Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR CAST SUP LNG ARM SPLINT FBRG

Professional

Both

$25.00

Service Code	HCPCS Q4018
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$12.17
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCN Commercial	$14.28
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50

PR CAST SUP LNG ARM SPLNT PED F

Professional

Both

$24.00

Service Code	HCPCS Q4020
Min. Negotiated Rate	$6.10
Max. Negotiated Rate	$16.80
Rate for Payer: Aetna Commercial	$6.10
Rate for Payer: BCBS Complete	$9.60
Rate for Payer: BCN Commercial	$7.17
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Priority Health Cigna Priority Health	$16.80

PR CAST SUP LNG LEG CYLINDER FB

Professional

Both

$98.00

Service Code	HCPCS Q4034
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$68.60
Rate for Payer: Aetna Commercial	$56.19
Rate for Payer: BCBS Complete	$39.20
Rate for Payer: BCN Commercial	$65.98
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Priority Health Cigna Priority Health	$68.60

PR CAST SUP LNGLEG CYLNDR PED F

Professional

Both

$50.00

Service Code	HCPCS Q4036
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$28.11
Rate for Payer: BCBS Complete	$20.00
Rate for Payer: BCN Commercial	$33.01
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Priority Health Cigna Priority Health	$35.00

PR CAST SUP LNG LEG PED FBRGLS

Professional

Both

$52.00

Service Code	HCPCS Q4032
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$37.44
Rate for Payer: Aetna Commercial	$31.89
Rate for Payer: BCBS Complete	$20.80
Rate for Payer: BCN Commercial	$37.44
Rate for Payer: Cash Price	$41.60
Rate for Payer: Cash Price	$41.60
Rate for Payer: Priority Health Cigna Priority Health	$36.40

PR CAST SUP LNG LEG SPLNT FBRGL

Professional

Both

$75.00

Service Code	HCPCS Q4042
Min. Negotiated Rate	$28.62
Max. Negotiated Rate	$52.50
Rate for Payer: Aetna Commercial	$28.62
Rate for Payer: BCBS Complete	$30.00
Rate for Payer: BCN Commercial	$33.60
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Priority Health Cigna Priority Health	$52.50

PR CAST SUP LNG LEG SPLNT PED F

Professional

Both

$38.00

Service Code	HCPCS Q4044
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$26.60
Rate for Payer: Aetna Commercial	$14.32
Rate for Payer: BCBS Complete	$15.20
Rate for Payer: BCN Commercial	$16.82
Rate for Payer: Cash Price	$30.40
Rate for Payer: Cash Price	$30.40
Rate for Payer: Priority Health Cigna Priority Health	$26.60

PR CAST SUP LONG ARM ADULT FBRG

Professional

Both

$55.00

Service Code	HCPCS Q4006
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$38.50
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: BCBS Complete	$22.00
Rate for Payer: BCN Commercial	$28.75
Rate for Payer: Cash Price	$44.00
Rate for Payer: Cash Price	$44.00
Rate for Payer: Priority Health Cigna Priority Health	$38.50

PR CAST SUP LONG ARM PED FBRGLS

Professional

Both

$25.00

Service Code	HCPCS Q4008
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$12.24
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCN Commercial	$14.36
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50

PR CAST SUP LONG LEG FIBERGLASS

Professional

Both

$114.00

Service Code	HCPCS Q4030
Min. Negotiated Rate	$45.60
Max. Negotiated Rate	$79.80
Rate for Payer: Aetna Commercial	$63.77
Rate for Payer: BCBS Complete	$45.60
Rate for Payer: BCN Commercial	$74.88
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Priority Health Cigna Priority Health	$79.80

PR CAST SUPPLIES UNLISTED

Professional

Both

$100.00

Service Code	HCPCS Q4050
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$70.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: BCN Commercial	$25.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00

PR CAST SUP SHOULDER CAST FBRGL

Professional

Both

$151.00

Service Code	HCPCS Q4004
Min. Negotiated Rate	$60.40
Max. Negotiated Rate	$119.78
Rate for Payer: Aetna Commercial	$102.02
Rate for Payer: BCBS Complete	$60.40
Rate for Payer: BCN Commercial	$119.78
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Priority Health Cigna Priority Health	$105.70

PR CAST SUP SHRT LEG FIBERGLASS

Professional

Both

$60.00

Service Code	HCPCS Q4038
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$34.52
Rate for Payer: BCBS Complete	$24.00
Rate for Payer: BCN Commercial	$40.55
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00

PR CAST SUP SHRT LEG PED FBRGLS

Professional

Both

$21.00

Service Code	HCPCS Q4040
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$20.27
Rate for Payer: Aetna Commercial	$17.26
Rate for Payer: BCBS Complete	$8.40
Rate for Payer: BCN Commercial	$20.27
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Priority Health Cigna Priority Health	$14.70

PR CAST SUP SHT ARM ADULT FBRGL

Professional

Both

$42.00

Service Code	HCPCS Q4010
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$29.40
Rate for Payer: Aetna Commercial	$16.32
Rate for Payer: BCBS Complete	$16.80
Rate for Payer: BCN Commercial	$19.16
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$33.60
Rate for Payer: Priority Health Cigna Priority Health	$29.40

PR CAST SUP SHT ARM PED FBRGLAS

Professional

Both

$20.00

Service Code	HCPCS Q4012
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$8.18
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCN Commercial	$9.60
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 CAST SUP SHT ARM SPLINT FBRG

Professional

Both

$25.00

Service Code	HCPCS Q4022
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$10.18
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCN Commercial	$11.97
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50

PR CAST SUP SHT ARM SPLNT PED F

Professional

Both

$27.00

Service Code	HCPCS Q4024
Min. Negotiated Rate	$5.11
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna Commercial	$5.11
Rate for Payer: BCBS Complete	$10.80
Rate for Payer: BCN Commercial	$5.99
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Priority Health Cigna Priority Health	$18.90

PR CAST SUP SHT LEG SPLNT FBRGL

Professional

Both

$30.00

Service Code	HCPCS Q4046
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$15.64
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: BCN Commercial	$18.37
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Priority Health Cigna Priority Health	$21.00

PR CAST SUP SHT LEG SPLNT PED F

Professional

Both

$25.00

Service Code	HCPCS Q4048
Min. Negotiated Rate	$7.83
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$7.83
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCN Commercial	$9.20
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Priority Health Cigna Priority Health	$17.50

PR CAST SUP SHT LEG SPLNT PED P

Professional

Both

$20.00

Service Code	HCPCS Q4047
Min. Negotiated Rate	$4.84
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$4.84
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCN Commercial	$5.69
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 CATHETERIZATION UMBILICAL NEWBORN ART DX/THERAPY

Professional

Both

$138.00

Service Code	HCPCS 36660
Min. Negotiated Rate	$42.81
Max. Negotiated Rate	$738.56
Rate for Payer: Aetna Commercial	$89.55
Rate for Payer: Aetna Medicare	$66.83
Rate for Payer: BCBS Complete	$44.95
Rate for Payer: BCBS MAPPO	$66.83
Rate for Payer: BCBS Trust/PPO	$738.56
Rate for Payer: BCN Commercial	$98.23
Rate for Payer: BCN Medicare Advantage	$66.83
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cofinity Commercial	$96.24
Rate for Payer: Cofinity Commercial	$89.55
Rate for Payer: Health Alliance Plan Medicare Advantage	$66.83
Rate for Payer: Healthscope Commercial	$80.20
Rate for Payer: Healthscope Whirlpool	$80.20
Rate for Payer: Meridian Medicaid	$44.95
Rate for Payer: Meridian Wellcare - Medicare Advantage	$70.17
Rate for Payer: PACE SWMI	$66.83
Rate for Payer: PHP Medicare Advantage	$66.83
Rate for Payer: Priority Health Choice Medicaid	$42.81
Rate for Payer: Priority Health Cigna Priority Health	$96.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$106.92
Rate for Payer: Priority Health Medicare	$66.83
Rate for Payer: Priority Health Narrow Network	$106.92
Rate for Payer: UHC Medicare Advantage	$68.83

PR CATHETERIZATION W/BRONCHIAL BRUSH BIOPSY

Professional

Both

$520.00

Service Code	HCPCS 31717
Min. Negotiated Rate	$66.46
Max. Negotiated Rate	$1,013.81
Rate for Payer: Aetna Commercial	$138.57
Rate for Payer: Aetna Medicare	$103.41
Rate for Payer: BCBS Complete	$69.78
Rate for Payer: BCBS MAPPO	$103.41
Rate for Payer: BCBS Trust/PPO	$1,013.81
Rate for Payer: BCN Commercial	$420.26
Rate for Payer: BCN Medicare Advantage	$103.41
Rate for Payer: Cash Price	$416.00
Rate for Payer: Cash Price	$416.00
Rate for Payer: Cofinity Commercial	$148.91
Rate for Payer: Cofinity Commercial	$138.57
Rate for Payer: Health Alliance Plan Medicare Advantage	$103.41
Rate for Payer: Healthscope Commercial	$124.09
Rate for Payer: Healthscope Whirlpool	$124.09
Rate for Payer: Meridian Medicaid	$69.78
Rate for Payer: Meridian Wellcare - Medicare Advantage	$108.58
Rate for Payer: PACE SWMI	$103.41
Rate for Payer: PHP Medicare Advantage	$103.41
Rate for Payer: Priority Health Choice Medicaid	$66.46
Rate for Payer: Priority Health Cigna Priority Health	$364.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$144.01
Rate for Payer: Priority Health Medicare	$103.41
Rate for Payer: Priority Health Narrow Network	$144.01
Rate for Payer: UHC Medicare Advantage	$106.51

PR CATHETERIZE FOR URINE SPEC

Professional

Both

$29.00

Service Code	HCPCS P9612
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$1,574.33
Rate for Payer: Aetna Commercial	$11.48
Rate for Payer: Aetna Medicare	$8.57
Rate for Payer: BCBS Complete	$11.60
Rate for Payer: BCBS MAPPO	$8.57
Rate for Payer: BCBS Trust/PPO	$1,574.33
Rate for Payer: BCN Commercial	$5.95
Rate for Payer: BCN Medicare Advantage	$8.57
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cofinity Commercial	$12.34
Rate for Payer: Cofinity Commercial	$11.48
Rate for Payer: Health Alliance Plan Medicare Advantage	$8.57
Rate for Payer: Healthscope Commercial	$10.28
Rate for Payer: Healthscope Whirlpool	$10.28
Rate for Payer: Meridian Wellcare - Medicare Advantage	$9.00
Rate for Payer: PACE SWMI	$8.57
Rate for Payer: PHP Medicare Advantage	$8.57
Rate for Payer: Priority Health Cigna Priority Health	$20.30
Rate for Payer: Priority Health Medicare	$8.57
Rate for Payer: UHC Medicare Advantage	$8.83

PR CATHJ UMBILICAL VEIN DX/THER NB

Professional

Both

$283.00

Service Code	HCPCS 36510
Min. Negotiated Rate	$33.44
Max. Negotiated Rate	$947.77
Rate for Payer: Aetna Commercial	$69.95
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS Complete	$35.11
Rate for Payer: BCBS MAPPO	$52.20
Rate for Payer: BCBS Trust/PPO	$947.77
Rate for Payer: BCN Commercial	$124.62
Rate for Payer: BCN Medicare Advantage	$52.20
Rate for Payer: Cash Price	$226.40
Rate for Payer: Cash Price	$226.40
Rate for Payer: Cofinity Commercial	$75.17
Rate for Payer: Cofinity Commercial	$69.95
Rate for Payer: Health Alliance Plan Medicare Advantage	$52.20
Rate for Payer: Healthscope Commercial	$62.64
Rate for Payer: Healthscope Whirlpool	$62.64
Rate for Payer: Meridian Medicaid	$35.11
Rate for Payer: Meridian Wellcare - Medicare Advantage	$54.81
Rate for Payer: PACE SWMI	$52.20
Rate for Payer: PHP Medicare Advantage	$52.20
Rate for Payer: Priority Health Choice Medicaid	$33.44
Rate for Payer: Priority Health Cigna Priority Health	$198.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$83.51
Rate for Payer: Priority Health Medicare	$52.20
Rate for Payer: Priority Health Narrow Network	$83.51
Rate for Payer: UHC Medicare Advantage	$53.77

Know your out-of-pocket cost for care.

All Charges