Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC INJECTION FACET JOINT L OR S 2ND LEVEL

Facility

$403.74

Service Code	CPT 64494
Hospital Charge Code	36100294
Hospital Revenue Code	361
Min. Negotiated Rate	$161.50
Max. Negotiated Rate	$403.74
Rate for Payer: Aetna Commercial	$363.37
Rate for Payer: ASR ASR	$391.63
Rate for Payer: BCBS Complete	$161.50
Rate for Payer: BCBS Trust/PPO	$313.02
Rate for Payer: BCN Commercial	$313.02
Rate for Payer: Cash Price	$322.99
Rate for Payer: Cofinity Commercial	$379.52
Rate for Payer: Encore Health Key Benefits Commercial	$322.99
Rate for Payer: Healthscope Commercial	$403.74
Rate for Payer: Healthscope Whirlpool	$391.63
Rate for Payer: Mclaren Commercial	$363.37
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$343.18
Rate for Payer: Priority Health Cigna Priority Health	$282.62
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$367.40
Rate for Payer: Priority Health Narrow Network	$286.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$355.29

HC INJECTION FACET JOINT L OR S 2ND LEVEL

Facility

$403.74

Service Code	CPT 64494
Hospital Charge Code	36100294
Hospital Revenue Code	361
Min. Negotiated Rate	$282.62
Max. Negotiated Rate	$403.74
Rate for Payer: Aetna Commercial	$363.37
Rate for Payer: ASR ASR	$391.63
Rate for Payer: BCBS Trust/PPO	$313.02
Rate for Payer: BCN Commercial	$313.02
Rate for Payer: Cash Price	$322.99
Rate for Payer: Cofinity Commercial	$379.52
Rate for Payer: Encore Health Key Benefits Commercial	$322.99
Rate for Payer: Healthscope Commercial	$403.74
Rate for Payer: Healthscope Whirlpool	$391.63
Rate for Payer: Mclaren Commercial	$363.37
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$343.18
Rate for Payer: Priority Health Cigna Priority Health	$282.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$355.29

HC INJECTION FACET JOINT L OR S 2ND LEVEL BIL

Facility

$605.60

Service Code	CPT 64494
Hospital Charge Code	36100630
Hospital Revenue Code	361
Min. Negotiated Rate	$423.92
Max. Negotiated Rate	$605.60
Rate for Payer: Aetna Commercial	$545.04
Rate for Payer: ASR ASR	$587.43
Rate for Payer: BCBS Trust/PPO	$469.52
Rate for Payer: BCN Commercial	$469.52
Rate for Payer: Cash Price	$484.48
Rate for Payer: Cofinity Commercial	$569.26
Rate for Payer: Encore Health Key Benefits Commercial	$484.48
Rate for Payer: Healthscope Commercial	$605.60
Rate for Payer: Healthscope Whirlpool	$587.43
Rate for Payer: Mclaren Commercial	$545.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$514.76
Rate for Payer: Priority Health Cigna Priority Health	$423.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$532.93

HC INJECTION FACET JOINT L OR S 2ND LEVEL BIL

Facility

$605.60

Service Code	CPT 64494
Hospital Charge Code	36100630
Hospital Revenue Code	361
Min. Negotiated Rate	$242.24
Max. Negotiated Rate	$605.60
Rate for Payer: Aetna Commercial	$545.04
Rate for Payer: ASR ASR	$587.43
Rate for Payer: BCBS Complete	$242.24
Rate for Payer: BCBS Trust/PPO	$469.52
Rate for Payer: BCN Commercial	$469.52
Rate for Payer: Cash Price	$484.48
Rate for Payer: Cofinity Commercial	$569.26
Rate for Payer: Encore Health Key Benefits Commercial	$484.48
Rate for Payer: Healthscope Commercial	$605.60
Rate for Payer: Healthscope Whirlpool	$587.43
Rate for Payer: Mclaren Commercial	$545.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$514.76
Rate for Payer: Priority Health Cigna Priority Health	$423.92
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$551.10
Rate for Payer: Priority Health Narrow Network	$429.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$532.93

HC INJECTION FACET JOINT L OR S 3RD + LE

Facility

$403.74

Service Code	CPT 64495
Hospital Charge Code	36100295
Hospital Revenue Code	361
Min. Negotiated Rate	$282.62
Max. Negotiated Rate	$403.74
Rate for Payer: Aetna Commercial	$363.37
Rate for Payer: ASR ASR	$391.63
Rate for Payer: BCBS Trust/PPO	$313.02
Rate for Payer: BCN Commercial	$313.02
Rate for Payer: Cash Price	$322.99
Rate for Payer: Cofinity Commercial	$379.52
Rate for Payer: Encore Health Key Benefits Commercial	$322.99
Rate for Payer: Healthscope Commercial	$403.74
Rate for Payer: Healthscope Whirlpool	$391.63
Rate for Payer: Mclaren Commercial	$363.37
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$343.18
Rate for Payer: Priority Health Cigna Priority Health	$282.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$355.29

HC INJECTION FACET JOINT L OR S 3RD + LE

Facility

$403.74

Service Code	CPT 64495
Hospital Charge Code	36100295
Hospital Revenue Code	361
Min. Negotiated Rate	$161.50
Max. Negotiated Rate	$403.74
Rate for Payer: Aetna Commercial	$363.37
Rate for Payer: ASR ASR	$391.63
Rate for Payer: BCBS Complete	$161.50
Rate for Payer: BCBS Trust/PPO	$313.02
Rate for Payer: BCN Commercial	$313.02
Rate for Payer: Cash Price	$322.99
Rate for Payer: Cofinity Commercial	$379.52
Rate for Payer: Encore Health Key Benefits Commercial	$322.99
Rate for Payer: Healthscope Commercial	$403.74
Rate for Payer: Healthscope Whirlpool	$391.63
Rate for Payer: Mclaren Commercial	$363.37
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$343.18
Rate for Payer: Priority Health Cigna Priority Health	$282.62
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$367.40
Rate for Payer: Priority Health Narrow Network	$286.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$355.29

HC INJECTION FACET JOINT L OR S 3RD + LEVEL BIL

Facility

$605.60

Service Code	CPT 64495
Hospital Charge Code	36100631
Hospital Revenue Code	361
Min. Negotiated Rate	$423.92
Max. Negotiated Rate	$605.60
Rate for Payer: Aetna Commercial	$545.04
Rate for Payer: ASR ASR	$587.43
Rate for Payer: BCBS Trust/PPO	$469.52
Rate for Payer: BCN Commercial	$469.52
Rate for Payer: Cash Price	$484.48
Rate for Payer: Cofinity Commercial	$569.26
Rate for Payer: Encore Health Key Benefits Commercial	$484.48
Rate for Payer: Healthscope Commercial	$605.60
Rate for Payer: Healthscope Whirlpool	$587.43
Rate for Payer: Mclaren Commercial	$545.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$514.76
Rate for Payer: Priority Health Cigna Priority Health	$423.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$532.93

HC INJECTION FACET JOINT L OR S 3RD + LEVEL BIL

Facility

$605.60

Service Code	CPT 64495
Hospital Charge Code	36100631
Hospital Revenue Code	361
Min. Negotiated Rate	$242.24
Max. Negotiated Rate	$605.60
Rate for Payer: Aetna Commercial	$545.04
Rate for Payer: ASR ASR	$587.43
Rate for Payer: BCBS Complete	$242.24
Rate for Payer: BCBS Trust/PPO	$469.52
Rate for Payer: BCN Commercial	$469.52
Rate for Payer: Cash Price	$484.48
Rate for Payer: Cofinity Commercial	$569.26
Rate for Payer: Encore Health Key Benefits Commercial	$484.48
Rate for Payer: Healthscope Commercial	$605.60
Rate for Payer: Healthscope Whirlpool	$587.43
Rate for Payer: Mclaren Commercial	$545.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$514.76
Rate for Payer: Priority Health Cigna Priority Health	$423.92
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$551.10
Rate for Payer: Priority Health Narrow Network	$429.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$532.93

HC INJECTION FOR CEREBRAL SHUNT

Facility

$810.15

Service Code	CPT 61070
Hospital Charge Code	36100270
Hospital Revenue Code	361
Min. Negotiated Rate	$567.10
Max. Negotiated Rate	$810.15
Rate for Payer: Aetna Commercial	$729.14
Rate for Payer: ASR ASR	$785.85
Rate for Payer: BCBS Trust/PPO	$628.11
Rate for Payer: BCN Commercial	$628.11
Rate for Payer: Cash Price	$648.12
Rate for Payer: Cofinity Commercial	$761.54
Rate for Payer: Encore Health Key Benefits Commercial	$648.12
Rate for Payer: Healthscope Commercial	$810.15
Rate for Payer: Healthscope Whirlpool	$785.85
Rate for Payer: Mclaren Commercial	$729.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$688.63
Rate for Payer: Priority Health Cigna Priority Health	$567.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$712.93

HC INJECTION FOR CEREBRAL SHUNT

Facility

$810.15

Service Code	CPT 61070
Hospital Charge Code	36100270
Hospital Revenue Code	361
Min. Negotiated Rate	$336.24
Max. Negotiated Rate	$810.15
Rate for Payer: Aetna Commercial	$729.14
Rate for Payer: Aetna Medicare	$614.70
Rate for Payer: Allen County Amish Medical Aid Commercial	$768.38
Rate for Payer: Amish Plain Church Group Commercial	$768.38
Rate for Payer: ASR ASR	$785.85
Rate for Payer: BCBS Complete	$353.08
Rate for Payer: BCBS MAPPO	$614.70
Rate for Payer: BCBS Trust/PPO	$628.11
Rate for Payer: BCN Commercial	$628.11
Rate for Payer: BCN Medicare Advantage	$614.70
Rate for Payer: Cash Price	$648.12
Rate for Payer: Cash Price	$648.12
Rate for Payer: Cofinity Commercial	$761.54
Rate for Payer: Encore Health Key Benefits Commercial	$648.12
Rate for Payer: Health Alliance Plan Medicare Advantage	$614.70
Rate for Payer: Healthscope Commercial	$810.15
Rate for Payer: Healthscope Whirlpool	$785.85
Rate for Payer: Humana Choice PPO Medicare	$614.70
Rate for Payer: Mclaren Commercial	$729.14
Rate for Payer: Mclaren Medicaid	$336.24
Rate for Payer: Mclaren Medicare	$614.70
Rate for Payer: Meridian Medicaid	$353.08
Rate for Payer: Meridian Wellcare - Medicare Advantage	$645.44
Rate for Payer: MI Amish Medical Board Commercial	$706.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$688.63
Rate for Payer: PACE Medicare	$583.96
Rate for Payer: PACE SWMI	$614.70
Rate for Payer: PHP Commercial	$676.17
Rate for Payer: PHP Medicaid	$336.24
Rate for Payer: PHP Medicare Advantage	$614.70
Rate for Payer: Priority Health Choice Medicaid	$336.24
Rate for Payer: Priority Health Cigna Priority Health	$567.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$737.24
Rate for Payer: Priority Health Medicare	$614.70
Rate for Payer: Priority Health Narrow Network	$575.21
Rate for Payer: Railroad Medicare Medicare	$614.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$712.93
Rate for Payer: UHC Medicare Advantage	$633.14
Rate for Payer: VA VA	$614.70

HC INJECTION FOR HYSTEROSALPINGOGRAM

Facility

$643.62

Service Code	CPT 58340
Hospital Charge Code	36100256
Hospital Revenue Code	761
Min. Negotiated Rate	$450.53
Max. Negotiated Rate	$643.62
Rate for Payer: Aetna Commercial	$579.26
Rate for Payer: ASR ASR	$624.31
Rate for Payer: BCBS Trust/PPO	$499.00
Rate for Payer: BCN Commercial	$499.00
Rate for Payer: Cash Price	$514.90
Rate for Payer: Cofinity Commercial	$605.00
Rate for Payer: Encore Health Key Benefits Commercial	$514.90
Rate for Payer: Healthscope Commercial	$643.62
Rate for Payer: Healthscope Whirlpool	$624.31
Rate for Payer: Mclaren Commercial	$579.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$547.08
Rate for Payer: Priority Health Cigna Priority Health	$450.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$566.39

HC INJECTION FOR HYSTEROSALPINGOGRAM

Facility

$643.62

Service Code	CPT 58340
Hospital Charge Code	36100256
Hospital Revenue Code	761
Min. Negotiated Rate	$131.35
Max. Negotiated Rate	$643.62
Rate for Payer: Aetna Commercial	$579.26
Rate for Payer: ASR ASR	$624.31
Rate for Payer: BCBS Complete	$257.45
Rate for Payer: BCBS Trust/PPO	$499.00
Rate for Payer: BCN Commercial	$499.00
Rate for Payer: Cash Price	$514.90
Rate for Payer: Cash Price	$514.90
Rate for Payer: Cofinity Commercial	$605.00
Rate for Payer: Encore Health Key Benefits Commercial	$514.90
Rate for Payer: Healthscope Commercial	$643.62
Rate for Payer: Healthscope Whirlpool	$624.31
Rate for Payer: Mclaren Commercial	$579.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$547.08
Rate for Payer: Priority Health Cigna Priority Health	$450.53
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$164.19
Rate for Payer: Priority Health Narrow Network	$131.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$566.39

HC INJECTION HIP ARTHROGRAM

Facility

$1,283.57

Service Code	CPT 27093
Hospital Charge Code	36100040
Hospital Revenue Code	361
Min. Negotiated Rate	$211.39
Max. Negotiated Rate	$1,283.57
Rate for Payer: Aetna Commercial	$1,155.21
Rate for Payer: ASR ASR	$1,245.06
Rate for Payer: BCBS Complete	$513.43
Rate for Payer: BCBS Trust/PPO	$995.15
Rate for Payer: BCN Commercial	$995.15
Rate for Payer: Cash Price	$1,026.86
Rate for Payer: Cash Price	$1,026.86
Rate for Payer: Cofinity Commercial	$1,206.56
Rate for Payer: Encore Health Key Benefits Commercial	$1,026.86
Rate for Payer: Healthscope Commercial	$1,283.57
Rate for Payer: Healthscope Whirlpool	$1,245.06
Rate for Payer: Mclaren Commercial	$1,155.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,091.03
Rate for Payer: Priority Health Cigna Priority Health	$898.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$264.24
Rate for Payer: Priority Health Narrow Network	$211.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,129.54

HC INJECTION HIP ARTHROGRAM

Facility

$1,283.57

Service Code	CPT 27093
Hospital Charge Code	36100040
Hospital Revenue Code	361
Min. Negotiated Rate	$898.50
Max. Negotiated Rate	$1,283.57
Rate for Payer: Aetna Commercial	$1,155.21
Rate for Payer: ASR ASR	$1,245.06
Rate for Payer: BCBS Trust/PPO	$995.15
Rate for Payer: BCN Commercial	$995.15
Rate for Payer: Cash Price	$1,026.86
Rate for Payer: Cofinity Commercial	$1,206.56
Rate for Payer: Encore Health Key Benefits Commercial	$1,026.86
Rate for Payer: Healthscope Commercial	$1,283.57
Rate for Payer: Healthscope Whirlpool	$1,245.06
Rate for Payer: Mclaren Commercial	$1,155.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,091.03
Rate for Payer: Priority Health Cigna Priority Health	$898.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,129.54

HC INJECTION HIP ARTHROGRAM BIL

Facility

$1,190.22

Service Code	CPT 27093
Hospital Charge Code	36100041
Hospital Revenue Code	361
Min. Negotiated Rate	$211.39
Max. Negotiated Rate	$1,190.22
Rate for Payer: Aetna Commercial	$1,071.20
Rate for Payer: ASR ASR	$1,154.51
Rate for Payer: BCBS Complete	$476.09
Rate for Payer: BCBS Trust/PPO	$922.78
Rate for Payer: BCN Commercial	$922.78
Rate for Payer: Cash Price	$952.18
Rate for Payer: Cash Price	$952.18
Rate for Payer: Cofinity Commercial	$1,118.81
Rate for Payer: Encore Health Key Benefits Commercial	$952.18
Rate for Payer: Healthscope Commercial	$1,190.22
Rate for Payer: Healthscope Whirlpool	$1,154.51
Rate for Payer: Mclaren Commercial	$1,071.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,011.69
Rate for Payer: Priority Health Cigna Priority Health	$833.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$264.24
Rate for Payer: Priority Health Narrow Network	$211.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,047.39

HC INJECTION HIP ARTHROGRAM BIL

Facility

$1,190.22

Service Code	CPT 27093
Hospital Charge Code	36100041
Hospital Revenue Code	361
Min. Negotiated Rate	$833.15
Max. Negotiated Rate	$1,190.22
Rate for Payer: Aetna Commercial	$1,071.20
Rate for Payer: ASR ASR	$1,154.51
Rate for Payer: BCBS Trust/PPO	$922.78
Rate for Payer: BCN Commercial	$922.78
Rate for Payer: Cash Price	$952.18
Rate for Payer: Cofinity Commercial	$1,118.81
Rate for Payer: Encore Health Key Benefits Commercial	$952.18
Rate for Payer: Healthscope Commercial	$1,190.22
Rate for Payer: Healthscope Whirlpool	$1,154.51
Rate for Payer: Mclaren Commercial	$1,071.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,011.69
Rate for Payer: Priority Health Cigna Priority Health	$833.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,047.39

HC INJECTION INTRALESIONAL UP TO 7 LESIONS

Facility

$144.23

Service Code	CPT 11900
Hospital Charge Code	76100134
Hospital Revenue Code	761
Min. Negotiated Rate	$100.96
Max. Negotiated Rate	$144.23
Rate for Payer: Aetna Commercial	$129.81
Rate for Payer: ASR ASR	$139.90
Rate for Payer: BCBS Trust/PPO	$111.82
Rate for Payer: BCN Commercial	$111.82
Rate for Payer: Cash Price	$115.38
Rate for Payer: Cofinity Commercial	$135.58
Rate for Payer: Encore Health Key Benefits Commercial	$115.38
Rate for Payer: Healthscope Commercial	$144.23
Rate for Payer: Healthscope Whirlpool	$139.90
Rate for Payer: Mclaren Commercial	$129.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$122.60
Rate for Payer: Priority Health Cigna Priority Health	$100.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$126.92

HC INJECTION INTRALESIONAL UP TO 7 LESIONS

Facility

$144.23

Service Code	CPT 11900
Hospital Charge Code	76100134
Hospital Revenue Code	761
Min. Negotiated Rate	$97.34
Max. Negotiated Rate	$222.44
Rate for Payer: Aetna Commercial	$129.81
Rate for Payer: Aetna Medicare	$177.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$222.44
Rate for Payer: Amish Plain Church Group Commercial	$222.44
Rate for Payer: ASR ASR	$139.90
Rate for Payer: BCBS Complete	$102.21
Rate for Payer: BCBS MAPPO	$177.95
Rate for Payer: BCBS Trust/PPO	$111.82
Rate for Payer: BCN Commercial	$111.82
Rate for Payer: BCN Medicare Advantage	$177.95
Rate for Payer: Cash Price	$115.38
Rate for Payer: Cash Price	$115.38
Rate for Payer: Cofinity Commercial	$135.58
Rate for Payer: Encore Health Key Benefits Commercial	$115.38
Rate for Payer: Health Alliance Plan Medicare Advantage	$177.95
Rate for Payer: Healthscope Commercial	$144.23
Rate for Payer: Healthscope Whirlpool	$139.90
Rate for Payer: Humana Choice PPO Medicare	$177.95
Rate for Payer: Mclaren Commercial	$129.81
Rate for Payer: Mclaren Medicaid	$97.34
Rate for Payer: Mclaren Medicare	$177.95
Rate for Payer: Meridian Medicaid	$102.21
Rate for Payer: Meridian Wellcare - Medicare Advantage	$186.85
Rate for Payer: MI Amish Medical Board Commercial	$204.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$122.60
Rate for Payer: PACE Medicare	$169.05
Rate for Payer: PACE SWMI	$177.95
Rate for Payer: PHP Commercial	$195.74
Rate for Payer: PHP Medicaid	$97.34
Rate for Payer: PHP Medicare Advantage	$177.95
Rate for Payer: Priority Health Choice Medicaid	$97.34
Rate for Payer: Priority Health Cigna Priority Health	$100.96
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$131.25
Rate for Payer: Priority Health Medicare	$177.95
Rate for Payer: Priority Health Narrow Network	$102.40
Rate for Payer: Railroad Medicare Medicare	$177.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$126.92
Rate for Payer: UHC Medicare Advantage	$183.29
Rate for Payer: VA VA	$177.95

HC INJECTION, IRON DEXTRAN, 50 MG

Facility

$61.20

Service Code	CPT J1750
Hospital Charge Code	63600097
Hospital Revenue Code	636
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$61.20
Rate for Payer: Aetna Commercial	$55.08
Rate for Payer: ASR ASR	$59.36
Rate for Payer: BCBS Trust/PPO	$47.45
Rate for Payer: BCN Commercial	$47.45
Rate for Payer: Cash Price	$48.96
Rate for Payer: Cofinity Commercial	$57.53
Rate for Payer: Encore Health Key Benefits Commercial	$48.96
Rate for Payer: Healthscope Commercial	$61.20
Rate for Payer: Healthscope Whirlpool	$59.36
Rate for Payer: Mclaren Commercial	$55.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$52.02
Rate for Payer: Priority Health Cigna Priority Health	$42.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$53.86

HC INJECTION, IRON DEXTRAN, 50 MG

Facility

$61.20

Service Code	CPT J1750
Hospital Charge Code	63600097
Hospital Revenue Code	636
Min. Negotiated Rate	$9.48
Max. Negotiated Rate	$61.20
Rate for Payer: Aetna Commercial	$55.08
Rate for Payer: Aetna Medicare	$17.32
Rate for Payer: Allen County Amish Medical Aid Commercial	$21.66
Rate for Payer: Amish Plain Church Group Commercial	$21.66
Rate for Payer: ASR ASR	$59.36
Rate for Payer: BCBS Complete	$9.95
Rate for Payer: BCBS MAPPO	$17.32
Rate for Payer: BCBS Trust/PPO	$47.45
Rate for Payer: BCN Commercial	$47.45
Rate for Payer: BCN Medicare Advantage	$17.32
Rate for Payer: Cash Price	$48.96
Rate for Payer: Cash Price	$48.96
Rate for Payer: Cofinity Commercial	$57.53
Rate for Payer: Encore Health Key Benefits Commercial	$48.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$17.32
Rate for Payer: Healthscope Commercial	$61.20
Rate for Payer: Healthscope Whirlpool	$59.36
Rate for Payer: Humana Choice PPO Medicare	$17.32
Rate for Payer: Mclaren Commercial	$55.08
Rate for Payer: Mclaren Medicaid	$9.48
Rate for Payer: Mclaren Medicare	$17.32
Rate for Payer: Meridian Medicaid	$9.95
Rate for Payer: Meridian Wellcare - Medicare Advantage	$18.19
Rate for Payer: MI Amish Medical Board Commercial	$19.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$52.02
Rate for Payer: PACE Medicare	$16.46
Rate for Payer: PACE SWMI	$17.32
Rate for Payer: PHP Commercial	$19.06
Rate for Payer: PHP Medicaid	$9.48
Rate for Payer: PHP Medicare Advantage	$17.32
Rate for Payer: Priority Health Choice Medicaid	$9.48
Rate for Payer: Priority Health Cigna Priority Health	$42.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$55.69
Rate for Payer: Priority Health Medicare	$17.32
Rate for Payer: Priority Health Narrow Network	$43.45
Rate for Payer: Railroad Medicare Medicare	$17.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$53.86
Rate for Payer: UHC Medicare Advantage	$17.84
Rate for Payer: VA VA	$17.32

HC INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG

Facility

$20.40

Service Code	CPT J1885
Hospital Charge Code	63600098
Hospital Revenue Code	636
Min. Negotiated Rate	$14.28
Max. Negotiated Rate	$20.40
Rate for Payer: Aetna Commercial	$18.36
Rate for Payer: ASR ASR	$19.79
Rate for Payer: BCBS Trust/PPO	$15.82
Rate for Payer: BCN Commercial	$15.82
Rate for Payer: Cash Price	$16.32
Rate for Payer: Cofinity Commercial	$19.18
Rate for Payer: Encore Health Key Benefits Commercial	$16.32
Rate for Payer: Healthscope Commercial	$20.40
Rate for Payer: Healthscope Whirlpool	$19.79
Rate for Payer: Mclaren Commercial	$18.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.34
Rate for Payer: Priority Health Cigna Priority Health	$14.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.95

HC INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG

Facility

$20.40

Service Code	CPT J1885
Hospital Charge Code	63600098
Hospital Revenue Code	636
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$20.40
Rate for Payer: Aetna Commercial	$18.36
Rate for Payer: ASR ASR	$19.79
Rate for Payer: BCBS Complete	$8.16
Rate for Payer: BCBS Trust/PPO	$15.82
Rate for Payer: BCN Commercial	$15.82
Rate for Payer: Cash Price	$16.32
Rate for Payer: Cofinity Commercial	$19.18
Rate for Payer: Encore Health Key Benefits Commercial	$16.32
Rate for Payer: Healthscope Commercial	$20.40
Rate for Payer: Healthscope Whirlpool	$19.79
Rate for Payer: Mclaren Commercial	$18.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.34
Rate for Payer: Priority Health Cigna Priority Health	$14.28
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$18.56
Rate for Payer: Priority Health Narrow Network	$14.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.95

HC INJECTION, LINCOMYCIN HCL, UP TO 300 MG

Facility

$44.88

Service Code	CPT J2010
Hospital Charge Code	63600099
Hospital Revenue Code	636
Min. Negotiated Rate	$31.42
Max. Negotiated Rate	$44.88
Rate for Payer: Aetna Commercial	$40.39
Rate for Payer: ASR ASR	$43.53
Rate for Payer: BCBS Trust/PPO	$34.80
Rate for Payer: BCN Commercial	$34.80
Rate for Payer: Cash Price	$35.90
Rate for Payer: Cofinity Commercial	$42.19
Rate for Payer: Encore Health Key Benefits Commercial	$35.90
Rate for Payer: Healthscope Commercial	$44.88
Rate for Payer: Healthscope Whirlpool	$43.53
Rate for Payer: Mclaren Commercial	$40.39
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.15
Rate for Payer: Priority Health Cigna Priority Health	$31.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.49

HC INJECTION, LINCOMYCIN HCL, UP TO 300 MG

Facility

$44.88

Service Code	CPT J2010
Hospital Charge Code	63600099
Hospital Revenue Code	636
Min. Negotiated Rate	$17.95
Max. Negotiated Rate	$44.88
Rate for Payer: Aetna Commercial	$40.39
Rate for Payer: ASR ASR	$43.53
Rate for Payer: BCBS Complete	$17.95
Rate for Payer: BCBS Trust/PPO	$34.80
Rate for Payer: BCN Commercial	$34.80
Rate for Payer: Cash Price	$35.90
Rate for Payer: Cofinity Commercial	$42.19
Rate for Payer: Encore Health Key Benefits Commercial	$35.90
Rate for Payer: Healthscope Commercial	$44.88
Rate for Payer: Healthscope Whirlpool	$43.53
Rate for Payer: Mclaren Commercial	$40.39
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.15
Rate for Payer: Priority Health Cigna Priority Health	$31.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$40.84
Rate for Payer: Priority Health Narrow Network	$31.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.49

HC INJECTION LUMBAR DISKOGRAPHY

Facility

$2,303.46

Service Code	CPT 62290
Hospital Charge Code	36100282
Hospital Revenue Code	361
Min. Negotiated Rate	$921.38
Max. Negotiated Rate	$2,303.46
Rate for Payer: Aetna Commercial	$2,073.11
Rate for Payer: ASR ASR	$2,234.36
Rate for Payer: BCBS Complete	$921.38
Rate for Payer: BCBS Trust/PPO	$1,785.87
Rate for Payer: BCN Commercial	$1,785.87
Rate for Payer: Cash Price	$1,842.77
Rate for Payer: Cofinity Commercial	$2,165.25
Rate for Payer: Encore Health Key Benefits Commercial	$1,842.77
Rate for Payer: Healthscope Commercial	$2,303.46
Rate for Payer: Healthscope Whirlpool	$2,234.36
Rate for Payer: Mclaren Commercial	$2,073.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,957.94
Rate for Payer: Priority Health Cigna Priority Health	$1,612.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,096.15
Rate for Payer: Priority Health Narrow Network	$1,635.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,027.04

Know your out-of-pocket cost for care.

All Charges