Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANES UPPER LEG W/BYPASS GRFT FEM ART EMBOLECTOMY

Professional

Both

$6.00

Service Code	HCPCS 01274
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 UPR ANT ABDL WALL PERCUTANEOUS LIVER BX

Professional

Both

$4.00

Service Code	HCPCS 00702
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.80
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.80

PR ANES URGENT HYSTERECTOMY FOLLOWING DELIVERY

Professional

Both

$8.00

Service Code	HCPCS 01962
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 VASECTOMY UNI/BI INCL OPEN URETHRAL PX

Professional

Both

$3.00

Service Code	HCPCS 00921
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 VEINS FOREARM WRIST & HAND PHLEBORRHAPHY

Professional

Both

$4.00

Service Code	HCPCS 01852
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.80
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.80

PR ANES VEINS LOWER LEG VENOUS THRMBC DIR/W/CATH

Professional

Both

$5.00

Service Code	HCPCS 01522
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 VEINS OF UPPER LEG INCLUDING EXPLORATION

Professional

Both

$3.00

Service Code	HCPCS 01260
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 VENOUS/LYMPHATIC NOS THER IVNTL RAD NOS

Professional

Both

$5.00

Service Code	HCPCS 01930
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 XTRNL MID & INNER EAR W/BX TYMPANOTOMY

Professional

Both

$4.00

Service Code	HCPCS 00126
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.80
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.80

PR ANES XTRPRTL LOWER ABD UR TRACT RENAL DON NFRCT

Professional

Both

$7.00

Service Code	HCPCS 00862
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.90
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.90

PR ANES XTRPRTL LOWER ABD W/URIN TRACT ADRENLECTOMY

Professional

Both

$10.00

Service Code	HCPCS 00866
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 XTRPRTL LWER ABD W/URINARY TRACT TOT CYSTEC

Professional

Both

$8.00

Service Code	HCPCS 00864
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 XTRPRTL LWR ABD W/URINARY TRACT RAD PRSTECT

Professional

Both

$7.00

Service Code	HCPCS 00865
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.90
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.90

PR ANES XTRPRTL LWR ABD W/URIN TRACT CSTOLITHOTOMY

Professional

Both

$5.00

Service Code	HCPCS 00870
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 XTRPRTL LWR ABD W/URIN TRACT RENAL TRANSPL

Professional

Both

$10.00

Service Code	HCPCS 00868
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 ANKLE CONTROL ORTHO PRE OTS

Professional

Both

$93.00

Service Code	HCPCS L4350
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$91.87
Rate for Payer: Aetna Commercial	$58.28
Rate for Payer: BCBS Complete	$37.20
Rate for Payer: BCN Commercial	$91.87
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cash Price	$74.40
Rate for Payer: Priority Health Cigna Priority Health	$65.10

PR ANKLE DISARTICULATION

Professional

Both

$1,310.00

Service Code	HCPCS 27889
Min. Negotiated Rate	$408.53
Max. Negotiated Rate	$1,940.55
Rate for Payer: Aetna Commercial	$843.65
Rate for Payer: Aetna Medicare	$629.59
Rate for Payer: BCBS Complete	$428.96
Rate for Payer: BCBS MAPPO	$629.59
Rate for Payer: BCBS Trust/PPO	$1,940.55
Rate for Payer: BCN Commercial	$924.57
Rate for Payer: BCN Medicare Advantage	$629.59
Rate for Payer: Cash Price	$1,048.00
Rate for Payer: Cash Price	$1,048.00
Rate for Payer: Cofinity Commercial	$843.65
Rate for Payer: Cofinity Commercial	$906.61
Rate for Payer: Health Alliance Plan Medicare Advantage	$629.59
Rate for Payer: Healthscope Commercial	$755.51
Rate for Payer: Healthscope Whirlpool	$755.51
Rate for Payer: Meridian Medicaid	$428.96
Rate for Payer: Meridian Wellcare - Medicare Advantage	$661.07
Rate for Payer: PACE SWMI	$629.59
Rate for Payer: PHP Medicare Advantage	$629.59
Rate for Payer: Priority Health Choice Medicaid	$408.53
Rate for Payer: Priority Health Cigna Priority Health	$917.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$966.16
Rate for Payer: Priority Health Medicare	$629.59
Rate for Payer: Priority Health Narrow Network	$966.16
Rate for Payer: UHC Medicare Advantage	$648.48

PR ANN BREAST EXAM

Professional

Both

$20.00

Service Code	HCPCS S0613
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$79.25
Rate for Payer: Aetna Commercial	$25.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS Trust/PPO	$79.25
Rate for Payer: BCN Commercial	$18.94
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00

PR ANNUAL GYNECOLOGICAL EXAMINA

Professional

Both

$79.00

Service Code	HCPCS S0612
Min. Negotiated Rate	$31.60
Max. Negotiated Rate	$176.98
Rate for Payer: Aetna Commercial	$55.00
Rate for Payer: BCBS Complete	$31.60
Rate for Payer: BCBS Trust/PPO	$176.98
Rate for Payer: BCN Commercial	$65.39
Rate for Payer: Cash Price	$63.20
Rate for Payer: Cash Price	$63.20
Rate for Payer: Priority Health Cigna Priority Health	$55.30

PR ANOGENITAL XM MAGNIFY CHILD/SUSPECT TRAUMA W IMG

Professional

Both

$263.00

Service Code	HCPCS 99170
Min. Negotiated Rate	$53.46
Max. Negotiated Rate	$820.45
Rate for Payer: Aetna Commercial	$111.81
Rate for Payer: Aetna Medicare	$83.44
Rate for Payer: BCBS Complete	$56.13
Rate for Payer: BCBS MAPPO	$83.44
Rate for Payer: BCBS Trust/PPO	$820.45
Rate for Payer: BCN Commercial	$236.52
Rate for Payer: BCN Medicare Advantage	$83.44
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cofinity Commercial	$111.81
Rate for Payer: Cofinity Commercial	$120.15
Rate for Payer: Health Alliance Plan Medicare Advantage	$83.44
Rate for Payer: Healthscope Commercial	$100.13
Rate for Payer: Healthscope Whirlpool	$100.13
Rate for Payer: Meridian Medicaid	$56.13
Rate for Payer: Meridian Wellcare - Medicare Advantage	$87.61
Rate for Payer: PACE SWMI	$83.44
Rate for Payer: PHP Medicare Advantage	$83.44
Rate for Payer: Priority Health Choice Medicaid	$53.46
Rate for Payer: Priority Health Cigna Priority Health	$184.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$112.74
Rate for Payer: Priority Health Medicare	$83.44
Rate for Payer: Priority Health Narrow Network	$112.74
Rate for Payer: UHC Medicare Advantage	$85.94

PR ANOPLASTY PLASTIC OPERATION STRICTURE ADULT

Professional

Both

$1,323.00

Service Code	HCPCS 46700
Min. Negotiated Rate	$272.07
Max. Negotiated Rate	$1,153.61
Rate for Payer: Aetna Commercial	$862.96
Rate for Payer: Aetna Medicare	$644.00
Rate for Payer: BCBS Complete	$439.70
Rate for Payer: BCBS MAPPO	$644.00
Rate for Payer: BCBS Trust/PPO	$272.07
Rate for Payer: BCN Commercial	$958.78
Rate for Payer: BCN Medicare Advantage	$644.00
Rate for Payer: Cash Price	$1,058.40
Rate for Payer: Cash Price	$1,058.40
Rate for Payer: Cofinity Commercial	$862.96
Rate for Payer: Cofinity Commercial	$927.36
Rate for Payer: Health Alliance Plan Medicare Advantage	$644.00
Rate for Payer: Healthscope Commercial	$772.80
Rate for Payer: Healthscope Whirlpool	$772.80
Rate for Payer: Meridian Medicaid	$439.70
Rate for Payer: Meridian Wellcare - Medicare Advantage	$676.20
Rate for Payer: PACE SWMI	$644.00
Rate for Payer: PHP Medicare Advantage	$644.00
Rate for Payer: Priority Health Choice Medicaid	$418.76
Rate for Payer: Priority Health Cigna Priority Health	$926.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,153.61
Rate for Payer: Priority Health Medicare	$644.00
Rate for Payer: Priority Health Narrow Network	$1,153.61
Rate for Payer: UHC Medicare Advantage	$663.32

PR ANOPLASTY PLASTIC OPERATION STRICTURE INFANT

Professional

Both

$1,397.00

Service Code	HCPCS 46705
Min. Negotiated Rate	$137.36
Max. Negotiated Rate	$1,012.49
Rate for Payer: Aetna Commercial	$756.46
Rate for Payer: Aetna Medicare	$564.52
Rate for Payer: BCBS Complete	$386.69
Rate for Payer: BCBS MAPPO	$564.52
Rate for Payer: BCBS Trust/PPO	$137.36
Rate for Payer: BCN Commercial	$841.50
Rate for Payer: BCN Medicare Advantage	$564.52
Rate for Payer: Cash Price	$1,117.60
Rate for Payer: Cash Price	$1,117.60
Rate for Payer: Cofinity Commercial	$812.91
Rate for Payer: Cofinity Commercial	$756.46
Rate for Payer: Health Alliance Plan Medicare Advantage	$564.52
Rate for Payer: Healthscope Commercial	$677.42
Rate for Payer: Healthscope Whirlpool	$677.42
Rate for Payer: Meridian Medicaid	$386.69
Rate for Payer: Meridian Wellcare - Medicare Advantage	$592.75
Rate for Payer: PACE SWMI	$564.52
Rate for Payer: PHP Medicare Advantage	$564.52
Rate for Payer: Priority Health Choice Medicaid	$368.28
Rate for Payer: Priority Health Cigna Priority Health	$977.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,012.49
Rate for Payer: Priority Health Medicare	$564.52
Rate for Payer: Priority Health Narrow Network	$1,012.49
Rate for Payer: UHC Medicare Advantage	$581.46

PR ANORECTAL MANOMETRY

Professional

Both

$385.00

Service Code	HCPCS 91122
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$1,146.94
Rate for Payer: Aetna Commercial	$348.09
Rate for Payer: Aetna Medicare	$259.77
Rate for Payer: BCBS Complete	$154.00
Rate for Payer: BCBS MAPPO	$259.77
Rate for Payer: BCBS Trust/PPO	$1,146.94
Rate for Payer: BCN Commercial	$401.69
Rate for Payer: BCN Medicare Advantage	$259.77
Rate for Payer: Cash Price	$308.00
Rate for Payer: Cash Price	$308.00
Rate for Payer: Cofinity Commercial	$374.07
Rate for Payer: Cofinity Commercial	$348.09
Rate for Payer: Health Alliance Plan Medicare Advantage	$259.77
Rate for Payer: Healthscope Commercial	$311.72
Rate for Payer: Healthscope Whirlpool	$311.72
Rate for Payer: Meridian Wellcare - Medicare Advantage	$272.76
Rate for Payer: PACE SWMI	$259.77
Rate for Payer: PHP Medicare Advantage	$259.77
Rate for Payer: Priority Health Cigna Priority Health	$269.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$369.19
Rate for Payer: Priority Health Medicare	$259.77
Rate for Payer: Priority Health Narrow Network	$369.19
Rate for Payer: UHC Medicare Advantage	$267.56

PR ANORECTAL MYOMECTOMY

Professional

Both

$1,632.00

Service Code	HCPCS 45108
Min. Negotiated Rate	$241.97
Max. Negotiated Rate	$1,142.40
Rate for Payer: Aetna Commercial	$495.25
Rate for Payer: Aetna Medicare	$369.59
Rate for Payer: BCBS Complete	$254.07
Rate for Payer: BCBS MAPPO	$369.59
Rate for Payer: BCBS Trust/PPO	$359.24
Rate for Payer: BCN Commercial	$549.27
Rate for Payer: BCN Medicare Advantage	$369.59
Rate for Payer: Cash Price	$1,305.60
Rate for Payer: Cash Price	$1,305.60
Rate for Payer: Cofinity Commercial	$532.21
Rate for Payer: Cofinity Commercial	$495.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$369.59
Rate for Payer: Healthscope Commercial	$443.51
Rate for Payer: Healthscope Whirlpool	$443.51
Rate for Payer: Meridian Medicaid	$254.07
Rate for Payer: Meridian Wellcare - Medicare Advantage	$388.07
Rate for Payer: PACE SWMI	$369.59
Rate for Payer: PHP Medicare Advantage	$369.59
Rate for Payer: Priority Health Choice Medicaid	$241.97
Rate for Payer: Priority Health Cigna Priority Health	$1,142.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$660.88
Rate for Payer: Priority Health Medicare	$369.59
Rate for Payer: Priority Health Narrow Network	$660.88
Rate for Payer: UHC Medicare Advantage	$380.68

PR ANOSCOPY ABLATION LESION

Professional

Both

$657.00

Service Code	HCPCS 46615
Min. Negotiated Rate	$57.72
Max. Negotiated Rate	$459.90
Rate for Payer: Aetna Commercial	$117.93
Rate for Payer: Aetna Medicare	$88.01
Rate for Payer: BCBS Complete	$60.61
Rate for Payer: BCBS MAPPO	$88.01
Rate for Payer: BCBS Trust/PPO	$245.13
Rate for Payer: BCN Commercial	$261.44
Rate for Payer: BCN Medicare Advantage	$88.01
Rate for Payer: Cash Price	$525.60
Rate for Payer: Cash Price	$525.60
Rate for Payer: Cofinity Commercial	$117.93
Rate for Payer: Cofinity Commercial	$126.73
Rate for Payer: Health Alliance Plan Medicare Advantage	$88.01
Rate for Payer: Healthscope Commercial	$105.61
Rate for Payer: Healthscope Whirlpool	$105.61
Rate for Payer: Meridian Medicaid	$60.61
Rate for Payer: Meridian Wellcare - Medicare Advantage	$92.41
Rate for Payer: PACE SWMI	$88.01
Rate for Payer: PHP Medicare Advantage	$88.01
Rate for Payer: Priority Health Choice Medicaid	$57.72
Rate for Payer: Priority Health Cigna Priority Health	$459.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$156.99
Rate for Payer: Priority Health Medicare	$88.01
Rate for Payer: Priority Health Narrow Network	$156.99
Rate for Payer: UHC Medicare Advantage	$90.65

Know your out-of-pocket cost for care.

All Charges