Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC V5264 EAR MOLD INSERT NOT DISPOSABLE ANY TYPE

Facility

$70.00

Service Code	CPT V5264
Hospital Charge Code	47000005
Hospital Revenue Code	470
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: ASR ASR	$67.90
Rate for Payer: BCBS Complete	$28.00
Rate for Payer: BCBS Trust/PPO	$54.27
Rate for Payer: BCN Commercial	$54.27
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$65.80
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$70.00
Rate for Payer: Healthscope Whirlpool	$67.90
Rate for Payer: Mclaren Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$63.70
Rate for Payer: Priority Health Narrow Network	$49.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.60

HC V5264 EAR MOLD INSERT NOT DISPOSABLE ANY TYPE

Facility

$70.00

Service Code	CPT V5264
Hospital Charge Code	47000005
Hospital Revenue Code	470
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: ASR ASR	$67.90
Rate for Payer: BCBS Trust/PPO	$54.27
Rate for Payer: BCN Commercial	$54.27
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$65.80
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$70.00
Rate for Payer: Healthscope Whirlpool	$67.90
Rate for Payer: Mclaren Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.60

HC VACC AIIV4 NO PRSRV 0.5ML IM

Facility

$178.26

Service Code	CPT 90694
Hospital Charge Code	63600224
Hospital Revenue Code	636
Min. Negotiated Rate	$124.78
Max. Negotiated Rate	$178.26
Rate for Payer: Aetna Commercial	$160.43
Rate for Payer: ASR ASR	$172.91
Rate for Payer: BCBS Trust/PPO	$138.20
Rate for Payer: BCN Commercial	$138.20
Rate for Payer: Cash Price	$142.61
Rate for Payer: Cofinity Commercial	$167.56
Rate for Payer: Encore Health Key Benefits Commercial	$142.61
Rate for Payer: Healthscope Commercial	$178.26
Rate for Payer: Healthscope Whirlpool	$172.91
Rate for Payer: Mclaren Commercial	$160.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$151.52
Rate for Payer: Priority Health Cigna Priority Health	$124.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$156.87

HC VACC AIIV4 NO PRSRV 0.5ML IM

Facility

$178.26

Service Code	CPT 90694
Hospital Charge Code	63600224
Hospital Revenue Code	636
Min. Negotiated Rate	$71.30
Max. Negotiated Rate	$178.26
Rate for Payer: Aetna Commercial	$160.43
Rate for Payer: ASR ASR	$172.91
Rate for Payer: BCBS Complete	$71.30
Rate for Payer: BCBS Trust/PPO	$138.20
Rate for Payer: BCN Commercial	$138.20
Rate for Payer: Cash Price	$142.61
Rate for Payer: Cofinity Commercial	$167.56
Rate for Payer: Encore Health Key Benefits Commercial	$142.61
Rate for Payer: Healthscope Commercial	$178.26
Rate for Payer: Healthscope Whirlpool	$172.91
Rate for Payer: Mclaren Commercial	$160.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$151.52
Rate for Payer: Priority Health Cigna Priority Health	$124.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$162.22
Rate for Payer: Priority Health Narrow Network	$126.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$156.87

HC VACC CCIIV4 ABX FREE 0.5 ML IM

Facility

$66.69

Service Code	CPT 90756
Hospital Charge Code	63600223
Hospital Revenue Code	636
Min. Negotiated Rate	$26.68
Max. Negotiated Rate	$66.69
Rate for Payer: Aetna Commercial	$60.02
Rate for Payer: ASR ASR	$64.69
Rate for Payer: BCBS Complete	$26.68
Rate for Payer: BCBS Trust/PPO	$51.70
Rate for Payer: BCN Commercial	$51.70
Rate for Payer: Cash Price	$53.35
Rate for Payer: Cofinity Commercial	$62.69
Rate for Payer: Encore Health Key Benefits Commercial	$53.35
Rate for Payer: Healthscope Commercial	$66.69
Rate for Payer: Healthscope Whirlpool	$64.69
Rate for Payer: Mclaren Commercial	$60.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$56.69
Rate for Payer: Priority Health Cigna Priority Health	$46.68
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$60.69
Rate for Payer: Priority Health Narrow Network	$47.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$58.69

HC VACC CCIIV4 ABX FREE 0.5 ML IM

Facility

$66.69

Service Code	CPT 90756
Hospital Charge Code	63600223
Hospital Revenue Code	636
Min. Negotiated Rate	$46.68
Max. Negotiated Rate	$66.69
Rate for Payer: Aetna Commercial	$60.02
Rate for Payer: ASR ASR	$64.69
Rate for Payer: BCBS Trust/PPO	$51.70
Rate for Payer: BCN Commercial	$51.70
Rate for Payer: Cash Price	$53.35
Rate for Payer: Cofinity Commercial	$62.69
Rate for Payer: Encore Health Key Benefits Commercial	$53.35
Rate for Payer: Healthscope Commercial	$66.69
Rate for Payer: Healthscope Whirlpool	$64.69
Rate for Payer: Mclaren Commercial	$60.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$56.69
Rate for Payer: Priority Health Cigna Priority Health	$46.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$58.69

HC VACC CCIIV4 NO PRSV 0.5 ML IM

Facility

$71.40

Service Code	CPT 90674
Hospital Charge Code	63600222
Hospital Revenue Code	636
Min. Negotiated Rate	$28.56
Max. Negotiated Rate	$71.40
Rate for Payer: Aetna Commercial	$64.26
Rate for Payer: ASR ASR	$69.26
Rate for Payer: BCBS Complete	$28.56
Rate for Payer: BCBS Trust/PPO	$55.36
Rate for Payer: BCN Commercial	$55.36
Rate for Payer: Cash Price	$57.12
Rate for Payer: Cofinity Commercial	$67.12
Rate for Payer: Encore Health Key Benefits Commercial	$57.12
Rate for Payer: Healthscope Commercial	$71.40
Rate for Payer: Healthscope Whirlpool	$69.26
Rate for Payer: Mclaren Commercial	$64.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$60.69
Rate for Payer: Priority Health Cigna Priority Health	$49.98
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$64.97
Rate for Payer: Priority Health Narrow Network	$50.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$62.83

HC VACC CCIIV4 NO PRSV 0.5 ML IM

Facility

$71.40

Service Code	CPT 90674
Hospital Charge Code	63600222
Hospital Revenue Code	636
Min. Negotiated Rate	$49.98
Max. Negotiated Rate	$71.40
Rate for Payer: Aetna Commercial	$64.26
Rate for Payer: ASR ASR	$69.26
Rate for Payer: BCBS Trust/PPO	$55.36
Rate for Payer: BCN Commercial	$55.36
Rate for Payer: Cash Price	$57.12
Rate for Payer: Cofinity Commercial	$67.12
Rate for Payer: Encore Health Key Benefits Commercial	$57.12
Rate for Payer: Healthscope Commercial	$71.40
Rate for Payer: Healthscope Whirlpool	$69.26
Rate for Payer: Mclaren Commercial	$64.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$60.69
Rate for Payer: Priority Health Cigna Priority Health	$49.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$62.83

HC VACC RSV PREF BIVALENT IM

Facility

$823.05

Service Code	CPT 90678
Hospital Charge Code	63600226
Hospital Revenue Code	636
Min. Negotiated Rate	$576.14
Max. Negotiated Rate	$823.05
Rate for Payer: Aetna Commercial	$740.74
Rate for Payer: ASR ASR	$798.36
Rate for Payer: BCBS Trust/PPO	$638.11
Rate for Payer: BCN Commercial	$638.11
Rate for Payer: Cash Price	$658.44
Rate for Payer: Cofinity Commercial	$773.67
Rate for Payer: Encore Health Key Benefits Commercial	$658.44
Rate for Payer: Healthscope Commercial	$823.05
Rate for Payer: Healthscope Whirlpool	$798.36
Rate for Payer: Mclaren Commercial	$740.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$699.59
Rate for Payer: Priority Health Cigna Priority Health	$576.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$724.28

HC VACC RSV PREF BIVALENT IM

Facility

$823.05

Service Code	CPT 90678
Hospital Charge Code	63600226
Hospital Revenue Code	636
Min. Negotiated Rate	$329.22
Max. Negotiated Rate	$823.05
Rate for Payer: Aetna Commercial	$740.74
Rate for Payer: ASR ASR	$798.36
Rate for Payer: BCBS Complete	$329.22
Rate for Payer: BCBS Trust/PPO	$638.11
Rate for Payer: BCN Commercial	$638.11
Rate for Payer: Cash Price	$658.44
Rate for Payer: Cofinity Commercial	$773.67
Rate for Payer: Encore Health Key Benefits Commercial	$658.44
Rate for Payer: Healthscope Commercial	$823.05
Rate for Payer: Healthscope Whirlpool	$798.36
Rate for Payer: Mclaren Commercial	$740.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$699.59
Rate for Payer: Priority Health Cigna Priority Health	$576.14
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$748.98
Rate for Payer: Priority Health Narrow Network	$584.37
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$724.28

HC VACC RSV PREF RECOMB ADJT IM

Facility

$781.20

Service Code	CPT 90679
Hospital Charge Code	63600225
Hospital Revenue Code	636
Min. Negotiated Rate	$312.48
Max. Negotiated Rate	$781.20
Rate for Payer: Aetna Commercial	$703.08
Rate for Payer: ASR ASR	$757.76
Rate for Payer: BCBS Complete	$312.48
Rate for Payer: BCBS Trust/PPO	$605.66
Rate for Payer: BCN Commercial	$605.66
Rate for Payer: Cash Price	$624.96
Rate for Payer: Cofinity Commercial	$734.33
Rate for Payer: Encore Health Key Benefits Commercial	$624.96
Rate for Payer: Healthscope Commercial	$781.20
Rate for Payer: Healthscope Whirlpool	$757.76
Rate for Payer: Mclaren Commercial	$703.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$664.02
Rate for Payer: Priority Health Cigna Priority Health	$546.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$710.89
Rate for Payer: Priority Health Narrow Network	$554.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$687.46

HC VACC RSV PREF RECOMB ADJT IM

Facility

$781.20

Service Code	CPT 90679
Hospital Charge Code	63600225
Hospital Revenue Code	636
Min. Negotiated Rate	$546.84
Max. Negotiated Rate	$781.20
Rate for Payer: Aetna Commercial	$703.08
Rate for Payer: ASR ASR	$757.76
Rate for Payer: BCBS Trust/PPO	$605.66
Rate for Payer: BCN Commercial	$605.66
Rate for Payer: Cash Price	$624.96
Rate for Payer: Cofinity Commercial	$734.33
Rate for Payer: Encore Health Key Benefits Commercial	$624.96
Rate for Payer: Healthscope Commercial	$781.20
Rate for Payer: Healthscope Whirlpool	$757.76
Rate for Payer: Mclaren Commercial	$703.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$664.02
Rate for Payer: Priority Health Cigna Priority Health	$546.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$687.46

HC VAGINAL DELIVERY (OB)

Facility

$1,757.26

Hospital Charge Code	72000006
Hospital Revenue Code	720
Min. Negotiated Rate	$1,230.08
Max. Negotiated Rate	$1,757.26
Rate for Payer: Aetna Commercial	$1,581.53
Rate for Payer: ASR ASR	$1,704.54
Rate for Payer: BCBS Trust/PPO	$1,362.40
Rate for Payer: BCN Commercial	$1,362.40
Rate for Payer: Cash Price	$1,405.81
Rate for Payer: Cofinity Commercial	$1,651.82
Rate for Payer: Encore Health Key Benefits Commercial	$1,405.81
Rate for Payer: Healthscope Commercial	$1,757.26
Rate for Payer: Healthscope Whirlpool	$1,704.54
Rate for Payer: Mclaren Commercial	$1,581.53
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,493.67
Rate for Payer: Priority Health Cigna Priority Health	$1,230.08
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,546.39

HC VAGINAL DELIVERY (OB)

Facility

$1,757.26

Hospital Charge Code	72000006
Hospital Revenue Code	720
Min. Negotiated Rate	$702.90
Max. Negotiated Rate	$1,757.26
Rate for Payer: Aetna Commercial	$1,581.53
Rate for Payer: ASR ASR	$1,704.54
Rate for Payer: BCBS Complete	$702.90
Rate for Payer: BCBS Trust/PPO	$1,362.40
Rate for Payer: BCN Commercial	$1,362.40
Rate for Payer: Cash Price	$1,405.81
Rate for Payer: Cofinity Commercial	$1,651.82
Rate for Payer: Encore Health Key Benefits Commercial	$1,405.81
Rate for Payer: Healthscope Commercial	$1,757.26
Rate for Payer: Healthscope Whirlpool	$1,704.54
Rate for Payer: Mclaren Commercial	$1,581.53
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,493.67
Rate for Payer: Priority Health Cigna Priority Health	$1,230.08
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,599.11
Rate for Payer: Priority Health Narrow Network	$1,247.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,546.39

HC VALPROIC ACID DEPAKENE LVL

Facility

$105.40

Service Code	CPT 80164
Hospital Charge Code	30100589
Hospital Revenue Code	301
Min. Negotiated Rate	$7.41
Max. Negotiated Rate	$105.40
Rate for Payer: Aetna Commercial	$94.86
Rate for Payer: Aetna Medicare	$13.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$16.92
Rate for Payer: Amish Plain Church Group Commercial	$16.92
Rate for Payer: ASR ASR	$102.24
Rate for Payer: BCBS Complete	$7.78
Rate for Payer: BCBS MAPPO	$13.54
Rate for Payer: BCBS Trust/PPO	$81.72
Rate for Payer: BCN Commercial	$81.72
Rate for Payer: BCN Medicare Advantage	$13.54
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cofinity Commercial	$99.08
Rate for Payer: Encore Health Key Benefits Commercial	$84.32
Rate for Payer: Health Alliance Plan Medicare Advantage	$13.54
Rate for Payer: Healthscope Commercial	$105.40
Rate for Payer: Healthscope Whirlpool	$102.24
Rate for Payer: Humana Choice PPO Medicare	$13.54
Rate for Payer: Mclaren Commercial	$94.86
Rate for Payer: Mclaren Medicaid	$7.41
Rate for Payer: Mclaren Medicare	$13.54
Rate for Payer: Meridian Medicaid	$7.78
Rate for Payer: Meridian Wellcare - Medicare Advantage	$14.22
Rate for Payer: MI Amish Medical Board Commercial	$15.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$89.59
Rate for Payer: PACE Medicare	$12.86
Rate for Payer: PACE SWMI	$13.54
Rate for Payer: PHP Commercial	$14.89
Rate for Payer: PHP Medicaid	$7.41
Rate for Payer: PHP Medicare Advantage	$13.54
Rate for Payer: Priority Health Choice Medicaid	$7.41
Rate for Payer: Priority Health Cigna Priority Health	$73.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$55.93
Rate for Payer: Priority Health Medicare	$13.54
Rate for Payer: Priority Health Narrow Network	$44.74
Rate for Payer: Railroad Medicare Medicare	$13.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$92.75
Rate for Payer: UHC Medicare Advantage	$13.95
Rate for Payer: VA VA	$13.54

HC VALPROIC ACID DEPAKENE LVL

Facility

$105.40

Service Code	CPT 80164
Hospital Charge Code	30100589
Hospital Revenue Code	301
Min. Negotiated Rate	$73.78
Max. Negotiated Rate	$105.40
Rate for Payer: Aetna Commercial	$94.86
Rate for Payer: ASR ASR	$102.24
Rate for Payer: BCBS Trust/PPO	$81.72
Rate for Payer: BCN Commercial	$81.72
Rate for Payer: Cash Price	$84.32
Rate for Payer: Cofinity Commercial	$99.08
Rate for Payer: Encore Health Key Benefits Commercial	$84.32
Rate for Payer: Healthscope Commercial	$105.40
Rate for Payer: Healthscope Whirlpool	$102.24
Rate for Payer: Mclaren Commercial	$94.86
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$89.59
Rate for Payer: Priority Health Cigna Priority Health	$73.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$92.75

HC VALVE VENT NONADJ

Facility

$51.00

Hospital Charge Code	27000277
Hospital Revenue Code	270
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: ASR ASR	$49.47
Rate for Payer: BCBS Complete	$20.40
Rate for Payer: BCBS Trust/PPO	$39.54
Rate for Payer: BCN Commercial	$39.54
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cofinity Commercial	$47.94
Rate for Payer: Encore Health Key Benefits Commercial	$40.80
Rate for Payer: Healthscope Commercial	$51.00
Rate for Payer: Healthscope Whirlpool	$49.47
Rate for Payer: Mclaren Commercial	$45.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$43.35
Rate for Payer: Priority Health Cigna Priority Health	$35.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$46.41
Rate for Payer: Priority Health Narrow Network	$36.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$44.88

HC VALVE VENT NONADJ

Facility

$51.00

Hospital Charge Code	27000277
Hospital Revenue Code	270
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$45.90
Rate for Payer: ASR ASR	$49.47
Rate for Payer: BCBS Trust/PPO	$39.54
Rate for Payer: BCN Commercial	$39.54
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cofinity Commercial	$47.94
Rate for Payer: Encore Health Key Benefits Commercial	$40.80
Rate for Payer: Healthscope Commercial	$51.00
Rate for Payer: Healthscope Whirlpool	$49.47
Rate for Payer: Mclaren Commercial	$45.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$43.35
Rate for Payer: Priority Health Cigna Priority Health	$35.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$44.88

HC VALVE VENT ONE WAY

Facility

$42.00

Hospital Charge Code	27000662
Hospital Revenue Code	270
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: ASR ASR	$40.74
Rate for Payer: BCBS Trust/PPO	$32.56
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 Multiplan/Beech St/PHCS	$35.70
Rate for Payer: Priority Health Cigna Priority Health	$29.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC VALVE VENT ONE WAY

Facility

$42.00

Hospital Charge Code	27000662
Hospital Revenue Code	270
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$37.80
Rate for Payer: ASR ASR	$40.74
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: BCBS Trust/PPO	$32.56
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 Multiplan/Beech St/PHCS	$35.70
Rate for Payer: Priority Health Cigna Priority Health	$29.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$38.22
Rate for Payer: Priority Health Narrow Network	$29.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.96

HC VANCOMYCIN LEVEL

Facility

$135.70

Service Code	CPT 80202
Hospital Charge Code	30100051
Hospital Revenue Code	301
Min. Negotiated Rate	$94.99
Max. Negotiated Rate	$135.70
Rate for Payer: Aetna Commercial	$122.13
Rate for Payer: ASR ASR	$131.63
Rate for Payer: BCBS Trust/PPO	$105.21
Rate for Payer: BCN Commercial	$105.21
Rate for Payer: Cash Price	$108.56
Rate for Payer: Cofinity Commercial	$127.56
Rate for Payer: Encore Health Key Benefits Commercial	$108.56
Rate for Payer: Healthscope Commercial	$135.70
Rate for Payer: Healthscope Whirlpool	$131.63
Rate for Payer: Mclaren Commercial	$122.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$115.34
Rate for Payer: Priority Health Cigna Priority Health	$94.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$119.42

HC VANCOMYCIN LEVEL

Facility

$135.70

Service Code	CPT 80202
Hospital Charge Code	30100051
Hospital Revenue Code	301
Min. Negotiated Rate	$7.41
Max. Negotiated Rate	$135.70
Rate for Payer: Aetna Commercial	$122.13
Rate for Payer: Aetna Medicare	$13.54
Rate for Payer: Allen County Amish Medical Aid Commercial	$16.92
Rate for Payer: Amish Plain Church Group Commercial	$16.92
Rate for Payer: ASR ASR	$131.63
Rate for Payer: BCBS Complete	$7.78
Rate for Payer: BCBS MAPPO	$13.54
Rate for Payer: BCBS Trust/PPO	$105.21
Rate for Payer: BCN Commercial	$105.21
Rate for Payer: BCN Medicare Advantage	$13.54
Rate for Payer: Cash Price	$108.56
Rate for Payer: Cash Price	$108.56
Rate for Payer: Cofinity Commercial	$127.56
Rate for Payer: Encore Health Key Benefits Commercial	$108.56
Rate for Payer: Health Alliance Plan Medicare Advantage	$13.54
Rate for Payer: Healthscope Commercial	$135.70
Rate for Payer: Healthscope Whirlpool	$131.63
Rate for Payer: Humana Choice PPO Medicare	$13.54
Rate for Payer: Mclaren Commercial	$122.13
Rate for Payer: Mclaren Medicaid	$7.41
Rate for Payer: Mclaren Medicare	$13.54
Rate for Payer: Meridian Medicaid	$7.78
Rate for Payer: Meridian Wellcare - Medicare Advantage	$14.22
Rate for Payer: MI Amish Medical Board Commercial	$15.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$115.34
Rate for Payer: PACE Medicare	$12.86
Rate for Payer: PACE SWMI	$13.54
Rate for Payer: PHP Commercial	$14.89
Rate for Payer: PHP Medicaid	$7.41
Rate for Payer: PHP Medicare Advantage	$13.54
Rate for Payer: Priority Health Choice Medicaid	$7.41
Rate for Payer: Priority Health Cigna Priority Health	$94.99
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$41.05
Rate for Payer: Priority Health Medicare	$13.54
Rate for Payer: Priority Health Narrow Network	$32.84
Rate for Payer: Railroad Medicare Medicare	$13.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$119.42
Rate for Payer: UHC Medicare Advantage	$13.95
Rate for Payer: VA VA	$13.54

HC VAP CHOLESTEROL

Facility

$81.60

Service Code	CPT 83701
Hospital Charge Code	30100281
Hospital Revenue Code	301
Min. Negotiated Rate	$57.12
Max. Negotiated Rate	$81.60
Rate for Payer: Aetna Commercial	$73.44
Rate for Payer: ASR ASR	$79.15
Rate for Payer: BCBS Trust/PPO	$63.26
Rate for Payer: BCN Commercial	$63.26
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cofinity Commercial	$76.70
Rate for Payer: Encore Health Key Benefits Commercial	$65.28
Rate for Payer: Healthscope Commercial	$81.60
Rate for Payer: Healthscope Whirlpool	$79.15
Rate for Payer: Mclaren Commercial	$73.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$69.36
Rate for Payer: Priority Health Cigna Priority Health	$57.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$71.81

HC VAP CHOLESTEROL

Facility

$81.60

Service Code	CPT 83701
Hospital Charge Code	30100281
Hospital Revenue Code	301
Min. Negotiated Rate	$18.52
Max. Negotiated Rate	$81.60
Rate for Payer: Aetna Commercial	$73.44
Rate for Payer: Aetna Medicare	$33.86
Rate for Payer: Allen County Amish Medical Aid Commercial	$42.32
Rate for Payer: Amish Plain Church Group Commercial	$42.32
Rate for Payer: ASR ASR	$79.15
Rate for Payer: BCBS Complete	$19.45
Rate for Payer: BCBS MAPPO	$33.86
Rate for Payer: BCBS Trust/PPO	$63.26
Rate for Payer: BCN Commercial	$63.26
Rate for Payer: BCN Medicare Advantage	$33.86
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cash Price	$65.28
Rate for Payer: Cofinity Commercial	$76.70
Rate for Payer: Encore Health Key Benefits Commercial	$65.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$33.86
Rate for Payer: Healthscope Commercial	$81.60
Rate for Payer: Healthscope Whirlpool	$79.15
Rate for Payer: Humana Choice PPO Medicare	$33.86
Rate for Payer: Mclaren Commercial	$73.44
Rate for Payer: Mclaren Medicaid	$18.52
Rate for Payer: Mclaren Medicare	$33.86
Rate for Payer: Meridian Medicaid	$19.45
Rate for Payer: Meridian Wellcare - Medicare Advantage	$35.55
Rate for Payer: MI Amish Medical Board Commercial	$38.94
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$69.36
Rate for Payer: PACE Medicare	$32.17
Rate for Payer: PACE SWMI	$33.86
Rate for Payer: PHP Commercial	$37.25
Rate for Payer: PHP Medicaid	$18.52
Rate for Payer: PHP Medicare Advantage	$33.86
Rate for Payer: Priority Health Choice Medicaid	$18.52
Rate for Payer: Priority Health Cigna Priority Health	$57.12
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$74.26
Rate for Payer: Priority Health Medicare	$33.86
Rate for Payer: Priority Health Narrow Network	$57.94
Rate for Payer: Railroad Medicare Medicare	$33.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$71.81
Rate for Payer: UHC Medicare Advantage	$34.88
Rate for Payer: VA VA	$33.86

HC VAP CHOLESTEROL CMPT

Facility

$20.40

Service Code	CPT 84478
Hospital Charge Code	30100445
Hospital Revenue Code	301
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

Know your out-of-pocket cost for care.

All Charges