Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
HC DEST BEN/PREMAL LES 15+
Hanover, PA
See all hospitals reporting CPT 17004 →Price type
UPMC Hanover’s median price of $465 is 3% above the median hospital's median price ($452), higher than 52% of the 1,860 hospitals reporting CPT 17004. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 9 payers, 19 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | |||||||
|---|---|---|---|---|---|---|---|
| 1 | Amerihealth Caritas community healthchoices (chc)/medicaid facility · fee schedule · outpatient | $148 | $148 | — | — | — | $148 – $148 |
| 2 | UnitedHealthcare pa medicaid facility · fee schedule · outpatient | $152 | $152 | — | — | — | $152 – $152 |
| 3 | Blue Cross Blue Shield medicare advantage facility · percent of total billed charges · outpatientfrom % of charges | $169 | $169 | — | — | — | $169 – $169 |
| 4 | Highmark medicare facility · fee schedule · outpatient | $378 | $378 | — | — | — | $378 – $378 |
| 5 | Humana medicare facility · fee schedule · outpatient | $382 | $382 | — | — | — | $382 – $382 |
| 6 | Aetna medicare facility · fee schedule · outpatient | $398 | $398 | — | — | — | $398 – $398 |
| 7 | Cigna medicare facility · fee schedule · outpatient | $401 | $401 | — | — | — | $401 – $401 |
| 8 | UnitedHealthcare medicare facility · fee schedule · outpatient | $408 | $408 | — | — | — | $408 – $408 |
| 9 | Aetna aco facility · percent of total billed charges · outpatientfrom % of charges | $504 | $504 | — | — | — | $504 – $504 |
| 10 | Blue Cross Blue Shield chip facility · percent of total billed charges · outpatientfrom % of charges | $603 | $603 | — | — | — | $603 – $603 |
| 11 | Blue Cross Blue Shield commercial facility · percent of total billed charges · outpatientfrom % of charges | $603 | $603 | — | — | — | $603 – $603 |
| 12 | Aetna commercial facility · percent of total billed charges · outpatientfrom % of charges | $646 | $646 | — | — | — | $646 – $646 |
| 13 | Cigna commercial facility · percent of total billed charges · outpatientfrom % of charges | $693 | $693 | — | — | — | $693 – $693 |
| 14 | Highmark medicaid facility · fee schedule · outpatient | $707 | $707 | $559 | 79% | — | $148 – $1.3k |
| 15 | Carefirst commercial facility · percent of total billed charges · inpatientfrom % of charges | $755 | $755 | — | — | — | $755 – $755 |
| 16 | Carefirst commercial facility · percent of total billed charges · outpatientfrom % of charges | $755 | $755 | — | — | — | $755 – $755 |
| 17 | MultiPlan ppo (includes phcs and humana as payers) facility · percent of total billed charges · inpatientfrom % of charges | $755 | $755 | — | — | — | $755 – $755 |
| 18 | MultiPlan ppo (includes phcs and humana as payers) facility · percent of total billed charges · outpatientfrom % of charges | $755 | $755 | — | — | — | $755 – $755 |
| 19 | Highmark commercial facility · fee schedule · outpatient | $1.4k | $1.4k | — | — | — | $1.4k – $1.4k |
Last updated: Mar 6, 2026
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