Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR REVJ/RMVL INTRACRANIAL NEUROSTIMULATOR ELTRDS

Professional

Both

$3,184.00

Service Code	HCPCS 61880
Min. Negotiated Rate	$387.02
Max. Negotiated Rate	$2,069.60
Rate for Payer: Aetna Commercial	$745.42
Rate for Payer: Aetna Medicare	$1,592.00
Rate for Payer: BCBS Complete	$406.37
Rate for Payer: BCBS Trust/PPO	$1,107.32
Rate for Payer: BCN Commercial	$871.31
Rate for Payer: Cash Price	$2,547.20
Rate for Payer: Cash Price	$2,547.20
Rate for Payer: Meridian Medicaid	$406.37
Rate for Payer: Priority Health Choice Medicaid	$387.02
Rate for Payer: Priority Health Cigna Priority Health	$2,069.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,025.97
Rate for Payer: Priority Health Narrow Network	$1,025.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$631.78
Rate for Payer: UHC Exchange	$631.78
Rate for Payer: UHCCP Medicaid	$387.02

PR REVJ/RMVL NEUROSTIMULATOR PULSE GENERATOR

Professional

Both

$1,048.00

Service Code	HCPCS 61888
Min. Negotiated Rate	$260.07
Max. Negotiated Rate	$1,422.71
Rate for Payer: Aetna Commercial	$512.47
Rate for Payer: Aetna Medicare	$524.00
Rate for Payer: BCBS Complete	$273.07
Rate for Payer: BCBS Trust/PPO	$1,422.71
Rate for Payer: BCN Commercial	$818.26
Rate for Payer: Cash Price	$838.40
Rate for Payer: Cash Price	$838.40
Rate for Payer: Meridian Medicaid	$273.07
Rate for Payer: Priority Health Choice Medicaid	$260.07
Rate for Payer: Priority Health Cigna Priority Health	$681.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$692.13
Rate for Payer: Priority Health Narrow Network	$692.13
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$449.29
Rate for Payer: UHC Exchange	$449.29
Rate for Payer: UHCCP Medicaid	$260.07

PR REVJ/RMVL PERPH NEUROSTIMULATOR ELECTRODE ARRAY

Professional

Both

$1,338.00

Service Code	HCPCS 64585
Min. Negotiated Rate	$92.66
Max. Negotiated Rate	$869.70
Rate for Payer: Aetna Commercial	$182.91
Rate for Payer: Aetna Medicare	$669.00
Rate for Payer: BCBS Complete	$97.29
Rate for Payer: BCBS Trust/PPO	$390.41
Rate for Payer: BCN Commercial	$354.29
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Meridian Medicaid	$97.29
Rate for Payer: Priority Health Choice Medicaid	$92.66
Rate for Payer: Priority Health Cigna Priority Health	$869.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$246.25
Rate for Payer: Priority Health Narrow Network	$246.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$180.84
Rate for Payer: UHC Exchange	$180.84
Rate for Payer: UHCCP Medicaid	$92.66

PR REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP

Professional

Both

$1,420.00

Service Code	HCPCS 57295
Min. Negotiated Rate	$322.48
Max. Negotiated Rate	$1,461.28
Rate for Payer: Aetna Commercial	$593.12
Rate for Payer: Aetna Medicare	$710.00
Rate for Payer: BCBS Complete	$338.60
Rate for Payer: BCBS Trust/PPO	$1,461.28
Rate for Payer: BCN Commercial	$1,021.64
Rate for Payer: Cash Price	$1,136.00
Rate for Payer: Cash Price	$1,136.00
Rate for Payer: Meridian Medicaid	$338.60
Rate for Payer: Priority Health Choice Medicaid	$322.48
Rate for Payer: Priority Health Cigna Priority Health	$923.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$752.01
Rate for Payer: Priority Health Narrow Network	$752.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$554.36
Rate for Payer: UHC Exchange	$554.36
Rate for Payer: UHCCP Medicaid	$322.48

PR REVJ/RPLCMT HPGLSL NERVE NSTIM RA PG&RESPIR SNR

Professional

Both

$1,754.00

Service Code	HCPCS 64583
Min. Negotiated Rate	$315.92
Max. Negotiated Rate	$1,475.25
Rate for Payer: Aetna Commercial	$1,017.89
Rate for Payer: Aetna Medicare	$877.00
Rate for Payer: BCBS Complete	$582.61
Rate for Payer: BCBS Trust/PPO	$315.92
Rate for Payer: BCN Commercial	$1,262.26
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Cash Price	$1,403.20
Rate for Payer: Meridian Medicaid	$582.61
Rate for Payer: Priority Health Choice Medicaid	$554.87
Rate for Payer: Priority Health Cigna Priority Health	$1,140.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,475.25
Rate for Payer: Priority Health Narrow Network	$1,475.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,023.88
Rate for Payer: UHC Exchange	$1,023.88
Rate for Payer: UHCCP Medicaid	$554.87

PR REVJ/RPLMNT CH WAL RESPIR ELTRD & CONJ PULSE GEN

Professional

Both

$816.00

Service Code	HCPCS 0467T
Min. Negotiated Rate	$326.40
Max. Negotiated Rate	$530.40
Rate for Payer: Aetna Medicare	$408.00
Rate for Payer: BCBS Complete	$326.40
Rate for Payer: Cash Price	$652.80
Rate for Payer: Priority Health Cigna Priority Health	$530.40

PR REVJ TOTAL KNEE ARTHRP W/WO ALGRFT 1 COMPONENT

Professional

Both

$4,568.00

Service Code	HCPCS 27486
Min. Negotiated Rate	$907.38
Max. Negotiated Rate	$2,969.20
Rate for Payer: Aetna Commercial	$1,879.07
Rate for Payer: Aetna Medicare	$2,284.00
Rate for Payer: BCBS Complete	$952.75
Rate for Payer: BCBS Trust/PPO	$1,429.05
Rate for Payer: BCN Commercial	$2,050.49
Rate for Payer: Cash Price	$3,654.40
Rate for Payer: Cash Price	$3,654.40
Rate for Payer: Meridian Medicaid	$952.75
Rate for Payer: Priority Health Choice Medicaid	$907.38
Rate for Payer: Priority Health Cigna Priority Health	$2,969.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,149.42
Rate for Payer: Priority Health Narrow Network	$2,149.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,640.41
Rate for Payer: UHC Exchange	$1,640.41
Rate for Payer: UHCCP Medicaid	$907.38

PR REVJ TOT HIP ARTHRP ACTBLR W/WO AGRFT/ALGRFT

Professional

Both

$3,038.00

Service Code	HCPCS 27137
Min. Negotiated Rate	$944.44
Max. Negotiated Rate	$2,238.48
Rate for Payer: Aetna Commercial	$1,964.36
Rate for Payer: Aetna Medicare	$1,519.00
Rate for Payer: BCBS Complete	$991.66
Rate for Payer: BCBS Trust/PPO	$1,779.31
Rate for Payer: BCN Commercial	$2,136.50
Rate for Payer: Cash Price	$2,430.40
Rate for Payer: Cash Price	$2,430.40
Rate for Payer: Meridian Medicaid	$991.66
Rate for Payer: Priority Health Choice Medicaid	$944.44
Rate for Payer: Priority Health Cigna Priority Health	$1,974.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,238.48
Rate for Payer: Priority Health Narrow Network	$2,238.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,730.28
Rate for Payer: UHC Exchange	$1,730.28
Rate for Payer: UHCCP Medicaid	$944.44

PR REVJ TOT HIP ARTHRP BTH W/WO AGRFT/ALGRFT

Professional

Both

$3,958.00

Service Code	HCPCS 27134
Min. Negotiated Rate	$409.96
Max. Negotiated Rate	$3,054.10
Rate for Payer: Aetna Commercial	$2,555.78
Rate for Payer: Aetna Medicare	$1,979.00
Rate for Payer: BCBS Complete	$1,285.10
Rate for Payer: BCBS Trust/PPO	$409.96
Rate for Payer: BCN Commercial	$3,054.10
Rate for Payer: Cash Price	$3,166.40
Rate for Payer: Cash Price	$3,166.40
Rate for Payer: Meridian Medicaid	$1,285.10
Rate for Payer: Priority Health Choice Medicaid	$1,223.90
Rate for Payer: Priority Health Cigna Priority Health	$2,572.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,902.54
Rate for Payer: Priority Health Narrow Network	$2,902.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,267.80
Rate for Payer: UHC Exchange	$2,267.80
Rate for Payer: UHCCP Medicaid	$1,223.90

PR REVJ TOT HIP ARTHRP FEM ONLY W/WO ALGRFT

Professional

Both

$3,157.00

Service Code	HCPCS 27138
Min. Negotiated Rate	$573.73
Max. Negotiated Rate	$2,324.47
Rate for Payer: Aetna Commercial	$2,041.22
Rate for Payer: Aetna Medicare	$1,578.50
Rate for Payer: BCBS Complete	$1,029.91
Rate for Payer: BCBS Trust/PPO	$573.73
Rate for Payer: BCN Commercial	$2,219.08
Rate for Payer: Cash Price	$2,525.60
Rate for Payer: Cash Price	$2,525.60
Rate for Payer: Meridian Medicaid	$1,029.91
Rate for Payer: Priority Health Choice Medicaid	$980.87
Rate for Payer: Priority Health Cigna Priority Health	$2,052.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,324.47
Rate for Payer: Priority Health Narrow Network	$2,324.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,801.30
Rate for Payer: UHC Exchange	$1,801.30
Rate for Payer: UHCCP Medicaid	$980.87

PR REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONE

Facility

$6,003.00

Service Code	CPT 27487
Hospital Charge Code	27487
Min. Negotiated Rate	$3,901.95
Max. Negotiated Rate	$6,003.00
Rate for Payer: Aetna Commercial	$5,402.70
Rate for Payer: ASR ASR	$5,822.91
Rate for Payer: ASR Commercial	$5,822.91
Rate for Payer: BCBS Trust/PPO	$4,891.84
Rate for Payer: BCN Commercial	$4,654.13
Rate for Payer: Cash Price	$4,802.40
Rate for Payer: Cofinity Commercial	$5,642.82
Rate for Payer: Encore Health Key Benefits Commercial	$4,802.40
Rate for Payer: Healthscope Commercial	$6,003.00
Rate for Payer: Healthscope Whirlpool	$5,822.91
Rate for Payer: Mclaren Commercial	$5,402.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,102.55
Rate for Payer: Nomi Health Commercial	$4,922.46
Rate for Payer: Priority Health Cigna Priority Health	$3,901.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,282.64

PR REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONE

Professional

Both

$6,003.00

Service Code	HCPCS 27487
Min. Negotiated Rate	$861.66
Max. Negotiated Rate	$3,901.95
Rate for Payer: Aetna Commercial	$2,348.25
Rate for Payer: Aetna Medicare	$3,001.50
Rate for Payer: BCBS Complete	$1,185.34
Rate for Payer: BCBS Trust/PPO	$861.66
Rate for Payer: BCN Commercial	$2,813.58
Rate for Payer: Cash Price	$4,802.40
Rate for Payer: Cash Price	$4,802.40
Rate for Payer: Meridian Medicaid	$1,185.34
Rate for Payer: Priority Health Choice Medicaid	$1,128.90
Rate for Payer: Priority Health Cigna Priority Health	$3,901.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,677.12
Rate for Payer: Priority Health Narrow Network	$2,677.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,065.90
Rate for Payer: UHC Exchange	$2,065.90
Rate for Payer: UHCCP Medicaid	$1,128.90

PR REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONE

Professional

Both

$6,003.00

Service Code	HCPCS 27487
Hospital Charge Code	27487
Min. Negotiated Rate	$861.66
Max. Negotiated Rate	$3,901.95
Rate for Payer: Aetna Commercial	$2,348.25
Rate for Payer: Aetna Medicare	$3,001.50
Rate for Payer: BCBS Complete	$1,185.34
Rate for Payer: BCBS Trust/PPO	$861.66
Rate for Payer: BCN Commercial	$2,813.58
Rate for Payer: Cash Price	$4,802.40
Rate for Payer: Cash Price	$4,802.40
Rate for Payer: Meridian Medicaid	$1,185.34
Rate for Payer: Priority Health Choice Medicaid	$1,128.90
Rate for Payer: Priority Health Cigna Priority Health	$3,901.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,677.12
Rate for Payer: Priority Health Narrow Network	$2,677.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,065.90
Rate for Payer: UHC Exchange	$2,065.90
Rate for Payer: UHCCP Medicaid	$1,128.90

PR REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONE

Facility

$6,003.00

Service Code	CPT 27487
Hospital Charge Code	27487
Min. Negotiated Rate	$2,401.20
Max. Negotiated Rate	$6,003.00
Rate for Payer: Aetna Commercial	$5,402.70
Rate for Payer: Aetna Medicare	$3,001.50
Rate for Payer: ASR ASR	$5,822.91
Rate for Payer: ASR Commercial	$5,822.91
Rate for Payer: BCBS Complete	$2,401.20
Rate for Payer: BCBS Trust/PPO	$4,915.86
Rate for Payer: BCN Commercial	$4,654.13
Rate for Payer: Cash Price	$4,802.40
Rate for Payer: Cofinity Commercial	$5,642.82
Rate for Payer: Encore Health Key Benefits Commercial	$4,802.40
Rate for Payer: Healthscope Commercial	$6,003.00
Rate for Payer: Healthscope Whirlpool	$5,822.91
Rate for Payer: Mclaren Commercial	$5,402.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5,102.55
Rate for Payer: Nomi Health Commercial	$4,922.46
Rate for Payer: Priority Health Cigna Priority Health	$3,901.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,259.83
Rate for Payer: Priority Health Narrow Network	$4,208.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,282.64

PR REVJ UR-CUTAN ANAST RPR FSCAL DFCT & HERNIA

Professional

Both

$1,435.00

Service Code	HCPCS 50728
Min. Negotiated Rate	$356.07
Max. Negotiated Rate	$1,116.34
Rate for Payer: Aetna Commercial	$942.32
Rate for Payer: Aetna Medicare	$717.50
Rate for Payer: BCBS Complete	$471.90
Rate for Payer: BCBS Trust/PPO	$356.07
Rate for Payer: BCN Commercial	$1,010.10
Rate for Payer: Cash Price	$1,148.00
Rate for Payer: Cash Price	$1,148.00
Rate for Payer: Meridian Medicaid	$471.90
Rate for Payer: Priority Health Choice Medicaid	$449.43
Rate for Payer: Priority Health Cigna Priority Health	$932.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,116.34
Rate for Payer: Priority Health Narrow Network	$1,116.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$828.52
Rate for Payer: UHC Exchange	$828.52
Rate for Payer: UHCCP Medicaid	$449.43

PR REVJ URINARY-CUTANEOUS ANASTAMOSIS

Professional

Both

$1,296.00

Service Code	HCPCS 50727
Min. Negotiated Rate	$328.66
Max. Negotiated Rate	$4,557.12
Rate for Payer: Aetna Commercial	$652.33
Rate for Payer: Aetna Medicare	$648.00
Rate for Payer: BCBS Complete	$345.09
Rate for Payer: BCBS Trust/PPO	$4,557.12
Rate for Payer: BCN Commercial	$739.37
Rate for Payer: Cash Price	$1,036.80
Rate for Payer: Cash Price	$1,036.80
Rate for Payer: Meridian Medicaid	$345.09
Rate for Payer: Priority Health Choice Medicaid	$328.66
Rate for Payer: Priority Health Cigna Priority Health	$842.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$820.21
Rate for Payer: Priority Health Narrow Network	$820.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$601.08
Rate for Payer: UHC Exchange	$601.08
Rate for Payer: UHCCP Medicaid	$328.66

PR REV/RMV PRPH SAC/GSTRC NPG/RCV DTCH CONN ELTR RA

Professional

Both

$696.00

Service Code	HCPCS 64595
Min. Negotiated Rate	$147.82
Max. Negotiated Rate	$2,181.88
Rate for Payer: Aetna Commercial	$161.68
Rate for Payer: Aetna Medicare	$348.00
Rate for Payer: BCBS Complete	$155.21
Rate for Payer: BCBS Trust/PPO	$2,181.88
Rate for Payer: BCN Commercial	$339.14
Rate for Payer: Cash Price	$556.80
Rate for Payer: Cash Price	$556.80
Rate for Payer: Meridian Medicaid	$155.21
Rate for Payer: Priority Health Choice Medicaid	$147.82
Rate for Payer: Priority Health Cigna Priority Health	$452.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$391.84
Rate for Payer: Priority Health Narrow Network	$391.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$158.36
Rate for Payer: UHC Exchange	$158.36
Rate for Payer: UHCCP Medicaid	$147.82

PR REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI

Professional

Both

$1,066.00

Service Code	HCPCS 37224
Min. Negotiated Rate	$276.05
Max. Negotiated Rate	$4,307.21
Rate for Payer: Aetna Commercial	$598.07
Rate for Payer: Aetna Medicare	$533.00
Rate for Payer: BCBS Complete	$289.85
Rate for Payer: BCBS Trust/PPO	$622.87
Rate for Payer: BCN Commercial	$4,307.21
Rate for Payer: Cash Price	$852.80
Rate for Payer: Cash Price	$852.80
Rate for Payer: Meridian Medicaid	$289.85
Rate for Payer: Priority Health Choice Medicaid	$276.05
Rate for Payer: Priority Health Cigna Priority Health	$692.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$688.18
Rate for Payer: Priority Health Narrow Network	$688.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$652.83
Rate for Payer: UHC Exchange	$652.83
Rate for Payer: UHCCP Medicaid	$276.05

PR REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL

Professional

Both

$2,317.00

Service Code	HCPCS 37225
Min. Negotiated Rate	$370.41
Max. Negotiated Rate	$12,917.21
Rate for Payer: Aetna Commercial	$809.21
Rate for Payer: Aetna Medicare	$1,158.50
Rate for Payer: BCBS Complete	$388.93
Rate for Payer: BCBS Trust/PPO	$1,131.41
Rate for Payer: BCN Commercial	$12,917.21
Rate for Payer: Cash Price	$1,853.60
Rate for Payer: Cash Price	$1,853.60
Rate for Payer: Meridian Medicaid	$388.93
Rate for Payer: Priority Health Choice Medicaid	$370.41
Rate for Payer: Priority Health Cigna Priority Health	$1,506.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$925.91
Rate for Payer: Priority Health Narrow Network	$925.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$879.74
Rate for Payer: UHC Exchange	$879.74
Rate for Payer: UHCCP Medicaid	$370.41

PR REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL

Professional

Both

$1,155.00

Service Code	HCPCS 37226
Min. Negotiated Rate	$322.27
Max. Negotiated Rate	$12,021.96
Rate for Payer: Aetna Commercial	$699.45
Rate for Payer: Aetna Medicare	$577.50
Rate for Payer: BCBS Complete	$338.38
Rate for Payer: BCBS Trust/PPO	$496.60
Rate for Payer: BCN Commercial	$12,021.96
Rate for Payer: Cash Price	$924.00
Rate for Payer: Cash Price	$924.00
Rate for Payer: Meridian Medicaid	$338.38
Rate for Payer: Priority Health Choice Medicaid	$322.27
Rate for Payer: Priority Health Cigna Priority Health	$750.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$802.53
Rate for Payer: Priority Health Narrow Network	$802.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$721.26
Rate for Payer: UHC Exchange	$721.26
Rate for Payer: UHCCP Medicaid	$322.27

PR REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL

Professional

Both

$1,967.00

Service Code	HCPCS 37227
Min. Negotiated Rate	$444.32
Max. Negotiated Rate	$16,544.66
Rate for Payer: Aetna Commercial	$970.23
Rate for Payer: Aetna Medicare	$983.50
Rate for Payer: BCBS Complete	$466.54
Rate for Payer: BCBS Trust/PPO	$690.49
Rate for Payer: BCN Commercial	$16,544.66
Rate for Payer: Cash Price	$1,573.60
Rate for Payer: Cash Price	$1,573.60
Rate for Payer: Meridian Medicaid	$466.54
Rate for Payer: Priority Health Choice Medicaid	$444.32
Rate for Payer: Priority Health Cigna Priority Health	$1,278.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,107.79
Rate for Payer: Priority Health Narrow Network	$1,107.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,062.66
Rate for Payer: UHC Exchange	$1,062.66
Rate for Payer: UHCCP Medicaid	$444.32

PR REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSILATL

Professional

Both

$499.00

Service Code	HCPCS 37223
Min. Negotiated Rate	$131.63
Max. Negotiated Rate	$1,876.52
Rate for Payer: Aetna Commercial	$286.46
Rate for Payer: Aetna Medicare	$249.50
Rate for Payer: BCBS Complete	$138.21
Rate for Payer: BCBS Trust/PPO	$374.83
Rate for Payer: BCN Commercial	$1,876.52
Rate for Payer: Cash Price	$399.20
Rate for Payer: Cash Price	$399.20
Rate for Payer: Meridian Medicaid	$138.21
Rate for Payer: Priority Health Choice Medicaid	$131.63
Rate for Payer: Priority Health Cigna Priority Health	$324.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$327.60
Rate for Payer: Priority Health Narrow Network	$327.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$305.66
Rate for Payer: UHC Exchange	$305.66
Rate for Payer: UHCCP Medicaid	$131.63

PR REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOPLSTY

Professional

Both

$2,022.00

Service Code	HCPCS 37221
Min. Negotiated Rate	$306.08
Max. Negotiated Rate	$4,542.26
Rate for Payer: Aetna Commercial	$664.33
Rate for Payer: Aetna Medicare	$1,011.00
Rate for Payer: BCBS Complete	$321.38
Rate for Payer: BCBS Trust/PPO	$652.45
Rate for Payer: BCN Commercial	$4,542.26
Rate for Payer: Cash Price	$1,617.60
Rate for Payer: Cash Price	$1,617.60
Rate for Payer: Meridian Medicaid	$321.38
Rate for Payer: Priority Health Choice Medicaid	$306.08
Rate for Payer: Priority Health Cigna Priority Health	$1,314.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$762.63
Rate for Payer: Priority Health Narrow Network	$762.63
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$720.64
Rate for Payer: UHC Exchange	$720.64
Rate for Payer: UHCCP Medicaid	$306.08

PR REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI

Professional

Both

$1,305.00

Service Code	HCPCS 37228
Min. Negotiated Rate	$336.11
Max. Negotiated Rate	$6,115.79
Rate for Payer: Aetna Commercial	$728.29
Rate for Payer: Aetna Medicare	$652.50
Rate for Payer: BCBS Complete	$352.92
Rate for Payer: BCBS Trust/PPO	$1,216.15
Rate for Payer: BCN Commercial	$6,115.79
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Meridian Medicaid	$352.92
Rate for Payer: Priority Health Choice Medicaid	$336.11
Rate for Payer: Priority Health Cigna Priority Health	$848.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$836.56
Rate for Payer: Priority Health Narrow Network	$836.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$798.06
Rate for Payer: UHC Exchange	$798.06
Rate for Payer: UHCCP Medicaid	$336.11

PR REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL

Professional

Both

$4,351.00

Service Code	HCPCS 37232
Min. Negotiated Rate	$123.54
Max. Negotiated Rate	$2,828.15
Rate for Payer: Aetna Commercial	$268.20
Rate for Payer: Aetna Medicare	$2,175.50
Rate for Payer: BCBS Complete	$129.72
Rate for Payer: BCBS Trust/PPO	$1,565.35
Rate for Payer: BCN Commercial	$1,206.05
Rate for Payer: Cash Price	$3,480.80
Rate for Payer: Cash Price	$3,480.80
Rate for Payer: Meridian Medicaid	$129.72
Rate for Payer: Priority Health Choice Medicaid	$123.54
Rate for Payer: Priority Health Cigna Priority Health	$2,828.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$307.92
Rate for Payer: Priority Health Narrow Network	$307.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$288.70
Rate for Payer: UHC Exchange	$288.70
Rate for Payer: UHCCP Medicaid	$123.54

Know your out-of-pocket cost for care.

All Charges