Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/<

Professional

Both

$1,299.00

Service Code	HCPCS 14040
Min. Negotiated Rate	$344.90
Max. Negotiated Rate	$1,110.28
Rate for Payer: Aetna Commercial	$663.21
Rate for Payer: Aetna Medicare	$649.50
Rate for Payer: BCBS Complete	$422.70
Rate for Payer: BCBS Trust/PPO	$344.90
Rate for Payer: BCN Commercial	$1,110.28
Rate for Payer: Cash Price	$1,039.20
Rate for Payer: Cash Price	$1,039.20
Rate for Payer: Meridian Medicaid	$422.70
Rate for Payer: Priority Health Choice Medicaid	$402.57
Rate for Payer: Priority Health Cigna Priority Health	$844.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$845.68
Rate for Payer: Priority Health Narrow Network	$845.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$681.73
Rate for Payer: UHC Exchange	$681.73
Rate for Payer: UHCCP Medicaid	$402.57

PR ADJUSTMENT GASTRIC BAND

Professional

Both

$115.00

Service Code	HCPCS S2083
Min. Negotiated Rate	$46.00
Max. Negotiated Rate	$486.56
Rate for Payer: Aetna Commercial	$67.62
Rate for Payer: Aetna Medicare	$57.50
Rate for Payer: BCBS Complete	$46.00
Rate for Payer: BCBS Trust/PPO	$486.56
Rate for Payer: BCN Commercial	$108.60
Rate for Payer: Cash Price	$92.00
Rate for Payer: Cash Price	$92.00
Rate for Payer: Priority Health Cigna Priority Health	$74.75

PR ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES

Professional

Both

$1,025.00

Service Code	HCPCS 20693
Min. Negotiated Rate	$294.15
Max. Negotiated Rate	$3,350.93
Rate for Payer: Aetna Commercial	$588.13
Rate for Payer: Aetna Medicare	$512.50
Rate for Payer: BCBS Complete	$308.86
Rate for Payer: BCBS Trust/PPO	$3,350.93
Rate for Payer: BCN Commercial	$649.94
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cash Price	$820.00
Rate for Payer: Meridian Medicaid	$308.86
Rate for Payer: Priority Health Choice Medicaid	$294.15
Rate for Payer: Priority Health Cigna Priority Health	$666.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$691.03
Rate for Payer: Priority Health Narrow Network	$691.03
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$520.10
Rate for Payer: UHC Exchange	$520.10
Rate for Payer: UHCCP Medicaid	$294.15

PR ADMIN HEPATITIS B VACCINE

Professional

Both

$30.00

Service Code	HCPCS G0010
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$1,469.20
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: Aetna Medicare	$15.00
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: BCBS Trust/PPO	$1,469.20
Rate for Payer: BCN Commercial	$21.88
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Priority Health Cigna Priority Health	$19.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44.32
Rate for Payer: Priority Health Narrow Network	$44.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.17
Rate for Payer: UHC Exchange	$20.17

PR ADMIN INFLUENZA VIRUS VAC

Professional

Both

$33.00

Service Code	HCPCS G0008
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$4,626.85
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: Aetna Medicare	$16.50
Rate for Payer: BCBS Complete	$13.20
Rate for Payer: BCBS Trust/PPO	$4,626.85
Rate for Payer: BCN Commercial	$21.88
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Priority Health Cigna Priority Health	$21.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44.32
Rate for Payer: Priority Health Narrow Network	$44.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.17
Rate for Payer: UHC Exchange	$20.17

PR ADMIN PNEUMOCOCCAL VACCINE

Professional

Both

$33.00

Service Code	HCPCS G0009
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$1,331.32
Rate for Payer: Aetna Commercial	$10.00
Rate for Payer: Aetna Medicare	$16.50
Rate for Payer: BCBS Complete	$13.20
Rate for Payer: BCBS Trust/PPO	$1,331.32
Rate for Payer: BCN Commercial	$21.88
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Priority Health Cigna Priority Health	$21.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44.32
Rate for Payer: Priority Health Narrow Network	$44.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.17
Rate for Payer: UHC Exchange	$20.17

PR ADMN RSV MONOC ANTB SEASONAL DOS IM CNSL PHY/QHP

Professional

Both

$85.00

Service Code	HCPCS 96380
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$55.25
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: Aetna Medicare	$42.50
Rate for Payer: BCBS Complete	$34.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$55.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$30.76
Rate for Payer: Priority Health Narrow Network	$30.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$24.50
Rate for Payer: UHC Exchange	$24.50

PR ADMN RSV MONOCLONAL ANTB SEASONAL DOSE IM NJX

Professional

Both

$85.00

Service Code	HCPCS 96381
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$55.25
Rate for Payer: Aetna Commercial	$12.00
Rate for Payer: Aetna Medicare	$42.50
Rate for Payer: BCBS Complete	$34.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$55.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$26.69
Rate for Payer: Priority Health Narrow Network	$26.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.21
Rate for Payer: UHC Exchange	$21.21

PR ADRENALECTOMY EXPL W/EXC RETROPERTINEAL TUMOR

Professional

Both

$4,437.00

Service Code	HCPCS 60545
Min. Negotiated Rate	$341.28
Max. Negotiated Rate	$2,884.05
Rate for Payer: Aetna Commercial	$1,609.79
Rate for Payer: Aetna Medicare	$2,218.50
Rate for Payer: BCBS Complete	$838.02
Rate for Payer: BCBS Trust/PPO	$341.28
Rate for Payer: BCN Commercial	$1,817.39
Rate for Payer: Cash Price	$3,549.60
Rate for Payer: Cash Price	$3,549.60
Rate for Payer: Meridian Medicaid	$838.02
Rate for Payer: Priority Health Choice Medicaid	$798.11
Rate for Payer: Priority Health Cigna Priority Health	$2,884.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,019.90
Rate for Payer: Priority Health Narrow Network	$2,019.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,394.19
Rate for Payer: UHC Exchange	$1,394.19
Rate for Payer: UHCCP Medicaid	$798.11

PR ADRENALECTOMY W/EXPL W/WO BX ABDL/LMBR/DRSAL SPX

Professional

Both

$3,369.00

Service Code	HCPCS 60540
Min. Negotiated Rate	$432.15
Max. Negotiated Rate	$2,189.85
Rate for Payer: Aetna Commercial	$1,390.93
Rate for Payer: Aetna Medicare	$1,684.50
Rate for Payer: BCBS Complete	$727.53
Rate for Payer: BCBS Trust/PPO	$432.15
Rate for Payer: BCN Commercial	$1,567.19
Rate for Payer: Cash Price	$2,695.20
Rate for Payer: Cash Price	$2,695.20
Rate for Payer: Meridian Medicaid	$727.53
Rate for Payer: Priority Health Choice Medicaid	$692.89
Rate for Payer: Priority Health Cigna Priority Health	$2,189.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,743.12
Rate for Payer: Priority Health Narrow Network	$1,743.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,216.53
Rate for Payer: UHC Exchange	$1,216.53
Rate for Payer: UHCCP Medicaid	$692.89

PR ADRENALIN EPINEPHRINE INJECT

Professional

Both

$5.00

Service Code	HCPCS J0171
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Commercial	$0.77
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: BCBS Trust/PPO	$0.15
Rate for Payer: BCN Commercial	$0.14
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$0.81
Rate for Payer: UHC Exchange	$0.81

PR ADVANCE CARE PLANNING EA ADDL 30 MINS

Professional

Both

$82.00

Service Code	HCPCS 99498
Min. Negotiated Rate	$41.00
Max. Negotiated Rate	$533.05
Rate for Payer: Aetna Commercial	$72.67
Rate for Payer: Aetna Medicare	$41.00
Rate for Payer: BCBS Complete	$47.42
Rate for Payer: BCBS Trust/PPO	$533.05
Rate for Payer: BCN Commercial	$75.95
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Meridian Medicaid	$47.42
Rate for Payer: Priority Health Choice Medicaid	$45.16
Rate for Payer: Priority Health Cigna Priority Health	$53.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$92.55
Rate for Payer: Priority Health Narrow Network	$92.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$83.81
Rate for Payer: UHC Exchange	$83.81
Rate for Payer: UHCCP Medicaid	$45.16

PR ADVANCE CARE PLANNING FIRST 30 MINS

Professional

Both

$103.00

Service Code	HCPCS 99497
Min. Negotiated Rate	$47.71
Max. Negotiated Rate	$569.51
Rate for Payer: Aetna Commercial	$77.18
Rate for Payer: Aetna Medicare	$51.50
Rate for Payer: BCBS Complete	$50.10
Rate for Payer: BCBS Trust/PPO	$569.51
Rate for Payer: BCN Commercial	$87.77
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cash Price	$82.40
Rate for Payer: Meridian Medicaid	$50.10
Rate for Payer: Priority Health Choice Medicaid	$47.71
Rate for Payer: Priority Health Cigna Priority Health	$66.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$98.24
Rate for Payer: Priority Health Narrow Network	$98.24
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.43
Rate for Payer: UHC Exchange	$89.43
Rate for Payer: UHCCP Medicaid	$47.71

PR AEP HEARING STATUS DETER BROADBAND STIMULI I&R

Professional

Both

$161.00

Service Code	HCPCS 92651
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$3,831.23
Rate for Payer: Aetna Commercial	$96.89
Rate for Payer: Aetna Medicare	$80.50
Rate for Payer: BCBS Complete	$64.40
Rate for Payer: BCBS Trust/PPO	$3,831.23
Rate for Payer: BCN Commercial	$123.64
Rate for Payer: Cash Price	$128.80
Rate for Payer: Cash Price	$128.80
Rate for Payer: Priority Health Cigna Priority Health	$104.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$112.17
Rate for Payer: Priority Health Narrow Network	$112.17
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$100.03
Rate for Payer: UHC Exchange	$100.03

PR AEP NEURODIAGNOSTIC INTERPRETATION AND REPORT

Professional

Both

$169.00

Service Code	HCPCS 92653
Min. Negotiated Rate	$67.60
Max. Negotiated Rate	$1,917.20
Rate for Payer: Aetna Commercial	$93.15
Rate for Payer: Aetna Medicare	$84.50
Rate for Payer: BCBS Complete	$67.60
Rate for Payer: BCBS Trust/PPO	$1,917.20
Rate for Payer: BCN Commercial	$123.15
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Priority Health Cigna Priority Health	$109.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$112.63
Rate for Payer: Priority Health Narrow Network	$112.63
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$97.60
Rate for Payer: UHC Exchange	$97.60

PR AEP SCR AUDITORY POTENTIAL W/STIMULI AUTO ALYS

Professional

Both

$55.00

Service Code	HCPCS 92650
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$1,517.28
Rate for Payer: Aetna Commercial	$30.47
Rate for Payer: Aetna Medicare	$27.50
Rate for Payer: BCBS Complete	$22.00
Rate for Payer: BCBS Trust/PPO	$1,517.28
Rate for Payer: BCN Commercial	$40.56
Rate for Payer: Cash Price	$44.00
Rate for Payer: Cash Price	$44.00
Rate for Payer: Priority Health Cigna Priority Health	$35.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.63
Rate for Payer: Priority Health Narrow Network	$36.63
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$32.12
Rate for Payer: UHC Exchange	$32.12

PR AEP THRESHOLD ESTIMATION MLT FREQUENCIES I&R

Professional

Both

$233.00

Service Code	HCPCS 92652
Min. Negotiated Rate	$93.20
Max. Negotiated Rate	$4,564.51
Rate for Payer: Aetna Commercial	$127.57
Rate for Payer: Aetna Medicare	$116.50
Rate for Payer: BCBS Complete	$93.20
Rate for Payer: BCBS Trust/PPO	$4,564.51
Rate for Payer: BCN Commercial	$165.18
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cash Price	$186.40
Rate for Payer: Priority Health Cigna Priority Health	$151.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$151.98
Rate for Payer: Priority Health Narrow Network	$151.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$132.62
Rate for Payer: UHC Exchange	$132.62

PR AFO ANKLE GAUNTLET PRE OTS

Professional

Both

$73.00

Service Code	HCPCS L1902
Min. Negotiated Rate	$29.20
Max. Negotiated Rate	$70.88
Rate for Payer: Aetna Commercial	$44.96
Rate for Payer: Aetna Medicare	$36.50
Rate for Payer: BCBS Complete	$29.20
Rate for Payer: BCN Commercial	$70.88
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cash Price	$58.40
Rate for Payer: Priority Health Cigna Priority Health	$47.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$40.55
Rate for Payer: UHC Exchange	$40.55

PR AFO MULTILIG ANK SUP PRE OTS

Professional

Both

$110.00

Service Code	HCPCS L1906
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$106.78
Rate for Payer: Aetna Commercial	$67.73
Rate for Payer: Aetna Medicare	$55.00
Rate for Payer: BCBS Complete	$44.00
Rate for Payer: BCN Commercial	$106.78
Rate for Payer: Cash Price	$88.00
Rate for Payer: Cash Price	$88.00
Rate for Payer: Priority Health Cigna Priority Health	$71.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.09
Rate for Payer: UHC Exchange	$61.09

PR AIIV4 VACC INACTIVATED PRSRV FR 0.5ML DOS IM USE

Professional

Both

$182.00

Service Code	HCPCS 90694
Min. Negotiated Rate	$71.68
Max. Negotiated Rate	$118.30
Rate for Payer: Aetna Commercial	$77.36
Rate for Payer: Aetna Medicare	$91.00
Rate for Payer: BCBS Complete	$72.80
Rate for Payer: BCBS Trust/PPO	$77.36
Rate for Payer: BCN Commercial	$71.68
Rate for Payer: Cash Price	$145.60
Rate for Payer: Cash Price	$145.60
Rate for Payer: Priority Health Cigna Priority Health	$118.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$92.83
Rate for Payer: UHC Exchange	$92.83

PR AK SLEEVE SUSP NEOPRENE/EQUA

Professional

Both

$159.00

Service Code	HCPCS L5695
Min. Negotiated Rate	$63.60
Max. Negotiated Rate	$171.39
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$79.50
Rate for Payer: BCBS Complete	$63.60
Rate for Payer: BCN Commercial	$171.39
Rate for Payer: Cash Price	$127.20
Rate for Payer: Cash Price	$127.20
Rate for Payer: Priority Health Cigna Priority Health	$103.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$88.26
Rate for Payer: UHC Exchange	$88.26

PR ALBUTEROL IPRATROP NON-COMP

Professional

Both

$2.00

Service Code	HCPCS J7620
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna Commercial	$0.18
Rate for Payer: Aetna Medicare	$1.00
Rate for Payer: BCBS Complete	$0.80
Rate for Payer: BCN Commercial	$0.02
Rate for Payer: Cash Price	$1.60
Rate for Payer: Cash Price	$1.60
Rate for Payer: Priority Health Cigna Priority Health	$1.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$0.19
Rate for Payer: UHC Exchange	$0.19

PR ALBUTEROL NON-COMP CON

Professional

Both

$2.00

Service Code	HCPCS J7611
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna Commercial	$0.15
Rate for Payer: Aetna Medicare	$1.00
Rate for Payer: BCBS Complete	$0.80
Rate for Payer: BCN Commercial	$0.06
Rate for Payer: Cash Price	$1.60
Rate for Payer: Cash Price	$1.60
Rate for Payer: Priority Health Cigna Priority Health	$1.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$0.17
Rate for Payer: UHC Exchange	$0.17

PR ALBUTEROL NON-COMP UNIT

Professional

Both

$2.00

Service Code	HCPCS J7613
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna Commercial	$0.04
Rate for Payer: Aetna Medicare	$1.00
Rate for Payer: BCBS Complete	$0.80
Rate for Payer: BCN Commercial	$0.01
Rate for Payer: Cash Price	$1.60
Rate for Payer: Cash Price	$1.60
Rate for Payer: Priority Health Cigna Priority Health	$1.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$0.05
Rate for Payer: UHC Exchange	$0.05

PR ALCOHOL AND/OR DRUG SERVICES

Professional

Both

$247.00

Service Code	HCPCS H0015
Min. Negotiated Rate	$98.80
Max. Negotiated Rate	$160.55
Rate for Payer: Aetna Commercial	$134.33
Rate for Payer: Aetna Medicare	$123.50
Rate for Payer: BCBS Complete	$98.80
Rate for Payer: Cash Price	$197.60
Rate for Payer: Cash Price	$197.60
Rate for Payer: Priority Health Cigna Priority Health	$160.55

Know your out-of-pocket cost for care.

All Charges