Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR DERMAL AUTOGRAFT F/S/N/H/F/G/M/DGT 1ST 100 SQCM

Professional

Both

$1,586.00

Service Code	HCPCS 15135
Min. Negotiated Rate	$116.11
Max. Negotiated Rate	$1,287.66
Rate for Payer: Aetna Commercial	$810.88
Rate for Payer: Aetna Medicare	$793.00
Rate for Payer: BCBS Complete	$511.94
Rate for Payer: BCBS Trust/PPO	$116.11
Rate for Payer: BCN Commercial	$1,287.66
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Cash Price	$1,268.80
Rate for Payer: Meridian Medicaid	$511.94
Rate for Payer: Priority Health Choice Medicaid	$487.56
Rate for Payer: Priority Health Cigna Priority Health	$1,030.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,026.29
Rate for Payer: Priority Health Narrow Network	$1,026.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$806.49
Rate for Payer: UHC Exchange	$806.49
Rate for Payer: UHCCP Medicaid	$487.56

PR DERMAL FILLER JUVEDERM ULTRA

Professional

Both

$689.00

Service Code	HCPCS 00087
Hospital Revenue Code	990
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 DERMAL FILLER JUVEDERM ULTRA PR PLUS

Professional

Both

$408.00

Service Code	HCPCS 00089
Hospital Revenue Code	990
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$265.20
Rate for Payer: Aetna Medicare	$204.00
Rate for Payer: BCBS Complete	$163.20
Rate for Payer: Cash Price	$326.40
Rate for Payer: Priority Health Cigna Priority Health	$265.20

PR DERMAL FILLER JUVEDERM ULTRA PR PLUS >1

Professional

Both

$689.00

Service Code	HCPCS 00090
Hospital Revenue Code	990
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 DERMAL FILLER JUVEDERM VOLLURE

Professional

Both

$714.00

Service Code	HCPCS 00118
Hospital Revenue Code	990
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$464.10
Rate for Payer: Aetna Medicare	$357.00
Rate for Payer: BCBS Complete	$285.60
Rate for Payer: Cash Price	$571.20
Rate for Payer: Priority Health Cigna Priority Health	$464.10

PR DERMAL FILLER JUVEDERM VOLUMA

Professional

Both

$816.00

Service Code	HCPCS 00091
Hospital Revenue Code	990
Min. Negotiated Rate	$326.40
Max. Negotiated Rate	$530.40
Rate for Payer: Aetna Medicare	$408.00
Rate for Payer: BCBS Complete	$326.40
Rate for Payer: Cash Price	$652.80
Rate for Payer: Priority Health Cigna Priority Health	$530.40

PR DERMAL FILLER RESTYLANE 1/2 UNIT

Professional

Both

$408.00

Service Code	HCPCS 00252
Hospital Revenue Code	990
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$265.20
Rate for Payer: Aetna Medicare	$204.00
Rate for Payer: BCBS Complete	$163.20
Rate for Payer: Cash Price	$326.40
Rate for Payer: Priority Health Cigna Priority Health	$265.20

PR DERMAL FILLER RESTYLANE 1 UNIT

Professional

Both

$663.00

Service Code	HCPCS 00253
Hospital Revenue Code	990
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$430.95
Rate for Payer: Aetna Medicare	$331.50
Rate for Payer: BCBS Complete	$265.20
Rate for Payer: Cash Price	$530.40
Rate for Payer: Priority Health Cigna Priority Health	$430.95

PR DERMAL FILLER RESTYLANE DEFYNE

Professional

Both

$714.00

Service Code	HCPCS 00360
Hospital Revenue Code	990
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$464.10
Rate for Payer: Aetna Medicare	$357.00
Rate for Payer: BCBS Complete	$285.60
Rate for Payer: Cash Price	$571.20
Rate for Payer: Priority Health Cigna Priority Health	$464.10

PR DERMAL FILLER RESTYLANE LYFT

Professional

Both

$663.00

Service Code	HCPCS 00359
Hospital Revenue Code	990
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$430.95
Rate for Payer: Aetna Medicare	$331.50
Rate for Payer: BCBS Complete	$265.20
Rate for Payer: Cash Price	$530.40
Rate for Payer: Priority Health Cigna Priority Health	$430.95

PR DERMAL FILLER RESTYLANE REFYNE

Professional

Both

$714.00

Service Code	HCPCS 00361
Hospital Revenue Code	990
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$464.10
Rate for Payer: Aetna Medicare	$357.00
Rate for Payer: BCBS Complete	$285.60
Rate for Payer: Cash Price	$571.20
Rate for Payer: Priority Health Cigna Priority Health	$464.10

PR DERMAL FILLER VOLBELLA

Professional

Both

$408.00

Service Code	HCPCS 00092
Hospital Revenue Code	990
Min. Negotiated Rate	$163.20
Max. Negotiated Rate	$265.20
Rate for Payer: Aetna Medicare	$204.00
Rate for Payer: BCBS Complete	$163.20
Rate for Payer: Cash Price	$326.40
Rate for Payer: Priority Health Cigna Priority Health	$265.20

PR DERMAL FILLER VOLBELLA >1

Professional

Both

$714.00

Service Code	HCPCS 00120
Hospital Revenue Code	990
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$464.10
Rate for Payer: Aetna Medicare	$357.00
Rate for Payer: BCBS Complete	$285.60
Rate for Payer: Cash Price	$571.20
Rate for Payer: Priority Health Cigna Priority Health	$464.10

PR DESTROY NERVE,CERV SPINAL MUSCLES

Professional

Both

$361.00

Service Code	HCPCS 64613
Min. Negotiated Rate	$144.40
Max. Negotiated Rate	$234.65
Rate for Payer: Aetna Medicare	$180.50
Rate for Payer: BCBS Complete	$144.40
Rate for Payer: Cash Price	$288.80
Rate for Payer: Priority Health Cigna Priority Health	$234.65

PR DESTRUCTION BENIGN LESIONS 15/>

Professional

Both

$217.00

Service Code	HCPCS 17111
Min. Negotiated Rate	$54.32
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna Commercial	$85.72
Rate for Payer: Aetna Medicare	$108.50
Rate for Payer: BCBS Complete	$57.04
Rate for Payer: BCBS Trust/PPO	$562.50
Rate for Payer: BCN Commercial	$156.28
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cash Price	$173.60
Rate for Payer: Meridian Medicaid	$57.04
Rate for Payer: Priority Health Choice Medicaid	$54.32
Rate for Payer: Priority Health Cigna Priority Health	$141.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$113.33
Rate for Payer: Priority Health Narrow Network	$113.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$88.17
Rate for Payer: UHC Exchange	$88.17
Rate for Payer: UHCCP Medicaid	$54.32

PR DESTRUCTION BENIGN LESIONS UP TO 14

Professional

Both

$183.00

Service Code	HCPCS 17110
Min. Negotiated Rate	$44.52
Max. Negotiated Rate	$4,160.00
Rate for Payer: Aetna Commercial	$69.33
Rate for Payer: Aetna Medicare	$91.50
Rate for Payer: BCBS Complete	$46.75
Rate for Payer: BCBS Trust/PPO	$4,160.00
Rate for Payer: BCN Commercial	$133.89
Rate for Payer: Cash Price	$146.40
Rate for Payer: Cash Price	$146.40
Rate for Payer: Meridian Medicaid	$46.75
Rate for Payer: Priority Health Choice Medicaid	$44.52
Rate for Payer: Priority Health Cigna Priority Health	$118.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$93.47
Rate for Payer: Priority Health Narrow Network	$93.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$70.43
Rate for Payer: UHC Exchange	$70.43
Rate for Payer: UHCCP Medicaid	$44.52

PR DESTRUCTION BENIGN LESIONS UP TO 14

Facility

$183.00

Service Code	CPT 17110
Hospital Charge Code	17110
Hospital Revenue Code	521
Min. Negotiated Rate	$118.95
Max. Negotiated Rate	$183.00
Rate for Payer: Aetna Commercial	$164.70
Rate for Payer: ASR ASR	$177.51
Rate for Payer: ASR Commercial	$177.51
Rate for Payer: BCBS Trust/PPO	$149.13
Rate for Payer: BCN Commercial	$141.88
Rate for Payer: Cash Price	$146.40
Rate for Payer: Cofinity Commercial	$172.02
Rate for Payer: Encore Health Key Benefits Commercial	$146.40
Rate for Payer: Healthscope Commercial	$183.00
Rate for Payer: Healthscope Whirlpool	$177.51
Rate for Payer: Mclaren Commercial	$164.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.55
Rate for Payer: Nomi Health Commercial	$150.06
Rate for Payer: Priority Health Cigna Priority Health	$118.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$161.04

PR DESTRUCTION BENIGN LESIONS UP TO 14

Professional

Both

$183.00

Service Code	HCPCS 17110
Hospital Charge Code	17110
Min. Negotiated Rate	$44.52
Max. Negotiated Rate	$4,160.00
Rate for Payer: Aetna Commercial	$69.33
Rate for Payer: Aetna Medicare	$91.50
Rate for Payer: BCBS Complete	$46.75
Rate for Payer: BCBS Trust/PPO	$4,160.00
Rate for Payer: BCN Commercial	$133.89
Rate for Payer: Cash Price	$146.40
Rate for Payer: Cash Price	$146.40
Rate for Payer: Meridian Medicaid	$46.75
Rate for Payer: Priority Health Choice Medicaid	$44.52
Rate for Payer: Priority Health Cigna Priority Health	$118.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$93.47
Rate for Payer: Priority Health Narrow Network	$93.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$70.43
Rate for Payer: UHC Exchange	$70.43
Rate for Payer: UHCCP Medicaid	$44.52

PR DESTRUCTION BENIGN LESIONS UP TO 14

Facility

$183.00

Service Code	CPT 17110
Hospital Charge Code	17110
Hospital Revenue Code	521
Min. Negotiated Rate	$104.35
Max. Negotiated Rate	$301.75
Rate for Payer: Aetna Commercial	$164.70
Rate for Payer: Aetna Medicare	$194.68
Rate for Payer: Allen County Amish Medical Aid Commercial	$243.35
Rate for Payer: Amish Plain Church Group Commercial	$243.35
Rate for Payer: ASR ASR	$177.51
Rate for Payer: ASR Commercial	$177.51
Rate for Payer: BCBS Complete	$109.57
Rate for Payer: BCBS MAPPO	$194.68
Rate for Payer: BCBS Trust/PPO	$149.86
Rate for Payer: BCN Commercial	$141.88
Rate for Payer: BCN Medicare Advantage	$194.68
Rate for Payer: Cash Price	$146.40
Rate for Payer: Cash Price	$146.40
Rate for Payer: Cofinity Commercial	$172.02
Rate for Payer: Encore Health Key Benefits Commercial	$146.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$194.68
Rate for Payer: Healthscope Commercial	$183.00
Rate for Payer: Healthscope Whirlpool	$177.51
Rate for Payer: Humana Choice PPO Medicare	$194.68
Rate for Payer: Mclaren Commercial	$164.70
Rate for Payer: Mclaren Medicaid	$104.35
Rate for Payer: Mclaren Medicare	$194.68
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$204.41
Rate for Payer: Meridian Medicaid	$109.57
Rate for Payer: MI Amish Medical Board Commercial	$223.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$155.55
Rate for Payer: Nomi Health Commercial	$150.06
Rate for Payer: PACE Medicare	$184.95
Rate for Payer: PACE SWMI	$194.68
Rate for Payer: PHP Commercial	$214.15
Rate for Payer: PHP Medicaid	$104.35
Rate for Payer: PHP Medicare Advantage	$194.68
Rate for Payer: Priority Health Choice Medicaid	$104.35
Rate for Payer: Priority Health Cigna Priority Health	$118.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$138.37
Rate for Payer: Priority Health Medicare	$194.68
Rate for Payer: Priority Health Narrow Network	$110.70
Rate for Payer: Railroad Medicare Medicare	$194.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$161.04
Rate for Payer: UHC Dual Complete DSNP	$194.68
Rate for Payer: UHC Exchange	$301.75
Rate for Payer: UHC Medicare Advantage	$194.68
Rate for Payer: UHCCP DNSP	$194.68
Rate for Payer: UHCCP Medicaid	$104.35
Rate for Payer: VA VA	$194.68

PR DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM

Professional

Both

$630.00

Service Code	HCPCS 17106
Min. Negotiated Rate	$178.71
Max. Negotiated Rate	$947.65
Rate for Payer: Aetna Commercial	$291.61
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS Complete	$187.65
Rate for Payer: BCBS Trust/PPO	$947.65
Rate for Payer: BCN Commercial	$403.66
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Meridian Medicaid	$187.65
Rate for Payer: Priority Health Choice Medicaid	$178.71
Rate for Payer: Priority Health Cigna Priority Health	$409.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$375.21
Rate for Payer: Priority Health Narrow Network	$375.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$291.65
Rate for Payer: UHC Exchange	$291.65
Rate for Payer: UHCCP Medicaid	$178.71

PR DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM

Facility

$630.00

Service Code	CPT 17106
Hospital Charge Code	17106
Hospital Revenue Code	521
Min. Negotiated Rate	$209.82
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$567.00
Rate for Payer: Aetna Medicare	$391.45
Rate for Payer: Allen County Amish Medical Aid Commercial	$489.31
Rate for Payer: Amish Plain Church Group Commercial	$489.31
Rate for Payer: ASR ASR	$611.10
Rate for Payer: ASR Commercial	$611.10
Rate for Payer: BCBS Complete	$220.31
Rate for Payer: BCBS MAPPO	$391.45
Rate for Payer: BCBS Trust/PPO	$515.91
Rate for Payer: BCN Commercial	$488.44
Rate for Payer: BCN Medicare Advantage	$391.45
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cofinity Commercial	$592.20
Rate for Payer: Encore Health Key Benefits Commercial	$504.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$391.45
Rate for Payer: Healthscope Commercial	$630.00
Rate for Payer: Healthscope Whirlpool	$611.10
Rate for Payer: Humana Choice PPO Medicare	$391.45
Rate for Payer: Mclaren Commercial	$567.00
Rate for Payer: Mclaren Medicaid	$209.82
Rate for Payer: Mclaren Medicare	$391.45
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$411.02
Rate for Payer: Meridian Medicaid	$220.31
Rate for Payer: MI Amish Medical Board Commercial	$450.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$535.50
Rate for Payer: Nomi Health Commercial	$516.60
Rate for Payer: PACE Medicare	$371.88
Rate for Payer: PACE SWMI	$391.45
Rate for Payer: PHP Commercial	$430.60
Rate for Payer: PHP Medicaid	$209.82
Rate for Payer: PHP Medicare Advantage	$391.45
Rate for Payer: Priority Health Choice Medicaid	$209.82
Rate for Payer: Priority Health Cigna Priority Health	$409.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$552.01
Rate for Payer: Priority Health Medicare	$391.45
Rate for Payer: Priority Health Narrow Network	$441.63
Rate for Payer: Railroad Medicare Medicare	$391.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$554.40
Rate for Payer: UHC Dual Complete DSNP	$391.45
Rate for Payer: UHC Exchange	$606.75
Rate for Payer: UHC Medicare Advantage	$391.45
Rate for Payer: UHCCP DNSP	$391.45
Rate for Payer: UHCCP Medicaid	$209.82
Rate for Payer: VA VA	$391.45

PR DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM

Professional

Both

$630.00

Service Code	HCPCS 17106
Hospital Charge Code	17106
Min. Negotiated Rate	$178.71
Max. Negotiated Rate	$947.65
Rate for Payer: Aetna Commercial	$291.61
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS Complete	$187.65
Rate for Payer: BCBS Trust/PPO	$947.65
Rate for Payer: BCN Commercial	$403.66
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Meridian Medicaid	$187.65
Rate for Payer: Priority Health Choice Medicaid	$178.71
Rate for Payer: Priority Health Cigna Priority Health	$409.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$375.21
Rate for Payer: Priority Health Narrow Network	$375.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$291.65
Rate for Payer: UHC Exchange	$291.65
Rate for Payer: UHCCP Medicaid	$178.71

PR DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM

Facility

$630.00

Service Code	CPT 17106
Hospital Charge Code	17106
Hospital Revenue Code	521
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$567.00
Rate for Payer: ASR ASR	$611.10
Rate for Payer: ASR Commercial	$611.10
Rate for Payer: BCBS Trust/PPO	$513.39
Rate for Payer: BCN Commercial	$488.44
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cofinity Commercial	$592.20
Rate for Payer: Encore Health Key Benefits Commercial	$504.00
Rate for Payer: Healthscope Commercial	$630.00
Rate for Payer: Healthscope Whirlpool	$611.10
Rate for Payer: Mclaren Commercial	$567.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$535.50
Rate for Payer: Nomi Health Commercial	$516.60
Rate for Payer: Priority Health Cigna Priority Health	$409.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$554.40

PR DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY

Professional

Both

$338.00

Service Code	HCPCS 46930
Min. Negotiated Rate	$99.47
Max. Negotiated Rate	$1,115.77
Rate for Payer: Aetna Commercial	$200.96
Rate for Payer: Aetna Medicare	$169.00
Rate for Payer: BCBS Complete	$104.44
Rate for Payer: BCBS Trust/PPO	$1,115.77
Rate for Payer: BCN Commercial	$255.24
Rate for Payer: Cash Price	$270.40
Rate for Payer: Cash Price	$270.40
Rate for Payer: Meridian Medicaid	$104.44
Rate for Payer: Priority Health Choice Medicaid	$99.47
Rate for Payer: Priority Health Cigna Priority Health	$219.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$273.25
Rate for Payer: Priority Health Narrow Network	$273.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$176.80
Rate for Payer: UHC Exchange	$176.80
Rate for Payer: UHCCP Medicaid	$99.47

PR DESTRUCTION LESION LID MARGIN < 1 CM

Professional

Both

$487.00

Service Code	HCPCS 67850
Min. Negotiated Rate	$83.92
Max. Negotiated Rate	$347.09
Rate for Payer: Aetna Commercial	$169.96
Rate for Payer: Aetna Medicare	$243.50
Rate for Payer: BCBS Complete	$88.12
Rate for Payer: BCBS Trust/PPO	$347.09
Rate for Payer: BCN Commercial	$318.13
Rate for Payer: Cash Price	$389.60
Rate for Payer: Cash Price	$389.60
Rate for Payer: Meridian Medicaid	$88.12
Rate for Payer: Priority Health Choice Medicaid	$83.92
Rate for Payer: Priority Health Cigna Priority Health	$316.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$228.69
Rate for Payer: Priority Health Narrow Network	$228.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$147.73
Rate for Payer: UHC Exchange	$147.73
Rate for Payer: UHCCP Medicaid	$83.92

Know your out-of-pocket cost for care.

All Charges