Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR 1ST/SBSQ PSYCH COLLAB CARE MGMT EA ADDL 30 MINS

Professional

Both

$129.00

Service Code	HCPCS 99494
Min. Negotiated Rate	$38.06
Max. Negotiated Rate	$83.85
Rate for Payer: Aetna Commercial	$51.00
Rate for Payer: Aetna Medicare	$38.06
Rate for Payer: BCBS Complete	$51.60
Rate for Payer: BCBS MAPPO	$38.06
Rate for Payer: BCN Medicare Advantage	$38.06
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cofinity Commercial	$54.81
Rate for Payer: Cofinity Commercial	$51.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$38.06
Rate for Payer: Healthscope Commercial	$41.87
Rate for Payer: Healthscope Whirlpool	$41.87
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$39.96
Rate for Payer: Nomi Health Commercial	$45.67
Rate for Payer: PACE SWMI	$38.06
Rate for Payer: PHP Medicare Advantage	$38.06
Rate for Payer: Priority Health Cigna Priority Health	$83.85
Rate for Payer: Priority Health Medicare	$38.06
Rate for Payer: UHC Dual Complete DSNP	$38.06
Rate for Payer: UHC Medicare Advantage	$38.06
Rate for Payer: UHCCP DNSP	$38.06

PR 2VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE

Professional

Both

$279.00

Service Code	HCPCS 90650
Min. Negotiated Rate	$111.60
Max. Negotiated Rate	$181.35
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS Complete	$111.60
Rate for Payer: Cash Price	$223.20
Rate for Payer: Priority Health Cigna Priority Health	$181.35

PR 4VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE

Professional

Both

$263.00

Service Code	HCPCS 90649
Min. Negotiated Rate	$105.20
Max. Negotiated Rate	$170.95
Rate for Payer: Aetna Medicare	$131.50
Rate for Payer: BCBS Complete	$105.20
Rate for Payer: Cash Price	$210.40
Rate for Payer: Priority Health Cigna Priority Health	$170.95

PR 5% DEXTROSE IN LAC RINGERS

Professional

Both

$31.00

Service Code	HCPCS J7121
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$20.15

PR 9VHPV VACC 2/3 DOSE SCHED IM USE

Professional

Both

$296.00

Service Code	HCPCS 90651
Min. Negotiated Rate	$118.40
Max. Negotiated Rate	$192.40
Rate for Payer: Aetna Medicare	$148.00
Rate for Payer: BCBS Complete	$118.40
Rate for Payer: Cash Price	$236.80
Rate for Payer: Priority Health Cigna Priority Health	$192.40

PR AAA REPAIR,AORTO-AORTIC TUBE PROSTH

Professional

Both

$3,937.00

Service Code	HCPCS 34800
Min. Negotiated Rate	$1,574.80
Max. Negotiated Rate	$2,559.05
Rate for Payer: Aetna Medicare	$1,968.50
Rate for Payer: BCBS Complete	$1,574.80
Rate for Payer: Cash Price	$3,149.60
Rate for Payer: Priority Health Cigna Priority Health	$2,559.05

PR AAA REPAIR,MODULR BIFURCATED PROSTH

Professional

Both

$2,555.00

Service Code	HCPCS 34802
Min. Negotiated Rate	$1,022.00
Max. Negotiated Rate	$1,660.75
Rate for Payer: Aetna Medicare	$1,277.50
Rate for Payer: BCBS Complete	$1,022.00
Rate for Payer: Cash Price	$2,044.00
Rate for Payer: Priority Health Cigna Priority Health	$1,660.75

PR AAA REPAIR,MODULR BIFUR PROSTH,2-DOCK

Professional

Both

$2,622.00

Service Code	HCPCS 34803
Min. Negotiated Rate	$1,048.80
Max. Negotiated Rate	$1,704.30
Rate for Payer: Aetna Medicare	$1,311.00
Rate for Payer: BCBS Complete	$1,048.80
Rate for Payer: Cash Price	$2,097.60
Rate for Payer: Priority Health Cigna Priority Health	$1,704.30

PR AAA REPAIR,UNIBODY BIFURCATED PROSTH

Professional

Both

$5,512.00

Service Code	HCPCS 34804
Min. Negotiated Rate	$2,204.80
Max. Negotiated Rate	$3,582.80
Rate for Payer: Aetna Medicare	$2,756.00
Rate for Payer: BCBS Complete	$2,204.80
Rate for Payer: Cash Price	$4,409.60
Rate for Payer: Priority Health Cigna Priority Health	$3,582.80

PR AAA REPR,1ST VESSEL,EXTENSION PROSTH

Professional

Both

$2,698.00

Service Code	HCPCS 34825
Min. Negotiated Rate	$1,079.20
Max. Negotiated Rate	$1,753.70
Rate for Payer: Aetna Medicare	$1,349.00
Rate for Payer: BCBS Complete	$1,079.20
Rate for Payer: Cash Price	$2,158.40
Rate for Payer: Priority Health Cigna Priority Health	$1,753.70

PR AAA REPR,ADD VESSEL,EXTENSION PROSTH

Professional

Both

$436.00

Service Code	HCPCS 34826
Min. Negotiated Rate	$174.40
Max. Negotiated Rate	$283.40
Rate for Payer: Aetna Medicare	$218.00
Rate for Payer: BCBS Complete	$174.40
Rate for Payer: Cash Price	$348.80
Rate for Payer: Priority Health Cigna Priority Health	$283.40

PR ABATACEPT INJECTION

Professional

Both

$41.00

Service Code	HCPCS J0129
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$63.52
Rate for Payer: Aetna Commercial	$59.11
Rate for Payer: Aetna Medicare	$44.11
Rate for Payer: BCBS Complete	$16.40
Rate for Payer: BCBS MAPPO	$44.11
Rate for Payer: BCN Medicare Advantage	$44.11
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cofinity Commercial	$63.52
Rate for Payer: Cofinity Commercial	$59.11
Rate for Payer: Health Alliance Plan Medicare Advantage	$44.11
Rate for Payer: Healthscope Commercial	$52.93
Rate for Payer: Healthscope Whirlpool	$52.93
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$46.32
Rate for Payer: Nomi Health Commercial	$52.93
Rate for Payer: PACE SWMI	$44.11
Rate for Payer: PHP Medicare Advantage	$44.11
Rate for Payer: Priority Health Cigna Priority Health	$26.65
Rate for Payer: Priority Health Medicare	$44.11
Rate for Payer: UHC Dual Complete DSNP	$44.11
Rate for Payer: UHC Medicare Advantage	$44.11
Rate for Payer: UHCCP DNSP	$44.11

PR ABDL LMPHADEC REG CELIAC GSTR PORTAL PRIPNCRTC

Professional

Both

$483.00

Service Code	HCPCS 38747
Min. Negotiated Rate	$193.20
Max. Negotiated Rate	$370.89
Rate for Payer: Aetna Commercial	$345.13
Rate for Payer: Aetna Medicare	$257.56
Rate for Payer: BCBS Complete	$193.20
Rate for Payer: BCBS MAPPO	$257.56
Rate for Payer: BCN Medicare Advantage	$257.56
Rate for Payer: Cash Price	$386.40
Rate for Payer: Cash Price	$386.40
Rate for Payer: Cofinity Commercial	$370.89
Rate for Payer: Cofinity Commercial	$345.13
Rate for Payer: Health Alliance Plan Medicare Advantage	$257.56
Rate for Payer: Healthscope Commercial	$309.07
Rate for Payer: Healthscope Whirlpool	$309.07
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$270.44
Rate for Payer: Nomi Health Commercial	$309.07
Rate for Payer: PACE SWMI	$257.56
Rate for Payer: PHP Medicare Advantage	$257.56
Rate for Payer: Priority Health Cigna Priority Health	$313.95
Rate for Payer: Priority Health Medicare	$257.56
Rate for Payer: UHC Dual Complete DSNP	$257.56
Rate for Payer: UHC Medicare Advantage	$257.56
Rate for Payer: UHCCP DNSP	$257.56

PR ABDOMINOPLASTY (2HRS)

Professional

Both

$2,652.00

Service Code	HCPCS 00364
Hospital Revenue Code	990
Min. Negotiated Rate	$1,060.80
Max. Negotiated Rate	$1,723.80
Rate for Payer: Aetna Medicare	$1,326.00
Rate for Payer: BCBS Complete	$1,060.80
Rate for Payer: Cash Price	$2,121.60
Rate for Payer: Priority Health Cigna Priority Health	$1,723.80

PR ABDOMINOPLASTY (3HRS)

Professional

Both

$4,284.00

Service Code	HCPCS 00365
Hospital Revenue Code	990
Min. Negotiated Rate	$1,713.60
Max. Negotiated Rate	$2,784.60
Rate for Payer: Aetna Medicare	$2,142.00
Rate for Payer: BCBS Complete	$1,713.60
Rate for Payer: Cash Price	$3,427.20
Rate for Payer: Priority Health Cigna Priority Health	$2,784.60

PR ABDOMINOPLASTY W/ BREAST AUGMENT

Professional

Both

$7,446.00

Service Code	HCPCS 00256
Hospital Revenue Code	990
Min. Negotiated Rate	$2,978.40
Max. Negotiated Rate	$4,839.90
Rate for Payer: Aetna Medicare	$3,723.00
Rate for Payer: BCBS Complete	$2,978.40
Rate for Payer: Cash Price	$5,956.80
Rate for Payer: Priority Health Cigna Priority Health	$4,839.90

PR ABDOMINO-VAG VESICAL NCK SSP W/WO NDSC CTRL

Professional

Both

$2,628.00

Service Code	HCPCS 51845
Min. Negotiated Rate	$557.77
Max. Negotiated Rate	$1,708.20
Rate for Payer: Aetna Commercial	$747.41
Rate for Payer: Aetna Medicare	$557.77
Rate for Payer: BCBS Complete	$1,051.20
Rate for Payer: BCBS MAPPO	$557.77
Rate for Payer: BCN Medicare Advantage	$557.77
Rate for Payer: Cash Price	$2,102.40
Rate for Payer: Cash Price	$2,102.40
Rate for Payer: Cofinity Commercial	$747.41
Rate for Payer: Cofinity Commercial	$803.19
Rate for Payer: Health Alliance Plan Medicare Advantage	$557.77
Rate for Payer: Healthscope Commercial	$669.32
Rate for Payer: Healthscope Whirlpool	$669.32
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$585.66
Rate for Payer: Nomi Health Commercial	$669.32
Rate for Payer: PACE SWMI	$557.77
Rate for Payer: PHP Medicare Advantage	$557.77
Rate for Payer: Priority Health Cigna Priority Health	$1,708.20
Rate for Payer: Priority Health Medicare	$557.77
Rate for Payer: UHC Dual Complete DSNP	$557.77
Rate for Payer: UHC Medicare Advantage	$557.77
Rate for Payer: UHCCP DNSP	$557.77

PR ABDOM PARACENTESIS DX/THER W/IMAGING GUIDANCE

Professional

Both

$475.00

Service Code	HCPCS 49083
Min. Negotiated Rate	$100.28
Max. Negotiated Rate	$308.75
Rate for Payer: Aetna Commercial	$134.38
Rate for Payer: Aetna Medicare	$100.28
Rate for Payer: BCBS Complete	$190.00
Rate for Payer: BCBS MAPPO	$100.28
Rate for Payer: BCN Medicare Advantage	$100.28
Rate for Payer: Cash Price	$380.00
Rate for Payer: Cash Price	$380.00
Rate for Payer: Cofinity Commercial	$144.40
Rate for Payer: Cofinity Commercial	$134.38
Rate for Payer: Health Alliance Plan Medicare Advantage	$100.28
Rate for Payer: Healthscope Commercial	$120.34
Rate for Payer: Healthscope Whirlpool	$120.34
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$105.29
Rate for Payer: Nomi Health Commercial	$120.34
Rate for Payer: PACE SWMI	$100.28
Rate for Payer: PHP Medicare Advantage	$100.28
Rate for Payer: Priority Health Cigna Priority Health	$308.75
Rate for Payer: Priority Health Medicare	$100.28
Rate for Payer: UHC Dual Complete DSNP	$100.28
Rate for Payer: UHC Medicare Advantage	$100.28
Rate for Payer: UHCCP DNSP	$100.28

PR ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE

Professional

Both

$260.00

Service Code	HCPCS 49082
Min. Negotiated Rate	$69.33
Max. Negotiated Rate	$169.00
Rate for Payer: Aetna Commercial	$92.90
Rate for Payer: Aetna Medicare	$69.33
Rate for Payer: BCBS Complete	$104.00
Rate for Payer: BCBS MAPPO	$69.33
Rate for Payer: BCN Medicare Advantage	$69.33
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cofinity Commercial	$99.84
Rate for Payer: Cofinity Commercial	$92.90
Rate for Payer: Health Alliance Plan Medicare Advantage	$69.33
Rate for Payer: Healthscope Commercial	$83.20
Rate for Payer: Healthscope Whirlpool	$83.20
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$72.80
Rate for Payer: Nomi Health Commercial	$83.20
Rate for Payer: PACE SWMI	$69.33
Rate for Payer: PHP Medicare Advantage	$69.33
Rate for Payer: Priority Health Cigna Priority Health	$169.00
Rate for Payer: Priority Health Medicare	$69.33
Rate for Payer: UHC Dual Complete DSNP	$69.33
Rate for Payer: UHC Medicare Advantage	$69.33
Rate for Payer: UHCCP DNSP	$69.33

PR ABLATE L/R ATRIAL FIBRIL W/ISOLATED PULM VEIN

Professional

Both

$876.00

Service Code	HCPCS 93657
Min. Negotiated Rate	$291.34
Max. Negotiated Rate	$569.40
Rate for Payer: Aetna Commercial	$390.40
Rate for Payer: Aetna Medicare	$291.34
Rate for Payer: BCBS Complete	$350.40
Rate for Payer: BCBS MAPPO	$291.34
Rate for Payer: BCN Medicare Advantage	$291.34
Rate for Payer: Cash Price	$700.80
Rate for Payer: Cash Price	$700.80
Rate for Payer: Cofinity Commercial	$419.53
Rate for Payer: Cofinity Commercial	$390.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$291.34
Rate for Payer: Healthscope Commercial	$349.61
Rate for Payer: Healthscope Whirlpool	$349.61
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$305.91
Rate for Payer: Nomi Health Commercial	$349.61
Rate for Payer: PACE SWMI	$291.34
Rate for Payer: PHP Medicare Advantage	$291.34
Rate for Payer: Priority Health Cigna Priority Health	$569.40
Rate for Payer: Priority Health Medicare	$291.34
Rate for Payer: UHC Dual Complete DSNP	$291.34
Rate for Payer: UHC Medicare Advantage	$291.34
Rate for Payer: UHCCP DNSP	$291.34

PR ABLATION BONE TUMOR RF PERQ W/IMG GDN WHEN DONE

Professional

Both

$7,268.00

Service Code	HCPCS 20982
Min. Negotiated Rate	$351.15
Max. Negotiated Rate	$4,724.20
Rate for Payer: Aetna Commercial	$470.54
Rate for Payer: Aetna Medicare	$351.15
Rate for Payer: BCBS Complete	$2,907.20
Rate for Payer: BCBS MAPPO	$351.15
Rate for Payer: BCN Medicare Advantage	$351.15
Rate for Payer: Cash Price	$5,814.40
Rate for Payer: Cash Price	$5,814.40
Rate for Payer: Cofinity Commercial	$505.66
Rate for Payer: Cofinity Commercial	$470.54
Rate for Payer: Health Alliance Plan Medicare Advantage	$351.15
Rate for Payer: Healthscope Commercial	$421.38
Rate for Payer: Healthscope Whirlpool	$421.38
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$368.71
Rate for Payer: Nomi Health Commercial	$421.38
Rate for Payer: PACE SWMI	$351.15
Rate for Payer: PHP Medicare Advantage	$351.15
Rate for Payer: Priority Health Cigna Priority Health	$4,724.20
Rate for Payer: Priority Health Medicare	$351.15
Rate for Payer: UHC Dual Complete DSNP	$351.15
Rate for Payer: UHC Medicare Advantage	$351.15
Rate for Payer: UHCCP DNSP	$351.15

PR ABLATION & RCNSTJ ATRIA EXTNSV W/BYPASS

Professional

Both

$3,766.00

Service Code	HCPCS 33256
Min. Negotiated Rate	$1,506.40
Max. Negotiated Rate	$2,652.52
Rate for Payer: Aetna Commercial	$2,468.32
Rate for Payer: Aetna Medicare	$1,842.03
Rate for Payer: BCBS Complete	$1,506.40
Rate for Payer: BCBS MAPPO	$1,842.03
Rate for Payer: BCN Medicare Advantage	$1,842.03
Rate for Payer: Cash Price	$3,012.80
Rate for Payer: Cash Price	$3,012.80
Rate for Payer: Cofinity Commercial	$2,652.52
Rate for Payer: Cofinity Commercial	$2,468.32
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,842.03
Rate for Payer: Healthscope Commercial	$2,210.44
Rate for Payer: Healthscope Whirlpool	$2,210.44
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,934.13
Rate for Payer: Nomi Health Commercial	$2,210.44
Rate for Payer: PACE SWMI	$1,842.03
Rate for Payer: PHP Medicare Advantage	$1,842.03
Rate for Payer: Priority Health Cigna Priority Health	$2,447.90
Rate for Payer: Priority Health Medicare	$1,842.03
Rate for Payer: UHC Dual Complete DSNP	$1,842.03
Rate for Payer: UHC Medicare Advantage	$1,842.03
Rate for Payer: UHCCP DNSP	$1,842.03

PR ABLATION & RECONSTRUCTION ATRIA LIMITED

Professional

Both

$3,359.00

Service Code	HCPCS 33254
Min. Negotiated Rate	$1,303.39
Max. Negotiated Rate	$2,183.35
Rate for Payer: Aetna Commercial	$1,746.54
Rate for Payer: Aetna Medicare	$1,303.39
Rate for Payer: BCBS Complete	$1,343.60
Rate for Payer: BCBS MAPPO	$1,303.39
Rate for Payer: BCN Medicare Advantage	$1,303.39
Rate for Payer: Cash Price	$2,687.20
Rate for Payer: Cash Price	$2,687.20
Rate for Payer: Cofinity Commercial	$1,876.88
Rate for Payer: Cofinity Commercial	$1,746.54
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,303.39
Rate for Payer: Healthscope Commercial	$1,564.07
Rate for Payer: Healthscope Whirlpool	$1,564.07
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,368.56
Rate for Payer: Nomi Health Commercial	$1,564.07
Rate for Payer: PACE SWMI	$1,303.39
Rate for Payer: PHP Medicare Advantage	$1,303.39
Rate for Payer: Priority Health Cigna Priority Health	$2,183.35
Rate for Payer: Priority Health Medicare	$1,303.39
Rate for Payer: UHC Dual Complete DSNP	$1,303.39
Rate for Payer: UHC Medicare Advantage	$1,303.39
Rate for Payer: UHCCP DNSP	$1,303.39

PR ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL

Professional

Both

$557.00

Service Code	HCPCS 30802
Min. Negotiated Rate	$186.43
Max. Negotiated Rate	$362.05
Rate for Payer: Aetna Commercial	$249.82
Rate for Payer: Aetna Medicare	$186.43
Rate for Payer: BCBS Complete	$222.80
Rate for Payer: BCBS MAPPO	$186.43
Rate for Payer: BCN Medicare Advantage	$186.43
Rate for Payer: Cash Price	$445.60
Rate for Payer: Cash Price	$445.60
Rate for Payer: Cofinity Commercial	$268.46
Rate for Payer: Cofinity Commercial	$249.82
Rate for Payer: Health Alliance Plan Medicare Advantage	$186.43
Rate for Payer: Healthscope Commercial	$223.72
Rate for Payer: Healthscope Whirlpool	$223.72
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$195.75
Rate for Payer: Nomi Health Commercial	$223.72
Rate for Payer: PACE SWMI	$186.43
Rate for Payer: PHP Medicare Advantage	$186.43
Rate for Payer: Priority Health Cigna Priority Health	$362.05
Rate for Payer: Priority Health Medicare	$186.43
Rate for Payer: UHC Dual Complete DSNP	$186.43
Rate for Payer: UHC Medicare Advantage	$186.43
Rate for Payer: UHCCP DNSP	$186.43

PR ABLTJ SOFT TIS INFERIOR TURBINATES UNI/BI SUPFC

Professional

Both

$372.00

Service Code	HCPCS 30801
Min. Negotiated Rate	$137.54
Max. Negotiated Rate	$241.80
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$137.54
Rate for Payer: BCBS Complete	$148.80
Rate for Payer: BCBS MAPPO	$137.54
Rate for Payer: BCN Medicare Advantage	$137.54
Rate for Payer: Cash Price	$297.60
Rate for Payer: Cash Price	$297.60
Rate for Payer: Cofinity Commercial	$198.06
Rate for Payer: Cofinity Commercial	$184.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$137.54
Rate for Payer: Healthscope Commercial	$165.05
Rate for Payer: Healthscope Whirlpool	$165.05
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$144.42
Rate for Payer: Nomi Health Commercial	$165.05
Rate for Payer: PACE SWMI	$137.54
Rate for Payer: PHP Medicare Advantage	$137.54
Rate for Payer: Priority Health Cigna Priority Health	$241.80
Rate for Payer: Priority Health Medicare	$137.54
Rate for Payer: UHC Dual Complete DSNP	$137.54
Rate for Payer: UHC Medicare Advantage	$137.54
Rate for Payer: UHCCP DNSP	$137.54

Know your out-of-pocket cost for care.

All Charges