Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR AMPUTATION TOE METATARSOPHALANGEAL JOINT

Facility

$1,557.00

Service Code	CPT 28820
Hospital Charge Code	28820
Hospital Revenue Code	960
Min. Negotiated Rate	$1,012.05
Max. Negotiated Rate	$4,927.45
Rate for Payer: Aetna Commercial	$1,401.30
Rate for Payer: Aetna Medicare	$3,179.00
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,973.75
Rate for Payer: Amish Plain Church Group Commercial	$3,973.75
Rate for Payer: ASR ASR	$1,510.29
Rate for Payer: ASR Commercial	$1,510.29
Rate for Payer: BCBS Complete	$1,789.14
Rate for Payer: BCBS MAPPO	$3,179.00
Rate for Payer: BCBS Trust/PPO	$1,275.03
Rate for Payer: BCN Commercial	$1,207.14
Rate for Payer: BCN Medicare Advantage	$3,179.00
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Cofinity Commercial	$1,463.58
Rate for Payer: Encore Health Key Benefits Commercial	$1,245.60
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,179.00
Rate for Payer: Healthscope Commercial	$1,557.00
Rate for Payer: Healthscope Whirlpool	$1,510.29
Rate for Payer: Humana Choice PPO Medicare	$3,179.00
Rate for Payer: Mclaren Commercial	$1,401.30
Rate for Payer: Mclaren Medicaid	$1,703.94
Rate for Payer: Mclaren Medicare	$3,179.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,337.95
Rate for Payer: Meridian Medicaid	$1,789.14
Rate for Payer: MI Amish Medical Board Commercial	$3,655.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,323.45
Rate for Payer: Nomi Health Commercial	$1,276.74
Rate for Payer: PACE Medicare	$3,020.05
Rate for Payer: PACE SWMI	$3,179.00
Rate for Payer: PHP Commercial	$3,496.90
Rate for Payer: PHP Medicaid	$1,703.94
Rate for Payer: PHP Medicare Advantage	$3,179.00
Rate for Payer: Priority Health Choice Medicaid	$1,703.94
Rate for Payer: Priority Health Cigna Priority Health	$1,012.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,364.24
Rate for Payer: Priority Health Medicare	$3,179.00
Rate for Payer: Priority Health Narrow Network	$1,091.46
Rate for Payer: Railroad Medicare Medicare	$3,179.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,370.16
Rate for Payer: UHC Dual Complete DSNP	$3,179.00
Rate for Payer: UHC Exchange	$4,927.45
Rate for Payer: UHC Medicare Advantage	$3,179.00
Rate for Payer: UHCCP DNSP	$3,179.00
Rate for Payer: UHCCP Medicaid	$1,703.94
Rate for Payer: VA VA	$3,179.00

PR ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG

Professional

Both

$316.00

Service Code	HCPCS 92603
Min. Negotiated Rate	$75.40
Max. Negotiated Rate	$219.91
Rate for Payer: Aetna Commercial	$133.74
Rate for Payer: Aetna Medicare	$158.00
Rate for Payer: BCBS Complete	$79.17
Rate for Payer: BCN Commercial	$219.91
Rate for Payer: Cash Price	$252.80
Rate for Payer: Cash Price	$252.80
Rate for Payer: Meridian Medicaid	$79.17
Rate for Payer: Priority Health Choice Medicaid	$75.40
Rate for Payer: Priority Health Cigna Priority Health	$205.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$159.21
Rate for Payer: Priority Health Narrow Network	$159.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$132.55
Rate for Payer: UHC Exchange	$132.55
Rate for Payer: UHCCP Medicaid	$75.40

PR ANALYSIS COCHLEAR IMPLT 7 YR/> SBSQ REPRGRMG

Professional

Both

$190.00

Service Code	HCPCS 92604
Min. Negotiated Rate	$41.96
Max. Negotiated Rate	$132.92
Rate for Payer: Aetna Commercial	$74.26
Rate for Payer: Aetna Medicare	$95.00
Rate for Payer: BCBS Complete	$44.06
Rate for Payer: BCN Commercial	$132.92
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Meridian Medicaid	$44.06
Rate for Payer: Priority Health Choice Medicaid	$41.96
Rate for Payer: Priority Health Cigna Priority Health	$123.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$88.20
Rate for Payer: Priority Health Narrow Network	$88.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$74.66
Rate for Payer: UHC Exchange	$74.66
Rate for Payer: UHCCP Medicaid	$41.96

PR ANALYZE NEUROSTIM BRAIN, FIRST 1H

Professional

Both

$507.00

Service Code	HCPCS 95978
Min. Negotiated Rate	$202.80
Max. Negotiated Rate	$329.55
Rate for Payer: Aetna Medicare	$253.50
Rate for Payer: BCBS Complete	$202.80
Rate for Payer: Cash Price	$405.60
Rate for Payer: Priority Health Cigna Priority Health	$329.55

PR ANALYZ NEUROSTIM BRAIN, EACH ADD 30 MIN

Professional

Both

$218.00

Service Code	HCPCS 95979
Min. Negotiated Rate	$87.20
Max. Negotiated Rate	$141.70
Rate for Payer: Aetna Medicare	$109.00
Rate for Payer: BCBS Complete	$87.20
Rate for Payer: Cash Price	$174.40
Rate for Payer: Priority Health Cigna Priority Health	$141.70

PR ANAST ARTL EXTRACRANIAL-INTRACRANIAL ARTERIES

Professional

Both

$7,866.00

Service Code	HCPCS 61711
Min. Negotiated Rate	$134.19
Max. Negotiated Rate	$5,246.52
Rate for Payer: Aetna Commercial	$3,326.27
Rate for Payer: Aetna Medicare	$3,933.00
Rate for Payer: BCBS Complete	$1,778.91
Rate for Payer: BCBS Trust/PPO	$134.19
Rate for Payer: BCN Commercial	$5,246.52
Rate for Payer: Cash Price	$6,292.80
Rate for Payer: Cash Price	$6,292.80
Rate for Payer: Meridian Medicaid	$1,778.91
Rate for Payer: Priority Health Choice Medicaid	$1,694.20
Rate for Payer: Priority Health Cigna Priority Health	$5,112.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,504.23
Rate for Payer: Priority Health Narrow Network	$4,504.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,029.34
Rate for Payer: UHC Exchange	$3,029.34
Rate for Payer: UHCCP Medicaid	$1,694.20

PR ANAST INTRAHEPATC DUCTS & GI TRACT

Professional

Both

$6,161.00

Service Code	HCPCS 47765
Min. Negotiated Rate	$1,935.74
Max. Negotiated Rate	$5,401.56
Rate for Payer: Aetna Commercial	$4,113.75
Rate for Payer: Aetna Medicare	$3,080.50
Rate for Payer: BCBS Complete	$2,032.53
Rate for Payer: BCN Commercial	$4,295.97
Rate for Payer: Cash Price	$4,928.80
Rate for Payer: Cash Price	$4,928.80
Rate for Payer: Meridian Medicaid	$2,032.53
Rate for Payer: Priority Health Choice Medicaid	$1,935.74
Rate for Payer: Priority Health Cigna Priority Health	$4,004.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,401.56
Rate for Payer: Priority Health Narrow Network	$5,401.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,626.11
Rate for Payer: UHC Exchange	$3,626.11
Rate for Payer: UHCCP Medicaid	$1,935.74

PR ANASTOMOSIS FACIAL HYPOGLOSSAL

Professional

Both

$1,858.00

Service Code	HCPCS 64868
Min. Negotiated Rate	$190.19
Max. Negotiated Rate	$1,700.47
Rate for Payer: Aetna Commercial	$1,278.09
Rate for Payer: Aetna Medicare	$929.00
Rate for Payer: BCBS Complete	$666.93
Rate for Payer: BCBS Trust/PPO	$190.19
Rate for Payer: BCN Commercial	$1,459.68
Rate for Payer: Cash Price	$1,486.40
Rate for Payer: Cash Price	$1,486.40
Rate for Payer: Meridian Medicaid	$666.93
Rate for Payer: Priority Health Choice Medicaid	$635.17
Rate for Payer: Priority Health Cigna Priority Health	$1,207.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,700.47
Rate for Payer: Priority Health Narrow Network	$1,700.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,201.84
Rate for Payer: UHC Exchange	$1,201.84
Rate for Payer: UHCCP Medicaid	$635.17

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

Professional

Both

$4,710.00

Service Code	HCPCS 47780
Min. Negotiated Rate	$1,284.83
Max. Negotiated Rate	$4,418.98
Rate for Payer: Aetna Commercial	$3,347.72
Rate for Payer: Aetna Medicare	$2,355.00
Rate for Payer: BCBS Complete	$1,661.72
Rate for Payer: BCBS Trust/PPO	$1,284.83
Rate for Payer: BCN Commercial	$3,600.09
Rate for Payer: Cash Price	$3,768.00
Rate for Payer: Cash Price	$3,768.00
Rate for Payer: Meridian Medicaid	$1,661.72
Rate for Payer: Priority Health Choice Medicaid	$1,582.59
Rate for Payer: Priority Health Cigna Priority Health	$3,061.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,418.98
Rate for Payer: Priority Health Narrow Network	$4,418.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,967.29
Rate for Payer: UHC Exchange	$2,967.29
Rate for Payer: UHCCP Medicaid	$1,582.59

PR ANAST XTRHEPATC BILIARY DUCTS & GI TRACT

Professional

Both

$4,268.00

Service Code	HCPCS 47760
Min. Negotiated Rate	$328.07
Max. Negotiated Rate	$4,021.64
Rate for Payer: Aetna Commercial	$3,045.85
Rate for Payer: Aetna Medicare	$2,134.00
Rate for Payer: BCBS Complete	$1,510.98
Rate for Payer: BCBS Trust/PPO	$328.07
Rate for Payer: BCN Commercial	$3,278.53
Rate for Payer: Cash Price	$3,414.40
Rate for Payer: Cash Price	$3,414.40
Rate for Payer: Meridian Medicaid	$1,510.98
Rate for Payer: Priority Health Choice Medicaid	$1,439.03
Rate for Payer: Priority Health Cigna Priority Health	$2,774.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,021.64
Rate for Payer: Priority Health Narrow Network	$4,021.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,702.65
Rate for Payer: UHC Exchange	$2,702.65
Rate for Payer: UHCCP Medicaid	$1,439.03

PR ANES 2&3 DGR BURN EXC/DBRDMT W/WO GRFG 4-9% TBSA

Professional

Both

$5.00

Service Code	HCPCS 01952
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANES 2&3 DGR BURN EXC/DBRDMT W/WO GRFG <4% TBSA

Professional

Both

$3.00

Service Code	HCPCS 01951
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

PR ANES 2&3 DGR BURN EXC/DBRDMT W/WO GRFG EA 9%TBSA

Professional

Both

$1.00

Service Code	HCPCS 01953
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Medicare	$0.50
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	$0.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$44.50
Rate for Payer: Priority Health Narrow Network	$44.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$55.00
Rate for Payer: UHC Exchange	$55.00

PR ANES ARTERIES FOREARM WRIST & HAND EMBOLECTOMY

Professional

Both

$6.00

Service Code	HCPCS 01842
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna Medicare	$3.00
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$3.90

PR ANES ARTERIES OF KNEE & POPLITEAL AREA NOS

Professional

Both

$8.00

Service Code	HCPCS 01440
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.20
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.20

PR ANES ARTERIES SHOULDER & AXILLA BYPASS GRAFT

Professional

Both

$8.00

Service Code	HCPCS 01654
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$5.20
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.20

PR ANES ARTHROSCOPIC TOTAL SHOULDER REPLACEMENT

Professional

Both

$10.00

Service Code	HCPCS 01638
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$6.50

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	$1.95
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95

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	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

PR ANES ARTHRS INTERTHORACOSCAPULAR AMPUTATION

Professional

Both

$15.00

Service Code	HCPCS 01636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$9.75

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	$5.20
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.20

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	$5.20
Rate for Payer: Aetna Medicare	$4.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Priority Health Cigna Priority Health	$5.20

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	$3.90
Rate for Payer: Aetna Medicare	$3.00
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Priority Health Cigna Priority Health	$3.90

PR ANES ART UPPER LEG W/BYPASS GRAFT FEM ART LIG

Professional

Both

$4.00

Service Code	HCPCS 01272
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna Medicare	$2.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Priority Health Cigna Priority Health	$2.60

PR ANES BONE MARROW ASPIR&/BX ANT/PST ILIAC CREST

Professional

Both

$5.00

Service Code	HCPCS 01112
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25

Know your out-of-pocket cost for care.

All Charges