Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE

Professional

Both

$51.00

Service Code	HCPCS 90633
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$46.12
Rate for Payer: Aetna Commercial	$38.42
Rate for Payer: Aetna Medicare	$25.50
Rate for Payer: BCBS Complete	$20.40
Rate for Payer: BCBS Trust/PPO	$31.32
Rate for Payer: BCN Commercial	$31.32
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	$46.12
Rate for Payer: UHC Exchange	$46.12

PR HEPA VACCINE ADULT DOSE FOR INTRAMUSCULAR USE

Professional

Both

$90.00

Service Code	HCPCS 90632
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$98.52
Rate for Payer: Aetna Commercial	$70.26
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS Complete	$36.00
Rate for Payer: BCBS Trust/PPO	$72.34
Rate for Payer: BCN Commercial	$73.37
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Priority Health Cigna Priority Health	$58.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$98.52
Rate for Payer: UHC Exchange	$98.52

PR HEPB VACCINE ADOLESCENT 2 DOSE SCHEDULE IM

Professional

Both

$103.00

Service Code	HCPCS 90743
Min. Negotiated Rate	$41.20
Max. Negotiated Rate	$82.57
Rate for Payer: Aetna Commercial	$75.15
Rate for Payer: Aetna Medicare	$51.50
Rate for Payer: BCBS Complete	$41.20
Rate for Payer: BCBS Trust/PPO	$76.66
Rate for Payer: BCN Commercial	$65.05
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cash Price	$82.40
Rate for Payer: Priority Health Cigna Priority Health	$66.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$82.57
Rate for Payer: UHC Exchange	$82.57

PR HEPB VACCINE ADULT 2/4 DOSE SCHEDULE FOR IM USE

Professional

Both

$326.00

Service Code	HCPCS 90739
Min. Negotiated Rate	$130.40
Max. Negotiated Rate	$211.90
Rate for Payer: Aetna Commercial	$160.28
Rate for Payer: Aetna Medicare	$163.00
Rate for Payer: BCBS Complete	$130.40
Rate for Payer: BCBS Trust/PPO	$166.39
Rate for Payer: BCN Commercial	$132.46
Rate for Payer: Cash Price	$260.80
Rate for Payer: Cash Price	$260.80
Rate for Payer: Priority Health Cigna Priority Health	$211.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$177.16
Rate for Payer: UHC Exchange	$177.16

PR HEPB VACCINE ADULT 3 DOSE SCHEDULE FOR IM USE

Professional

Both

$83.00

Service Code	HCPCS 90746
Min. Negotiated Rate	$33.20
Max. Negotiated Rate	$83.11
Rate for Payer: Aetna Commercial	$70.38
Rate for Payer: Aetna Medicare	$41.50
Rate for Payer: BCBS Complete	$33.20
Rate for Payer: BCBS Trust/PPO	$73.05
Rate for Payer: BCN Commercial	$65.05
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cash Price	$66.40
Rate for Payer: Priority Health Cigna Priority Health	$53.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$83.11
Rate for Payer: UHC Exchange	$83.11

PR HEPB VACCINE PED/ADOLESC 3 DOSE SCHEDULE IM

Professional

Both

$36.00

Service Code	HCPCS 90744
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$33.80
Rate for Payer: Aetna Commercial	$30.77
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS Complete	$14.40
Rate for Payer: BCBS Trust/PPO	$31.03
Rate for Payer: BCN Commercial	$25.88
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Priority Health Cigna Priority Health	$23.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$33.80
Rate for Payer: UHC Exchange	$33.80

PR HFO FLEXION GLOVE PRE OTS

Professional

Both

$99.00

Service Code	HCPCS L3912
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$91.04
Rate for Payer: Aetna Commercial	$57.75
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS Complete	$39.60
Rate for Payer: BCN Commercial	$91.04
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cash Price	$79.20
Rate for Payer: Priority Health Cigna Priority Health	$64.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$52.09
Rate for Payer: UHC Exchange	$52.09

PR HFO NONTORSION JNTS PRE CST

Professional

Both

$86.00

Service Code	HCPCS L3929
Min. Negotiated Rate	$34.40
Max. Negotiated Rate	$78.93
Rate for Payer: Aetna Commercial	$50.06
Rate for Payer: Aetna Medicare	$43.00
Rate for Payer: BCBS Complete	$34.40
Rate for Payer: BCN Commercial	$78.93
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cash Price	$68.80
Rate for Payer: Priority Health Cigna Priority Health	$55.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$45.16
Rate for Payer: UHC Exchange	$45.16

PR HFO W/JOINT(S) CF

Professional

Both

$300.00

Service Code	HCPCS L3921
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$277.59
Rate for Payer: Aetna Commercial	$176.08
Rate for Payer: Aetna Medicare	$150.00
Rate for Payer: BCBS Complete	$120.00
Rate for Payer: BCN Commercial	$277.59
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Priority Health Cigna Priority Health	$195.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$158.81
Rate for Payer: UHC Exchange	$158.81

PR HFO W/O JOINTS CF

Professional

Both

$253.00

Service Code	HCPCS L3913
Min. Negotiated Rate	$101.20
Max. Negotiated Rate	$234.03
Rate for Payer: Aetna Commercial	$148.45
Rate for Payer: Aetna Medicare	$126.50
Rate for Payer: BCBS Complete	$101.20
Rate for Payer: BCN Commercial	$234.03
Rate for Payer: Cash Price	$202.40
Rate for Payer: Cash Price	$202.40
Rate for Payer: Priority Health Cigna Priority Health	$164.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$133.90
Rate for Payer: UHC Exchange	$133.90

PR HIB-HEPB VACCINE FOR INTRAMUSCULAR USE

Professional

Both

$265.00

Service Code	HCPCS 90748
Min. Negotiated Rate	$42.06
Max. Negotiated Rate	$172.25
Rate for Payer: Aetna Commercial	$42.90
Rate for Payer: Aetna Medicare	$132.50
Rate for Payer: BCBS Complete	$106.00
Rate for Payer: BCBS Trust/PPO	$42.85
Rate for Payer: BCN Commercial	$42.06
Rate for Payer: Cash Price	$212.00
Rate for Payer: Cash Price	$212.00
Rate for Payer: Priority Health Cigna Priority Health	$172.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$60.56
Rate for Payer: UHC Exchange	$60.56

PR HIB PRP-OMP VACCINE 3 DOSE SCHEDULE IM USE

Professional

Both

$37.00

Service Code	HCPCS 90647
Min. Negotiated Rate	$14.80
Max. Negotiated Rate	$36.70
Rate for Payer: Aetna Commercial	$30.53
Rate for Payer: Aetna Medicare	$18.50
Rate for Payer: BCBS Complete	$14.80
Rate for Payer: BCBS Trust/PPO	$28.36
Rate for Payer: BCN Commercial	$28.36
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Priority Health Cigna Priority Health	$24.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.70
Rate for Payer: UHC Exchange	$36.70

PR HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE

Professional

Both

$33.00

Service Code	HCPCS 90648
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$21.45
Rate for Payer: Aetna Commercial	$13.32
Rate for Payer: Aetna Medicare	$16.50
Rate for Payer: BCBS Complete	$13.20
Rate for Payer: BCBS Trust/PPO	$18.57
Rate for Payer: BCN Commercial	$18.57
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Priority Health Cigna Priority Health	$21.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15.43
Rate for Payer: UHC Exchange	$15.43

PR HIB VACCINE, HBOC, IM

Professional

Both

$32.00

Service Code	HCPCS 90645
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 HIB VACCINE, PRP-D, IM

Professional

Both

$33.00

Service Code	HCPCS 90646
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$21.45
Rate for Payer: Aetna Medicare	$16.50
Rate for Payer: BCBS Complete	$13.20
Rate for Payer: Cash Price	$26.40
Rate for Payer: Priority Health Cigna Priority Health	$21.45

PR HINGE EXTENSION/FLEX WRIST/F

Professional

Both

$1,512.00

Service Code	HCPCS L3900
Min. Negotiated Rate	$604.80
Max. Negotiated Rate	$1,399.87
Rate for Payer: Aetna Commercial	$887.96
Rate for Payer: Aetna Medicare	$756.00
Rate for Payer: BCBS Complete	$604.80
Rate for Payer: BCN Commercial	$1,399.87
Rate for Payer: Cash Price	$1,209.60
Rate for Payer: Cash Price	$1,209.60
Rate for Payer: Priority Health Cigna Priority Health	$982.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$800.95
Rate for Payer: UHC Exchange	$800.95

PR HOME HEALTH CARE SUPERVISION

Professional

Both

$184.00

Service Code	HCPCS G0181
Min. Negotiated Rate	$73.60
Max. Negotiated Rate	$150.52
Rate for Payer: Aetna Commercial	$103.61
Rate for Payer: Aetna Medicare	$92.00
Rate for Payer: BCBS Complete	$73.60
Rate for Payer: BCBS Trust/PPO	$90.87
Rate for Payer: BCN Commercial	$150.52
Rate for Payer: Cash Price	$147.20
Rate for Payer: Cash Price	$147.20
Rate for Payer: Priority Health Cigna Priority Health	$119.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$142.02
Rate for Payer: Priority Health Narrow Network	$142.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$107.53
Rate for Payer: UHC Exchange	$107.53

PR HOME/RES VISIT EST PATIENT HIGH MDM 60 MINUTES

Professional

Both

$306.00

Service Code	HCPCS 99350
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$507.70
Rate for Payer: Aetna Commercial	$175.20
Rate for Payer: Aetna Medicare	$153.00
Rate for Payer: BCBS Complete	$122.40
Rate for Payer: BCBS Trust/PPO	$507.70
Rate for Payer: BCN Commercial	$268.78
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Priority Health Cigna Priority Health	$198.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$247.70
Rate for Payer: Priority Health Narrow Network	$247.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$185.33
Rate for Payer: UHC Exchange	$185.33

PR HOME/RES VISIT EST PATIENT LOW MDM 30 MINUTES

Professional

Both

$150.00

Service Code	HCPCS 99348
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$125.21
Rate for Payer: Aetna Commercial	$82.16
Rate for Payer: Aetna Medicare	$75.00
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: BCBS Trust/PPO	$125.21
Rate for Payer: BCN Commercial	$109.95
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Priority Health Cigna Priority Health	$97.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$102.31
Rate for Payer: Priority Health Narrow Network	$102.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$90.15
Rate for Payer: UHC Exchange	$90.15

PR HOME/RES VISIT EST PATIENT MOD MDM 40 MINUTES

Professional

Both

$220.00

Service Code	HCPCS 99349
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$288.45
Rate for Payer: Aetna Commercial	$126.46
Rate for Payer: Aetna Medicare	$110.00
Rate for Payer: BCBS Complete	$88.00
Rate for Payer: BCBS Trust/PPO	$288.45
Rate for Payer: BCN Commercial	$184.23
Rate for Payer: Cash Price	$176.00
Rate for Payer: Cash Price	$176.00
Rate for Payer: Priority Health Cigna Priority Health	$143.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$170.06
Rate for Payer: Priority Health Narrow Network	$170.06
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$132.45
Rate for Payer: UHC Exchange	$132.45

PR HOME/RES VISIT EST PATIENT SF MDM 20 MINUTES

Professional

Both

$101.00

Service Code	HCPCS 99347
Min. Negotiated Rate	$40.40
Max. Negotiated Rate	$728.53
Rate for Payer: Aetna Commercial	$53.66
Rate for Payer: Aetna Medicare	$50.50
Rate for Payer: BCBS Complete	$40.40
Rate for Payer: BCBS Trust/PPO	$728.53
Rate for Payer: BCN Commercial	$64.51
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cash Price	$80.80
Rate for Payer: Priority Health Cigna Priority Health	$65.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$60.57
Rate for Payer: Priority Health Narrow Network	$60.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.93
Rate for Payer: UHC Exchange	$59.93

PR HOME/RES VISIT NEW PATIENT HIGH MDM 75 MINUTES

Professional

Both

$404.00

Service Code	HCPCS 99345
Min. Negotiated Rate	$161.60
Max. Negotiated Rate	$321.73
Rate for Payer: Aetna Commercial	$216.48
Rate for Payer: Aetna Medicare	$202.00
Rate for Payer: BCBS Complete	$161.60
Rate for Payer: BCBS Trust/PPO	$321.73
Rate for Payer: BCN Commercial	$292.23
Rate for Payer: Cash Price	$323.20
Rate for Payer: Cash Price	$323.20
Rate for Payer: Priority Health Cigna Priority Health	$262.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$269.68
Rate for Payer: Priority Health Narrow Network	$269.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$228.87
Rate for Payer: UHC Exchange	$228.87

PR HOME/RES VISIT NEW PATIENT LOW MDM 30 MINUTES

Professional

Both

$162.00

Service Code	HCPCS 99342
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$133.13
Rate for Payer: Aetna Commercial	$75.54
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS Complete	$64.80
Rate for Payer: BCBS Trust/PPO	$133.13
Rate for Payer: BCN Commercial	$112.40
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cash Price	$129.60
Rate for Payer: Priority Health Cigna Priority Health	$105.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$104.55
Rate for Payer: Priority Health Narrow Network	$104.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$88.19
Rate for Payer: UHC Exchange	$88.19

PR HOME/RES VISIT NEW PATIENT MOD MDM 60 MINUTES

Professional

Both

$315.00

Service Code	HCPCS 99344
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$207.69
Rate for Payer: Aetna Commercial	$177.73
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS Complete	$126.00
Rate for Payer: BCBS Trust/PPO	$178.57
Rate for Payer: BCN Commercial	$207.69
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Priority Health Cigna Priority Health	$204.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$189.81
Rate for Payer: Priority Health Narrow Network	$189.81
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$190.55
Rate for Payer: UHC Exchange	$190.55

PR HOME/RES VISIT NEW PATIENT SF MDM 15 MINUTES

Professional

Both

$130.00

Service Code	HCPCS 99341
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$431.62
Rate for Payer: Aetna Commercial	$53.37
Rate for Payer: Aetna Medicare	$65.00
Rate for Payer: BCBS Complete	$52.00
Rate for Payer: BCBS Trust/PPO	$431.62
Rate for Payer: BCN Commercial	$70.37
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Priority Health Cigna Priority Health	$84.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$65.96
Rate for Payer: Priority Health Narrow Network	$65.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$60.34
Rate for Payer: UHC Exchange	$60.34

Know your out-of-pocket cost for care.

All Charges