Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR MEDICATION THERAPY EACH ADDITIONAL 15 MIN

Professional

Both

$13.00

Service Code	HCPCS 99607
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$370.34
Rate for Payer: Aetna Commercial	$45.29
Rate for Payer: BCBS Complete	$5.20
Rate for Payer: BCBS Trust/PPO	$370.34
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cash Price	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$9.10

PR MEDICATION THERAPY INITIAL 15 MIN ESTABLISHED PT

Professional

Both

$31.00

Service Code	HCPCS 99606
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$62.87
Rate for Payer: Aetna Commercial	$33.89
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: BCBS Trust/PPO	$62.87
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cash Price	$24.80
Rate for Payer: Priority Health Cigna Priority Health	$21.70

PR MEDICATION THERAPY INITIAL 15 MIN NEW PATIENT

Professional

Both

$63.00

Service Code	HCPCS 99605
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$79.81
Rate for Payer: Aetna Commercial	$67.55
Rate for Payer: BCBS Complete	$25.20
Rate for Payer: BCBS Trust/PPO	$79.81
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Priority Health Cigna Priority Health	$44.10

PR MEDROXYPROGESTERONE ACETATE

Professional

Both

$1.00

Service Code	HCPCS J1050
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna Commercial	$0.52
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: BCBS Trust/PPO	$0.14
Rate for Payer: BCN Commercial	$0.14
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cash Price	$0.80
Rate for Payer: Priority Health Cigna Priority Health	$0.70

PR MEDROXYPROGESTERONE INJ

Professional

Both

$30.00

Service Code	HCPCS J1051
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$21.00
Rate for Payer: BCBS Complete	$12.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Priority Health Cigna Priority Health	$21.00

PR MEDRXYPROGESTER ACETATE INJ

Professional

Both

$80.00

Service Code	HCPCS J1055
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$56.00
Rate for Payer: BCBS Complete	$32.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00

PR MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE

Professional

Both

$140.00

Service Code	HCPCS 90734
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$151.33
Rate for Payer: Aetna Commercial	$151.33
Rate for Payer: BCBS Complete	$56.00
Rate for Payer: BCBS Trust/PPO	$150.00
Rate for Payer: BCN Commercial	$147.22
Rate for Payer: Cash Price	$112.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Priority Health Cigna Priority Health	$98.00

PR MENACWY-TT CONJ VACC SEROGROUPS ACWY FOR IM USE

Professional

Both

$180.00

Service Code	HCPCS 90619
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$168.36
Rate for Payer: Aetna Commercial	$159.10
Rate for Payer: BCBS Complete	$72.00
Rate for Payer: BCBS Trust/PPO	$168.36
Rate for Payer: BCN Commercial	$168.36
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Priority Health Cigna Priority Health	$126.00

PR MENB-4C RECOMBNT PROT & OUTER MEMB VESIC VACC IM

Professional

Both

$232.00

Service Code	HCPCS 90620
Min. Negotiated Rate	$92.80
Max. Negotiated Rate	$215.42
Rate for Payer: Aetna Commercial	$215.42
Rate for Payer: BCBS Complete	$92.80
Rate for Payer: BCBS Trust/PPO	$198.55
Rate for Payer: BCN Commercial	$198.55
Rate for Payer: Cash Price	$185.60
Rate for Payer: Cash Price	$185.60
Rate for Payer: Priority Health Cigna Priority Health	$162.40

PR MENB-FHBP RECOMBNT LIPOPROTEIN VACC 2/3 DOSE IM

Professional

Both

$180.00

Service Code	HCPCS 90621
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$183.17
Rate for Payer: Aetna Commercial	$183.17
Rate for Payer: BCBS Complete	$72.00
Rate for Payer: BCBS Trust/PPO	$165.84
Rate for Payer: BCN Commercial	$165.84
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Priority Health Cigna Priority Health	$126.00

PR MEPERIDINE HYDROCHL /100 MG

Professional

Both

$10.00

Service Code	HCPCS J2175
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$10.52
Rate for Payer: Aetna Commercial	$9.79
Rate for Payer: Aetna Medicare	$7.31
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS MAPPO	$7.31
Rate for Payer: BCBS Trust/PPO	$1.87
Rate for Payer: BCN Commercial	$1.88
Rate for Payer: BCN Medicare Advantage	$7.31
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$9.79
Rate for Payer: Cofinity Commercial	$10.52
Rate for Payer: Health Alliance Plan Medicare Advantage	$7.31
Rate for Payer: Healthscope Commercial	$8.77
Rate for Payer: Healthscope Whirlpool	$8.77
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7.67
Rate for Payer: PACE SWMI	$7.31
Rate for Payer: PHP Medicare Advantage	$7.31
Rate for Payer: Priority Health Cigna Priority Health	$7.00
Rate for Payer: Priority Health Medicare	$7.31
Rate for Payer: UHC Medicare Advantage	$7.53

PR MEPERIDINE/PROMETHAZINE INJ

Professional

Both

$11.00

Service Code	HCPCS J2180
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$7.70
Rate for Payer: Aetna Commercial	$7.58
Rate for Payer: BCBS Complete	$4.40
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cash Price	$8.80
Rate for Payer: Priority Health Cigna Priority Health	$7.70

PR METATARSECTOMY

Professional

Both

$1,050.00

Service Code	HCPCS 28140
Min. Negotiated Rate	$273.49
Max. Negotiated Rate	$1,034.26
Rate for Payer: Aetna Commercial	$562.28
Rate for Payer: Aetna Medicare	$419.61
Rate for Payer: BCBS Complete	$287.16
Rate for Payer: BCBS MAPPO	$419.61
Rate for Payer: BCBS Trust/PPO	$1,034.26
Rate for Payer: BCN Commercial	$830.26
Rate for Payer: BCN Medicare Advantage	$419.61
Rate for Payer: Cash Price	$840.00
Rate for Payer: Cash Price	$840.00
Rate for Payer: Cofinity Commercial	$604.24
Rate for Payer: Cofinity Commercial	$562.28
Rate for Payer: Health Alliance Plan Medicare Advantage	$419.61
Rate for Payer: Healthscope Commercial	$503.53
Rate for Payer: Healthscope Whirlpool	$503.53
Rate for Payer: Meridian Medicaid	$287.16
Rate for Payer: Meridian Wellcare - Medicare Advantage	$440.59
Rate for Payer: PACE SWMI	$419.61
Rate for Payer: PHP Medicare Advantage	$419.61
Rate for Payer: Priority Health Choice Medicaid	$273.49
Rate for Payer: Priority Health Cigna Priority Health	$735.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$650.05
Rate for Payer: Priority Health Medicare	$419.61
Rate for Payer: Priority Health Narrow Network	$650.05
Rate for Payer: UHC Medicare Advantage	$432.20

PR METHYLPREDNISOLONE 20 MG INJ

Professional

Both

$10.00

Service Code	HCPCS J1020
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$10.32
Rate for Payer: Aetna Commercial	$9.60
Rate for Payer: Aetna Medicare	$7.17
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS MAPPO	$7.17
Rate for Payer: BCBS Trust/PPO	$1.79
Rate for Payer: BCN Commercial	$1.75
Rate for Payer: BCN Medicare Advantage	$7.17
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$9.60
Rate for Payer: Cofinity Commercial	$10.32
Rate for Payer: Health Alliance Plan Medicare Advantage	$7.17
Rate for Payer: Healthscope Commercial	$8.60
Rate for Payer: Healthscope Whirlpool	$8.60
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7.53
Rate for Payer: PACE SWMI	$7.17
Rate for Payer: PHP Medicare Advantage	$7.17
Rate for Payer: Priority Health Cigna Priority Health	$7.00
Rate for Payer: Priority Health Medicare	$7.17
Rate for Payer: UHC Medicare Advantage	$7.38

PR METHYLPREDNISOLONE 40 MG INJ

Professional

Both

$15.00

Service Code	HCPCS J1030
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$10.96
Rate for Payer: Aetna Commercial	$10.20
Rate for Payer: Aetna Medicare	$7.61
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: BCBS MAPPO	$7.61
Rate for Payer: BCBS Trust/PPO	$3.27
Rate for Payer: BCN Commercial	$6.37
Rate for Payer: BCN Medicare Advantage	$7.61
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cofinity Commercial	$10.96
Rate for Payer: Cofinity Commercial	$10.20
Rate for Payer: Health Alliance Plan Medicare Advantage	$7.61
Rate for Payer: Healthscope Commercial	$9.14
Rate for Payer: Healthscope Whirlpool	$9.14
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7.99
Rate for Payer: PACE SWMI	$7.61
Rate for Payer: PHP Medicare Advantage	$7.61
Rate for Payer: Priority Health Cigna Priority Health	$10.50
Rate for Payer: Priority Health Medicare	$7.61
Rate for Payer: UHC Medicare Advantage	$7.84

PR METHYLPREDNISOLONE 80 MG INJ

Professional

Both

$25.00

Service Code	HCPCS J1040
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$15.96
Rate for Payer: Aetna Medicare	$11.91
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCBS MAPPO	$11.91
Rate for Payer: BCBS Trust/PPO	$5.37
Rate for Payer: BCN Commercial	$10.71
Rate for Payer: BCN Medicare Advantage	$11.91
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cofinity Commercial	$17.15
Rate for Payer: Cofinity Commercial	$15.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$11.91
Rate for Payer: Healthscope Commercial	$14.29
Rate for Payer: Healthscope Whirlpool	$14.29
Rate for Payer: Meridian Wellcare - Medicare Advantage	$12.51
Rate for Payer: PACE SWMI	$11.91
Rate for Payer: PHP Medicare Advantage	$11.91
Rate for Payer: Priority Health Cigna Priority Health	$17.50
Rate for Payer: Priority Health Medicare	$11.91
Rate for Payer: UHC Medicare Advantage	$12.27

PR METHYLPREDNISOLONE INJECTION

Professional

Both

$10.00

Service Code	HCPCS J2920
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$5.68
Rate for Payer: Aetna Medicare	$4.24
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS MAPPO	$4.24
Rate for Payer: BCBS Trust/PPO	$3.17
Rate for Payer: BCN Commercial	$3.53
Rate for Payer: BCN Medicare Advantage	$4.24
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$5.68
Rate for Payer: Cofinity Commercial	$6.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$4.24
Rate for Payer: Healthscope Commercial	$5.08
Rate for Payer: Healthscope Whirlpool	$5.08
Rate for Payer: Meridian Wellcare - Medicare Advantage	$4.45
Rate for Payer: PACE SWMI	$4.24
Rate for Payer: PHP Medicare Advantage	$4.24
Rate for Payer: Priority Health Cigna Priority Health	$7.00
Rate for Payer: Priority Health Medicare	$4.24
Rate for Payer: UHC Medicare Advantage	$4.36

PR METHYLPREDNISOLONE INJECTION

Professional

Both

$25.00

Service Code	HCPCS J2930
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$17.50
Rate for Payer: Aetna Commercial	$7.67
Rate for Payer: Aetna Medicare	$5.72
Rate for Payer: BCBS Complete	$10.00
Rate for Payer: BCBS MAPPO	$5.72
Rate for Payer: BCBS Trust/PPO	$3.00
Rate for Payer: BCN Commercial	$2.84
Rate for Payer: BCN Medicare Advantage	$5.72
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cofinity Commercial	$7.67
Rate for Payer: Cofinity Commercial	$8.24
Rate for Payer: Health Alliance Plan Medicare Advantage	$5.72
Rate for Payer: Healthscope Commercial	$6.87
Rate for Payer: Healthscope Whirlpool	$6.87
Rate for Payer: Meridian Wellcare - Medicare Advantage	$6.01
Rate for Payer: PACE SWMI	$5.72
Rate for Payer: PHP Medicare Advantage	$5.72
Rate for Payer: Priority Health Cigna Priority Health	$17.50
Rate for Payer: Priority Health Medicare	$5.72
Rate for Payer: UHC Medicare Advantage	$5.90

PR MGMT LVR HEMRRG CPLX SUTR WND/INJ

Professional

Both

$3,386.00

Service Code	HCPCS 47360
Min. Negotiated Rate	$331.24
Max. Negotiated Rate	$3,287.35
Rate for Payer: Aetna Commercial	$2,498.14
Rate for Payer: Aetna Medicare	$1,864.28
Rate for Payer: BCBS Complete	$1,254.68
Rate for Payer: BCBS MAPPO	$1,864.28
Rate for Payer: BCBS Trust/PPO	$331.24
Rate for Payer: BCN Commercial	$2,732.20
Rate for Payer: BCN Medicare Advantage	$1,864.28
Rate for Payer: Cash Price	$2,708.80
Rate for Payer: Cash Price	$2,708.80
Rate for Payer: Cofinity Commercial	$2,498.14
Rate for Payer: Cofinity Commercial	$2,684.56
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,864.28
Rate for Payer: Healthscope Commercial	$2,237.14
Rate for Payer: Healthscope Whirlpool	$2,237.14
Rate for Payer: Meridian Medicaid	$1,254.68
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,957.49
Rate for Payer: PACE SWMI	$1,864.28
Rate for Payer: PHP Medicare Advantage	$1,864.28
Rate for Payer: Priority Health Choice Medicaid	$1,194.93
Rate for Payer: Priority Health Cigna Priority Health	$2,370.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,287.35
Rate for Payer: Priority Health Medicare	$1,864.28
Rate for Payer: Priority Health Narrow Network	$3,287.35
Rate for Payer: UHC Medicare Advantage	$1,920.21

PR MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ

Professional

Both

$2,846.00

Service Code	HCPCS 47350
Min. Negotiated Rate	$870.32
Max. Negotiated Rate	$2,400.11
Rate for Payer: Aetna Commercial	$1,819.29
Rate for Payer: Aetna Medicare	$1,357.68
Rate for Payer: BCBS Complete	$913.84
Rate for Payer: BCBS MAPPO	$1,357.68
Rate for Payer: BCBS Trust/PPO	$1,888.67
Rate for Payer: BCN Commercial	$1,994.78
Rate for Payer: BCN Medicare Advantage	$1,357.68
Rate for Payer: Cash Price	$2,276.80
Rate for Payer: Cash Price	$2,276.80
Rate for Payer: Cofinity Commercial	$1,955.06
Rate for Payer: Cofinity Commercial	$1,819.29
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,357.68
Rate for Payer: Healthscope Commercial	$1,629.22
Rate for Payer: Healthscope Whirlpool	$1,629.22
Rate for Payer: Meridian Medicaid	$913.84
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,425.56
Rate for Payer: PACE SWMI	$1,357.68
Rate for Payer: PHP Medicare Advantage	$1,357.68
Rate for Payer: Priority Health Choice Medicaid	$870.32
Rate for Payer: Priority Health Cigna Priority Health	$1,992.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,400.11
Rate for Payer: Priority Health Medicare	$1,357.68
Rate for Payer: Priority Health Narrow Network	$2,400.11
Rate for Payer: UHC Medicare Advantage	$1,398.41

PR MH PARTIAL HOSP TX UNDER 24H

Professional

Both

$254.00

Service Code	HCPCS H0035
Min. Negotiated Rate	$101.60
Max. Negotiated Rate	$268.86
Rate for Payer: Aetna Commercial	$268.86
Rate for Payer: BCBS Complete	$101.60
Rate for Payer: Cash Price	$203.20
Rate for Payer: Cash Price	$203.20
Rate for Payer: Priority Health Cigna Priority Health	$177.80

PR MICRONEEDLING PIN ADB/THIGHS/BACK

Professional

Both

$450.00

Service Code	HCPCS 00108
Hospital Revenue Code	990
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$315.00
Rate for Payer: BCBS Complete	$180.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Priority Health Cigna Priority Health	$315.00

PR MICRONEEDLING PIN FULL FACE

Professional

Both

$400.00

Service Code	HCPCS 00105
Hospital Revenue Code	990
Min. Negotiated Rate	$160.00
Max. Negotiated Rate	$280.00
Rate for Payer: BCBS Complete	$160.00
Rate for Payer: Cash Price	$320.00
Rate for Payer: Priority Health Cigna Priority Health	$280.00

PR MICRONEEDLING PIN NECK

Professional

Both

$150.00

Service Code	HCPCS 00107
Hospital Revenue Code	990
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$105.00
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Priority Health Cigna Priority Health	$105.00

PR MICRONEEDLING PIN UPPER OR LOWER FACE

Professional

Both

$250.00

Service Code	HCPCS 00106
Hospital Revenue Code	990
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$175.00
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Priority Health Cigna Priority Health	$175.00

Know your out-of-pocket cost for care.

All Charges