Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC LEVEL 0.5 INIT 30 MIN

Facility

$939.78

Hospital Charge Code	36000060
Hospital Revenue Code	360
Min. Negotiated Rate	$375.91
Max. Negotiated Rate	$939.78
Rate for Payer: Aetna Commercial	$845.80
Rate for Payer: Aetna Medicare	$469.89
Rate for Payer: ASR ASR	$911.59
Rate for Payer: ASR Commercial	$911.59
Rate for Payer: BCBS Complete	$375.91
Rate for Payer: BCBS Trust/PPO	$769.59
Rate for Payer: BCN Commercial	$728.61
Rate for Payer: Cash Price	$751.82
Rate for Payer: Cofinity Commercial	$883.39
Rate for Payer: Encore Health Key Benefits Commercial	$751.82
Rate for Payer: Healthscope Commercial	$939.78
Rate for Payer: Healthscope Whirlpool	$911.59
Rate for Payer: Mclaren Commercial	$845.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$798.81
Rate for Payer: Nomi Health Commercial	$770.62
Rate for Payer: Priority Health Cigna Priority Health	$610.86
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$823.44
Rate for Payer: Priority Health Narrow Network	$658.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$827.01

HC LEVEL 0.5 INIT 30 MIN

Facility

$939.78

Hospital Charge Code	36000060
Hospital Revenue Code	360
Min. Negotiated Rate	$610.86
Max. Negotiated Rate	$939.78
Rate for Payer: Aetna Commercial	$845.80
Rate for Payer: ASR ASR	$911.59
Rate for Payer: ASR Commercial	$911.59
Rate for Payer: BCBS Trust/PPO	$765.83
Rate for Payer: BCN Commercial	$728.61
Rate for Payer: Cash Price	$751.82
Rate for Payer: Cofinity Commercial	$883.39
Rate for Payer: Encore Health Key Benefits Commercial	$751.82
Rate for Payer: Healthscope Commercial	$939.78
Rate for Payer: Healthscope Whirlpool	$911.59
Rate for Payer: Mclaren Commercial	$845.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$798.81
Rate for Payer: Nomi Health Commercial	$770.62
Rate for Payer: Priority Health Cigna Priority Health	$610.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$827.01

HC LEVEL 0.5 SUBSQ 15 MIN

Facility

$270.72

Hospital Charge Code	36000061
Hospital Revenue Code	360
Min. Negotiated Rate	$175.97
Max. Negotiated Rate	$270.72
Rate for Payer: Aetna Commercial	$243.65
Rate for Payer: ASR ASR	$262.60
Rate for Payer: ASR Commercial	$262.60
Rate for Payer: BCBS Trust/PPO	$220.61
Rate for Payer: BCN Commercial	$209.89
Rate for Payer: Cash Price	$216.58
Rate for Payer: Cofinity Commercial	$254.48
Rate for Payer: Encore Health Key Benefits Commercial	$216.58
Rate for Payer: Healthscope Commercial	$270.72
Rate for Payer: Healthscope Whirlpool	$262.60
Rate for Payer: Mclaren Commercial	$243.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$230.11
Rate for Payer: Nomi Health Commercial	$221.99
Rate for Payer: Priority Health Cigna Priority Health	$175.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$238.23

HC LEVEL 0.5 SUBSQ 15 MIN

Facility

$270.72

Hospital Charge Code	36000061
Hospital Revenue Code	360
Min. Negotiated Rate	$108.29
Max. Negotiated Rate	$270.72
Rate for Payer: Aetna Commercial	$243.65
Rate for Payer: Aetna Medicare	$135.36
Rate for Payer: ASR ASR	$262.60
Rate for Payer: ASR Commercial	$262.60
Rate for Payer: BCBS Complete	$108.29
Rate for Payer: BCBS Trust/PPO	$221.69
Rate for Payer: BCN Commercial	$209.89
Rate for Payer: Cash Price	$216.58
Rate for Payer: Cofinity Commercial	$254.48
Rate for Payer: Encore Health Key Benefits Commercial	$216.58
Rate for Payer: Healthscope Commercial	$270.72
Rate for Payer: Healthscope Whirlpool	$262.60
Rate for Payer: Mclaren Commercial	$243.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$230.11
Rate for Payer: Nomi Health Commercial	$221.99
Rate for Payer: Priority Health Cigna Priority Health	$175.97
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$237.20
Rate for Payer: Priority Health Narrow Network	$189.77
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$238.23

HC LEVEL 1 INIT 30 MIN

Facility

$2,074.72

Hospital Charge Code	36000062
Hospital Revenue Code	360
Min. Negotiated Rate	$1,348.57
Max. Negotiated Rate	$2,074.72
Rate for Payer: Aetna Commercial	$1,867.25
Rate for Payer: ASR ASR	$2,012.48
Rate for Payer: ASR Commercial	$2,012.48
Rate for Payer: BCBS Trust/PPO	$1,690.69
Rate for Payer: BCN Commercial	$1,608.53
Rate for Payer: Cash Price	$1,659.78
Rate for Payer: Cofinity Commercial	$1,950.24
Rate for Payer: Encore Health Key Benefits Commercial	$1,659.78
Rate for Payer: Healthscope Commercial	$2,074.72
Rate for Payer: Healthscope Whirlpool	$2,012.48
Rate for Payer: Mclaren Commercial	$1,867.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,763.51
Rate for Payer: Nomi Health Commercial	$1,701.27
Rate for Payer: Priority Health Cigna Priority Health	$1,348.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,825.75

HC LEVEL 1 INIT 30 MIN

Facility

$2,074.72

Hospital Charge Code	36000062
Hospital Revenue Code	360
Min. Negotiated Rate	$829.89
Max. Negotiated Rate	$2,074.72
Rate for Payer: Aetna Commercial	$1,867.25
Rate for Payer: Aetna Medicare	$1,037.36
Rate for Payer: ASR ASR	$2,012.48
Rate for Payer: ASR Commercial	$2,012.48
Rate for Payer: BCBS Complete	$829.89
Rate for Payer: BCBS Trust/PPO	$1,698.99
Rate for Payer: BCN Commercial	$1,608.53
Rate for Payer: Cash Price	$1,659.78
Rate for Payer: Cofinity Commercial	$1,950.24
Rate for Payer: Encore Health Key Benefits Commercial	$1,659.78
Rate for Payer: Healthscope Commercial	$2,074.72
Rate for Payer: Healthscope Whirlpool	$2,012.48
Rate for Payer: Mclaren Commercial	$1,867.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,763.51
Rate for Payer: Nomi Health Commercial	$1,701.27
Rate for Payer: Priority Health Cigna Priority Health	$1,348.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,817.87
Rate for Payer: Priority Health Narrow Network	$1,454.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,825.75

HC LEVEL 1 SUBSQ 15 MIN

Facility

$412.97

Hospital Charge Code	36000063
Hospital Revenue Code	360
Min. Negotiated Rate	$268.43
Max. Negotiated Rate	$412.97
Rate for Payer: Aetna Commercial	$371.67
Rate for Payer: ASR ASR	$400.58
Rate for Payer: ASR Commercial	$400.58
Rate for Payer: BCBS Trust/PPO	$336.53
Rate for Payer: BCN Commercial	$320.18
Rate for Payer: Cash Price	$330.38
Rate for Payer: Cofinity Commercial	$388.19
Rate for Payer: Encore Health Key Benefits Commercial	$330.38
Rate for Payer: Healthscope Commercial	$412.97
Rate for Payer: Healthscope Whirlpool	$400.58
Rate for Payer: Mclaren Commercial	$371.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$351.02
Rate for Payer: Nomi Health Commercial	$338.64
Rate for Payer: Priority Health Cigna Priority Health	$268.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$363.41

HC LEVEL 1 SUBSQ 15 MIN

Facility

$412.97

Hospital Charge Code	36000063
Hospital Revenue Code	360
Min. Negotiated Rate	$165.19
Max. Negotiated Rate	$412.97
Rate for Payer: Aetna Commercial	$371.67
Rate for Payer: Aetna Medicare	$206.48
Rate for Payer: ASR ASR	$400.58
Rate for Payer: ASR Commercial	$400.58
Rate for Payer: BCBS Complete	$165.19
Rate for Payer: BCBS Trust/PPO	$338.18
Rate for Payer: BCN Commercial	$320.18
Rate for Payer: Cash Price	$330.38
Rate for Payer: Cofinity Commercial	$388.19
Rate for Payer: Encore Health Key Benefits Commercial	$330.38
Rate for Payer: Healthscope Commercial	$412.97
Rate for Payer: Healthscope Whirlpool	$400.58
Rate for Payer: Mclaren Commercial	$371.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$351.02
Rate for Payer: Nomi Health Commercial	$338.64
Rate for Payer: Priority Health Cigna Priority Health	$268.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$361.84
Rate for Payer: Priority Health Narrow Network	$289.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$363.41

HC LEVEL 2 INIT 30 MIN

Facility

$3,226.85

Hospital Charge Code	36000064
Hospital Revenue Code	360
Min. Negotiated Rate	$2,097.45
Max. Negotiated Rate	$3,226.85
Rate for Payer: Aetna Commercial	$2,904.16
Rate for Payer: ASR ASR	$3,130.04
Rate for Payer: ASR Commercial	$3,130.04
Rate for Payer: BCBS Trust/PPO	$2,629.56
Rate for Payer: BCN Commercial	$2,501.78
Rate for Payer: Cash Price	$2,581.48
Rate for Payer: Cofinity Commercial	$3,033.24
Rate for Payer: Encore Health Key Benefits Commercial	$2,581.48
Rate for Payer: Healthscope Commercial	$3,226.85
Rate for Payer: Healthscope Whirlpool	$3,130.04
Rate for Payer: Mclaren Commercial	$2,904.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,742.82
Rate for Payer: Nomi Health Commercial	$2,646.02
Rate for Payer: Priority Health Cigna Priority Health	$2,097.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,839.63

HC LEVEL 2 INIT 30 MIN

Facility

$3,226.85

Hospital Charge Code	36000064
Hospital Revenue Code	360
Min. Negotiated Rate	$1,290.74
Max. Negotiated Rate	$3,226.85
Rate for Payer: Aetna Commercial	$2,904.16
Rate for Payer: Aetna Medicare	$1,613.42
Rate for Payer: ASR ASR	$3,130.04
Rate for Payer: ASR Commercial	$3,130.04
Rate for Payer: BCBS Complete	$1,290.74
Rate for Payer: BCBS Trust/PPO	$2,642.47
Rate for Payer: BCN Commercial	$2,501.78
Rate for Payer: Cash Price	$2,581.48
Rate for Payer: Cofinity Commercial	$3,033.24
Rate for Payer: Encore Health Key Benefits Commercial	$2,581.48
Rate for Payer: Healthscope Commercial	$3,226.85
Rate for Payer: Healthscope Whirlpool	$3,130.04
Rate for Payer: Mclaren Commercial	$2,904.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,742.82
Rate for Payer: Nomi Health Commercial	$2,646.02
Rate for Payer: Priority Health Cigna Priority Health	$2,097.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,827.37
Rate for Payer: Priority Health Narrow Network	$2,262.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,839.63

HC LEVEL 2 SUBSQ 15 MIN

Facility

$1,237.94

Hospital Charge Code	36000065
Hospital Revenue Code	360
Min. Negotiated Rate	$495.18
Max. Negotiated Rate	$1,237.94
Rate for Payer: Aetna Commercial	$1,114.15
Rate for Payer: Aetna Medicare	$618.97
Rate for Payer: ASR ASR	$1,200.80
Rate for Payer: ASR Commercial	$1,200.80
Rate for Payer: BCBS Complete	$495.18
Rate for Payer: BCBS Trust/PPO	$1,013.75
Rate for Payer: BCN Commercial	$959.77
Rate for Payer: Cash Price	$990.35
Rate for Payer: Cofinity Commercial	$1,163.66
Rate for Payer: Encore Health Key Benefits Commercial	$990.35
Rate for Payer: Healthscope Commercial	$1,237.94
Rate for Payer: Healthscope Whirlpool	$1,200.80
Rate for Payer: Mclaren Commercial	$1,114.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,052.25
Rate for Payer: Nomi Health Commercial	$1,015.11
Rate for Payer: Priority Health Cigna Priority Health	$804.66
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,084.68
Rate for Payer: Priority Health Narrow Network	$867.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,089.39

HC LEVEL 2 SUBSQ 15 MIN

Facility

$1,237.94

Hospital Charge Code	36000065
Hospital Revenue Code	360
Min. Negotiated Rate	$804.66
Max. Negotiated Rate	$1,237.94
Rate for Payer: Aetna Commercial	$1,114.15
Rate for Payer: ASR ASR	$1,200.80
Rate for Payer: ASR Commercial	$1,200.80
Rate for Payer: BCBS Trust/PPO	$1,008.80
Rate for Payer: BCN Commercial	$959.77
Rate for Payer: Cash Price	$990.35
Rate for Payer: Cofinity Commercial	$1,163.66
Rate for Payer: Encore Health Key Benefits Commercial	$990.35
Rate for Payer: Healthscope Commercial	$1,237.94
Rate for Payer: Healthscope Whirlpool	$1,200.80
Rate for Payer: Mclaren Commercial	$1,114.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,052.25
Rate for Payer: Nomi Health Commercial	$1,015.11
Rate for Payer: Priority Health Cigna Priority Health	$804.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,089.39

HC LEVEL 3 INIT 30 MIN

Facility

$3,827.33

Hospital Charge Code	36000066
Hospital Revenue Code	360
Min. Negotiated Rate	$2,487.76
Max. Negotiated Rate	$3,827.33
Rate for Payer: Aetna Commercial	$3,444.60
Rate for Payer: ASR ASR	$3,712.51
Rate for Payer: ASR Commercial	$3,712.51
Rate for Payer: BCBS Trust/PPO	$3,118.89
Rate for Payer: BCN Commercial	$2,967.33
Rate for Payer: Cash Price	$3,061.86
Rate for Payer: Cofinity Commercial	$3,597.69
Rate for Payer: Encore Health Key Benefits Commercial	$3,061.86
Rate for Payer: Healthscope Commercial	$3,827.33
Rate for Payer: Healthscope Whirlpool	$3,712.51
Rate for Payer: Mclaren Commercial	$3,444.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,253.23
Rate for Payer: Nomi Health Commercial	$3,138.41
Rate for Payer: Priority Health Cigna Priority Health	$2,487.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,368.05

HC LEVEL 3 INIT 30 MIN

Facility

$3,827.33

Hospital Charge Code	36000066
Hospital Revenue Code	360
Min. Negotiated Rate	$1,530.93
Max. Negotiated Rate	$3,827.33
Rate for Payer: Aetna Commercial	$3,444.60
Rate for Payer: Aetna Medicare	$1,913.66
Rate for Payer: ASR ASR	$3,712.51
Rate for Payer: ASR Commercial	$3,712.51
Rate for Payer: BCBS Complete	$1,530.93
Rate for Payer: BCBS Trust/PPO	$3,134.20
Rate for Payer: BCN Commercial	$2,967.33
Rate for Payer: Cash Price	$3,061.86
Rate for Payer: Cofinity Commercial	$3,597.69
Rate for Payer: Encore Health Key Benefits Commercial	$3,061.86
Rate for Payer: Healthscope Commercial	$3,827.33
Rate for Payer: Healthscope Whirlpool	$3,712.51
Rate for Payer: Mclaren Commercial	$3,444.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,253.23
Rate for Payer: Nomi Health Commercial	$3,138.41
Rate for Payer: Priority Health Cigna Priority Health	$2,487.76
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,353.51
Rate for Payer: Priority Health Narrow Network	$2,682.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,368.05

HC LEVEL 3 SUBSQ 15 MIN

Facility

$1,487.89

Hospital Charge Code	36000067
Hospital Revenue Code	360
Min. Negotiated Rate	$595.16
Max. Negotiated Rate	$1,487.89
Rate for Payer: Aetna Commercial	$1,339.10
Rate for Payer: Aetna Medicare	$743.94
Rate for Payer: ASR ASR	$1,443.25
Rate for Payer: ASR Commercial	$1,443.25
Rate for Payer: BCBS Complete	$595.16
Rate for Payer: BCBS Trust/PPO	$1,218.43
Rate for Payer: BCN Commercial	$1,153.56
Rate for Payer: Cash Price	$1,190.31
Rate for Payer: Cofinity Commercial	$1,398.62
Rate for Payer: Encore Health Key Benefits Commercial	$1,190.31
Rate for Payer: Healthscope Commercial	$1,487.89
Rate for Payer: Healthscope Whirlpool	$1,443.25
Rate for Payer: Mclaren Commercial	$1,339.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,264.71
Rate for Payer: Nomi Health Commercial	$1,220.07
Rate for Payer: Priority Health Cigna Priority Health	$967.13
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,303.69
Rate for Payer: Priority Health Narrow Network	$1,043.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,309.34

HC LEVEL 3 SUBSQ 15 MIN

Facility

$1,487.89

Hospital Charge Code	36000067
Hospital Revenue Code	360
Min. Negotiated Rate	$967.13
Max. Negotiated Rate	$1,487.89
Rate for Payer: Aetna Commercial	$1,339.10
Rate for Payer: ASR ASR	$1,443.25
Rate for Payer: ASR Commercial	$1,443.25
Rate for Payer: BCBS Trust/PPO	$1,212.48
Rate for Payer: BCN Commercial	$1,153.56
Rate for Payer: Cash Price	$1,190.31
Rate for Payer: Cofinity Commercial	$1,398.62
Rate for Payer: Encore Health Key Benefits Commercial	$1,190.31
Rate for Payer: Healthscope Commercial	$1,487.89
Rate for Payer: Healthscope Whirlpool	$1,443.25
Rate for Payer: Mclaren Commercial	$1,339.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,264.71
Rate for Payer: Nomi Health Commercial	$1,220.07
Rate for Payer: Priority Health Cigna Priority Health	$967.13
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,309.34

HC LEVEL 4 INIT 30 MIN

Facility

$4,556.50

Hospital Charge Code	36000068
Hospital Revenue Code	360
Min. Negotiated Rate	$1,822.60
Max. Negotiated Rate	$4,556.50
Rate for Payer: Aetna Commercial	$4,100.85
Rate for Payer: Aetna Medicare	$2,278.25
Rate for Payer: ASR ASR	$4,419.80
Rate for Payer: ASR Commercial	$4,419.80
Rate for Payer: BCBS Complete	$1,822.60
Rate for Payer: BCBS Trust/PPO	$3,731.32
Rate for Payer: BCN Commercial	$3,532.65
Rate for Payer: Cash Price	$3,645.20
Rate for Payer: Cofinity Commercial	$4,283.11
Rate for Payer: Encore Health Key Benefits Commercial	$3,645.20
Rate for Payer: Healthscope Commercial	$4,556.50
Rate for Payer: Healthscope Whirlpool	$4,419.80
Rate for Payer: Mclaren Commercial	$4,100.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,873.02
Rate for Payer: Nomi Health Commercial	$3,736.33
Rate for Payer: Priority Health Cigna Priority Health	$2,961.72
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,992.41
Rate for Payer: Priority Health Narrow Network	$3,194.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,009.72

HC LEVEL 4 INIT 30 MIN

Facility

$4,556.50

Hospital Charge Code	36000068
Hospital Revenue Code	360
Min. Negotiated Rate	$2,961.72
Max. Negotiated Rate	$4,556.50
Rate for Payer: Aetna Commercial	$4,100.85
Rate for Payer: ASR ASR	$4,419.80
Rate for Payer: ASR Commercial	$4,419.80
Rate for Payer: BCBS Trust/PPO	$3,713.09
Rate for Payer: BCN Commercial	$3,532.65
Rate for Payer: Cash Price	$3,645.20
Rate for Payer: Cofinity Commercial	$4,283.11
Rate for Payer: Encore Health Key Benefits Commercial	$3,645.20
Rate for Payer: Healthscope Commercial	$4,556.50
Rate for Payer: Healthscope Whirlpool	$4,419.80
Rate for Payer: Mclaren Commercial	$4,100.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,873.02
Rate for Payer: Nomi Health Commercial	$3,736.33
Rate for Payer: Priority Health Cigna Priority Health	$2,961.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,009.72

HC LEVEL 4 SUBSQ 15 MIN

Facility

$1,658.07

Hospital Charge Code	36000069
Hospital Revenue Code	360
Min. Negotiated Rate	$663.23
Max. Negotiated Rate	$1,658.07
Rate for Payer: Aetna Commercial	$1,492.26
Rate for Payer: Aetna Medicare	$829.04
Rate for Payer: ASR ASR	$1,608.33
Rate for Payer: ASR Commercial	$1,608.33
Rate for Payer: BCBS Complete	$663.23
Rate for Payer: BCBS Trust/PPO	$1,357.79
Rate for Payer: BCN Commercial	$1,285.50
Rate for Payer: Cash Price	$1,326.46
Rate for Payer: Cofinity Commercial	$1,558.59
Rate for Payer: Encore Health Key Benefits Commercial	$1,326.46
Rate for Payer: Healthscope Commercial	$1,658.07
Rate for Payer: Healthscope Whirlpool	$1,608.33
Rate for Payer: Mclaren Commercial	$1,492.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,409.36
Rate for Payer: Nomi Health Commercial	$1,359.62
Rate for Payer: Priority Health Cigna Priority Health	$1,077.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,452.80
Rate for Payer: Priority Health Narrow Network	$1,162.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,459.10

HC LEVEL 4 SUBSQ 15 MIN

Facility

$1,658.07

Hospital Charge Code	36000069
Hospital Revenue Code	360
Min. Negotiated Rate	$1,077.75
Max. Negotiated Rate	$1,658.07
Rate for Payer: Aetna Commercial	$1,492.26
Rate for Payer: ASR ASR	$1,608.33
Rate for Payer: ASR Commercial	$1,608.33
Rate for Payer: BCBS Trust/PPO	$1,351.16
Rate for Payer: BCN Commercial	$1,285.50
Rate for Payer: Cash Price	$1,326.46
Rate for Payer: Cofinity Commercial	$1,558.59
Rate for Payer: Encore Health Key Benefits Commercial	$1,326.46
Rate for Payer: Healthscope Commercial	$1,658.07
Rate for Payer: Healthscope Whirlpool	$1,608.33
Rate for Payer: Mclaren Commercial	$1,492.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,409.36
Rate for Payer: Nomi Health Commercial	$1,359.62
Rate for Payer: Priority Health Cigna Priority Health	$1,077.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,459.10

HC LEVEL 5 INIT 30 MIN

Facility

$5,084.43

Hospital Charge Code	36000070
Hospital Revenue Code	360
Min. Negotiated Rate	$2,033.77
Max. Negotiated Rate	$5,084.43
Rate for Payer: Aetna Commercial	$4,575.99
Rate for Payer: Aetna Medicare	$2,542.22
Rate for Payer: ASR ASR	$4,931.90
Rate for Payer: ASR Commercial	$4,931.90
Rate for Payer: BCBS Complete	$2,033.77
Rate for Payer: BCBS Trust/PPO	$4,163.64
Rate for Payer: BCN Commercial	$3,941.96
Rate for Payer: Cash Price	$4,067.54
Rate for Payer: Cofinity Commercial	$4,779.36
Rate for Payer: Encore Health Key Benefits Commercial	$4,067.54
Rate for Payer: Healthscope Commercial	$5,084.43
Rate for Payer: Healthscope Whirlpool	$4,931.90
Rate for Payer: Mclaren Commercial	$4,575.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,321.77
Rate for Payer: Nomi Health Commercial	$4,169.23
Rate for Payer: Priority Health Cigna Priority Health	$3,304.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,454.98
Rate for Payer: Priority Health Narrow Network	$3,564.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,474.30

HC LEVEL 5 INIT 30 MIN

Facility

$5,084.43

Hospital Charge Code	36000070
Hospital Revenue Code	360
Min. Negotiated Rate	$3,304.88
Max. Negotiated Rate	$5,084.43
Rate for Payer: Aetna Commercial	$4,575.99
Rate for Payer: ASR ASR	$4,931.90
Rate for Payer: ASR Commercial	$4,931.90
Rate for Payer: BCBS Trust/PPO	$4,143.30
Rate for Payer: BCN Commercial	$3,941.96
Rate for Payer: Cash Price	$4,067.54
Rate for Payer: Cofinity Commercial	$4,779.36
Rate for Payer: Encore Health Key Benefits Commercial	$4,067.54
Rate for Payer: Healthscope Commercial	$5,084.43
Rate for Payer: Healthscope Whirlpool	$4,931.90
Rate for Payer: Mclaren Commercial	$4,575.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4,321.77
Rate for Payer: Nomi Health Commercial	$4,169.23
Rate for Payer: Priority Health Cigna Priority Health	$3,304.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,474.30

HC LEVEL 5 SUBSQ 15 MIN

Facility

$2,078.52

Hospital Charge Code	36000071
Hospital Revenue Code	360
Min. Negotiated Rate	$831.41
Max. Negotiated Rate	$2,078.52
Rate for Payer: Aetna Commercial	$1,870.67
Rate for Payer: Aetna Medicare	$1,039.26
Rate for Payer: ASR ASR	$2,016.16
Rate for Payer: ASR Commercial	$2,016.16
Rate for Payer: BCBS Complete	$831.41
Rate for Payer: BCBS Trust/PPO	$1,702.10
Rate for Payer: BCN Commercial	$1,611.48
Rate for Payer: Cash Price	$1,662.82
Rate for Payer: Cofinity Commercial	$1,953.81
Rate for Payer: Encore Health Key Benefits Commercial	$1,662.82
Rate for Payer: Healthscope Commercial	$2,078.52
Rate for Payer: Healthscope Whirlpool	$2,016.16
Rate for Payer: Mclaren Commercial	$1,870.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,766.74
Rate for Payer: Nomi Health Commercial	$1,704.39
Rate for Payer: Priority Health Cigna Priority Health	$1,351.04
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,821.20
Rate for Payer: Priority Health Narrow Network	$1,457.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,829.10

HC LEVEL 5 SUBSQ 15 MIN

Facility

$2,078.52

Hospital Charge Code	36000071
Hospital Revenue Code	360
Min. Negotiated Rate	$1,351.04
Max. Negotiated Rate	$2,078.52
Rate for Payer: Aetna Commercial	$1,870.67
Rate for Payer: ASR ASR	$2,016.16
Rate for Payer: ASR Commercial	$2,016.16
Rate for Payer: BCBS Trust/PPO	$1,693.79
Rate for Payer: BCN Commercial	$1,611.48
Rate for Payer: Cash Price	$1,662.82
Rate for Payer: Cofinity Commercial	$1,953.81
Rate for Payer: Encore Health Key Benefits Commercial	$1,662.82
Rate for Payer: Healthscope Commercial	$2,078.52
Rate for Payer: Healthscope Whirlpool	$2,016.16
Rate for Payer: Mclaren Commercial	$1,870.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,766.74
Rate for Payer: Nomi Health Commercial	$1,704.39
Rate for Payer: Priority Health Cigna Priority Health	$1,351.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,829.10

HC LEVETIRACETAM LEVEL

Facility

$76.79

Service Code	CPT 80177
Hospital Charge Code	30100057
Hospital Revenue Code	301
Min. Negotiated Rate	$49.91
Max. Negotiated Rate	$76.79
Rate for Payer: Aetna Commercial	$69.11
Rate for Payer: ASR ASR	$74.49
Rate for Payer: ASR Commercial	$74.49
Rate for Payer: BCBS Trust/PPO	$62.58
Rate for Payer: BCN Commercial	$59.54
Rate for Payer: Cash Price	$61.43
Rate for Payer: Cofinity Commercial	$72.18
Rate for Payer: Encore Health Key Benefits Commercial	$61.43
Rate for Payer: Healthscope Commercial	$76.79
Rate for Payer: Healthscope Whirlpool	$74.49
Rate for Payer: Mclaren Commercial	$69.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.27
Rate for Payer: Nomi Health Commercial	$62.97
Rate for Payer: Priority Health Cigna Priority Health	$49.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$67.58

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