Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR AMPUTATION THIGH THRU FEMUR OPEN CIRCULAR

Professional

Both

$3,036.00

Service Code	HCPCS 27592
Min. Negotiated Rate	$427.49
Max. Negotiated Rate	$2,125.20
Rate for Payer: Aetna Commercial	$889.67
Rate for Payer: Aetna Medicare	$663.93
Rate for Payer: BCBS Complete	$448.86
Rate for Payer: BCBS MAPPO	$663.93
Rate for Payer: BCBS Trust/PPO	$1,803.62
Rate for Payer: BCN Commercial	$975.89
Rate for Payer: BCN Medicare Advantage	$663.93
Rate for Payer: Cash Price	$2,428.80
Rate for Payer: Cash Price	$2,428.80
Rate for Payer: Cofinity Commercial	$889.67
Rate for Payer: Cofinity Commercial	$956.06
Rate for Payer: Health Alliance Plan Medicare Advantage	$663.93
Rate for Payer: Healthscope Commercial	$796.72
Rate for Payer: Healthscope Whirlpool	$796.72
Rate for Payer: Meridian Medicaid	$448.86
Rate for Payer: Meridian Wellcare - Medicare Advantage	$697.13
Rate for Payer: PACE SWMI	$663.93
Rate for Payer: PHP Medicare Advantage	$663.93
Rate for Payer: Priority Health Choice Medicaid	$427.49
Rate for Payer: Priority Health Cigna Priority Health	$2,125.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,019.77
Rate for Payer: Priority Health Medicare	$663.93
Rate for Payer: Priority Health Narrow Network	$1,019.77
Rate for Payer: UHC Medicare Advantage	$683.85

PR AMPUTATION TOE INTERPHALANGEAL JOINT

Professional

Both

$1,320.00

Service Code	HCPCS 28825
Min. Negotiated Rate	$110.12
Max. Negotiated Rate	$995.32
Rate for Payer: Aetna Commercial	$228.01
Rate for Payer: Aetna Medicare	$170.16
Rate for Payer: BCBS Complete	$115.63
Rate for Payer: BCBS MAPPO	$170.16
Rate for Payer: BCBS Trust/PPO	$995.32
Rate for Payer: BCN Commercial	$425.15
Rate for Payer: BCN Medicare Advantage	$170.16
Rate for Payer: Cash Price	$1,056.00
Rate for Payer: Cash Price	$1,056.00
Rate for Payer: Cofinity Commercial	$245.03
Rate for Payer: Cofinity Commercial	$228.01
Rate for Payer: Health Alliance Plan Medicare Advantage	$170.16
Rate for Payer: Healthscope Commercial	$204.19
Rate for Payer: Healthscope Whirlpool	$204.19
Rate for Payer: Meridian Medicaid	$115.63
Rate for Payer: Meridian Wellcare - Medicare Advantage	$178.67
Rate for Payer: PACE SWMI	$170.16
Rate for Payer: PHP Medicare Advantage	$170.16
Rate for Payer: Priority Health Choice Medicaid	$110.12
Rate for Payer: Priority Health Cigna Priority Health	$924.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$260.94
Rate for Payer: Priority Health Medicare	$170.16
Rate for Payer: Priority Health Narrow Network	$260.94
Rate for Payer: UHC Medicare Advantage	$175.26

PR AMPUTATION TOE METATARSOPHALANGEAL JOINT

Facility

$1,526.00

Service Code	CPT 28820
Hospital Charge Code	28820
Hospital Revenue Code	960
Min. Negotiated Rate	$1,068.20
Max. Negotiated Rate	$1,526.00
Rate for Payer: Aetna Commercial	$1,373.40
Rate for Payer: ASR ASR	$1,480.22
Rate for Payer: BCBS Trust/PPO	$1,183.11
Rate for Payer: BCN Commercial	$1,183.11
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cofinity Commercial	$1,434.44
Rate for Payer: Encore Health Key Benefits Commercial	$1,220.80
Rate for Payer: Healthscope Commercial	$1,526.00
Rate for Payer: Healthscope Whirlpool	$1,480.22
Rate for Payer: Mclaren Commercial	$1,373.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,297.10
Rate for Payer: Priority Health Cigna Priority Health	$1,068.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,342.88

PR AMPUTATION TOE METATARSOPHALANGEAL JOINT

Professional

Both

$1,526.00

Service Code	HCPCS 28820
Min. Negotiated Rate	$112.89
Max. Negotiated Rate	$1,068.20
Rate for Payer: Aetna Commercial	$235.75
Rate for Payer: Aetna Medicare	$175.93
Rate for Payer: BCBS Complete	$118.53
Rate for Payer: BCBS MAPPO	$175.93
Rate for Payer: BCBS Trust/PPO	$852.68
Rate for Payer: BCN Commercial	$434.44
Rate for Payer: BCN Medicare Advantage	$175.93
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cofinity Commercial	$253.34
Rate for Payer: Cofinity Commercial	$235.75
Rate for Payer: Health Alliance Plan Medicare Advantage	$175.93
Rate for Payer: Healthscope Commercial	$211.12
Rate for Payer: Healthscope Whirlpool	$211.12
Rate for Payer: Meridian Medicaid	$118.53
Rate for Payer: Meridian Wellcare - Medicare Advantage	$184.73
Rate for Payer: PACE SWMI	$175.93
Rate for Payer: PHP Medicare Advantage	$175.93
Rate for Payer: Priority Health Choice Medicaid	$112.89
Rate for Payer: Priority Health Cigna Priority Health	$1,068.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$269.62
Rate for Payer: Priority Health Medicare	$175.93
Rate for Payer: Priority Health Narrow Network	$269.62
Rate for Payer: UHC Medicare Advantage	$181.21

PR AMPUTATION TOE METATARSOPHALANGEAL JOINT

Facility

$1,526.00

Service Code	CPT 28820
Hospital Charge Code	28820
Hospital Revenue Code	960
Min. Negotiated Rate	$1,068.20
Max. Negotiated Rate	$3,596.44
Rate for Payer: Aetna Commercial	$1,373.40
Rate for Payer: Aetna Medicare	$2,877.15
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,596.44
Rate for Payer: Amish Plain Church Group Commercial	$3,596.44
Rate for Payer: ASR ASR	$1,480.22
Rate for Payer: BCBS Complete	$1,652.63
Rate for Payer: BCBS MAPPO	$2,877.15
Rate for Payer: BCBS Trust/PPO	$1,183.11
Rate for Payer: BCN Commercial	$1,183.11
Rate for Payer: BCN Medicare Advantage	$2,877.15
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cofinity Commercial	$1,434.44
Rate for Payer: Encore Health Key Benefits Commercial	$1,220.80
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,877.15
Rate for Payer: Healthscope Commercial	$1,526.00
Rate for Payer: Healthscope Whirlpool	$1,480.22
Rate for Payer: Humana Choice PPO Medicare	$2,877.15
Rate for Payer: Mclaren Commercial	$1,373.40
Rate for Payer: Mclaren Medicaid	$1,573.80
Rate for Payer: Mclaren Medicare	$2,877.15
Rate for Payer: Meridian Medicaid	$1,652.63
Rate for Payer: Meridian Wellcare - Medicare Advantage	$3,021.01
Rate for Payer: MI Amish Medical Board Commercial	$3,308.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,297.10
Rate for Payer: PACE Medicare	$2,733.29
Rate for Payer: PACE SWMI	$2,877.15
Rate for Payer: PHP Commercial	$3,164.86
Rate for Payer: PHP Medicaid	$1,573.80
Rate for Payer: PHP Medicare Advantage	$2,877.15
Rate for Payer: Priority Health Choice Medicaid	$1,573.80
Rate for Payer: Priority Health Cigna Priority Health	$1,068.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,388.66
Rate for Payer: Priority Health Medicare	$2,877.15
Rate for Payer: Priority Health Narrow Network	$1,083.46
Rate for Payer: Railroad Medicare Medicare	$2,877.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,342.88
Rate for Payer: UHC Medicare Advantage	$2,963.46
Rate for Payer: VA VA	$2,877.15

PR AMPUTATION TOE METATARSOPHALANGEAL JOINT

Professional

Both

$1,526.00

Service Code	HCPCS 28820
Hospital Charge Code	28820
Min. Negotiated Rate	$112.89
Max. Negotiated Rate	$1,068.20
Rate for Payer: Aetna Commercial	$235.75
Rate for Payer: Aetna Medicare	$175.93
Rate for Payer: BCBS Complete	$118.53
Rate for Payer: BCBS MAPPO	$175.93
Rate for Payer: BCBS Trust/PPO	$852.68
Rate for Payer: BCN Commercial	$434.44
Rate for Payer: BCN Medicare Advantage	$175.93
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cash Price	$1,220.80
Rate for Payer: Cofinity Commercial	$253.34
Rate for Payer: Cofinity Commercial	$235.75
Rate for Payer: Health Alliance Plan Medicare Advantage	$175.93
Rate for Payer: Healthscope Commercial	$211.12
Rate for Payer: Healthscope Whirlpool	$211.12
Rate for Payer: Meridian Medicaid	$118.53
Rate for Payer: Meridian Wellcare - Medicare Advantage	$184.73
Rate for Payer: PACE SWMI	$175.93
Rate for Payer: PHP Medicare Advantage	$175.93
Rate for Payer: Priority Health Choice Medicaid	$112.89
Rate for Payer: Priority Health Cigna Priority Health	$1,068.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$269.62
Rate for Payer: Priority Health Medicare	$175.93
Rate for Payer: Priority Health Narrow Network	$269.62
Rate for Payer: UHC Medicare Advantage	$181.21

PR ANALYZE NEUROSTIM BRAIN, FIRST 1H

Professional

Both

$497.00

Service Code	HCPCS 95978
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$347.90
Rate for Payer: BCBS Complete	$198.80
Rate for Payer: Cash Price	$397.60
Rate for Payer: Priority Health Cigna Priority Health	$347.90

PR ANALYZ NEUROSTIM BRAIN, EACH ADD 30 MIN

Professional

Both

$214.00

Service Code	HCPCS 95979
Min. Negotiated Rate	$85.60
Max. Negotiated Rate	$149.80
Rate for Payer: BCBS Complete	$85.60
Rate for Payer: Cash Price	$171.20
Rate for Payer: Priority Health Cigna Priority Health	$149.80

PR ANAST ARTL EXTRACRANIAL-INTRACRANIAL ARTERIES

Professional

Both

$7,712.00

Service Code	HCPCS 61711
Min. Negotiated Rate	$134.19
Max. Negotiated Rate	$5,398.40
Rate for Payer: Aetna Commercial	$3,465.47
Rate for Payer: Aetna Medicare	$2,586.17
Rate for Payer: BCBS Complete	$1,771.31
Rate for Payer: BCBS MAPPO	$2,586.17
Rate for Payer: BCBS Trust/PPO	$134.19
Rate for Payer: BCN Commercial	$5,246.52
Rate for Payer: BCN Medicare Advantage	$2,586.17
Rate for Payer: Cash Price	$6,169.60
Rate for Payer: Cash Price	$6,169.60
Rate for Payer: Cofinity Commercial	$3,724.08
Rate for Payer: Cofinity Commercial	$3,465.47
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,586.17
Rate for Payer: Healthscope Commercial	$3,103.40
Rate for Payer: Healthscope Whirlpool	$3,103.40
Rate for Payer: Meridian Medicaid	$1,771.31
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,715.48
Rate for Payer: PACE SWMI	$2,586.17
Rate for Payer: PHP Medicare Advantage	$2,586.17
Rate for Payer: Priority Health Choice Medicaid	$1,686.96
Rate for Payer: Priority Health Cigna Priority Health	$5,398.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,382.00
Rate for Payer: Priority Health Medicare	$2,586.17
Rate for Payer: Priority Health Narrow Network	$4,382.00
Rate for Payer: UHC Medicare Advantage	$2,663.76

PR ANASTOMOSIS FACIAL HYPOGLOSSAL

Professional

Both

$1,822.00

Service Code	HCPCS 64868
Min. Negotiated Rate	$190.19
Max. Negotiated Rate	$1,691.31
Rate for Payer: Aetna Commercial	$1,311.59
Rate for Payer: Aetna Medicare	$978.80
Rate for Payer: BCBS Complete	$668.71
Rate for Payer: BCBS MAPPO	$978.80
Rate for Payer: BCBS Trust/PPO	$190.19
Rate for Payer: BCN Commercial	$1,459.68
Rate for Payer: BCN Medicare Advantage	$978.80
Rate for Payer: Cash Price	$1,457.60
Rate for Payer: Cash Price	$1,457.60
Rate for Payer: Cofinity Commercial	$1,409.47
Rate for Payer: Cofinity Commercial	$1,311.59
Rate for Payer: Health Alliance Plan Medicare Advantage	$978.80
Rate for Payer: Healthscope Commercial	$1,174.56
Rate for Payer: Healthscope Whirlpool	$1,174.56
Rate for Payer: Meridian Medicaid	$668.71
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,027.74
Rate for Payer: PACE SWMI	$978.80
Rate for Payer: PHP Medicare Advantage	$978.80
Rate for Payer: Priority Health Choice Medicaid	$636.87
Rate for Payer: Priority Health Cigna Priority Health	$1,275.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,691.31
Rate for Payer: Priority Health Medicare	$978.80
Rate for Payer: Priority Health Narrow Network	$1,691.31
Rate for Payer: UHC Medicare Advantage	$1,008.16

PR ANAST ROUX-EN-Y XTRHEPATC BILIARY DUCTS & GI

Professional

Both

$4,618.00

Service Code	HCPCS 47780
Min. Negotiated Rate	$1,284.83
Max. Negotiated Rate	$4,331.60
Rate for Payer: Aetna Commercial	$3,296.57
Rate for Payer: Aetna Medicare	$2,460.13
Rate for Payer: BCBS Complete	$1,656.57
Rate for Payer: BCBS MAPPO	$2,460.13
Rate for Payer: BCBS Trust/PPO	$1,284.83
Rate for Payer: BCN Commercial	$3,600.09
Rate for Payer: BCN Medicare Advantage	$2,460.13
Rate for Payer: Cash Price	$3,694.40
Rate for Payer: Cash Price	$3,694.40
Rate for Payer: Cofinity Commercial	$3,542.59
Rate for Payer: Cofinity Commercial	$3,296.57
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,460.13
Rate for Payer: Healthscope Commercial	$2,952.16
Rate for Payer: Healthscope Whirlpool	$2,952.16
Rate for Payer: Meridian Medicaid	$1,656.57
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,583.14
Rate for Payer: PACE SWMI	$2,460.13
Rate for Payer: PHP Medicare Advantage	$2,460.13
Rate for Payer: Priority Health Choice Medicaid	$1,577.69
Rate for Payer: Priority Health Cigna Priority Health	$3,232.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,331.60
Rate for Payer: Priority Health Medicare	$2,460.13
Rate for Payer: Priority Health Narrow Network	$4,331.60
Rate for Payer: UHC Medicare Advantage	$2,533.93

PR ANAST XTRHEPATC BILIARY DUCTS & GI TRACT

Professional

Both

$4,184.00

Service Code	HCPCS 47760
Min. Negotiated Rate	$328.07
Max. Negotiated Rate	$3,944.71
Rate for Payer: Aetna Commercial	$2,999.51
Rate for Payer: Aetna Medicare	$2,238.44
Rate for Payer: BCBS Complete	$1,507.62
Rate for Payer: BCBS MAPPO	$2,238.44
Rate for Payer: BCBS Trust/PPO	$328.07
Rate for Payer: BCN Commercial	$3,278.53
Rate for Payer: BCN Medicare Advantage	$2,238.44
Rate for Payer: Cash Price	$3,347.20
Rate for Payer: Cash Price	$3,347.20
Rate for Payer: Cofinity Commercial	$3,223.35
Rate for Payer: Cofinity Commercial	$2,999.51
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,238.44
Rate for Payer: Healthscope Commercial	$2,686.13
Rate for Payer: Healthscope Whirlpool	$2,686.13
Rate for Payer: Meridian Medicaid	$1,507.62
Rate for Payer: Meridian Wellcare - Medicare Advantage	$2,350.36
Rate for Payer: PACE SWMI	$2,238.44
Rate for Payer: PHP Medicare Advantage	$2,238.44
Rate for Payer: Priority Health Choice Medicaid	$1,435.83
Rate for Payer: Priority Health Cigna Priority Health	$2,928.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,944.71
Rate for Payer: Priority Health Medicare	$2,238.44
Rate for Payer: Priority Health Narrow Network	$3,944.71
Rate for Payer: UHC Medicare Advantage	$2,305.59

PR ANES 2/3 DGR BRN EXC/DBRDMT W/WO GRF EA 9% TBS

Professional

Both

$1.00

Service Code	HCPCS 01953
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$44.50
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cash Price	$0.80
Rate for Payer: Priority Health Cigna Priority Health	$0.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44.50
Rate for Payer: Priority Health Narrow Network	$44.50

PR ANES 2/3 DGR BRN EXC/DBRDMT W/WO GRFT 4-9 % TBSA

Professional

Both

$5.00

Service Code	HCPCS 01952
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.50

PR ANES 2/3 DGR BRN EXC/DBRDMT W/WO GRFT 4 % TBSA

Professional

Both

$3.00

Service Code	HCPCS 01951
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.10
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$2.10

PR ANES ARTERIES FOREARM WRIST & HAND EMBOLECTOMY

Professional

Both

$6.00

Service Code	HCPCS 01842
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.20
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$4.20

PR ANES ARTERIES OF KNEE & POPLITEAL AREA NOS

Professional

Both

$8.00

Service Code	HCPCS 01440
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.60
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.60

PR ANES ARTERIES SHOULDER & AXILLA BYPASS GRAFT

Professional

Both

$8.00

Service Code	HCPCS 01654
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.60
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.60

PR ANES ARTHROSCOPIC TOTAL SHOULDER REPLACEMENT

Professional

Both

$10.00

Service Code	HCPCS 01638
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$7.00

PR ANES ARTHRS/ENDSCPY DSTL RADIUS ULNA/WRIST/HAND

Professional

Both

$3.00

Service Code	HCPCS 01830
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.10
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$2.10

PR ANES ARTHRS HUMERAL H/N STRNCLAV & SHOULDER NOS

Professional

Both

$5.00

Service Code	HCPCS 01630
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.50

PR ANES ARTHRS INTERTHORACOSCAPULAR AMPUTATION

Professional

Both

$15.00

Service Code	HCPCS 01636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$10.50
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$10.50

PR ANES ART KNEE POPLITEAL EXC&GRF/RPR OCCLS/ARYS

Professional

Both

$8.00

Service Code	HCPCS 01444
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.60
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.60

PR ANES ART KNEE POPLITEAL TEAEC W/WO PATCH GRAFT

Professional

Both

$8.00

Service Code	HCPCS 01442
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.60
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.60

PR ANES ART LOWER LEG W/BYP GRAFT EMBLC DIR/W/CATH

Professional

Both

$6.00

Service Code	HCPCS 01502
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.20
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$4.20

Know your out-of-pocket cost for care.

All Charges