Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE (LAIV4) INTRANASAL

Facility

$32.25

Service Code	CPT 90672
Hospital Charge Code	63600075
Hospital Revenue Code	636
Min. Negotiated Rate	$20.96
Max. Negotiated Rate	$32.25
Rate for Payer: Aetna Commercial	$29.02
Rate for Payer: ASR ASR	$31.28
Rate for Payer: ASR Commercial	$31.28
Rate for Payer: BCBS Trust/PPO	$26.28
Rate for Payer: BCN Commercial	$25.00
Rate for Payer: Cash Price	$25.80
Rate for Payer: Cofinity Commercial	$30.32
Rate for Payer: Encore Health Key Benefits Commercial	$25.80
Rate for Payer: Healthscope Commercial	$32.25
Rate for Payer: Healthscope Whirlpool	$31.28
Rate for Payer: Mclaren Commercial	$29.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$27.41
Rate for Payer: Nomi Health Commercial	$26.45
Rate for Payer: Priority Health Cigna Priority Health	$20.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$28.38

HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, 0.25 ML IM

Facility

$26.01

Service Code	CPT 90687
Hospital Charge Code	63600126
Hospital Revenue Code	636
Min. Negotiated Rate	$16.91
Max. Negotiated Rate	$26.01
Rate for Payer: Aetna Commercial	$23.41
Rate for Payer: ASR ASR	$25.23
Rate for Payer: ASR Commercial	$25.23
Rate for Payer: BCBS Trust/PPO	$21.20
Rate for Payer: BCN Commercial	$20.17
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cofinity Commercial	$24.45
Rate for Payer: Encore Health Key Benefits Commercial	$20.81
Rate for Payer: Healthscope Commercial	$26.01
Rate for Payer: Healthscope Whirlpool	$25.23
Rate for Payer: Mclaren Commercial	$23.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.11
Rate for Payer: Nomi Health Commercial	$21.33
Rate for Payer: Priority Health Cigna Priority Health	$16.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.89

HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, 0.25 ML IM

Facility

$26.01

Service Code	CPT 90687
Hospital Charge Code	63600126
Hospital Revenue Code	636
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$26.01
Rate for Payer: Aetna Commercial	$23.41
Rate for Payer: Aetna Medicare	$13.01
Rate for Payer: ASR ASR	$25.23
Rate for Payer: ASR Commercial	$25.23
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: BCBS Trust/PPO	$21.30
Rate for Payer: BCN Commercial	$20.17
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cofinity Commercial	$24.45
Rate for Payer: Encore Health Key Benefits Commercial	$20.81
Rate for Payer: Healthscope Commercial	$26.01
Rate for Payer: Healthscope Whirlpool	$25.23
Rate for Payer: Mclaren Commercial	$23.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.11
Rate for Payer: Nomi Health Commercial	$21.33
Rate for Payer: Priority Health Cigna Priority Health	$16.91
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.79
Rate for Payer: Priority Health Narrow Network	$18.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.89

HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, PF, 0.5 ML IM

Facility

$26.01

Service Code	CPT 90686
Hospital Charge Code	63600078
Hospital Revenue Code	636
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$26.01
Rate for Payer: Aetna Commercial	$23.41
Rate for Payer: Aetna Medicare	$13.01
Rate for Payer: ASR ASR	$25.23
Rate for Payer: ASR Commercial	$25.23
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: BCBS Trust/PPO	$21.30
Rate for Payer: BCN Commercial	$20.17
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cofinity Commercial	$24.45
Rate for Payer: Encore Health Key Benefits Commercial	$20.81
Rate for Payer: Healthscope Commercial	$26.01
Rate for Payer: Healthscope Whirlpool	$25.23
Rate for Payer: Mclaren Commercial	$23.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.11
Rate for Payer: Nomi Health Commercial	$21.33
Rate for Payer: Priority Health Cigna Priority Health	$16.91
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.79
Rate for Payer: Priority Health Narrow Network	$18.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.89

HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, PF, 0.5 ML IM

Facility

$26.01

Service Code	CPT 90686
Hospital Charge Code	63600078
Hospital Revenue Code	636
Min. Negotiated Rate	$16.91
Max. Negotiated Rate	$26.01
Rate for Payer: Aetna Commercial	$23.41
Rate for Payer: ASR ASR	$25.23
Rate for Payer: ASR Commercial	$25.23
Rate for Payer: BCBS Trust/PPO	$21.20
Rate for Payer: BCN Commercial	$20.17
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cofinity Commercial	$24.45
Rate for Payer: Encore Health Key Benefits Commercial	$20.81
Rate for Payer: Healthscope Commercial	$26.01
Rate for Payer: Healthscope Whirlpool	$25.23
Rate for Payer: Mclaren Commercial	$23.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.11
Rate for Payer: Nomi Health Commercial	$21.33
Rate for Payer: Priority Health Cigna Priority Health	$16.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.89

HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, PF, CHILD 6-35 MONTHS, IM

Facility

$26.01

Service Code	CPT 90685
Hospital Charge Code	63600077
Hospital Revenue Code	636
Min. Negotiated Rate	$16.91
Max. Negotiated Rate	$26.01
Rate for Payer: Aetna Commercial	$23.41
Rate for Payer: ASR ASR	$25.23
Rate for Payer: ASR Commercial	$25.23
Rate for Payer: BCBS Trust/PPO	$21.20
Rate for Payer: BCN Commercial	$20.17
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cofinity Commercial	$24.45
Rate for Payer: Encore Health Key Benefits Commercial	$20.81
Rate for Payer: Healthscope Commercial	$26.01
Rate for Payer: Healthscope Whirlpool	$25.23
Rate for Payer: Mclaren Commercial	$23.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.11
Rate for Payer: Nomi Health Commercial	$21.33
Rate for Payer: Priority Health Cigna Priority Health	$16.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.89

HC INFLUENZA VIRUS VAC, QUAD (IIV4), SPLIT VIRUS, PF, CHILD 6-35 MONTHS, IM

Facility

$26.01

Service Code	CPT 90685
Hospital Charge Code	63600077
Hospital Revenue Code	636
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$26.01
Rate for Payer: Aetna Commercial	$23.41
Rate for Payer: Aetna Medicare	$13.01
Rate for Payer: ASR ASR	$25.23
Rate for Payer: ASR Commercial	$25.23
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: BCBS Trust/PPO	$21.30
Rate for Payer: BCN Commercial	$20.17
Rate for Payer: Cash Price	$20.81
Rate for Payer: Cofinity Commercial	$24.45
Rate for Payer: Encore Health Key Benefits Commercial	$20.81
Rate for Payer: Healthscope Commercial	$26.01
Rate for Payer: Healthscope Whirlpool	$25.23
Rate for Payer: Mclaren Commercial	$23.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.11
Rate for Payer: Nomi Health Commercial	$21.33
Rate for Payer: Priority Health Cigna Priority Health	$16.91
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.79
Rate for Payer: Priority Health Narrow Network	$18.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.89

HC INFLUENZA VIRUS VAC, TRIVALENT (CCIIV3) 0.5 ML IM

Facility

$42.00

Service Code	CPT 90661
Hospital Charge Code	63600250
Hospital Revenue Code	636
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: ASR ASR	$40.74
Rate for Payer: ASR Commercial	$40.74
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: BCBS Trust/PPO	$34.39
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.70
Rate for Payer: Nomi Health Commercial	$34.44
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.80
Rate for Payer: Priority Health Narrow Network	$29.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC INFLUENZA VIRUS VAC, TRIVALENT (CCIIV3) 0.5 ML IM

Facility

$42.00

Service Code	CPT 90661
Hospital Charge Code	63600250
Hospital Revenue Code	636
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: ASR ASR	$40.74
Rate for Payer: ASR Commercial	$40.74
Rate for Payer: BCBS Trust/PPO	$34.23
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.70
Rate for Payer: Nomi Health Commercial	$34.44
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC INFLUENZA VIRUS VAC, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML IM

Facility

$42.00

Service Code	CPT 90657
Hospital Charge Code	63600248
Hospital Revenue Code	636
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: ASR ASR	$40.74
Rate for Payer: ASR Commercial	$40.74
Rate for Payer: BCBS Trust/PPO	$34.23
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.70
Rate for Payer: Nomi Health Commercial	$34.44
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC INFLUENZA VIRUS VAC, TRIVALENT (IIV3), SPLIT VIRUS, 0.25 ML IM

Facility

$42.00

Service Code	CPT 90657
Hospital Charge Code	63600248
Hospital Revenue Code	636
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: ASR ASR	$40.74
Rate for Payer: ASR Commercial	$40.74
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: BCBS Trust/PPO	$34.39
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.70
Rate for Payer: Nomi Health Commercial	$34.44
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.80
Rate for Payer: Priority Health Narrow Network	$29.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC INFLUENZA VIRUS VAC TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML IM

Facility

$42.00

Service Code	CPT 90658
Hospital Charge Code	63600247
Hospital Revenue Code	636
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: ASR ASR	$40.74
Rate for Payer: ASR Commercial	$40.74
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: BCBS Trust/PPO	$34.39
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.70
Rate for Payer: Nomi Health Commercial	$34.44
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.80
Rate for Payer: Priority Health Narrow Network	$29.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC INFLUENZA VIRUS VAC TRIVALENT (IIV3), SPLIT VIRUS, 0.5 ML IM

Facility

$42.00

Service Code	CPT 90658
Hospital Charge Code	63600247
Hospital Revenue Code	636
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: ASR ASR	$40.74
Rate for Payer: ASR Commercial	$40.74
Rate for Payer: BCBS Trust/PPO	$34.23
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.70
Rate for Payer: Nomi Health Commercial	$34.44
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC INFLUENZA VIRUS VAC, TRIVALENT (IIV3), SPLIT VIRUS PF, 0.5 ML IM

Facility

$42.00

Service Code	CPT 90656
Hospital Charge Code	63600072
Hospital Revenue Code	636
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: Aetna Medicare	$21.00
Rate for Payer: ASR ASR	$40.74
Rate for Payer: ASR Commercial	$40.74
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: BCBS Trust/PPO	$34.39
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.70
Rate for Payer: Nomi Health Commercial	$34.44
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.80
Rate for Payer: Priority Health Narrow Network	$29.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC INFLUENZA VIRUS VAC, TRIVALENT (IIV3), SPLIT VIRUS PF, 0.5 ML IM

Facility

$42.00

Service Code	CPT 90656
Hospital Charge Code	63600072
Hospital Revenue Code	636
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: ASR ASR	$40.74
Rate for Payer: ASR Commercial	$40.74
Rate for Payer: BCBS Trust/PPO	$34.23
Rate for Payer: BCN Commercial	$32.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cofinity Commercial	$39.48
Rate for Payer: Encore Health Key Benefits Commercial	$33.60
Rate for Payer: Healthscope Commercial	$42.00
Rate for Payer: Healthscope Whirlpool	$40.74
Rate for Payer: Mclaren Commercial	$37.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.70
Rate for Payer: Nomi Health Commercial	$34.44
Rate for Payer: Priority Health Cigna Priority Health	$27.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC INFLUENZA VIRUS VAC, TRIVALENT LIVE, INTRANASAL

Facility

$68.00

Service Code	CPT 90660
Hospital Charge Code	63600252
Hospital Revenue Code	636
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$61.20
Rate for Payer: Aetna Medicare	$34.00
Rate for Payer: ASR ASR	$65.96
Rate for Payer: ASR Commercial	$65.96
Rate for Payer: BCBS Complete	$27.20
Rate for Payer: BCBS Trust/PPO	$55.69
Rate for Payer: BCN Commercial	$52.72
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cofinity Commercial	$63.92
Rate for Payer: Encore Health Key Benefits Commercial	$54.40
Rate for Payer: Healthscope Commercial	$68.00
Rate for Payer: Healthscope Whirlpool	$65.96
Rate for Payer: Mclaren Commercial	$61.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$57.80
Rate for Payer: Nomi Health Commercial	$55.76
Rate for Payer: Priority Health Cigna Priority Health	$44.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$59.58
Rate for Payer: Priority Health Narrow Network	$47.67
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.84

HC INFLUENZA VIRUS VAC, TRIVALENT LIVE, INTRANASAL

Facility

$68.00

Service Code	CPT 90660
Hospital Charge Code	63600252
Hospital Revenue Code	636
Min. Negotiated Rate	$44.20
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$61.20
Rate for Payer: ASR ASR	$65.96
Rate for Payer: ASR Commercial	$65.96
Rate for Payer: BCBS Trust/PPO	$55.41
Rate for Payer: BCN Commercial	$52.72
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cofinity Commercial	$63.92
Rate for Payer: Encore Health Key Benefits Commercial	$54.40
Rate for Payer: Healthscope Commercial	$68.00
Rate for Payer: Healthscope Whirlpool	$65.96
Rate for Payer: Mclaren Commercial	$61.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$57.80
Rate for Payer: Nomi Health Commercial	$55.76
Rate for Payer: Priority Health Cigna Priority Health	$44.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.84

HC INFLUENZA VIRUS VAC, TRIVALENT (RIV3), PF IM

Facility

$109.00

Service Code	CPT 90673
Hospital Charge Code	63600249
Hospital Revenue Code	636
Min. Negotiated Rate	$43.60
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$98.10
Rate for Payer: Aetna Medicare	$54.50
Rate for Payer: ASR ASR	$105.73
Rate for Payer: ASR Commercial	$105.73
Rate for Payer: BCBS Complete	$43.60
Rate for Payer: BCBS Trust/PPO	$89.26
Rate for Payer: BCN Commercial	$84.51
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cofinity Commercial	$102.46
Rate for Payer: Encore Health Key Benefits Commercial	$87.20
Rate for Payer: Healthscope Commercial	$109.00
Rate for Payer: Healthscope Whirlpool	$105.73
Rate for Payer: Mclaren Commercial	$98.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$92.65
Rate for Payer: Nomi Health Commercial	$89.38
Rate for Payer: Priority Health Cigna Priority Health	$70.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$95.51
Rate for Payer: Priority Health Narrow Network	$76.41
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$95.92

HC INFLUENZA VIRUS VAC, TRIVALENT (RIV3), PF IM

Facility

$109.00

Service Code	CPT 90673
Hospital Charge Code	63600249
Hospital Revenue Code	636
Min. Negotiated Rate	$70.85
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$98.10
Rate for Payer: ASR ASR	$105.73
Rate for Payer: ASR Commercial	$105.73
Rate for Payer: BCBS Trust/PPO	$88.82
Rate for Payer: BCN Commercial	$84.51
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cofinity Commercial	$102.46
Rate for Payer: Encore Health Key Benefits Commercial	$87.20
Rate for Payer: Healthscope Commercial	$109.00
Rate for Payer: Healthscope Whirlpool	$105.73
Rate for Payer: Mclaren Commercial	$98.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$92.65
Rate for Payer: Nomi Health Commercial	$89.38
Rate for Payer: Priority Health Cigna Priority Health	$70.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$95.92

HC INF PUMP PROGRAMMABLE LVL 6

Facility

$690.00

Service Code	HCPCS C1772
Hospital Charge Code	27800141
Hospital Revenue Code	278
Min. Negotiated Rate	$448.50
Max. Negotiated Rate	$690.00
Rate for Payer: Aetna Commercial	$621.00
Rate for Payer: ASR ASR	$669.30
Rate for Payer: ASR Commercial	$669.30
Rate for Payer: BCBS Trust/PPO	$562.28
Rate for Payer: BCN Commercial	$534.96
Rate for Payer: Cash Price	$552.00
Rate for Payer: Cofinity Commercial	$648.60
Rate for Payer: Encore Health Key Benefits Commercial	$552.00
Rate for Payer: Healthscope Commercial	$690.00
Rate for Payer: Healthscope Whirlpool	$669.30
Rate for Payer: Mclaren Commercial	$621.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$586.50
Rate for Payer: Nomi Health Commercial	$565.80
Rate for Payer: Priority Health Cigna Priority Health	$448.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$607.20

HC INF PUMP PROGRAMMABLE LVL 6

Facility

$690.00

Service Code	HCPCS C1772
Hospital Charge Code	27800141
Hospital Revenue Code	278
Min. Negotiated Rate	$276.00
Max. Negotiated Rate	$690.00
Rate for Payer: Aetna Commercial	$621.00
Rate for Payer: Aetna Medicare	$345.00
Rate for Payer: ASR ASR	$669.30
Rate for Payer: ASR Commercial	$669.30
Rate for Payer: BCBS Complete	$276.00
Rate for Payer: BCBS Trust/PPO	$565.04
Rate for Payer: BCN Commercial	$534.96
Rate for Payer: Cash Price	$552.00
Rate for Payer: Cofinity Commercial	$648.60
Rate for Payer: Encore Health Key Benefits Commercial	$552.00
Rate for Payer: Healthscope Commercial	$690.00
Rate for Payer: Healthscope Whirlpool	$669.30
Rate for Payer: Mclaren Commercial	$621.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$586.50
Rate for Payer: Nomi Health Commercial	$565.80
Rate for Payer: Priority Health Cigna Priority Health	$448.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$604.58
Rate for Payer: Priority Health Narrow Network	$483.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$607.20

HC INFRARED THERAPY

Facility

$58.63

Service Code	CPT 97026
Hospital Charge Code	42000013
Hospital Revenue Code	420
Min. Negotiated Rate	$23.45
Max. Negotiated Rate	$58.63
Rate for Payer: Aetna Commercial	$52.77
Rate for Payer: Aetna Medicare	$29.32
Rate for Payer: ASR ASR	$56.87
Rate for Payer: ASR Commercial	$56.87
Rate for Payer: BCBS Complete	$23.45
Rate for Payer: BCBS Trust/PPO	$48.01
Rate for Payer: BCN Commercial	$45.46
Rate for Payer: Cash Price	$46.90
Rate for Payer: Cofinity Commercial	$55.11
Rate for Payer: Encore Health Key Benefits Commercial	$46.90
Rate for Payer: Healthscope Commercial	$58.63
Rate for Payer: Healthscope Whirlpool	$56.87
Rate for Payer: Mclaren Commercial	$52.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.84
Rate for Payer: Nomi Health Commercial	$48.08
Rate for Payer: Priority Health Cigna Priority Health	$38.11
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$51.37
Rate for Payer: Priority Health Narrow Network	$41.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$51.59

HC INFRARED THERAPY

Facility

$58.63

Service Code	CPT 97026
Hospital Charge Code	42000013
Hospital Revenue Code	420
Min. Negotiated Rate	$38.11
Max. Negotiated Rate	$58.63
Rate for Payer: Aetna Commercial	$52.77
Rate for Payer: ASR ASR	$56.87
Rate for Payer: ASR Commercial	$56.87
Rate for Payer: BCBS Trust/PPO	$47.78
Rate for Payer: BCN Commercial	$45.46
Rate for Payer: Cash Price	$46.90
Rate for Payer: Cofinity Commercial	$55.11
Rate for Payer: Encore Health Key Benefits Commercial	$46.90
Rate for Payer: Healthscope Commercial	$58.63
Rate for Payer: Healthscope Whirlpool	$56.87
Rate for Payer: Mclaren Commercial	$52.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$49.84
Rate for Payer: Nomi Health Commercial	$48.08
Rate for Payer: Priority Health Cigna Priority Health	$38.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$51.59

HC INFUSION CATHETER LVL 1

Facility

$160.65

Service Code	HCPCS C1751
Hospital Charge Code	27200278
Hospital Revenue Code	272
Min. Negotiated Rate	$104.42
Max. Negotiated Rate	$160.65
Rate for Payer: Aetna Commercial	$144.59
Rate for Payer: ASR ASR	$155.83
Rate for Payer: ASR Commercial	$155.83
Rate for Payer: BCBS Trust/PPO	$130.91
Rate for Payer: BCN Commercial	$124.55
Rate for Payer: Cash Price	$128.52
Rate for Payer: Cofinity Commercial	$151.01
Rate for Payer: Encore Health Key Benefits Commercial	$128.52
Rate for Payer: Healthscope Commercial	$160.65
Rate for Payer: Healthscope Whirlpool	$155.83
Rate for Payer: Mclaren Commercial	$144.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$136.55
Rate for Payer: Nomi Health Commercial	$131.73
Rate for Payer: Priority Health Cigna Priority Health	$104.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$141.37

HC INFUSION CATHETER LVL 1

Facility

$160.65

Service Code	HCPCS C1751
Hospital Charge Code	27200278
Hospital Revenue Code	272
Min. Negotiated Rate	$64.26
Max. Negotiated Rate	$160.65
Rate for Payer: Aetna Commercial	$144.59
Rate for Payer: Aetna Medicare	$80.33
Rate for Payer: ASR ASR	$155.83
Rate for Payer: ASR Commercial	$155.83
Rate for Payer: BCBS Complete	$64.26
Rate for Payer: BCBS Trust/PPO	$131.56
Rate for Payer: BCN Commercial	$124.55
Rate for Payer: Cash Price	$128.52
Rate for Payer: Cofinity Commercial	$151.01
Rate for Payer: Encore Health Key Benefits Commercial	$128.52
Rate for Payer: Healthscope Commercial	$160.65
Rate for Payer: Healthscope Whirlpool	$155.83
Rate for Payer: Mclaren Commercial	$144.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$136.55
Rate for Payer: Nomi Health Commercial	$131.73
Rate for Payer: Priority Health Cigna Priority Health	$104.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$140.76
Rate for Payer: Priority Health Narrow Network	$112.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$141.37

Know your out-of-pocket cost for care.

All Charges