
Rate for Payer: Railroad Medicare Medicare	$5.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.95
Rate for Payer: UHC Medicare Advantage	$5.96
Rate for Payer: VA VA	$5.79

HC EOSINOPHIL NASAL SMEAR

Facility

$45.40

Service Code	CPT 89190
Hospital Charge Code	30000003
Hospital Revenue Code	300
Min. Negotiated Rate	$31.78
Max. Negotiated Rate	$45.40
Rate for Payer: Aetna Commercial	$40.86
Rate for Payer: ASR ASR	$44.04
Rate for Payer: BCBS Trust/PPO	$35.20
Rate for Payer: BCN Commercial	$35.20
Rate for Payer: Cash Price	$36.32
Rate for Payer: Cofinity Commercial	$42.68
Rate for Payer: Encore Health Key Benefits Commercial	$36.32
Rate for Payer: Healthscope Commercial	$45.40
Rate for Payer: Healthscope Whirlpool	$44.04
Rate for Payer: Mclaren Commercial	$40.86
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.59
Rate for Payer: Priority Health Cigna Priority Health	$31.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.95

HC EOVIST PER ML

Facility

$30.70

Service Code	HCPCS A9581
Hospital Charge Code	63600009
Hospital Revenue Code	636
Min. Negotiated Rate	$21.49
Max. Negotiated Rate	$30.70
Rate for Payer: Aetna Commercial	$27.63
Rate for Payer: ASR ASR	$29.78
Rate for Payer: BCBS Trust/PPO	$23.80
Rate for Payer: BCN Commercial	$23.80
Rate for Payer: Cash Price	$24.56
Rate for Payer: Cofinity Commercial	$28.86
Rate for Payer: Encore Health Key Benefits Commercial	$24.56
Rate for Payer: Healthscope Commercial	$30.70
Rate for Payer: Healthscope Whirlpool	$29.78
Rate for Payer: Mclaren Commercial	$27.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$26.10
Rate for Payer: Priority Health Cigna Priority Health	$21.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$27.02

HC EOVIST PER ML

Facility

$30.70

Service Code	HCPCS A9581
Hospital Charge Code	63600009
Hospital Revenue Code	636
Min. Negotiated Rate	$12.28
Max. Negotiated Rate	$30.70
Rate for Payer: Aetna Commercial	$27.63
Rate for Payer: ASR ASR	$29.78
Rate for Payer: BCBS Complete	$12.28
Rate for Payer: BCBS Trust/PPO	$23.80
Rate for Payer: BCN Commercial	$23.80
Rate for Payer: Cash Price	$24.56
Rate for Payer: Cofinity Commercial	$28.86
Rate for Payer: Encore Health Key Benefits Commercial	$24.56
Rate for Payer: Healthscope Commercial	$30.70
Rate for Payer: Healthscope Whirlpool	$29.78
Rate for Payer: Mclaren Commercial	$27.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$26.10
Rate for Payer: Priority Health Cigna Priority Health	$21.49
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27.94
Rate for Payer: Priority Health Narrow Network	$21.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$27.02

HC EO W/O JOINTS CF

Facility

$270.30

Service Code	HCPCS L3702
Hospital Charge Code	27400050
Hospital Revenue Code	274
Min. Negotiated Rate	$189.21
Max. Negotiated Rate	$270.30
Rate for Payer: Aetna Commercial	$243.27
Rate for Payer: ASR ASR	$262.19
Rate for Payer: BCBS Trust/PPO	$209.56
Rate for Payer: BCN Commercial	$209.56
Rate for Payer: Cash Price	$216.24
Rate for Payer: Cofinity Commercial	$254.08
Rate for Payer: Encore Health Key Benefits Commercial	$216.24
Rate for Payer: Healthscope Commercial	$270.30
Rate for Payer: Healthscope Whirlpool	$262.19
Rate for Payer: Mclaren Commercial	$243.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$229.76
Rate for Payer: Priority Health Cigna Priority Health	$189.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$237.86

HC EO W/O JOINTS CF

Facility

$270.30

Service Code	HCPCS L3702
Hospital Charge Code	27400050
Hospital Revenue Code	274
Min. Negotiated Rate	$108.12
Max. Negotiated Rate	$270.30
Rate for Payer: Aetna Commercial	$243.27
Rate for Payer: ASR ASR	$262.19
Rate for Payer: BCBS Complete	$108.12
Rate for Payer: BCBS Trust/PPO	$209.56
Rate for Payer: BCN Commercial	$209.56
Rate for Payer: Cash Price	$216.24
Rate for Payer: Cofinity Commercial	$254.08
Rate for Payer: Encore Health Key Benefits Commercial	$216.24
Rate for Payer: Healthscope Commercial	$270.30
Rate for Payer: Healthscope Whirlpool	$262.19
Rate for Payer: Mclaren Commercial	$243.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$229.76
Rate for Payer: Priority Health Cigna Priority Health	$189.21
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$245.97
Rate for Payer: Priority Health Narrow Network	$191.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$237.86

HC EP+ABL ARRHYTHMIA

Facility

$17,391.67

Service Code	CPT 93653
Hospital Charge Code	48100091
Hospital Revenue Code	481
Min. Negotiated Rate	$12,174.17
Max. Negotiated Rate	$17,391.67
Rate for Payer: Aetna Commercial	$15,652.50
Rate for Payer: ASR ASR	$16,869.92
Rate for Payer: BCBS Trust/PPO	$13,483.76
Rate for Payer: BCN Commercial	$13,483.76
Rate for Payer: Cash Price	$13,913.34
Rate for Payer: Cofinity Commercial	$16,348.17
Rate for Payer: Encore Health Key Benefits Commercial	$13,913.34
Rate for Payer: Healthscope Commercial	$17,391.67
Rate for Payer: Healthscope Whirlpool	$16,869.92
Rate for Payer: Mclaren Commercial	$15,652.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14,782.92
Rate for Payer: Priority Health Cigna Priority Health	$12,174.17
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15,304.67

HC EP+ABL ARRHYTHMIA

Facility

$17,391.67

Service Code	CPT 93653
Hospital Charge Code	48100091
Hospital Revenue Code	481
Min. Negotiated Rate	$9,540.74
Max. Negotiated Rate	$26,389.02
Rate for Payer: Aetna Commercial	$15,652.50
Rate for Payer: Aetna Medicare	$21,111.22
Rate for Payer: Allen County Amish Medical Aid Commercial	$26,389.02
Rate for Payer: Amish Plain Church Group Commercial	$26,389.02
Rate for Payer: ASR ASR	$16,869.92
Rate for Payer: BCBS Complete	$12,126.28
Rate for Payer: BCBS MAPPO	$21,111.22
Rate for Payer: BCBS Trust/PPO	$13,483.76
Rate for Payer: BCN Commercial	$13,483.76
Rate for Payer: BCN Medicare Advantage	$21,111.22
Rate for Payer: Cash Price	$13,913.34
Rate for Payer: Cash Price	$13,913.34
Rate for Payer: Cofinity Commercial	$16,348.17
Rate for Payer: Encore Health Key Benefits Commercial	$13,913.34
Rate for Payer: Health Alliance Plan Medicare Advantage	$21,111.22
Rate for Payer: Healthscope Commercial	$17,391.67
Rate for Payer: Healthscope Whirlpool	$16,869.92
Rate for Payer: Humana Choice PPO Medicare	$21,111.22
Rate for Payer: Mclaren Commercial	$15,652.50
Rate for Payer: Mclaren Medicaid	$11,547.84
Rate for Payer: Mclaren Medicare	$21,111.22
Rate for Payer: Meridian Medicaid	$12,126.28
Rate for Payer: Meridian Wellcare - Medicare Advantage	$22,166.78
Rate for Payer: MI Amish Medical Board Commercial	$24,277.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14,782.92
Rate for Payer: PACE Medicare	$20,055.66
Rate for Payer: PACE SWMI	$21,111.22
Rate for Payer: PHP Commercial	$23,222.34
Rate for Payer: PHP Medicaid	$11,547.84
Rate for Payer: PHP Medicare Advantage	$21,111.22
Rate for Payer: Priority Health Choice Medicaid	$11,547.84
Rate for Payer: Priority Health Cigna Priority Health	$12,174.17
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11,925.92
Rate for Payer: Priority Health Medicare	$21,111.22
Rate for Payer: Priority Health Narrow Network	$9,540.74
Rate for Payer: Railroad Medicare Medicare	$21,111.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15,304.67
Rate for Payer: UHC Medicare Advantage	$21,744.56
Rate for Payer: VA VA	$21,111.22

HC EP+ABL VT

Facility

$17,391.67

Service Code	CPT 93654
Hospital Charge Code	48100092
Hospital Revenue Code	481
Min. Negotiated Rate	$9,540.74
Max. Negotiated Rate	$26,389.02
Rate for Payer: Aetna Commercial	$15,652.50
Rate for Payer: Aetna Medicare	$21,111.22
Rate for Payer: Allen County Amish Medical Aid Commercial	$26,389.02
Rate for Payer: Amish Plain Church Group Commercial	$26,389.02
Rate for Payer: ASR ASR	$16,869.92
Rate for Payer: BCBS Complete	$12,126.28
Rate for Payer: BCBS MAPPO	$21,111.22
Rate for Payer: BCBS Trust/PPO	$13,483.76
Rate for Payer: BCN Commercial	$13,483.76
Rate for Payer: BCN Medicare Advantage	$21,111.22
Rate for Payer: Cash Price	$13,913.34
Rate for Payer: Cash Price	$13,913.34
Rate for Payer: Cofinity Commercial	$16,348.17
Rate for Payer: Encore Health Key Benefits Commercial	$13,913.34
Rate for Payer: Health Alliance Plan Medicare Advantage	$21,111.22
Rate for Payer: Healthscope Commercial	$17,391.67
Rate for Payer: Healthscope Whirlpool	$16,869.92
Rate for Payer: Humana Choice PPO Medicare	$21,111.22
Rate for Payer: Mclaren Commercial	$15,652.50
Rate for Payer: Mclaren Medicaid	$11,547.84
Rate for Payer: Mclaren Medicare	$21,111.22
Rate for Payer: Meridian Medicaid	$12,126.28
Rate for Payer: Meridian Wellcare - Medicare Advantage	$22,166.78
Rate for Payer: MI Amish Medical Board Commercial	$24,277.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14,782.92
Rate for Payer: PACE Medicare	$20,055.66
Rate for Payer: PACE SWMI	$21,111.22
Rate for Payer: PHP Commercial	$23,222.34
Rate for Payer: PHP Medicaid	$11,547.84
Rate for Payer: PHP Medicare Advantage	$21,111.22
Rate for Payer: Priority Health Choice Medicaid	$11,547.84
Rate for Payer: Priority Health Cigna Priority Health	$12,174.17
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11,925.92
Rate for Payer: Priority Health Medicare	$21,111.22
Rate for Payer: Priority Health Narrow Network	$9,540.74
Rate for Payer: Railroad Medicare Medicare	$21,111.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15,304.67
Rate for Payer: UHC Medicare Advantage	$21,744.56
Rate for Payer: VA VA	$21,111.22

HC EP+ABL VT

Facility

$17,391.67

Service Code	CPT 93654
Hospital Charge Code	48100092
Hospital Revenue Code	481
Min. Negotiated Rate	$12,174.17
Max. Negotiated Rate	$17,391.67
Rate for Payer: Aetna Commercial	$15,652.50
Rate for Payer: ASR ASR	$16,869.92
Rate for Payer: BCBS Trust/PPO	$13,483.76
Rate for Payer: BCN Commercial	$13,483.76
Rate for Payer: Cash Price	$13,913.34
Rate for Payer: Cofinity Commercial	$16,348.17
Rate for Payer: Encore Health Key Benefits Commercial	$13,913.34
Rate for Payer: Healthscope Commercial	$17,391.67
Rate for Payer: Healthscope Whirlpool	$16,869.92
Rate for Payer: Mclaren Commercial	$15,652.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14,782.92
Rate for Payer: Priority Health Cigna Priority Health	$12,174.17
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15,304.67

HC EP AFTER DRUGS

Facility

$7,278.36

Service Code	CPT 93623
Hospital Charge Code	48100039
Hospital Revenue Code	481
Min. Negotiated Rate	$2,911.34
Max. Negotiated Rate	$7,278.36
Rate for Payer: Aetna Commercial	$6,550.52
Rate for Payer: ASR ASR	$7,060.01
Rate for Payer: BCBS Complete	$2,911.34
Rate for Payer: BCBS Trust/PPO	$5,642.91
Rate for Payer: BCN Commercial	$5,642.91
Rate for Payer: Cash Price	$5,822.69
Rate for Payer: Cofinity Commercial	$6,841.66
Rate for Payer: Encore Health Key Benefits Commercial	$5,822.69
Rate for Payer: Healthscope Commercial	$7,278.36
Rate for Payer: Healthscope Whirlpool	$7,060.01
Rate for Payer: Mclaren Commercial	$6,550.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6,186.61
Rate for Payer: Priority Health Cigna Priority Health	$5,094.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$6,623.31
Rate for Payer: Priority Health Narrow Network	$5,167.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$6,404.96

HC EP AFTER DRUGS

Facility

$7,278.36

Service Code	CPT 93623
Hospital Charge Code	48100039
Hospital Revenue Code	481
Min. Negotiated Rate	$5,094.85
Max. Negotiated Rate	$7,278.36
Rate for Payer: Aetna Commercial	$6,550.52
Rate for Payer: ASR ASR	$7,060.01
Rate for Payer: BCBS Trust/PPO	$5,642.91
Rate for Payer: BCN Commercial	$5,642.91
Rate for Payer: Cash Price	$5,822.69
Rate for Payer: Cofinity Commercial	$6,841.66
Rate for Payer: Encore Health Key Benefits Commercial	$5,822.69
Rate for Payer: Healthscope Commercial	$7,278.36
Rate for Payer: Healthscope Whirlpool	$7,060.01
Rate for Payer: Mclaren Commercial	$6,550.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6,186.61
Rate for Payer: Priority Health Cigna Priority Health	$5,094.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$6,404.96

HC EP EVAL OF SQ ICD

Facility

$3,277.26

Service Code	CPT 93644
Hospital Charge Code	48000027
Hospital Revenue Code	480
Min. Negotiated Rate	$1,310.90
Max. Negotiated Rate	$3,277.26
Rate for Payer: Aetna Commercial	$2,949.53
Rate for Payer: ASR ASR	$3,178.94
Rate for Payer: BCBS Complete	$1,310.90
Rate for Payer: BCBS Trust/PPO	$2,540.86
Rate for Payer: BCN Commercial	$2,540.86
Rate for Payer: Cash Price	$2,621.81
Rate for Payer: Cofinity Commercial	$3,080.62
Rate for Payer: Encore Health Key Benefits Commercial	$2,621.81
Rate for Payer: Healthscope Commercial	$3,277.26
Rate for Payer: Healthscope Whirlpool	$3,178.94
Rate for Payer: Mclaren Commercial	$2,949.53
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,785.67
Rate for Payer: Priority Health Cigna Priority Health	$2,294.08
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,982.31
Rate for Payer: Priority Health Narrow Network	$2,326.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,883.99

HC EP EVAL OF SQ ICD

Facility

$3,277.26

Service Code	CPT 93644
Hospital Charge Code	48000027
Hospital Revenue Code	480
Min. Negotiated Rate	$2,294.08
Max. Negotiated Rate	$3,277.26
Rate for Payer: Aetna Commercial	$2,949.53
Rate for Payer: ASR ASR	$3,178.94
Rate for Payer: BCBS Trust/PPO	$2,540.86
Rate for Payer: BCN Commercial	$2,540.86
Rate for Payer: Cash Price	$2,621.81
Rate for Payer: Cofinity Commercial	$3,080.62
Rate for Payer: Encore Health Key Benefits Commercial	$2,621.81
Rate for Payer: Healthscope Commercial	$3,277.26
Rate for Payer: Healthscope Whirlpool	$3,178.94
Rate for Payer: Mclaren Commercial	$2,949.53
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,785.67
Rate for Payer: Priority Health Cigna Priority Health	$2,294.08
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,883.99

HC EP EVALUATION OF GEN/LEADS

Facility

$2,341.80

Service Code	CPT 93641
Hospital Charge Code	48100042
Hospital Revenue Code	481
Min. Negotiated Rate	$936.72
Max. Negotiated Rate	$2,341.80
Rate for Payer: Aetna Commercial	$2,107.62
Rate for Payer: ASR ASR	$2,271.55
Rate for Payer: BCBS Complete	$936.72
Rate for Payer: BCBS Trust/PPO	$1,815.60
Rate for Payer: BCN Commercial	$1,815.60
Rate for Payer: Cash Price	$1,873.44
Rate for Payer: Cofinity Commercial	$2,201.29
Rate for Payer: Encore Health Key Benefits Commercial	$1,873.44
Rate for Payer: Healthscope Commercial	$2,341.80
Rate for Payer: Healthscope Whirlpool	$2,271.55
Rate for Payer: Mclaren Commercial	$2,107.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,990.53
Rate for Payer: Priority Health Cigna Priority Health	$1,639.26
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,131.04
Rate for Payer: Priority Health Narrow Network	$1,662.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,060.78

HC EP EVALUATION OF GEN/LEADS

Facility

$2,341.80

Service Code	CPT 93641
Hospital Charge Code	48100042
Hospital Revenue Code	481
Min. Negotiated Rate	$1,639.26
Max. Negotiated Rate	$2,341.80
Rate for Payer: Aetna Commercial	$2,107.62
Rate for Payer: ASR ASR	$2,271.55
Rate for Payer: BCBS Trust/PPO	$1,815.60
Rate for Payer: BCN Commercial	$1,815.60
Rate for Payer: Cash Price	$1,873.44
Rate for Payer: Cofinity Commercial	$2,201.29
Rate for Payer: Encore Health Key Benefits Commercial	$1,873.44
Rate for Payer: Healthscope Commercial	$2,341.80
Rate for Payer: Healthscope Whirlpool	$2,271.55
Rate for Payer: Mclaren Commercial	$2,107.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,990.53
Rate for Payer: Priority Health Cigna Priority Health	$1,639.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,060.78

HC EP EVALUATION OF LEADS

Facility

$2,146.53

Service Code	CPT 93640
Hospital Charge Code	48100041
Hospital Revenue Code	481
Min. Negotiated Rate	$1,502.57
Max. Negotiated Rate	$2,146.53
Rate for Payer: Aetna Commercial	$1,931.88
Rate for Payer: ASR ASR	$2,082.13
Rate for Payer: BCBS Trust/PPO	$1,664.20
Rate for Payer: BCN Commercial	$1,664.20
Rate for Payer: Cash Price	$1,717.22
Rate for Payer: Cofinity Commercial	$2,017.74
Rate for Payer: Encore Health Key Benefits Commercial	$1,717.22
Rate for Payer: Healthscope Commercial	$2,146.53
Rate for Payer: Healthscope Whirlpool	$2,082.13
Rate for Payer: Mclaren Commercial	$1,931.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,824.55
Rate for Payer: Priority Health Cigna Priority Health	$1,502.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,888.95

HC EP EVALUATION OF LEADS

Facility

$2,146.53

Service Code	CPT 93640
Hospital Charge Code	48100041
Hospital Revenue Code	481
Min. Negotiated Rate	$858.61
Max. Negotiated Rate	$2,146.53
Rate for Payer: Aetna Commercial	$1,931.88
Rate for Payer: ASR ASR	$2,082.13
Rate for Payer: BCBS Complete	$858.61
Rate for Payer: BCBS Trust/PPO	$1,664.20
Rate for Payer: BCN Commercial	$1,664.20
Rate for Payer: Cash Price	$1,717.22
Rate for Payer: Cofinity Commercial	$2,017.74
Rate for Payer: Encore Health Key Benefits Commercial	$1,717.22
Rate for Payer: Healthscope Commercial	$2,146.53
Rate for Payer: Healthscope Whirlpool	$2,082.13
Rate for Payer: Mclaren Commercial	$1,931.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,824.55
Rate for Payer: Priority Health Cigna Priority Health	$1,502.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,953.34
Rate for Payer: Priority Health Narrow Network	$1,524.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,888.95

HC EPIDURAL PREP (OB)

Facility

$633.42

Hospital Charge Code	37000003
Hospital Revenue Code	370
Min. Negotiated Rate	$443.39
Max. Negotiated Rate	$633.42
Rate for Payer: Aetna Commercial	$570.08
Rate for Payer: ASR ASR	$614.42
Rate for Payer: BCBS Trust/PPO	$491.09
Rate for Payer: BCN Commercial	$491.09
Rate for Payer: Cash Price	$506.74
Rate for Payer: Cofinity Commercial	$595.41
Rate for Payer: Encore Health Key Benefits Commercial	$506.74
Rate for Payer: Healthscope Commercial	$633.42
Rate for Payer: Healthscope Whirlpool	$614.42
Rate for Payer: Mclaren Commercial	$570.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$538.41
Rate for Payer: Priority Health Cigna Priority Health	$443.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$557.41

HC EPIDURAL PREP (OB)

Facility

$633.42

Hospital Charge Code	37000003
Hospital Revenue Code	370
Min. Negotiated Rate	$253.37
Max. Negotiated Rate	$633.42
Rate for Payer: Aetna Commercial	$570.08
Rate for Payer: ASR ASR	$614.42
Rate for Payer: BCBS Complete	$253.37
Rate for Payer: BCBS Trust/PPO	$491.09
Rate for Payer: BCN Commercial	$491.09
Rate for Payer: Cash Price	$506.74
Rate for Payer: Cofinity Commercial	$595.41
Rate for Payer: Encore Health Key Benefits Commercial	$506.74
Rate for Payer: Healthscope Commercial	$633.42
Rate for Payer: Healthscope Whirlpool	$614.42
Rate for Payer: Mclaren Commercial	$570.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$538.41
Rate for Payer: Priority Health Cigna Priority Health	$443.39
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$576.41
Rate for Payer: Priority Health Narrow Network	$449.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$557.41

HC EPIFIX (14 MM DISC) PER SQ CM

Facility

$478.89

Service Code	HCPCS Q4186
Hospital Charge Code	63600135
Hospital Revenue Code	636
Min. Negotiated Rate	$335.22
Max. Negotiated Rate	$478.89
Rate for Payer: Aetna Commercial	$431.00
Rate for Payer: ASR ASR	$464.52
Rate for Payer: BCBS Trust/PPO	$371.28
Rate for Payer: BCN Commercial	$371.28
Rate for Payer: Cash Price	$383.11
Rate for Payer: Cofinity Commercial	$450.16
Rate for Payer: Encore Health Key Benefits Commercial	$383.11
Rate for Payer: Healthscope Commercial	$478.89
Rate for Payer: Healthscope Whirlpool	$464.52
Rate for Payer: Mclaren Commercial	$431.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$407.06
Rate for Payer: Priority Health Cigna Priority Health	$335.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$421.42

HC EPIFIX (14 MM DISC) PER SQ CM

Facility

$478.89

Service Code	HCPCS Q4186
Hospital Charge Code	63600135
Hospital Revenue Code	636
Min. Negotiated Rate	$191.56
Max. Negotiated Rate	$478.89
Rate for Payer: Aetna Commercial	$431.00
Rate for Payer: ASR ASR	$464.52
Rate for Payer: BCBS Complete	$191.56
Rate for Payer: BCBS Trust/PPO	$371.28
Rate for Payer: BCN Commercial	$371.28
Rate for Payer: Cash Price	$383.11
Rate for Payer: Cofinity Commercial	$450.16
Rate for Payer: Encore Health Key Benefits Commercial	$383.11
Rate for Payer: Healthscope Commercial	$478.89
Rate for Payer: Healthscope Whirlpool	$464.52
Rate for Payer: Mclaren Commercial	$431.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$407.06
Rate for Payer: Priority Health Cigna Priority Health	$335.22
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$435.79
Rate for Payer: Priority Health Narrow Network	$340.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$421.42

HC EPIFIX (18 MM DISC) PER SQ CM

Facility

$695.64

Service Code	HCPCS Q4186
Hospital Charge Code	63600136
Hospital Revenue Code	636
Min. Negotiated Rate	$278.26
Max. Negotiated Rate	$695.64
Rate for Payer: Aetna Commercial	$626.08
Rate for Payer: ASR ASR	$674.77
Rate for Payer: BCBS Complete	$278.26
Rate for Payer: BCBS Trust/PPO	$539.33
Rate for Payer: BCN Commercial	$539.33
Rate for Payer: Cash Price	$556.51
Rate for Payer: Cofinity Commercial	$653.90
Rate for Payer: Encore Health Key Benefits Commercial	$556.51
Rate for Payer: Healthscope Commercial	$695.64
Rate for Payer: Healthscope Whirlpool	$674.77
Rate for Payer: Mclaren Commercial	$626.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$591.29
Rate for Payer: Priority Health Cigna Priority Health	$486.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$633.03
Rate for Payer: Priority Health Narrow Network	$493.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$612.16

Know your out-of-pocket cost for care.

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