Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC OPTISON 3RD ML

Facility

$89.76

Service Code	HCPCS Q9956
Hospital Charge Code	63600170
Hospital Revenue Code	636
Min. Negotiated Rate	$62.83
Max. Negotiated Rate	$89.76
Rate for Payer: Aetna Commercial	$80.78
Rate for Payer: ASR ASR	$87.07
Rate for Payer: BCBS Trust/PPO	$69.59
Rate for Payer: BCN Commercial	$69.59
Rate for Payer: Cash Price	$71.81
Rate for Payer: Cofinity Commercial	$84.37
Rate for Payer: Encore Health Key Benefits Commercial	$71.81
Rate for Payer: Healthscope Commercial	$89.76
Rate for Payer: Healthscope Whirlpool	$87.07
Rate for Payer: Mclaren Commercial	$80.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$76.30
Rate for Payer: Priority Health Cigna Priority Health	$62.83
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$78.99

HC OP VISIT LEVEL 1

Facility

$154.65

Service Code	CPT 99211
Hospital Charge Code	51000015
Hospital Revenue Code	761
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$154.65
Rate for Payer: Aetna Commercial	$139.18
Rate for Payer: ASR ASR	$150.01
Rate for Payer: BCBS Complete	$61.86
Rate for Payer: BCBS Trust/PPO	$119.90
Rate for Payer: BCCCP Commercial	$22.00
Rate for Payer: BCN Commercial	$119.90
Rate for Payer: Cash Price	$123.72
Rate for Payer: Cash Price	$123.72
Rate for Payer: Cofinity Commercial	$145.37
Rate for Payer: Encore Health Key Benefits Commercial	$123.72
Rate for Payer: Healthscope Commercial	$154.65
Rate for Payer: Healthscope Whirlpool	$150.01
Rate for Payer: Mclaren Commercial	$139.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$131.45
Rate for Payer: Priority Health Cigna Priority Health	$108.26
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$111.86
Rate for Payer: Priority Health Narrow Network	$89.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$136.09

HC OP VISIT LEVEL 1

Facility

$154.65

Service Code	CPT 99211
Hospital Charge Code	51000015
Hospital Revenue Code	761
Min. Negotiated Rate	$108.26
Max. Negotiated Rate	$154.65
Rate for Payer: Aetna Commercial	$139.18
Rate for Payer: ASR ASR	$150.01
Rate for Payer: BCBS Trust/PPO	$119.90
Rate for Payer: BCN Commercial	$119.90
Rate for Payer: Cash Price	$123.72
Rate for Payer: Cofinity Commercial	$145.37
Rate for Payer: Encore Health Key Benefits Commercial	$123.72
Rate for Payer: Healthscope Commercial	$154.65
Rate for Payer: Healthscope Whirlpool	$150.01
Rate for Payer: Mclaren Commercial	$139.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$131.45
Rate for Payer: Priority Health Cigna Priority Health	$108.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$136.09

HC OP VISIT LEVEL 2

Facility

$174.09

Service Code	CPT 99212
Hospital Charge Code	51000020
Hospital Revenue Code	761
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$177.52
Rate for Payer: Aetna Commercial	$156.68
Rate for Payer: ASR ASR	$168.87
Rate for Payer: BCBS Complete	$69.64
Rate for Payer: BCBS Trust/PPO	$134.97
Rate for Payer: BCCCP Commercial	$22.00
Rate for Payer: BCN Commercial	$134.97
Rate for Payer: Cash Price	$139.27
Rate for Payer: Cash Price	$139.27
Rate for Payer: Cofinity Commercial	$163.64
Rate for Payer: Encore Health Key Benefits Commercial	$139.27
Rate for Payer: Healthscope Commercial	$174.09
Rate for Payer: Healthscope Whirlpool	$168.87
Rate for Payer: Mclaren Commercial	$156.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$147.98
Rate for Payer: Priority Health Cigna Priority Health	$121.86
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$177.52
Rate for Payer: Priority Health Narrow Network	$142.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$153.20

HC OP VISIT LEVEL 2

Facility

$174.09

Service Code	CPT 99212
Hospital Charge Code	51000020
Hospital Revenue Code	761
Min. Negotiated Rate	$121.86
Max. Negotiated Rate	$174.09
Rate for Payer: Aetna Commercial	$156.68
Rate for Payer: ASR ASR	$168.87
Rate for Payer: BCBS Trust/PPO	$134.97
Rate for Payer: BCN Commercial	$134.97
Rate for Payer: Cash Price	$139.27
Rate for Payer: Cofinity Commercial	$163.64
Rate for Payer: Encore Health Key Benefits Commercial	$139.27
Rate for Payer: Healthscope Commercial	$174.09
Rate for Payer: Healthscope Whirlpool	$168.87
Rate for Payer: Mclaren Commercial	$156.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$147.98
Rate for Payer: Priority Health Cigna Priority Health	$121.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$153.20

HC OP VISIT LEVEL 3

Facility

$211.25

Service Code	CPT 99213
Hospital Charge Code	51000026
Hospital Revenue Code	761
Min. Negotiated Rate	$72.85
Max. Negotiated Rate	$211.25
Rate for Payer: Aetna Commercial	$190.12
Rate for Payer: ASR ASR	$204.91
Rate for Payer: BCBS Complete	$84.50
Rate for Payer: BCBS Trust/PPO	$163.78
Rate for Payer: BCCCP Commercial	$72.85
Rate for Payer: BCN Commercial	$163.78
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cofinity Commercial	$198.58
Rate for Payer: Encore Health Key Benefits Commercial	$169.00
Rate for Payer: Healthscope Commercial	$211.25
Rate for Payer: Healthscope Whirlpool	$204.91
Rate for Payer: Mclaren Commercial	$190.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$179.56
Rate for Payer: Priority Health Cigna Priority Health	$147.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$198.06
Rate for Payer: Priority Health Narrow Network	$158.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$185.90

HC OP VISIT LEVEL 3

Facility

$211.25

Service Code	CPT 99213
Hospital Charge Code	51000026
Hospital Revenue Code	761
Min. Negotiated Rate	$147.88
Max. Negotiated Rate	$211.25
Rate for Payer: Aetna Commercial	$190.12
Rate for Payer: ASR ASR	$204.91
Rate for Payer: BCBS Trust/PPO	$163.78
Rate for Payer: BCN Commercial	$163.78
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cofinity Commercial	$198.58
Rate for Payer: Encore Health Key Benefits Commercial	$169.00
Rate for Payer: Healthscope Commercial	$211.25
Rate for Payer: Healthscope Whirlpool	$204.91
Rate for Payer: Mclaren Commercial	$190.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$179.56
Rate for Payer: Priority Health Cigna Priority Health	$147.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$185.90

HC OP VISIT LEVEL 4

Facility

$303.37

Service Code	CPT 99214
Hospital Charge Code	51000030
Hospital Revenue Code	761
Min. Negotiated Rate	$212.36
Max. Negotiated Rate	$303.37
Rate for Payer: Aetna Commercial	$273.03
Rate for Payer: ASR ASR	$294.27
Rate for Payer: BCBS Trust/PPO	$235.20
Rate for Payer: BCN Commercial	$235.20
Rate for Payer: Cash Price	$242.70
Rate for Payer: Cofinity Commercial	$285.17
Rate for Payer: Encore Health Key Benefits Commercial	$242.70
Rate for Payer: Healthscope Commercial	$303.37
Rate for Payer: Healthscope Whirlpool	$294.27
Rate for Payer: Mclaren Commercial	$273.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$257.86
Rate for Payer: Priority Health Cigna Priority Health	$212.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$266.97

HC OP VISIT LEVEL 4

Facility

$303.37

Service Code	CPT 99214
Hospital Charge Code	51000030
Hospital Revenue Code	761
Min. Negotiated Rate	$72.85
Max. Negotiated Rate	$303.37
Rate for Payer: Aetna Commercial	$273.03
Rate for Payer: ASR ASR	$294.27
Rate for Payer: BCBS Complete	$121.35
Rate for Payer: BCBS Trust/PPO	$235.20
Rate for Payer: BCCCP Commercial	$72.85
Rate for Payer: BCN Commercial	$235.20
Rate for Payer: Cash Price	$242.70
Rate for Payer: Cash Price	$242.70
Rate for Payer: Cofinity Commercial	$285.17
Rate for Payer: Encore Health Key Benefits Commercial	$242.70
Rate for Payer: Healthscope Commercial	$303.37
Rate for Payer: Healthscope Whirlpool	$294.27
Rate for Payer: Mclaren Commercial	$273.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$257.86
Rate for Payer: Priority Health Cigna Priority Health	$212.36
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$218.58
Rate for Payer: Priority Health Narrow Network	$174.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$266.97

HC OP VISIT LEVEL 5

Facility

$505.14

Service Code	CPT 99215
Hospital Charge Code	51000037
Hospital Revenue Code	761
Min. Negotiated Rate	$202.06
Max. Negotiated Rate	$505.14
Rate for Payer: Aetna Commercial	$454.63
Rate for Payer: ASR ASR	$489.99
Rate for Payer: BCBS Complete	$202.06
Rate for Payer: BCBS Trust/PPO	$391.64
Rate for Payer: BCN Commercial	$391.64
Rate for Payer: Cash Price	$404.11
Rate for Payer: Cofinity Commercial	$474.83
Rate for Payer: Encore Health Key Benefits Commercial	$404.11
Rate for Payer: Healthscope Commercial	$505.14
Rate for Payer: Healthscope Whirlpool	$489.99
Rate for Payer: Mclaren Commercial	$454.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$429.37
Rate for Payer: Priority Health Cigna Priority Health	$353.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$459.68
Rate for Payer: Priority Health Narrow Network	$358.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$444.52

HC OP VISIT LEVEL 5

Facility

$505.14

Service Code	CPT 99215
Hospital Charge Code	51000037
Hospital Revenue Code	761
Min. Negotiated Rate	$353.60
Max. Negotiated Rate	$505.14
Rate for Payer: Aetna Commercial	$454.63
Rate for Payer: ASR ASR	$489.99
Rate for Payer: BCBS Trust/PPO	$391.64
Rate for Payer: BCN Commercial	$391.64
Rate for Payer: Cash Price	$404.11
Rate for Payer: Cofinity Commercial	$474.83
Rate for Payer: Encore Health Key Benefits Commercial	$404.11
Rate for Payer: Healthscope Commercial	$505.14
Rate for Payer: Healthscope Whirlpool	$489.99
Rate for Payer: Mclaren Commercial	$454.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$429.37
Rate for Payer: Priority Health Cigna Priority Health	$353.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$444.52

HC ORAL CHEMO ADMINISTRATION

Facility

$134.71

Service Code	CPT 99211
Hospital Charge Code	51000089
Hospital Revenue Code	510
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$134.71
Rate for Payer: Aetna Commercial	$121.24
Rate for Payer: ASR ASR	$130.67
Rate for Payer: BCBS Complete	$53.88
Rate for Payer: BCBS Trust/PPO	$104.44
Rate for Payer: BCCCP Commercial	$22.00
Rate for Payer: BCN Commercial	$104.44
Rate for Payer: Cash Price	$107.77
Rate for Payer: Cash Price	$107.77
Rate for Payer: Cofinity Commercial	$126.63
Rate for Payer: Encore Health Key Benefits Commercial	$107.77
Rate for Payer: Healthscope Commercial	$134.71
Rate for Payer: Healthscope Whirlpool	$130.67
Rate for Payer: Mclaren Commercial	$121.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$114.50
Rate for Payer: Priority Health Cigna Priority Health	$94.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$111.86
Rate for Payer: Priority Health Narrow Network	$89.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$118.54

HC ORAL CHEMO ADMINISTRATION

Facility

$134.71

Service Code	CPT 99211
Hospital Charge Code	51000089
Hospital Revenue Code	510
Min. Negotiated Rate	$94.30
Max. Negotiated Rate	$134.71
Rate for Payer: Aetna Commercial	$121.24
Rate for Payer: ASR ASR	$130.67
Rate for Payer: BCBS Trust/PPO	$104.44
Rate for Payer: BCN Commercial	$104.44
Rate for Payer: Cash Price	$107.77
Rate for Payer: Cofinity Commercial	$126.63
Rate for Payer: Encore Health Key Benefits Commercial	$107.77
Rate for Payer: Healthscope Commercial	$134.71
Rate for Payer: Healthscope Whirlpool	$130.67
Rate for Payer: Mclaren Commercial	$121.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$114.50
Rate for Payer: Priority Health Cigna Priority Health	$94.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$118.54

HC ORCHARD GRASS IGE

Facility

$24.89

Service Code	CPT 86003
Hospital Charge Code	30200052
Hospital Revenue Code	302
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$24.89
Rate for Payer: Aetna Commercial	$22.40
Rate for Payer: ASR ASR	$24.14
Rate for Payer: BCBS Trust/PPO	$19.30
Rate for Payer: BCN Commercial	$19.30
Rate for Payer: Cash Price	$19.91
Rate for Payer: Cofinity Commercial	$23.40
Rate for Payer: Encore Health Key Benefits Commercial	$19.91
Rate for Payer: Healthscope Commercial	$24.89
Rate for Payer: Healthscope Whirlpool	$24.14
Rate for Payer: Mclaren Commercial	$22.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.16
Rate for Payer: Priority Health Cigna Priority Health	$17.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.90

HC ORCHARD GRASS IGE

Facility

$24.89

Service Code	CPT 86003
Hospital Charge Code	30200052
Hospital Revenue Code	302
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$24.89
Rate for Payer: Aetna Commercial	$22.40
Rate for Payer: Aetna Medicare	$5.22
Rate for Payer: Allen County Amish Medical Aid Commercial	$6.52
Rate for Payer: Amish Plain Church Group Commercial	$6.52
Rate for Payer: ASR ASR	$24.14
Rate for Payer: BCBS Complete	$3.00
Rate for Payer: BCBS MAPPO	$5.22
Rate for Payer: BCBS Trust/PPO	$19.30
Rate for Payer: BCN Commercial	$19.30
Rate for Payer: BCN Medicare Advantage	$5.22
Rate for Payer: Cash Price	$19.91
Rate for Payer: Cash Price	$19.91
Rate for Payer: Cofinity Commercial	$23.40
Rate for Payer: Encore Health Key Benefits Commercial	$19.91
Rate for Payer: Health Alliance Plan Medicare Advantage	$5.22
Rate for Payer: Healthscope Commercial	$24.89
Rate for Payer: Healthscope Whirlpool	$24.14
Rate for Payer: Humana Choice PPO Medicare	$5.22
Rate for Payer: Mclaren Commercial	$22.40
Rate for Payer: Mclaren Medicaid	$2.86
Rate for Payer: Mclaren Medicare	$5.22
Rate for Payer: Meridian Medicaid	$3.00
Rate for Payer: Meridian Wellcare - Medicare Advantage	$5.48
Rate for Payer: MI Amish Medical Board Commercial	$6.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.16
Rate for Payer: PACE Medicare	$4.96
Rate for Payer: PACE SWMI	$5.22
Rate for Payer: PHP Commercial	$5.74
Rate for Payer: PHP Medicaid	$2.86
Rate for Payer: PHP Medicare Advantage	$5.22
Rate for Payer: Priority Health Choice Medicaid	$2.86
Rate for Payer: Priority Health Cigna Priority Health	$17.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.65
Rate for Payer: Priority Health Medicare	$5.22
Rate for Payer: Priority Health Narrow Network	$17.67
Rate for Payer: Railroad Medicare Medicare	$5.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.90
Rate for Payer: UHC Medicare Advantage	$5.38
Rate for Payer: VA VA	$5.22

HC ORGANIC ACIDS SCREEN URINE

Facility

$74.00

Service Code	CPT 83918
Hospital Charge Code	30100372
Hospital Revenue Code	301
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$74.00
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: Aetna Medicare	$23.60
Rate for Payer: Allen County Amish Medical Aid Commercial	$29.50
Rate for Payer: Amish Plain Church Group Commercial	$29.50
Rate for Payer: ASR ASR	$71.78
Rate for Payer: BCBS Complete	$13.56
Rate for Payer: BCBS MAPPO	$23.60
Rate for Payer: BCBS Trust/PPO	$57.37
Rate for Payer: BCN Commercial	$57.37
Rate for Payer: BCN Medicare Advantage	$23.60
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cofinity Commercial	$69.56
Rate for Payer: Encore Health Key Benefits Commercial	$59.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$23.60
Rate for Payer: Healthscope Commercial	$74.00
Rate for Payer: Healthscope Whirlpool	$71.78
Rate for Payer: Humana Choice PPO Medicare	$23.60
Rate for Payer: Mclaren Commercial	$66.60
Rate for Payer: Mclaren Medicaid	$12.91
Rate for Payer: Mclaren Medicare	$23.60
Rate for Payer: Meridian Medicaid	$13.56
Rate for Payer: Meridian Wellcare - Medicare Advantage	$24.78
Rate for Payer: MI Amish Medical Board Commercial	$27.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.90
Rate for Payer: PACE Medicare	$22.42
Rate for Payer: PACE SWMI	$23.60
Rate for Payer: PHP Commercial	$25.96
Rate for Payer: PHP Medicaid	$12.91
Rate for Payer: PHP Medicare Advantage	$23.60
Rate for Payer: Priority Health Choice Medicaid	$12.91
Rate for Payer: Priority Health Cigna Priority Health	$51.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$67.34
Rate for Payer: Priority Health Medicare	$23.60
Rate for Payer: Priority Health Narrow Network	$52.54
Rate for Payer: Railroad Medicare Medicare	$23.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$65.12
Rate for Payer: UHC Medicare Advantage	$24.31
Rate for Payer: VA VA	$23.60

HC ORGANIC ACIDS SCREEN URINE

Facility

$74.00

Service Code	CPT 83918
Hospital Charge Code	30100372
Hospital Revenue Code	301
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$74.00
Rate for Payer: Aetna Commercial	$66.60
Rate for Payer: ASR ASR	$71.78
Rate for Payer: BCBS Trust/PPO	$57.37
Rate for Payer: BCN Commercial	$57.37
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cofinity Commercial	$69.56
Rate for Payer: Encore Health Key Benefits Commercial	$59.20
Rate for Payer: Healthscope Commercial	$74.00
Rate for Payer: Healthscope Whirlpool	$71.78
Rate for Payer: Mclaren Commercial	$66.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.90
Rate for Payer: Priority Health Cigna Priority Health	$51.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$65.12

HC ORPHENADRINE INJECTION, PER 60MG

Facility

$29.58

Service Code	HCPCS J2360
Hospital Charge Code	63600143
Hospital Revenue Code	636
Min. Negotiated Rate	$20.71
Max. Negotiated Rate	$29.58
Rate for Payer: Aetna Commercial	$26.62
Rate for Payer: ASR ASR	$28.69
Rate for Payer: BCBS Trust/PPO	$22.93
Rate for Payer: BCN Commercial	$22.93
Rate for Payer: Cash Price	$23.66
Rate for Payer: Cofinity Commercial	$27.81
Rate for Payer: Encore Health Key Benefits Commercial	$23.66
Rate for Payer: Healthscope Commercial	$29.58
Rate for Payer: Healthscope Whirlpool	$28.69
Rate for Payer: Mclaren Commercial	$26.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$25.14
Rate for Payer: Priority Health Cigna Priority Health	$20.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$26.03

HC ORPHENADRINE INJECTION, PER 60MG

Facility

$29.58

Service Code	HCPCS J2360
Hospital Charge Code	63600143
Hospital Revenue Code	636
Min. Negotiated Rate	$11.83
Max. Negotiated Rate	$29.58
Rate for Payer: Aetna Commercial	$26.62
Rate for Payer: ASR ASR	$28.69
Rate for Payer: BCBS Complete	$11.83
Rate for Payer: BCBS Trust/PPO	$22.93
Rate for Payer: BCN Commercial	$22.93
Rate for Payer: Cash Price	$23.66
Rate for Payer: Cofinity Commercial	$27.81
Rate for Payer: Encore Health Key Benefits Commercial	$23.66
Rate for Payer: Healthscope Commercial	$29.58
Rate for Payer: Healthscope Whirlpool	$28.69
Rate for Payer: Mclaren Commercial	$26.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$25.14
Rate for Payer: Priority Health Cigna Priority Health	$20.71
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$26.92
Rate for Payer: Priority Health Narrow Network	$21.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$26.03

HC ORTHOPOX (AKA MONKEY)

Facility

$120.85

Service Code	CPT 87593
Hospital Charge Code	30600334
Hospital Revenue Code	306
Min. Negotiated Rate	$48.34
Max. Negotiated Rate	$120.85
Rate for Payer: Aetna Commercial	$108.76
Rate for Payer: ASR ASR	$117.22
Rate for Payer: BCBS Complete	$48.34
Rate for Payer: BCBS Trust/PPO	$93.70
Rate for Payer: BCN Commercial	$93.70
Rate for Payer: Cash Price	$96.68
Rate for Payer: Cofinity Commercial	$113.60
Rate for Payer: Encore Health Key Benefits Commercial	$96.68
Rate for Payer: Healthscope Commercial	$120.85
Rate for Payer: Healthscope Whirlpool	$117.22
Rate for Payer: Mclaren Commercial	$108.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$102.72
Rate for Payer: Priority Health Cigna Priority Health	$84.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$109.97
Rate for Payer: Priority Health Narrow Network	$85.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$106.35

HC ORTHOPOX (AKA MONKEY)

Facility

$120.85

Service Code	CPT 87593
Hospital Charge Code	30600334
Hospital Revenue Code	306
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$120.85
Rate for Payer: Aetna Commercial	$108.76
Rate for Payer: ASR ASR	$117.22
Rate for Payer: BCBS Trust/PPO	$93.70
Rate for Payer: BCN Commercial	$93.70
Rate for Payer: Cash Price	$96.68
Rate for Payer: Cofinity Commercial	$113.60
Rate for Payer: Encore Health Key Benefits Commercial	$96.68
Rate for Payer: Healthscope Commercial	$120.85
Rate for Payer: Healthscope Whirlpool	$117.22
Rate for Payer: Mclaren Commercial	$108.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$102.72
Rate for Payer: Priority Health Cigna Priority Health	$84.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$106.35

HC ORTHOPOX DNA, PCR

Facility

$75.00

Service Code	CPT 87593
Hospital Charge Code	30600332
Hospital Revenue Code	306
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: ASR ASR	$72.75
Rate for Payer: BCBS Complete	$30.00
Rate for Payer: BCBS Trust/PPO	$58.15
Rate for Payer: BCN Commercial	$58.15
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cofinity Commercial	$70.50
Rate for Payer: Encore Health Key Benefits Commercial	$60.00
Rate for Payer: Healthscope Commercial	$75.00
Rate for Payer: Healthscope Whirlpool	$72.75
Rate for Payer: Mclaren Commercial	$67.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$63.75
Rate for Payer: Priority Health Cigna Priority Health	$52.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$68.25
Rate for Payer: Priority Health Narrow Network	$53.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$66.00

HC ORTHOPOX DNA, PCR

Facility

$75.00

Service Code	CPT 87593
Hospital Charge Code	30600332
Hospital Revenue Code	306
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$67.50
Rate for Payer: ASR ASR	$72.75
Rate for Payer: BCBS Trust/PPO	$58.15
Rate for Payer: BCN Commercial	$58.15
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cofinity Commercial	$70.50
Rate for Payer: Encore Health Key Benefits Commercial	$60.00
Rate for Payer: Healthscope Commercial	$75.00
Rate for Payer: Healthscope Whirlpool	$72.75
Rate for Payer: Mclaren Commercial	$67.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$63.75
Rate for Payer: Priority Health Cigna Priority Health	$52.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$66.00

HC ORTHO/PROSTH MGMT SUBSEQ EA 15 MIN

Facility

$126.91

Service Code	CPT 97763
Hospital Charge Code	42000056
Hospital Revenue Code	420
Min. Negotiated Rate	$88.84
Max. Negotiated Rate	$126.91
Rate for Payer: Aetna Commercial	$114.22
Rate for Payer: ASR ASR	$123.10
Rate for Payer: BCBS Trust/PPO	$98.39
Rate for Payer: BCN Commercial	$98.39
Rate for Payer: Cash Price	$101.53
Rate for Payer: Cofinity Commercial	$119.30
Rate for Payer: Encore Health Key Benefits Commercial	$101.53
Rate for Payer: Healthscope Commercial	$126.91
Rate for Payer: Healthscope Whirlpool	$123.10
Rate for Payer: Mclaren Commercial	$114.22
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$107.87
Rate for Payer: Priority Health Cigna Priority Health	$88.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$111.68

HC ORTHO/PROSTH MGMT SUBSEQ EA 15 MIN

Facility

$126.91

Service Code	CPT 97763
Hospital Charge Code	42000056
Hospital Revenue Code	420
Min. Negotiated Rate	$26.81
Max. Negotiated Rate	$126.91
Rate for Payer: Aetna Commercial	$114.22
Rate for Payer: ASR ASR	$123.10
Rate for Payer: BCBS Complete	$50.76
Rate for Payer: BCBS Trust/PPO	$98.39
Rate for Payer: BCN Commercial	$98.39
Rate for Payer: Cash Price	$101.53
Rate for Payer: Cash Price	$101.53
Rate for Payer: Cofinity Commercial	$119.30
Rate for Payer: Encore Health Key Benefits Commercial	$101.53
Rate for Payer: Healthscope Commercial	$126.91
Rate for Payer: Healthscope Whirlpool	$123.10
Rate for Payer: Mclaren Commercial	$114.22
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$107.87
Rate for Payer: Priority Health Cigna Priority Health	$88.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$33.51
Rate for Payer: Priority Health Narrow Network	$26.81
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$111.68

Know your out-of-pocket cost for care.

All Charges