Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC INJECTION, CERTOLIZUMAB PEGOL, 1 MG

Facility

$10.00

Service Code	CPT J0717
Hospital Charge Code	63600090
Hospital Revenue Code	636
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: ASR ASR	$9.70
Rate for Payer: BCBS Trust/PPO	$7.75
Rate for Payer: BCN Commercial	$7.75
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$9.40
Rate for Payer: Encore Health Key Benefits Commercial	$8.00
Rate for Payer: Healthscope Commercial	$10.00
Rate for Payer: Healthscope Whirlpool	$9.70
Rate for Payer: Mclaren Commercial	$9.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8.50
Rate for Payer: Priority Health Cigna Priority Health	$7.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.80

HC INJECTION CERVICAL OR THORACIC

Facility

$991.13

Service Code	CPT 62291
Hospital Charge Code	36100283
Hospital Revenue Code	361
Min. Negotiated Rate	$396.45
Max. Negotiated Rate	$991.13
Rate for Payer: Aetna Commercial	$892.02
Rate for Payer: ASR ASR	$961.40
Rate for Payer: BCBS Complete	$396.45
Rate for Payer: BCBS Trust/PPO	$768.42
Rate for Payer: BCN Commercial	$768.42
Rate for Payer: Cash Price	$792.90
Rate for Payer: Cofinity Commercial	$931.66
Rate for Payer: Encore Health Key Benefits Commercial	$792.90
Rate for Payer: Healthscope Commercial	$991.13
Rate for Payer: Healthscope Whirlpool	$961.40
Rate for Payer: Mclaren Commercial	$892.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$842.46
Rate for Payer: Priority Health Cigna Priority Health	$693.79
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$901.93
Rate for Payer: Priority Health Narrow Network	$703.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$872.19

HC INJECTION CERVICAL OR THORACIC

Facility

$991.13

Service Code	CPT 62291
Hospital Charge Code	36100283
Hospital Revenue Code	361
Min. Negotiated Rate	$693.79
Max. Negotiated Rate	$991.13
Rate for Payer: Aetna Commercial	$892.02
Rate for Payer: ASR ASR	$961.40
Rate for Payer: BCBS Trust/PPO	$768.42
Rate for Payer: BCN Commercial	$768.42
Rate for Payer: Cash Price	$792.90
Rate for Payer: Cofinity Commercial	$931.66
Rate for Payer: Encore Health Key Benefits Commercial	$792.90
Rate for Payer: Healthscope Commercial	$991.13
Rate for Payer: Healthscope Whirlpool	$961.40
Rate for Payer: Mclaren Commercial	$892.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$842.46
Rate for Payer: Priority Health Cigna Priority Health	$693.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$872.19

HC INJECTION CONTRAST FOR TUBE ASSESSMENT

Facility

$998.88

Service Code	CPT 49424
Hospital Charge Code	36100223
Hospital Revenue Code	361
Min. Negotiated Rate	$699.22
Max. Negotiated Rate	$998.88
Rate for Payer: Aetna Commercial	$898.99
Rate for Payer: ASR ASR	$968.91
Rate for Payer: BCBS Trust/PPO	$774.43
Rate for Payer: BCN Commercial	$774.43
Rate for Payer: Cash Price	$799.10
Rate for Payer: Cofinity Commercial	$938.95
Rate for Payer: Encore Health Key Benefits Commercial	$799.10
Rate for Payer: Healthscope Commercial	$998.88
Rate for Payer: Healthscope Whirlpool	$968.91
Rate for Payer: Mclaren Commercial	$898.99
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$849.05
Rate for Payer: Priority Health Cigna Priority Health	$699.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$879.01

HC INJECTION CONTRAST FOR TUBE ASSESSMENT

Facility

$998.88

Service Code	CPT 49424
Hospital Charge Code	36100223
Hospital Revenue Code	361
Min. Negotiated Rate	$399.55
Max. Negotiated Rate	$998.88
Rate for Payer: Aetna Commercial	$898.99
Rate for Payer: ASR ASR	$968.91
Rate for Payer: BCBS Complete	$399.55
Rate for Payer: BCBS Trust/PPO	$774.43
Rate for Payer: BCN Commercial	$774.43
Rate for Payer: Cash Price	$799.10
Rate for Payer: Cofinity Commercial	$938.95
Rate for Payer: Encore Health Key Benefits Commercial	$799.10
Rate for Payer: Healthscope Commercial	$998.88
Rate for Payer: Healthscope Whirlpool	$968.91
Rate for Payer: Mclaren Commercial	$898.99
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$849.05
Rate for Payer: Priority Health Cigna Priority Health	$699.22
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$908.98
Rate for Payer: Priority Health Narrow Network	$709.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$879.01

HC INJECTION, DENOSUMAB, 1MG

Facility

$25.00

Service Code	CPT J0897
Hospital Charge Code	63600091
Hospital Revenue Code	636
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna Commercial	$22.50
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: Allen County Amish Medical Aid Commercial	$31.50
Rate for Payer: Amish Plain Church Group Commercial	$31.50
Rate for Payer: ASR ASR	$24.25
Rate for Payer: BCBS Complete	$14.47
Rate for Payer: BCBS MAPPO	$25.20
Rate for Payer: BCBS Trust/PPO	$19.38
Rate for Payer: BCN Commercial	$19.38
Rate for Payer: BCN Medicare Advantage	$25.20
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cofinity Commercial	$23.50
Rate for Payer: Encore Health Key Benefits Commercial	$20.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$25.20
Rate for Payer: Healthscope Commercial	$25.00
Rate for Payer: Healthscope Whirlpool	$24.25
Rate for Payer: Humana Choice PPO Medicare	$25.20
Rate for Payer: Mclaren Commercial	$22.50
Rate for Payer: Mclaren Medicaid	$13.78
Rate for Payer: Mclaren Medicare	$25.20
Rate for Payer: Meridian Medicaid	$14.47
Rate for Payer: Meridian Wellcare - Medicare Advantage	$26.46
Rate for Payer: MI Amish Medical Board Commercial	$28.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.25
Rate for Payer: PACE Medicare	$23.94
Rate for Payer: PACE SWMI	$25.20
Rate for Payer: PHP Commercial	$27.72
Rate for Payer: PHP Medicaid	$13.78
Rate for Payer: PHP Medicare Advantage	$25.20
Rate for Payer: Priority Health Choice Medicaid	$13.78
Rate for Payer: Priority Health Cigna Priority Health	$17.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.75
Rate for Payer: Priority Health Medicare	$25.20
Rate for Payer: Priority Health Narrow Network	$17.75
Rate for Payer: Railroad Medicare Medicare	$25.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.00
Rate for Payer: UHC Medicare Advantage	$25.95
Rate for Payer: VA VA	$25.20

HC INJECTION, DENOSUMAB, 1MG

Facility

$25.00

Service Code	CPT J0897
Hospital Charge Code	63600091
Hospital Revenue Code	636
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$22.50
Rate for Payer: ASR ASR	$24.25
Rate for Payer: BCBS Trust/PPO	$19.38
Rate for Payer: BCN Commercial	$19.38
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cofinity Commercial	$23.50
Rate for Payer: Encore Health Key Benefits Commercial	$20.00
Rate for Payer: Healthscope Commercial	$25.00
Rate for Payer: Healthscope Whirlpool	$24.25
Rate for Payer: Mclaren Commercial	$22.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.25
Rate for Payer: Priority Health Cigna Priority Health	$17.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.00

HC INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG

Facility

$14.28

Service Code	CPT J1000
Hospital Charge Code	63600092
Hospital Revenue Code	636
Min. Negotiated Rate	$5.71
Max. Negotiated Rate	$14.28
Rate for Payer: Aetna Commercial	$12.85
Rate for Payer: ASR ASR	$13.85
Rate for Payer: BCBS Complete	$5.71
Rate for Payer: BCBS Trust/PPO	$11.07
Rate for Payer: BCN Commercial	$11.07
Rate for Payer: Cash Price	$11.42
Rate for Payer: Cofinity Commercial	$13.42
Rate for Payer: Encore Health Key Benefits Commercial	$11.42
Rate for Payer: Healthscope Commercial	$14.28
Rate for Payer: Healthscope Whirlpool	$13.85
Rate for Payer: Mclaren Commercial	$12.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.14
Rate for Payer: Priority Health Cigna Priority Health	$10.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12.99
Rate for Payer: Priority Health Narrow Network	$10.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.57

HC INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG

Facility

$14.28

Service Code	CPT J1000
Hospital Charge Code	63600092
Hospital Revenue Code	636
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$14.28
Rate for Payer: Aetna Commercial	$12.85
Rate for Payer: ASR ASR	$13.85
Rate for Payer: BCBS Trust/PPO	$11.07
Rate for Payer: BCN Commercial	$11.07
Rate for Payer: Cash Price	$11.42
Rate for Payer: Cofinity Commercial	$13.42
Rate for Payer: Encore Health Key Benefits Commercial	$11.42
Rate for Payer: Healthscope Commercial	$14.28
Rate for Payer: Healthscope Whirlpool	$13.85
Rate for Payer: Mclaren Commercial	$12.85
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.14
Rate for Payer: Priority Health Cigna Priority Health	$10.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.57

HC INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG

Facility

$2.04

Service Code	HCPCS J1200
Hospital Charge Code	63600167
Hospital Revenue Code	636
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna Commercial	$1.84
Rate for Payer: ASR ASR	$1.98
Rate for Payer: BCBS Complete	$0.82
Rate for Payer: BCBS Trust/PPO	$1.58
Rate for Payer: BCN Commercial	$1.58
Rate for Payer: Cash Price	$1.63
Rate for Payer: Cofinity Commercial	$1.92
Rate for Payer: Encore Health Key Benefits Commercial	$1.63
Rate for Payer: Healthscope Commercial	$2.04
Rate for Payer: Healthscope Whirlpool	$1.98
Rate for Payer: Mclaren Commercial	$1.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.73
Rate for Payer: Priority Health Cigna Priority Health	$1.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1.86
Rate for Payer: Priority Health Narrow Network	$1.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.80

HC INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG

Facility

$2.04

Service Code	HCPCS J1200
Hospital Charge Code	63600167
Hospital Revenue Code	636
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna Commercial	$1.84
Rate for Payer: ASR ASR	$1.98
Rate for Payer: BCBS Trust/PPO	$1.58
Rate for Payer: BCN Commercial	$1.58
Rate for Payer: Cash Price	$1.63
Rate for Payer: Cofinity Commercial	$1.92
Rate for Payer: Encore Health Key Benefits Commercial	$1.63
Rate for Payer: Healthscope Commercial	$2.04
Rate for Payer: Healthscope Whirlpool	$1.98
Rate for Payer: Mclaren Commercial	$1.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1.73
Rate for Payer: Priority Health Cigna Priority Health	$1.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.80

HC INJECTION ELBOW ARTHROGRAM

Facility

$1,109.88

Service Code	CPT 24220
Hospital Charge Code	36100038
Hospital Revenue Code	361
Min. Negotiated Rate	$443.95
Max. Negotiated Rate	$1,109.88
Rate for Payer: Aetna Commercial	$998.89
Rate for Payer: ASR ASR	$1,076.58
Rate for Payer: BCBS Complete	$443.95
Rate for Payer: BCBS Trust/PPO	$860.49
Rate for Payer: BCN Commercial	$860.49
Rate for Payer: Cash Price	$887.90
Rate for Payer: Cofinity Commercial	$1,043.29
Rate for Payer: Encore Health Key Benefits Commercial	$887.90
Rate for Payer: Healthscope Commercial	$1,109.88
Rate for Payer: Healthscope Whirlpool	$1,076.58
Rate for Payer: Mclaren Commercial	$998.89
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$943.40
Rate for Payer: Priority Health Cigna Priority Health	$776.92
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,009.99
Rate for Payer: Priority Health Narrow Network	$788.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$976.69

HC INJECTION ELBOW ARTHROGRAM

Facility

$1,109.88

Service Code	CPT 24220
Hospital Charge Code	36100038
Hospital Revenue Code	361
Min. Negotiated Rate	$776.92
Max. Negotiated Rate	$1,109.88
Rate for Payer: Aetna Commercial	$998.89
Rate for Payer: ASR ASR	$1,076.58
Rate for Payer: BCBS Trust/PPO	$860.49
Rate for Payer: BCN Commercial	$860.49
Rate for Payer: Cash Price	$887.90
Rate for Payer: Cofinity Commercial	$1,043.29
Rate for Payer: Encore Health Key Benefits Commercial	$887.90
Rate for Payer: Healthscope Commercial	$1,109.88
Rate for Payer: Healthscope Whirlpool	$1,076.58
Rate for Payer: Mclaren Commercial	$998.89
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$943.40
Rate for Payer: Priority Health Cigna Priority Health	$776.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$976.69

HC INJECTION FACET JOINT C OR T 1ST LEVEL BIL

Facility

$1,864.36

Service Code	CPT 64490
Hospital Charge Code	36100626
Hospital Revenue Code	361
Min. Negotiated Rate	$1,305.05
Max. Negotiated Rate	$1,864.36
Rate for Payer: Aetna Commercial	$1,677.92
Rate for Payer: ASR ASR	$1,808.43
Rate for Payer: BCBS Trust/PPO	$1,445.44
Rate for Payer: BCN Commercial	$1,445.44
Rate for Payer: Cash Price	$1,491.49
Rate for Payer: Cofinity Commercial	$1,752.50
Rate for Payer: Encore Health Key Benefits Commercial	$1,491.49
Rate for Payer: Healthscope Commercial	$1,864.36
Rate for Payer: Healthscope Whirlpool	$1,808.43
Rate for Payer: Mclaren Commercial	$1,677.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,584.71
Rate for Payer: Priority Health Cigna Priority Health	$1,305.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,640.64

HC INJECTION FACET JOINT C OR T 1ST LEVEL BIL

Facility

$1,864.36

Service Code	CPT 64490
Hospital Charge Code	36100626
Hospital Revenue Code	361
Min. Negotiated Rate	$443.17
Max. Negotiated Rate	$1,864.36
Rate for Payer: Aetna Commercial	$1,677.92
Rate for Payer: Aetna Medicare	$810.19
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,012.74
Rate for Payer: Amish Plain Church Group Commercial	$1,012.74
Rate for Payer: ASR ASR	$1,808.43
Rate for Payer: BCBS Complete	$465.37
Rate for Payer: BCBS MAPPO	$810.19
Rate for Payer: BCBS Trust/PPO	$1,445.44
Rate for Payer: BCN Commercial	$1,445.44
Rate for Payer: BCN Medicare Advantage	$810.19
Rate for Payer: Cash Price	$1,491.49
Rate for Payer: Cash Price	$1,491.49
Rate for Payer: Cofinity Commercial	$1,752.50
Rate for Payer: Encore Health Key Benefits Commercial	$1,491.49
Rate for Payer: Health Alliance Plan Medicare Advantage	$810.19
Rate for Payer: Healthscope Commercial	$1,864.36
Rate for Payer: Healthscope Whirlpool	$1,808.43
Rate for Payer: Humana Choice PPO Medicare	$810.19
Rate for Payer: Mclaren Commercial	$1,677.92
Rate for Payer: Mclaren Medicaid	$443.17
Rate for Payer: Mclaren Medicare	$810.19
Rate for Payer: Meridian Medicaid	$465.37
Rate for Payer: Meridian Wellcare - Medicare Advantage	$850.70
Rate for Payer: MI Amish Medical Board Commercial	$931.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,584.71
Rate for Payer: PACE Medicare	$769.68
Rate for Payer: PACE SWMI	$810.19
Rate for Payer: PHP Commercial	$891.21
Rate for Payer: PHP Medicaid	$443.17
Rate for Payer: PHP Medicare Advantage	$810.19
Rate for Payer: Priority Health Choice Medicaid	$443.17
Rate for Payer: Priority Health Cigna Priority Health	$1,305.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,696.57
Rate for Payer: Priority Health Medicare	$810.19
Rate for Payer: Priority Health Narrow Network	$1,323.70
Rate for Payer: Railroad Medicare Medicare	$810.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,640.64
Rate for Payer: UHC Medicare Advantage	$834.50
Rate for Payer: VA VA	$810.19

HC INJECTION FACET JOINT C OR T 2ND LEVEL

Facility

$333.67

Service Code	CPT 64491
Hospital Charge Code	36100291
Hospital Revenue Code	361
Min. Negotiated Rate	$233.57
Max. Negotiated Rate	$333.67
Rate for Payer: Aetna Commercial	$300.30
Rate for Payer: ASR ASR	$323.66
Rate for Payer: BCBS Trust/PPO	$258.69
Rate for Payer: BCN Commercial	$258.69
Rate for Payer: Cash Price	$266.94
Rate for Payer: Cofinity Commercial	$313.65
Rate for Payer: Encore Health Key Benefits Commercial	$266.94
Rate for Payer: Healthscope Commercial	$333.67
Rate for Payer: Healthscope Whirlpool	$323.66
Rate for Payer: Mclaren Commercial	$300.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$283.62
Rate for Payer: Priority Health Cigna Priority Health	$233.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$293.63

HC INJECTION FACET JOINT C OR T 2ND LEVEL

Facility

$333.67

Service Code	CPT 64491
Hospital Charge Code	36100291
Hospital Revenue Code	361
Min. Negotiated Rate	$133.47
Max. Negotiated Rate	$333.67
Rate for Payer: Aetna Commercial	$300.30
Rate for Payer: ASR ASR	$323.66
Rate for Payer: BCBS Complete	$133.47
Rate for Payer: BCBS Trust/PPO	$258.69
Rate for Payer: BCN Commercial	$258.69
Rate for Payer: Cash Price	$266.94
Rate for Payer: Cofinity Commercial	$313.65
Rate for Payer: Encore Health Key Benefits Commercial	$266.94
Rate for Payer: Healthscope Commercial	$333.67
Rate for Payer: Healthscope Whirlpool	$323.66
Rate for Payer: Mclaren Commercial	$300.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$283.62
Rate for Payer: Priority Health Cigna Priority Health	$233.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$303.64
Rate for Payer: Priority Health Narrow Network	$236.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$293.63

HC INJECTION FACET JOINT C OR T 2ND LEVEL BIL

Facility

$500.51

Service Code	CPT 64491
Hospital Charge Code	36100627
Hospital Revenue Code	361
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$500.51
Rate for Payer: Aetna Commercial	$450.46
Rate for Payer: ASR ASR	$485.49
Rate for Payer: BCBS Complete	$200.20
Rate for Payer: BCBS Trust/PPO	$388.05
Rate for Payer: BCN Commercial	$388.05
Rate for Payer: Cash Price	$400.41
Rate for Payer: Cofinity Commercial	$470.48
Rate for Payer: Encore Health Key Benefits Commercial	$400.41
Rate for Payer: Healthscope Commercial	$500.51
Rate for Payer: Healthscope Whirlpool	$485.49
Rate for Payer: Mclaren Commercial	$450.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$425.43
Rate for Payer: Priority Health Cigna Priority Health	$350.36
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$455.46
Rate for Payer: Priority Health Narrow Network	$355.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$440.45

HC INJECTION FACET JOINT C OR T 2ND LEVEL BIL

Facility

$500.51

Service Code	CPT 64491
Hospital Charge Code	36100627
Hospital Revenue Code	361
Min. Negotiated Rate	$350.36
Max. Negotiated Rate	$500.51
Rate for Payer: Aetna Commercial	$450.46
Rate for Payer: ASR ASR	$485.49
Rate for Payer: BCBS Trust/PPO	$388.05
Rate for Payer: BCN Commercial	$388.05
Rate for Payer: Cash Price	$400.41
Rate for Payer: Cofinity Commercial	$470.48
Rate for Payer: Encore Health Key Benefits Commercial	$400.41
Rate for Payer: Healthscope Commercial	$500.51
Rate for Payer: Healthscope Whirlpool	$485.49
Rate for Payer: Mclaren Commercial	$450.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$425.43
Rate for Payer: Priority Health Cigna Priority Health	$350.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$440.45

HC INJECTION FACET JOINT C OR T 3RD + LEVEL

Facility

$333.67

Service Code	CPT 64492
Hospital Charge Code	36100292
Hospital Revenue Code	361
Min. Negotiated Rate	$133.47
Max. Negotiated Rate	$333.67
Rate for Payer: Aetna Commercial	$300.30
Rate for Payer: ASR ASR	$323.66
Rate for Payer: BCBS Complete	$133.47
Rate for Payer: BCBS Trust/PPO	$258.69
Rate for Payer: BCN Commercial	$258.69
Rate for Payer: Cash Price	$266.94
Rate for Payer: Cofinity Commercial	$313.65
Rate for Payer: Encore Health Key Benefits Commercial	$266.94
Rate for Payer: Healthscope Commercial	$333.67
Rate for Payer: Healthscope Whirlpool	$323.66
Rate for Payer: Mclaren Commercial	$300.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$283.62
Rate for Payer: Priority Health Cigna Priority Health	$233.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$303.64
Rate for Payer: Priority Health Narrow Network	$236.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$293.63

HC INJECTION FACET JOINT C OR T 3RD + LEVEL

Facility

$333.67

Service Code	CPT 64492
Hospital Charge Code	36100292
Hospital Revenue Code	361
Min. Negotiated Rate	$233.57
Max. Negotiated Rate	$333.67
Rate for Payer: Aetna Commercial	$300.30
Rate for Payer: ASR ASR	$323.66
Rate for Payer: BCBS Trust/PPO	$258.69
Rate for Payer: BCN Commercial	$258.69
Rate for Payer: Cash Price	$266.94
Rate for Payer: Cofinity Commercial	$313.65
Rate for Payer: Encore Health Key Benefits Commercial	$266.94
Rate for Payer: Healthscope Commercial	$333.67
Rate for Payer: Healthscope Whirlpool	$323.66
Rate for Payer: Mclaren Commercial	$300.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$283.62
Rate for Payer: Priority Health Cigna Priority Health	$233.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$293.63

HC INJECTION FACET JOINT C OR T 3RD + LEVEL BIL

Facility

$500.51

Service Code	CPT 64492
Hospital Charge Code	36100628
Hospital Revenue Code	361
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$500.51
Rate for Payer: Aetna Commercial	$450.46
Rate for Payer: ASR ASR	$485.49
Rate for Payer: BCBS Complete	$200.20
Rate for Payer: BCBS Trust/PPO	$388.05
Rate for Payer: BCN Commercial	$388.05
Rate for Payer: Cash Price	$400.41
Rate for Payer: Cofinity Commercial	$470.48
Rate for Payer: Encore Health Key Benefits Commercial	$400.41
Rate for Payer: Healthscope Commercial	$500.51
Rate for Payer: Healthscope Whirlpool	$485.49
Rate for Payer: Mclaren Commercial	$450.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$425.43
Rate for Payer: Priority Health Cigna Priority Health	$350.36
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$455.46
Rate for Payer: Priority Health Narrow Network	$355.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$440.45

HC INJECTION FACET JOINT C OR T 3RD + LEVEL BIL

Facility

$500.51

Service Code	CPT 64492
Hospital Charge Code	36100628
Hospital Revenue Code	361
Min. Negotiated Rate	$350.36
Max. Negotiated Rate	$500.51
Rate for Payer: Aetna Commercial	$450.46
Rate for Payer: ASR ASR	$485.49
Rate for Payer: BCBS Trust/PPO	$388.05
Rate for Payer: BCN Commercial	$388.05
Rate for Payer: Cash Price	$400.41
Rate for Payer: Cofinity Commercial	$470.48
Rate for Payer: Encore Health Key Benefits Commercial	$400.41
Rate for Payer: Healthscope Commercial	$500.51
Rate for Payer: Healthscope Whirlpool	$485.49
Rate for Payer: Mclaren Commercial	$450.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$425.43
Rate for Payer: Priority Health Cigna Priority Health	$350.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$440.45

HC INJECTION FACET JOINT L OR S 1ST LEVEL BIL

Facility

$2,427.77

Service Code	CPT 64493
Hospital Charge Code	36100629
Hospital Revenue Code	361
Min. Negotiated Rate	$1,699.44
Max. Negotiated Rate	$2,427.77
Rate for Payer: Aetna Commercial	$2,184.99
Rate for Payer: ASR ASR	$2,354.94
Rate for Payer: BCBS Trust/PPO	$1,882.25
Rate for Payer: BCN Commercial	$1,882.25
Rate for Payer: Cash Price	$1,942.22
Rate for Payer: Cofinity Commercial	$2,282.10
Rate for Payer: Encore Health Key Benefits Commercial	$1,942.22
Rate for Payer: Healthscope Commercial	$2,427.77
Rate for Payer: Healthscope Whirlpool	$2,354.94
Rate for Payer: Mclaren Commercial	$2,184.99
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,063.60
Rate for Payer: Priority Health Cigna Priority Health	$1,699.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,136.44

HC INJECTION FACET JOINT L OR S 1ST LEVEL BIL

Facility

$2,427.77

Service Code	CPT 64493
Hospital Charge Code	36100629
Hospital Revenue Code	361
Min. Negotiated Rate	$443.17
Max. Negotiated Rate	$2,427.77
Rate for Payer: Aetna Commercial	$2,184.99
Rate for Payer: Aetna Medicare	$810.19
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,012.74
Rate for Payer: Amish Plain Church Group Commercial	$1,012.74
Rate for Payer: ASR ASR	$2,354.94
Rate for Payer: BCBS Complete	$465.37
Rate for Payer: BCBS MAPPO	$810.19
Rate for Payer: BCBS Trust/PPO	$1,882.25
Rate for Payer: BCN Commercial	$1,882.25
Rate for Payer: BCN Medicare Advantage	$810.19
Rate for Payer: Cash Price	$1,942.22
Rate for Payer: Cash Price	$1,942.22
Rate for Payer: Cofinity Commercial	$2,282.10
Rate for Payer: Encore Health Key Benefits Commercial	$1,942.22
Rate for Payer: Health Alliance Plan Medicare Advantage	$810.19
Rate for Payer: Healthscope Commercial	$2,427.77
Rate for Payer: Healthscope Whirlpool	$2,354.94
Rate for Payer: Humana Choice PPO Medicare	$810.19
Rate for Payer: Mclaren Commercial	$2,184.99
Rate for Payer: Mclaren Medicaid	$443.17
Rate for Payer: Mclaren Medicare	$810.19
Rate for Payer: Meridian Medicaid	$465.37
Rate for Payer: Meridian Wellcare - Medicare Advantage	$850.70
Rate for Payer: MI Amish Medical Board Commercial	$931.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,063.60
Rate for Payer: PACE Medicare	$769.68
Rate for Payer: PACE SWMI	$810.19
Rate for Payer: PHP Commercial	$891.21
Rate for Payer: PHP Medicaid	$443.17
Rate for Payer: PHP Medicare Advantage	$810.19
Rate for Payer: Priority Health Choice Medicaid	$443.17
Rate for Payer: Priority Health Cigna Priority Health	$1,699.44
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,209.27
Rate for Payer: Priority Health Medicare	$810.19
Rate for Payer: Priority Health Narrow Network	$1,723.72
Rate for Payer: Railroad Medicare Medicare	$810.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,136.44
Rate for Payer: UHC Medicare Advantage	$834.50
Rate for Payer: VA VA	$810.19

Know your out-of-pocket cost for care.

All Charges