Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR CBHC MAILING CHARGE

Professional

Both

$46.00

Service Code	HCPCS 00584
Hospital Revenue Code	990
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$29.90
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$29.90

PR CBHC RECASE BTE

Professional

Both

$61.00

Service Code	HCPCS 00582
Hospital Revenue Code	990
Min. Negotiated Rate	$24.40
Max. Negotiated Rate	$39.65
Rate for Payer: Aetna Medicare	$30.50
Rate for Payer: BCBS Complete	$24.40
Rate for Payer: Cash Price	$48.80
Rate for Payer: Priority Health Cigna Priority Health	$39.65

PR CBHC RECASE ITE

Professional

Both

$179.00

Service Code	HCPCS 00583
Hospital Revenue Code	990
Min. Negotiated Rate	$71.60
Max. Negotiated Rate	$116.35
Rate for Payer: Aetna Medicare	$89.50
Rate for Payer: BCBS Complete	$71.60
Rate for Payer: Cash Price	$143.20
Rate for Payer: Priority Health Cigna Priority Health	$116.35

PR CBHC REPAIR 5 YRS AND OLDER

Professional

Both

$434.00

Service Code	HCPCS 00589
Hospital Revenue Code	990
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$282.10
Rate for Payer: Aetna Medicare	$217.00
Rate for Payer: BCBS Complete	$173.60
Rate for Payer: Cash Price	$347.20
Rate for Payer: Priority Health Cigna Priority Health	$282.10

PR CBHC REPAIR DIGITAL/CIC

Professional

Both

$306.00

Service Code	HCPCS 00588
Hospital Revenue Code	990
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna Medicare	$153.00
Rate for Payer: BCBS Complete	$122.40
Rate for Payer: Cash Price	$244.80
Rate for Payer: Priority Health Cigna Priority Health	$198.90

PR CBHC REPAIR RECEIVER

Professional

Both

$128.00

Service Code	HCPCS 00587
Hospital Revenue Code	990
Min. Negotiated Rate	$51.20
Max. Negotiated Rate	$83.20
Rate for Payer: Aetna Medicare	$64.00
Rate for Payer: BCBS Complete	$51.20
Rate for Payer: Cash Price	$102.40
Rate for Payer: Priority Health Cigna Priority Health	$83.20

PR CCIIV3 VACCINE ABX FREE 0.5 ML FOR IM USE

Professional

Both

$43.00

Service Code	HCPCS 90661
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$38.94
Rate for Payer: Aetna Commercial	$19.94
Rate for Payer: Aetna Medicare	$21.50
Rate for Payer: BCBS Complete	$17.20
Rate for Payer: BCBS Trust/PPO	$17.00
Rate for Payer: BCN Commercial	$17.00
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	$38.94
Rate for Payer: UHC Exchange	$38.94

PR CCIIV4 VACCINE ANTIBIOTIC FREE 0.5 ML DOS IM USE

Professional

Both

$68.00

Service Code	HCPCS 90756
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$44.20
Rate for Payer: Aetna Commercial	$32.37
Rate for Payer: Aetna Medicare	$34.00
Rate for Payer: BCBS Complete	$27.20
Rate for Payer: BCBS Trust/PPO	$33.00
Rate for Payer: BCN Commercial	$17.00
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cash Price	$54.40
Rate for Payer: Priority Health Cigna Priority Health	$44.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$38.84
Rate for Payer: UHC Exchange	$38.84

PR CCIIV4 VACCINE PRESERVATIVE FREE 0.5 ML IM USE

Professional

Both

$73.00

Service Code	HCPCS 90674
Min. Negotiated Rate	$29.20
Max. Negotiated Rate	$47.45
Rate for Payer: Aetna Commercial	$34.17
Rate for Payer: Aetna Medicare	$36.50
Rate for Payer: BCBS Complete	$29.20
Rate for Payer: BCBS Trust/PPO	$33.98
Rate for Payer: BCN Commercial	$33.98
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	$41.00
Rate for Payer: UHC Exchange	$41.00

PR CCM/BHI BY RHC/FQHC 20MIN MO

Professional

Both

$251.00

Service Code	HCPCS G0511
Min. Negotiated Rate	$30.74
Max. Negotiated Rate	$589.58
Rate for Payer: Aetna Commercial	$63.19
Rate for Payer: Aetna Medicare	$125.50
Rate for Payer: BCBS Complete	$100.40
Rate for Payer: BCBS Trust/PPO	$589.58
Rate for Payer: BCN Commercial	$112.40
Rate for Payer: Cash Price	$200.80
Rate for Payer: Cash Price	$200.80
Rate for Payer: Priority Health Cigna Priority Health	$163.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$56.53
Rate for Payer: Priority Health Narrow Network	$56.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$30.74
Rate for Payer: UHC Exchange	$30.74

PR CEFTRIAXONE SODIUM INJECTION

Professional

Both

$20.00

Service Code	HCPCS J0696
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$0.51
Rate for Payer: Aetna Medicare	$10.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS Trust/PPO	$0.03
Rate for Payer: BCN Commercial	$0.04
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Priority Health Cigna Priority Health	$13.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$0.46
Rate for Payer: UHC Exchange	$0.46

PR CERCLAGE CERVIX PREGNANCY VAGINAL

Professional

Both

$734.00

Service Code	HCPCS 59320
Min. Negotiated Rate	$97.55
Max. Negotiated Rate	$477.10
Rate for Payer: Aetna Commercial	$165.15
Rate for Payer: Aetna Medicare	$367.00
Rate for Payer: BCBS Complete	$102.43
Rate for Payer: BCBS Trust/PPO	$213.43
Rate for Payer: BCN Commercial	$220.88
Rate for Payer: Cash Price	$587.20
Rate for Payer: Cash Price	$587.20
Rate for Payer: Meridian Medicaid	$102.43
Rate for Payer: Priority Health Choice Medicaid	$97.55
Rate for Payer: Priority Health Cigna Priority Health	$477.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$212.39
Rate for Payer: Priority Health Narrow Network	$212.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$175.09
Rate for Payer: UHC Exchange	$175.09
Rate for Payer: UHCCP Medicaid	$97.55

PR CERCLAGE UTERINE CERVIX NONOBSTETRICAL

Professional

Both

$827.00

Service Code	HCPCS 57700
Min. Negotiated Rate	$228.55
Max. Negotiated Rate	$915.54
Rate for Payer: Aetna Commercial	$412.98
Rate for Payer: Aetna Medicare	$413.50
Rate for Payer: BCBS Complete	$239.98
Rate for Payer: BCBS Trust/PPO	$915.54
Rate for Payer: BCN Commercial	$526.80
Rate for Payer: Cash Price	$661.60
Rate for Payer: Cash Price	$661.60
Rate for Payer: Meridian Medicaid	$239.98
Rate for Payer: Priority Health Choice Medicaid	$228.55
Rate for Payer: Priority Health Cigna Priority Health	$537.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$537.72
Rate for Payer: Priority Health Narrow Network	$537.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$349.53
Rate for Payer: UHC Exchange	$349.53
Rate for Payer: UHCCP Medicaid	$228.55

PR CERTOLIZUMAB PEGOL INJ 1MG

Professional

Both

$10.00

Service Code	HCPCS J0717
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Commercial	$4.96
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$4.90
Rate for Payer: BCN Commercial	$5.06
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$6.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.46
Rate for Payer: UHC Exchange	$4.46

PR CERV FLEX N/ADJ FOAM PRE OTS

Professional

Both

$27.00

Service Code	HCPCS L0120
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$25.11
Rate for Payer: Aetna Commercial	$15.93
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS Complete	$10.80
Rate for Payer: BCN Commercial	$25.11
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Priority Health Cigna Priority Health	$17.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$14.36
Rate for Payer: UHC Exchange	$14.36

PR CERVICAL CAP CONTRACEPTIVE

Professional

Both

$102.00

Service Code	HCPCS A4261
Min. Negotiated Rate	$26.50
Max. Negotiated Rate	$1,481.35
Rate for Payer: Aetna Commercial	$26.50
Rate for Payer: Aetna Medicare	$51.00
Rate for Payer: BCBS Complete	$40.80
Rate for Payer: BCBS Trust/PPO	$1,481.35
Rate for Payer: BCN Commercial	$78.84
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 CERVICAL LYMPHADEC MODIFIED RADICAL NECK DSJ

Professional

Both

$3,995.00

Service Code	HCPCS 38724
Min. Negotiated Rate	$931.88
Max. Negotiated Rate	$2,902.68
Rate for Payer: Aetna Commercial	$1,778.47
Rate for Payer: Aetna Medicare	$1,997.50
Rate for Payer: BCBS Complete	$978.47
Rate for Payer: BCBS Trust/PPO	$1,321.28
Rate for Payer: BCN Commercial	$2,122.33
Rate for Payer: Cash Price	$3,196.00
Rate for Payer: Cash Price	$3,196.00
Rate for Payer: Meridian Medicaid	$978.47
Rate for Payer: Priority Health Choice Medicaid	$931.88
Rate for Payer: Priority Health Cigna Priority Health	$2,596.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,902.68
Rate for Payer: Priority Health Narrow Network	$2,902.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,622.95
Rate for Payer: UHC Exchange	$1,622.95
Rate for Payer: UHCCP Medicaid	$931.88

PR CERVICAL LYMPHADENECTOMY

Professional

Both

$2,444.00

Service Code	HCPCS 38720
Min. Negotiated Rate	$671.47
Max. Negotiated Rate	$2,689.64
Rate for Payer: Aetna Commercial	$1,646.91
Rate for Payer: Aetna Medicare	$1,222.00
Rate for Payer: BCBS Complete	$907.35
Rate for Payer: BCBS Trust/PPO	$671.47
Rate for Payer: BCN Commercial	$1,958.62
Rate for Payer: Cash Price	$1,955.20
Rate for Payer: Cash Price	$1,955.20
Rate for Payer: Meridian Medicaid	$907.35
Rate for Payer: Priority Health Choice Medicaid	$864.14
Rate for Payer: Priority Health Cigna Priority Health	$1,588.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,689.64
Rate for Payer: Priority Health Narrow Network	$2,689.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,503.63
Rate for Payer: UHC Exchange	$1,503.63
Rate for Payer: UHCCP Medicaid	$864.14

PR CESAREAN DELIVERY ATTEMPTED VBAC

Professional

Both

$2,499.00

Service Code	HCPCS 59620
Min. Negotiated Rate	$874.34
Max. Negotiated Rate	$1,636.60
Rate for Payer: Aetna Commercial	$1,034.69
Rate for Payer: Aetna Medicare	$1,249.50
Rate for Payer: BCBS Complete	$918.06
Rate for Payer: BCBS Trust/PPO	$1,066.64
Rate for Payer: BCN Commercial	$1,636.60
Rate for Payer: Cash Price	$1,999.20
Rate for Payer: Cash Price	$1,999.20
Rate for Payer: Meridian Medicaid	$918.06
Rate for Payer: Priority Health Choice Medicaid	$874.34
Rate for Payer: Priority Health Cigna Priority Health	$1,624.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,312.97
Rate for Payer: Priority Health Narrow Network	$1,312.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,207.03
Rate for Payer: UHC Exchange	$1,207.03
Rate for Payer: UHCCP Medicaid	$874.34

PR CESAREAN DELIVERY ONLY

Professional

Both

$2,321.00

Service Code	HCPCS 59514
Min. Negotiated Rate	$164.30
Max. Negotiated Rate	$1,558.66
Rate for Payer: Aetna Commercial	$1,001.86
Rate for Payer: Aetna Medicare	$1,160.50
Rate for Payer: BCBS Complete	$886.28
Rate for Payer: BCBS Trust/PPO	$164.30
Rate for Payer: BCN Commercial	$1,558.66
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Meridian Medicaid	$886.28
Rate for Payer: Priority Health Choice Medicaid	$844.08
Rate for Payer: Priority Health Cigna Priority Health	$1,508.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,268.27
Rate for Payer: Priority Health Narrow Network	$1,268.27
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,097.74
Rate for Payer: UHC Exchange	$1,097.74
Rate for Payer: UHCCP Medicaid	$844.08

PR CESAREAN DELIVERY ONLY W/POSTPARTUM CARE

Professional

Both

$2,593.00

Service Code	HCPCS 59515
Min. Negotiated Rate	$181.74
Max. Negotiated Rate	$1,880.28
Rate for Payer: Aetna Commercial	$1,434.55
Rate for Payer: Aetna Medicare	$1,296.50
Rate for Payer: BCBS Complete	$1,307.84
Rate for Payer: BCBS Trust/PPO	$181.74
Rate for Payer: BCN Commercial	$1,809.19
Rate for Payer: Cash Price	$2,074.40
Rate for Payer: Cash Price	$2,074.40
Rate for Payer: Meridian Medicaid	$1,307.84
Rate for Payer: Priority Health Choice Medicaid	$1,245.56
Rate for Payer: Priority Health Cigna Priority Health	$1,685.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,880.28
Rate for Payer: Priority Health Narrow Network	$1,880.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,306.27
Rate for Payer: UHC Exchange	$1,306.27
Rate for Payer: UHCCP Medicaid	$1,245.56

PR CESAREAN DLVRY & POSTPARTUM CARE ATTEMPTED VBA

Professional

Both

$2,771.00

Service Code	HCPCS 59622
Min. Negotiated Rate	$1,128.98
Max. Negotiated Rate	$1,949.21
Rate for Payer: Aetna Commercial	$1,484.84
Rate for Payer: Aetna Medicare	$1,385.50
Rate for Payer: BCBS Complete	$1,352.38
Rate for Payer: BCBS Trust/PPO	$1,128.98
Rate for Payer: BCN Commercial	$1,899.65
Rate for Payer: Cash Price	$2,216.80
Rate for Payer: Cash Price	$2,216.80
Rate for Payer: Meridian Medicaid	$1,352.38
Rate for Payer: Priority Health Choice Medicaid	$1,287.98
Rate for Payer: Priority Health Cigna Priority Health	$1,801.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,949.21
Rate for Payer: Priority Health Narrow Network	$1,949.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,416.19
Rate for Payer: UHC Exchange	$1,416.19
Rate for Payer: UHCCP Medicaid	$1,287.98

PR CESSATION THROMBOLYTIC THER W/CATHETER REMOVAL

Professional

Both

$247.00

Service Code	HCPCS 37214
Min. Negotiated Rate	$76.47
Max. Negotiated Rate	$705.28
Rate for Payer: Aetna Commercial	$164.52
Rate for Payer: Aetna Medicare	$123.50
Rate for Payer: BCBS Complete	$80.29
Rate for Payer: BCBS Trust/PPO	$705.28
Rate for Payer: BCN Commercial	$173.96
Rate for Payer: Cash Price	$197.60
Rate for Payer: Cash Price	$197.60
Rate for Payer: Meridian Medicaid	$80.29
Rate for Payer: Priority Health Choice Medicaid	$76.47
Rate for Payer: Priority Health Cigna Priority Health	$160.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$188.80
Rate for Payer: Priority Health Narrow Network	$188.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$199.46
Rate for Payer: UHC Exchange	$199.46
Rate for Payer: UHCCP Medicaid	$76.47

PR CHANGE CYSTOSTOMY TUBE COMPLICATED

Professional

Both

$341.00

Service Code	HCPCS 51710
Min. Negotiated Rate	$51.12
Max. Negotiated Rate	$2,051.39
Rate for Payer: Aetna Commercial	$100.96
Rate for Payer: Aetna Medicare	$170.50
Rate for Payer: BCBS Complete	$53.68
Rate for Payer: BCBS Trust/PPO	$2,051.39
Rate for Payer: BCN Commercial	$198.89
Rate for Payer: Cash Price	$272.80
Rate for Payer: Cash Price	$272.80
Rate for Payer: Meridian Medicaid	$53.68
Rate for Payer: Priority Health Choice Medicaid	$51.12
Rate for Payer: Priority Health Cigna Priority Health	$221.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$127.30
Rate for Payer: Priority Health Narrow Network	$127.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$113.10
Rate for Payer: UHC Exchange	$113.10
Rate for Payer: UHCCP Medicaid	$51.12

PR CHANGE CYSTOSTOMY TUBE SIMPLE

Professional

Both

$198.00

Service Code	HCPCS 51705
Min. Negotiated Rate	$33.44
Max. Negotiated Rate	$1,992.75
Rate for Payer: Aetna Commercial	$65.96
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS Complete	$35.11
Rate for Payer: BCBS Trust/PPO	$1,992.75
Rate for Payer: BCN Commercial	$141.72
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Meridian Medicaid	$35.11
Rate for Payer: Priority Health Choice Medicaid	$33.44
Rate for Payer: Priority Health Cigna Priority Health	$128.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$82.02
Rate for Payer: Priority Health Narrow Network	$82.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$79.96
Rate for Payer: UHC Exchange	$79.96
Rate for Payer: UHCCP Medicaid	$33.44

Know your out-of-pocket cost for care.

All Charges