Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR CARPECTOMY ALL BONES PROXIMAL ROW

Professional

Both

$2,289.00

Service Code	HCPCS 25215
Min. Negotiated Rate	$407.47
Max. Negotiated Rate	$1,487.85
Rate for Payer: Aetna Commercial	$824.12
Rate for Payer: Aetna Medicare	$1,144.50
Rate for Payer: BCBS Complete	$427.84
Rate for Payer: BCBS Trust/PPO	$1,436.98
Rate for Payer: BCN Commercial	$916.27
Rate for Payer: Cash Price	$1,831.20
Rate for Payer: Cash Price	$1,831.20
Rate for Payer: Meridian Medicaid	$427.84
Rate for Payer: Priority Health Choice Medicaid	$407.47
Rate for Payer: Priority Health Cigna Priority Health	$1,487.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$963.27
Rate for Payer: Priority Health Narrow Network	$963.27
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$710.47
Rate for Payer: UHC Exchange	$710.47
Rate for Payer: UHCCP Medicaid	$407.47

PR CARTILAGE GRAFT COSTOCHONDRAL

Professional

Both

$939.00

Service Code	HCPCS 20910
Min. Negotiated Rate	$312.90
Max. Negotiated Rate	$8,557.53
Rate for Payer: Aetna Commercial	$625.78
Rate for Payer: Aetna Medicare	$469.50
Rate for Payer: BCBS Complete	$328.54
Rate for Payer: BCBS Trust/PPO	$8,557.53
Rate for Payer: BCN Commercial	$701.25
Rate for Payer: Cash Price	$751.20
Rate for Payer: Cash Price	$751.20
Rate for Payer: Meridian Medicaid	$328.54
Rate for Payer: Priority Health Choice Medicaid	$312.90
Rate for Payer: Priority Health Cigna Priority Health	$610.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$740.39
Rate for Payer: Priority Health Narrow Network	$740.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$484.56
Rate for Payer: UHC Exchange	$484.56
Rate for Payer: UHCCP Medicaid	$312.90

PR CARTILAGE GRAFT NASAL SEPTUM

Professional

Both

$1,056.00

Service Code	HCPCS 20912
Min. Negotiated Rate	$86.88
Max. Negotiated Rate	$743.95
Rate for Payer: Aetna Commercial	$630.42
Rate for Payer: Aetna Medicare	$528.00
Rate for Payer: BCBS Complete	$327.87
Rate for Payer: BCBS Trust/PPO	$86.88
Rate for Payer: BCN Commercial	$707.61
Rate for Payer: Cash Price	$844.80
Rate for Payer: Cash Price	$844.80
Rate for Payer: Meridian Medicaid	$327.87
Rate for Payer: Priority Health Choice Medicaid	$312.26
Rate for Payer: Priority Health Cigna Priority Health	$686.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$743.95
Rate for Payer: Priority Health Narrow Network	$743.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$557.20
Rate for Payer: UHC Exchange	$557.20
Rate for Payer: UHCCP Medicaid	$312.26

PR CA SCREEN;FLEXI SIGMOIDSCOPE

Facility

$410.00

Service Code	HCPCS G0104
Hospital Charge Code	G0104
Hospital Revenue Code	730
Min. Negotiated Rate	$266.50
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$369.00
Rate for Payer: ASR ASR	$397.70
Rate for Payer: ASR Commercial	$397.70
Rate for Payer: BCBS Trust/PPO	$334.11
Rate for Payer: BCN Commercial	$317.87
Rate for Payer: Cash Price	$328.00
Rate for Payer: Cofinity Commercial	$385.40
Rate for Payer: Encore Health Key Benefits Commercial	$328.00
Rate for Payer: Healthscope Commercial	$410.00
Rate for Payer: Healthscope Whirlpool	$397.70
Rate for Payer: Mclaren Commercial	$369.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$348.50
Rate for Payer: Nomi Health Commercial	$336.20
Rate for Payer: Priority Health Cigna Priority Health	$266.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$360.80

PR CA SCREEN;FLEXI SIGMOIDSCOPE

Professional

Both

$410.00

Service Code	HCPCS G0104
Hospital Charge Code	G0104
Min. Negotiated Rate	$36.21
Max. Negotiated Rate	$1,681.05
Rate for Payer: Aetna Commercial	$54.91
Rate for Payer: Aetna Medicare	$205.00
Rate for Payer: BCBS Complete	$38.02
Rate for Payer: BCBS Trust/PPO	$1,681.05
Rate for Payer: BCN Commercial	$273.17
Rate for Payer: Cash Price	$328.00
Rate for Payer: Cash Price	$328.00
Rate for Payer: Meridian Medicaid	$38.02
Rate for Payer: Priority Health Choice Medicaid	$36.21
Rate for Payer: Priority Health Cigna Priority Health	$266.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$100.83
Rate for Payer: Priority Health Narrow Network	$100.83
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$76.73
Rate for Payer: UHC Exchange	$76.73
Rate for Payer: UHCCP Medicaid	$36.21

PR CA SCREEN;FLEXI SIGMOIDSCOPE

Professional

Both

$410.00

Service Code	HCPCS G0104
Min. Negotiated Rate	$36.21
Max. Negotiated Rate	$1,681.05
Rate for Payer: Aetna Commercial	$54.91
Rate for Payer: Aetna Medicare	$205.00
Rate for Payer: BCBS Complete	$38.02
Rate for Payer: BCBS Trust/PPO	$1,681.05
Rate for Payer: BCN Commercial	$273.17
Rate for Payer: Cash Price	$328.00
Rate for Payer: Cash Price	$328.00
Rate for Payer: Meridian Medicaid	$38.02
Rate for Payer: Priority Health Choice Medicaid	$36.21
Rate for Payer: Priority Health Cigna Priority Health	$266.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$100.83
Rate for Payer: Priority Health Narrow Network	$100.83
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$76.73
Rate for Payer: UHC Exchange	$76.73
Rate for Payer: UHCCP Medicaid	$36.21

PR CA SCREEN;FLEXI SIGMOIDSCOPE

Facility

$410.00

Service Code	HCPCS G0104
Hospital Charge Code	G0104
Hospital Revenue Code	730
Min. Negotiated Rate	$266.50
Max. Negotiated Rate	$1,384.58
Rate for Payer: Aetna Commercial	$369.00
Rate for Payer: Aetna Medicare	$893.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,116.60
Rate for Payer: Amish Plain Church Group Commercial	$1,116.60
Rate for Payer: ASR ASR	$397.70
Rate for Payer: ASR Commercial	$397.70
Rate for Payer: BCBS Complete	$502.74
Rate for Payer: BCBS MAPPO	$893.28
Rate for Payer: BCBS Trust/PPO	$335.75
Rate for Payer: BCN Commercial	$317.87
Rate for Payer: BCN Medicare Advantage	$893.28
Rate for Payer: Cash Price	$328.00
Rate for Payer: Cash Price	$328.00
Rate for Payer: Cofinity Commercial	$385.40
Rate for Payer: Encore Health Key Benefits Commercial	$328.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$893.28
Rate for Payer: Healthscope Commercial	$410.00
Rate for Payer: Healthscope Whirlpool	$397.70
Rate for Payer: Humana Choice PPO Medicare	$893.28
Rate for Payer: Mclaren Commercial	$369.00
Rate for Payer: Mclaren Medicaid	$478.80
Rate for Payer: Mclaren Medicare	$893.28
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$937.94
Rate for Payer: Meridian Medicaid	$502.74
Rate for Payer: MI Amish Medical Board Commercial	$1,027.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$348.50
Rate for Payer: Nomi Health Commercial	$336.20
Rate for Payer: PACE Medicare	$848.62
Rate for Payer: PACE SWMI	$893.28
Rate for Payer: PHP Commercial	$982.61
Rate for Payer: PHP Medicaid	$478.80
Rate for Payer: PHP Medicare Advantage	$893.28
Rate for Payer: Priority Health Choice Medicaid	$478.80
Rate for Payer: Priority Health Cigna Priority Health	$266.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$359.24
Rate for Payer: Priority Health Medicare	$893.28
Rate for Payer: Priority Health Narrow Network	$287.41
Rate for Payer: Railroad Medicare Medicare	$893.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$360.80
Rate for Payer: UHC Dual Complete DSNP	$893.28
Rate for Payer: UHC Exchange	$1,384.58
Rate for Payer: UHC Medicare Advantage	$893.28
Rate for Payer: UHCCP DNSP	$893.28
Rate for Payer: UHCCP Medicaid	$478.80
Rate for Payer: VA VA	$893.28

PR CA SCREEN;PELVIC/BREAST EXAM

Professional

Both

$68.00

Service Code	HCPCS G0101
Min. Negotiated Rate	$17.25
Max. Negotiated Rate	$1,696.90
Rate for Payer: Aetna Commercial	$27.24
Rate for Payer: Aetna Medicare	$34.00
Rate for Payer: BCBS Complete	$18.11
Rate for Payer: BCBS Trust/PPO	$1,696.90
Rate for Payer: BCN Commercial	$57.17
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cash Price	$54.40
Rate for Payer: Meridian Medicaid	$18.11
Rate for Payer: Priority Health Choice Medicaid	$17.25
Rate for Payer: Priority Health Cigna Priority Health	$44.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.80
Rate for Payer: Priority Health Narrow Network	$36.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.89
Rate for Payer: UHC Exchange	$36.89
Rate for Payer: UHCCP Medicaid	$17.25

PR CAST SUP GAUNTLET FIBERGLASS

Professional

Both

$56.00

Service Code	HCPCS Q4014
Min. Negotiated Rate	$14.37
Max. Negotiated Rate	$36.40
Rate for Payer: Aetna Commercial	$22.26
Rate for Payer: Aetna Medicare	$28.00
Rate for Payer: BCBS Complete	$22.40
Rate for Payer: BCN Commercial	$26.15
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cash Price	$44.80
Rate for Payer: Priority Health Cigna Priority Health	$36.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$14.37
Rate for Payer: UHC Exchange	$14.37

PR CAST SUP LNG ARM SPLINT FBRG

Professional

Both

$26.00

Service Code	HCPCS Q4018
Min. Negotiated Rate	$7.85
Max. Negotiated Rate	$16.90
Rate for Payer: Aetna Commercial	$12.17
Rate for Payer: Aetna Medicare	$13.00
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: BCN Commercial	$14.28
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Priority Health Cigna Priority Health	$16.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7.85
Rate for Payer: UHC Exchange	$7.85

PR CAST SUP LNG ARM SPLINT PLST

Professional

Both

$43.00

Service Code	HCPCS Q4017
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$27.95
Rate for Payer: Aetna Commercial	$7.63
Rate for Payer: Aetna Medicare	$21.50
Rate for Payer: BCBS Complete	$17.20
Rate for Payer: BCN Commercial	$8.96
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cash Price	$34.40
Rate for Payer: Priority Health Cigna Priority Health	$27.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.93
Rate for Payer: UHC Exchange	$4.93

PR CAST SUP LNG ARM SPLNT PED F

Professional

Both

$24.00

Service Code	HCPCS Q4020
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$15.60
Rate for Payer: Aetna Commercial	$6.10
Rate for Payer: Aetna Medicare	$12.00
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	$15.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.93
Rate for Payer: UHC Exchange	$3.93

PR CAST SUP LNG LEG CYLINDER FB

Professional

Both

$100.00

Service Code	HCPCS Q4034
Min. Negotiated Rate	$36.26
Max. Negotiated Rate	$65.98
Rate for Payer: Aetna Commercial	$56.19
Rate for Payer: Aetna Medicare	$50.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: BCN Commercial	$65.98
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Priority Health Cigna Priority Health	$65.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.26
Rate for Payer: UHC Exchange	$36.26

PR CAST SUP LNGLEG CYLNDR PED F

Professional

Both

$51.00

Service Code	HCPCS Q4036
Min. Negotiated Rate	$18.14
Max. Negotiated Rate	$33.15
Rate for Payer: Aetna Commercial	$28.11
Rate for Payer: Aetna Medicare	$25.50
Rate for Payer: BCBS Complete	$20.40
Rate for Payer: BCN Commercial	$33.01
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cash Price	$40.80
Rate for Payer: Priority Health Cigna Priority Health	$33.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$18.14
Rate for Payer: UHC Exchange	$18.14

PR CAST SUP LNG LEG PED FBRGLS

Professional

Both

$53.00

Service Code	HCPCS Q4032
Min. Negotiated Rate	$20.57
Max. Negotiated Rate	$37.44
Rate for Payer: Aetna Commercial	$31.89
Rate for Payer: Aetna Medicare	$26.50
Rate for Payer: BCBS Complete	$21.20
Rate for Payer: BCN Commercial	$37.44
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cash Price	$42.40
Rate for Payer: Priority Health Cigna Priority Health	$34.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.57
Rate for Payer: UHC Exchange	$20.57

PR CAST SUP LNG LEG SPLNT FBRGL

Professional

Both

$77.00

Service Code	HCPCS Q4042
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$50.05
Rate for Payer: Aetna Commercial	$28.62
Rate for Payer: Aetna Medicare	$38.50
Rate for Payer: BCBS Complete	$30.80
Rate for Payer: BCN Commercial	$33.60
Rate for Payer: Cash Price	$61.60
Rate for Payer: Cash Price	$61.60
Rate for Payer: Priority Health Cigna Priority Health	$50.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$18.46
Rate for Payer: UHC Exchange	$18.46

PR CAST SUP LNG LEG SPLNT PED F

Professional

Both

$39.00

Service Code	HCPCS Q4044
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$25.35
Rate for Payer: Aetna Commercial	$14.32
Rate for Payer: Aetna Medicare	$19.50
Rate for Payer: BCBS Complete	$15.60
Rate for Payer: BCN Commercial	$16.82
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Priority Health Cigna Priority Health	$25.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.23
Rate for Payer: UHC Exchange	$9.23

PR CAST SUP LONG ARM ADULT FBRG

Professional

Both

$56.00

Service Code	HCPCS Q4006
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$36.40
Rate for Payer: Aetna Commercial	$24.48
Rate for Payer: Aetna Medicare	$28.00
Rate for Payer: BCBS Complete	$22.40
Rate for Payer: BCN Commercial	$28.75
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cash Price	$44.80
Rate for Payer: Priority Health Cigna Priority Health	$36.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15.80
Rate for Payer: UHC Exchange	$15.80

PR CAST SUP LONG ARM PED FBRGLS

Professional

Both

$26.00

Service Code	HCPCS Q4008
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$16.90
Rate for Payer: Aetna Commercial	$12.24
Rate for Payer: Aetna Medicare	$13.00
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: BCN Commercial	$14.36
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Priority Health Cigna Priority Health	$16.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7.90
Rate for Payer: UHC Exchange	$7.90

PR CAST SUP LONG LEG FIBERGLASS

Professional

Both

$116.00

Service Code	HCPCS Q4030
Min. Negotiated Rate	$41.15
Max. Negotiated Rate	$75.40
Rate for Payer: Aetna Commercial	$63.77
Rate for Payer: Aetna Medicare	$58.00
Rate for Payer: BCBS Complete	$46.40
Rate for Payer: BCN Commercial	$74.88
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cash Price	$92.80
Rate for Payer: Priority Health Cigna Priority Health	$75.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$41.15
Rate for Payer: UHC Exchange	$41.15

PR CAST SUPPLIES UNLISTED

Professional

Both

$102.00

Service Code	HCPCS Q4050
Min. Negotiated Rate	$25.00
Max. Negotiated Rate	$66.30
Rate for Payer: Aetna Medicare	$51.00
Rate for Payer: BCBS Complete	$40.80
Rate for Payer: BCN Commercial	$25.00
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Priority Health Cigna Priority Health	$66.30

PR CAST SUP SHOULDER CAST FBRGL

Professional

Both

$154.00

Service Code	HCPCS Q4004
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$119.78
Rate for Payer: Aetna Commercial	$102.02
Rate for Payer: Aetna Medicare	$77.00
Rate for Payer: BCBS Complete	$61.60
Rate for Payer: BCN Commercial	$119.78
Rate for Payer: Cash Price	$123.20
Rate for Payer: Cash Price	$123.20
Rate for Payer: Priority Health Cigna Priority Health	$100.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$65.83
Rate for Payer: UHC Exchange	$65.83

PR CAST SUP SHRT LEG FIBERGLASS

Professional

Both

$61.00

Service Code	HCPCS Q4038
Min. Negotiated Rate	$22.28
Max. Negotiated Rate	$40.55
Rate for Payer: Aetna Commercial	$34.52
Rate for Payer: Aetna Medicare	$30.50
Rate for Payer: BCBS Complete	$24.40
Rate for Payer: BCN Commercial	$40.55
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Priority Health Cigna Priority Health	$39.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.28
Rate for Payer: UHC Exchange	$22.28

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: Aetna Medicare	$10.50
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	$13.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$11.14
Rate for Payer: UHC Exchange	$11.14

PR CAST SUP SHT ARM ADULT FBRGL

Professional

Both

$43.00

Service Code	HCPCS Q4010
Min. Negotiated Rate	$10.54
Max. Negotiated Rate	$27.95
Rate for Payer: Aetna Commercial	$16.32
Rate for Payer: Aetna Medicare	$21.50
Rate for Payer: BCBS Complete	$17.20
Rate for Payer: BCN Commercial	$19.16
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cash Price	$34.40
Rate for Payer: Priority Health Cigna Priority Health	$27.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.54
Rate for Payer: UHC Exchange	$10.54

Know your out-of-pocket cost for care.

All Charges