Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR B1 GRF FEM H/N INTERTRCHNTRIC/SUBTRCHNTRIC AREA

Professional

Both

$2,174.00

Service Code	HCPCS 27170
Min. Negotiated Rate	$869.60
Max. Negotiated Rate	$1,625.44
Rate for Payer: Aetna Commercial	$1,512.57
Rate for Payer: Aetna Medicare	$1,128.78
Rate for Payer: BCBS Complete	$869.60
Rate for Payer: BCBS MAPPO	$1,128.78
Rate for Payer: BCN Medicare Advantage	$1,128.78
Rate for Payer: Cash Price	$1,739.20
Rate for Payer: Cash Price	$1,739.20
Rate for Payer: Cofinity Commercial	$1,625.44
Rate for Payer: Cofinity Commercial	$1,512.57
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,128.78
Rate for Payer: Healthscope Commercial	$1,354.54
Rate for Payer: Healthscope Whirlpool	$1,354.54
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,185.22
Rate for Payer: Nomi Health Commercial	$1,354.54
Rate for Payer: PACE SWMI	$1,128.78
Rate for Payer: PHP Medicare Advantage	$1,128.78
Rate for Payer: Priority Health Cigna Priority Health	$1,413.10
Rate for Payer: Priority Health Medicare	$1,128.78
Rate for Payer: UHC Dual Complete DSNP	$1,128.78
Rate for Payer: UHC Medicare Advantage	$1,128.78
Rate for Payer: UHCCP DNSP	$1,128.78

PR BACILLUS CALMETTE-GUERIN VACCINE INTRAVESICAL

Professional

Both

$273.00

Service Code	HCPCS 90586
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$234.69
Rate for Payer: Aetna Commercial	$218.39
Rate for Payer: Aetna Medicare	$162.98
Rate for Payer: BCBS Complete	$109.20
Rate for Payer: BCBS MAPPO	$162.98
Rate for Payer: BCN Medicare Advantage	$162.98
Rate for Payer: Cash Price	$218.40
Rate for Payer: Cash Price	$218.40
Rate for Payer: Cofinity Commercial	$234.69
Rate for Payer: Cofinity Commercial	$218.39
Rate for Payer: Health Alliance Plan Medicare Advantage	$162.98
Rate for Payer: Healthscope Commercial	$195.58
Rate for Payer: Healthscope Whirlpool	$195.58
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$171.13
Rate for Payer: Nomi Health Commercial	$195.58
Rate for Payer: PACE SWMI	$162.98
Rate for Payer: PHP Medicare Advantage	$162.98
Rate for Payer: Priority Health Cigna Priority Health	$177.45
Rate for Payer: Priority Health Medicare	$162.98
Rate for Payer: UHC Dual Complete DSNP	$162.98
Rate for Payer: UHC Medicare Advantage	$162.98
Rate for Payer: UHCCP DNSP	$162.98

PR BALLN ANGIOPLASTY OPEN,BRACHCEPH

Professional

Both

$958.00

Service Code	HCPCS 35458
Min. Negotiated Rate	$383.20
Max. Negotiated Rate	$622.70
Rate for Payer: Aetna Medicare	$479.00
Rate for Payer: BCBS Complete	$383.20
Rate for Payer: Cash Price	$766.40
Rate for Payer: Priority Health Cigna Priority Health	$622.70

PR BALLN ANGIOPLASTY PERC,AORTIC

Professional

Both

$689.00

Service Code	HCPCS 35472
Min. Negotiated Rate	$275.60
Max. Negotiated Rate	$447.85
Rate for Payer: Aetna Medicare	$344.50
Rate for Payer: BCBS Complete	$275.60
Rate for Payer: Cash Price	$551.20
Rate for Payer: Priority Health Cigna Priority Health	$447.85

PR BALLN ANGIOPLASTY PERC,BRACHIOCEPH

Professional

Both

$2,039.00

Service Code	HCPCS 35475
Min. Negotiated Rate	$815.60
Max. Negotiated Rate	$1,325.35
Rate for Payer: Aetna Medicare	$1,019.50
Rate for Payer: BCBS Complete	$815.60
Rate for Payer: Cash Price	$1,631.20
Rate for Payer: Priority Health Cigna Priority Health	$1,325.35

PR BALLN ANGIOPLASTY,PERC VENOUS

Professional

Both

$3,441.00

Service Code	HCPCS 35476
Min. Negotiated Rate	$1,376.40
Max. Negotiated Rate	$2,236.65
Rate for Payer: Aetna Medicare	$1,720.50
Rate for Payer: BCBS Complete	$1,376.40
Rate for Payer: Cash Price	$2,752.80
Rate for Payer: Priority Health Cigna Priority Health	$2,236.65

PR BALLN ANGIOPLASTY PERC,VISCERAL

Professional

Both

$2,857.00

Service Code	HCPCS 35471
Min. Negotiated Rate	$1,142.80
Max. Negotiated Rate	$1,857.05
Rate for Payer: Aetna Medicare	$1,428.50
Rate for Payer: BCBS Complete	$1,142.80
Rate for Payer: Cash Price	$2,285.60
Rate for Payer: Priority Health Cigna Priority Health	$1,857.05

PR BALLOON ANGIOPLASTY INTRACRANIAL PERCUTANEOUS

Professional

Both

$4,922.00

Service Code	HCPCS 61630
Min. Negotiated Rate	$1,331.64
Max. Negotiated Rate	$3,199.30
Rate for Payer: Aetna Commercial	$1,784.40
Rate for Payer: Aetna Medicare	$1,331.64
Rate for Payer: BCBS Complete	$1,968.80
Rate for Payer: BCBS MAPPO	$1,331.64
Rate for Payer: BCN Medicare Advantage	$1,331.64
Rate for Payer: Cash Price	$3,937.60
Rate for Payer: Cash Price	$3,937.60
Rate for Payer: Cofinity Commercial	$1,917.56
Rate for Payer: Cofinity Commercial	$1,784.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,331.64
Rate for Payer: Healthscope Commercial	$1,597.97
Rate for Payer: Healthscope Whirlpool	$1,597.97
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,398.22
Rate for Payer: Nomi Health Commercial	$1,597.97
Rate for Payer: PACE SWMI	$1,331.64
Rate for Payer: PHP Medicare Advantage	$1,331.64
Rate for Payer: Priority Health Cigna Priority Health	$3,199.30
Rate for Payer: Priority Health Medicare	$1,331.64
Rate for Payer: UHC Dual Complete DSNP	$1,331.64
Rate for Payer: UHC Medicare Advantage	$1,331.64
Rate for Payer: UHCCP DNSP	$1,331.64

PR BALLOON DILAT BILIARY DUCT/AMPULLA PRQ EACH DUCT

Professional

Both

$1,175.00

Service Code	HCPCS 47542
Min. Negotiated Rate	$127.35
Max. Negotiated Rate	$763.75
Rate for Payer: Aetna Commercial	$170.65
Rate for Payer: Aetna Medicare	$127.35
Rate for Payer: BCBS Complete	$470.00
Rate for Payer: BCBS MAPPO	$127.35
Rate for Payer: BCN Medicare Advantage	$127.35
Rate for Payer: Cash Price	$940.00
Rate for Payer: Cash Price	$940.00
Rate for Payer: Cofinity Commercial	$183.38
Rate for Payer: Cofinity Commercial	$170.65
Rate for Payer: Health Alliance Plan Medicare Advantage	$127.35
Rate for Payer: Healthscope Commercial	$152.82
Rate for Payer: Healthscope Whirlpool	$152.82
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$133.72
Rate for Payer: Nomi Health Commercial	$152.82
Rate for Payer: PACE SWMI	$127.35
Rate for Payer: PHP Medicare Advantage	$127.35
Rate for Payer: Priority Health Cigna Priority Health	$763.75
Rate for Payer: Priority Health Medicare	$127.35
Rate for Payer: UHC Dual Complete DSNP	$127.35
Rate for Payer: UHC Medicare Advantage	$127.35
Rate for Payer: UHCCP DNSP	$127.35

PR BALLOON DILAT INTRACRANIAL VASOSPASM PRQ INITIAL

Professional

Both

$986.00

Service Code	HCPCS 61640
Min. Negotiated Rate	$394.40
Max. Negotiated Rate	$640.90
Rate for Payer: Aetna Medicare	$493.00
Rate for Payer: BCBS Complete	$394.40
Rate for Payer: Cash Price	$788.80
Rate for Payer: Priority Health Cigna Priority Health	$640.90

PR BALLOON DILAT URETERAL STRICTURE W/IMG GID RS&I

Professional

Both

$1,921.00

Service Code	HCPCS 50706
Min. Negotiated Rate	$170.13
Max. Negotiated Rate	$1,248.65
Rate for Payer: Aetna Commercial	$227.97
Rate for Payer: Aetna Medicare	$170.13
Rate for Payer: BCBS Complete	$768.40
Rate for Payer: BCBS MAPPO	$170.13
Rate for Payer: BCN Medicare Advantage	$170.13
Rate for Payer: Cash Price	$1,536.80
Rate for Payer: Cash Price	$1,536.80
Rate for Payer: Cofinity Commercial	$244.99
Rate for Payer: Cofinity Commercial	$227.97
Rate for Payer: Health Alliance Plan Medicare Advantage	$170.13
Rate for Payer: Healthscope Commercial	$204.16
Rate for Payer: Healthscope Whirlpool	$204.16
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$178.64
Rate for Payer: Nomi Health Commercial	$204.16
Rate for Payer: PACE SWMI	$170.13
Rate for Payer: PHP Medicare Advantage	$170.13
Rate for Payer: Priority Health Cigna Priority Health	$1,248.65
Rate for Payer: Priority Health Medicare	$170.13
Rate for Payer: UHC Dual Complete DSNP	$170.13
Rate for Payer: UHC Medicare Advantage	$170.13
Rate for Payer: UHCCP DNSP	$170.13

PR BCG LIVE INTRAVESICAL VAC

Professional

Both

$180.00

Service Code	HCPCS J9031
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: BCBS Complete	$72.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Priority Health Cigna Priority Health	$117.00

PR BCN APNEALINK PLUS

Professional

Both

$753.00

Service Code	HCPCS 00119
Hospital Revenue Code	960
Min. Negotiated Rate	$301.20
Max. Negotiated Rate	$489.45
Rate for Payer: Aetna Medicare	$376.50
Rate for Payer: BCBS Complete	$301.20
Rate for Payer: Cash Price	$602.40
Rate for Payer: Priority Health Cigna Priority Health	$489.45

PR BCN WATCHPAT

Professional

Both

$559.00

Service Code	HCPCS 00120
Hospital Revenue Code	960
Min. Negotiated Rate	$223.60
Max. Negotiated Rate	$363.35
Rate for Payer: Aetna Medicare	$279.50
Rate for Payer: BCBS Complete	$223.60
Rate for Payer: Cash Price	$447.20
Rate for Payer: Priority Health Cigna Priority Health	$363.35

PR BEDSIDE DRAINAGE BAG

Professional

Both

$15.00

Service Code	HCPCS A4357
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$19.54
Rate for Payer: Aetna Commercial	$18.18
Rate for Payer: Aetna Medicare	$13.57
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: BCBS MAPPO	$13.57
Rate for Payer: BCN Medicare Advantage	$13.57
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cofinity Commercial	$19.54
Rate for Payer: Cofinity Commercial	$18.18
Rate for Payer: Health Alliance Plan Medicare Advantage	$13.57
Rate for Payer: Healthscope Commercial	$16.28
Rate for Payer: Healthscope Whirlpool	$16.28
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$14.25
Rate for Payer: Nomi Health Commercial	$16.28
Rate for Payer: PACE SWMI	$13.57
Rate for Payer: PHP Medicare Advantage	$13.57
Rate for Payer: Priority Health Cigna Priority Health	$9.75
Rate for Payer: Priority Health Medicare	$13.57
Rate for Payer: UHC Dual Complete DSNP	$13.57
Rate for Payer: UHC Medicare Advantage	$13.57
Rate for Payer: UHCCP DNSP	$13.57

PR BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT

Professional

Both

$11.00

Service Code	HCPCS 96127
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$7.15
Rate for Payer: Aetna Commercial	$5.64
Rate for Payer: Aetna Medicare	$4.21
Rate for Payer: BCBS Complete	$4.40
Rate for Payer: BCBS MAPPO	$4.21
Rate for Payer: BCN Medicare Advantage	$4.21
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cofinity Commercial	$6.06
Rate for Payer: Cofinity Commercial	$5.64
Rate for Payer: Health Alliance Plan Medicare Advantage	$4.21
Rate for Payer: Healthscope Commercial	$5.05
Rate for Payer: Healthscope Whirlpool	$5.05
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$4.42
Rate for Payer: Nomi Health Commercial	$5.05
Rate for Payer: PACE SWMI	$4.21
Rate for Payer: PHP Medicare Advantage	$4.21
Rate for Payer: Priority Health Cigna Priority Health	$7.15
Rate for Payer: Priority Health Medicare	$4.21
Rate for Payer: UHC Dual Complete DSNP	$4.21
Rate for Payer: UHC Medicare Advantage	$4.21
Rate for Payer: UHCCP DNSP	$4.21

PR BEHAV HLTH DAY TREAT, PER HR

Professional

Both

$550.00

Service Code	HCPCS H2012
Min. Negotiated Rate	$220.00
Max. Negotiated Rate	$357.50
Rate for Payer: Aetna Medicare	$275.00
Rate for Payer: BCBS Complete	$220.00
Rate for Payer: Cash Price	$440.00
Rate for Payer: Priority Health Cigna Priority Health	$357.50

PR BEHAVIORAL & QUALIT ANALYSIS VOICE AND RESONANCE

Professional

Both

$180.00

Service Code	HCPCS 92524
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$148.59
Rate for Payer: Aetna Commercial	$138.27
Rate for Payer: Aetna Medicare	$103.19
Rate for Payer: BCBS Complete	$72.00
Rate for Payer: BCBS MAPPO	$103.19
Rate for Payer: BCN Medicare Advantage	$103.19
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cofinity Commercial	$148.59
Rate for Payer: Cofinity Commercial	$138.27
Rate for Payer: Health Alliance Plan Medicare Advantage	$103.19
Rate for Payer: Healthscope Commercial	$123.83
Rate for Payer: Healthscope Whirlpool	$123.83
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$108.35
Rate for Payer: Nomi Health Commercial	$123.83
Rate for Payer: PACE SWMI	$103.19
Rate for Payer: PHP Medicare Advantage	$103.19
Rate for Payer: Priority Health Cigna Priority Health	$117.00
Rate for Payer: Priority Health Medicare	$103.19
Rate for Payer: UHC Dual Complete DSNP	$103.19
Rate for Payer: UHC Medicare Advantage	$103.19
Rate for Payer: UHCCP DNSP	$103.19

PR BEHAVIOR COUNSEL OBESITY 15M

Professional

Both

$45.00

Service Code	HCPCS G0447
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$41.17
Rate for Payer: Aetna Commercial	$38.31
Rate for Payer: Aetna Medicare	$28.59
Rate for Payer: BCBS Complete	$18.00
Rate for Payer: BCBS MAPPO	$28.59
Rate for Payer: BCN Medicare Advantage	$28.59
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cofinity Commercial	$41.17
Rate for Payer: Cofinity Commercial	$38.31
Rate for Payer: Health Alliance Plan Medicare Advantage	$28.59
Rate for Payer: Healthscope Commercial	$34.31
Rate for Payer: Healthscope Whirlpool	$34.31
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$30.02
Rate for Payer: Nomi Health Commercial	$34.31
Rate for Payer: PACE SWMI	$28.59
Rate for Payer: PHP Medicare Advantage	$28.59
Rate for Payer: Priority Health Cigna Priority Health	$29.25
Rate for Payer: Priority Health Medicare	$28.59
Rate for Payer: UHC Dual Complete DSNP	$28.59
Rate for Payer: UHC Medicare Advantage	$28.59
Rate for Payer: UHCCP DNSP	$28.59

PR BEHAVIOR ID ASSESSMENT BY PHYS/QHP EA 15 MIN

Professional

Both

$62.00

Service Code	HCPCS 97151
Min. Negotiated Rate	$24.80
Max. Negotiated Rate	$40.30
Rate for Payer: Aetna Medicare	$31.00
Rate for Payer: BCBS Complete	$24.80
Rate for Payer: Cash Price	$49.60
Rate for Payer: Priority Health Cigna Priority Health	$40.30

PR BETAMETHASONE ACET&SOD PHOSP

Professional

Both

$10.00

Service Code	HCPCS J0702
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$10.02
Rate for Payer: Aetna Commercial	$9.33
Rate for Payer: Aetna Medicare	$6.96
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS MAPPO	$6.96
Rate for Payer: BCN Medicare Advantage	$6.96
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$9.33
Rate for Payer: Cofinity Commercial	$10.02
Rate for Payer: Health Alliance Plan Medicare Advantage	$6.96
Rate for Payer: Healthscope Commercial	$8.35
Rate for Payer: Healthscope Whirlpool	$8.35
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$7.31
Rate for Payer: Nomi Health Commercial	$8.35
Rate for Payer: PACE SWMI	$6.96
Rate for Payer: PHP Medicare Advantage	$6.96
Rate for Payer: Priority Health Cigna Priority Health	$6.50
Rate for Payer: Priority Health Medicare	$6.96
Rate for Payer: UHC Dual Complete DSNP	$6.96
Rate for Payer: UHC Medicare Advantage	$6.96
Rate for Payer: UHCCP DNSP	$6.96

PR BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT

Professional

Both

$168.00

Service Code	HCPCS 90912
Min. Negotiated Rate	$40.06
Max. Negotiated Rate	$109.20
Rate for Payer: Aetna Commercial	$53.68
Rate for Payer: Aetna Medicare	$40.06
Rate for Payer: BCBS Complete	$67.20
Rate for Payer: BCBS MAPPO	$40.06
Rate for Payer: BCN Medicare Advantage	$40.06
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cofinity Commercial	$57.69
Rate for Payer: Cofinity Commercial	$53.68
Rate for Payer: Health Alliance Plan Medicare Advantage	$40.06
Rate for Payer: Healthscope Commercial	$48.07
Rate for Payer: Healthscope Whirlpool	$48.07
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$42.06
Rate for Payer: Nomi Health Commercial	$48.07
Rate for Payer: PACE SWMI	$40.06
Rate for Payer: PHP Medicare Advantage	$40.06
Rate for Payer: Priority Health Cigna Priority Health	$109.20
Rate for Payer: Priority Health Medicare	$40.06
Rate for Payer: UHC Dual Complete DSNP	$40.06
Rate for Payer: UHC Medicare Advantage	$40.06
Rate for Payer: UHCCP DNSP	$40.06

PR BIA WHOLE BODY COMPOSITION ASSESSMENT W/I&R

Professional

Both

$32.00

Service Code	HCPCS 0358T
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna Medicare	$16.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Priority Health Cigna Priority Health	$20.80

PR BILATERAL GYNECOMASTIA

Professional

Both

$3,264.00

Service Code	HCPCS 00524
Hospital Revenue Code	990
Min. Negotiated Rate	$1,305.60
Max. Negotiated Rate	$2,121.60
Rate for Payer: Aetna Medicare	$1,632.00
Rate for Payer: BCBS Complete	$1,305.60
Rate for Payer: Cash Price	$2,611.20
Rate for Payer: Priority Health Cigna Priority Health	$2,121.60

PR BILATERAL MASTOPEXY

Professional

Both

$3,876.00

Service Code	HCPCS 00525
Hospital Revenue Code	990
Min. Negotiated Rate	$1,550.40
Max. Negotiated Rate	$2,519.40
Rate for Payer: Aetna Medicare	$1,938.00
Rate for Payer: BCBS Complete	$1,550.40
Rate for Payer: Cash Price	$3,100.80
Rate for Payer: Priority Health Cigna Priority Health	$2,519.40

Know your out-of-pocket cost for care.

All Charges