Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR

Professional

Both

$38.00

Service Code	HCPCS 96366
Min. Negotiated Rate	$15.20
Max. Negotiated Rate	$1,006.94
Rate for Payer: Aetna Commercial	$23.44
Rate for Payer: Aetna Medicare	$19.00
Rate for Payer: BCBS Complete	$15.20
Rate for Payer: BCBS Trust/PPO	$1,006.94
Rate for Payer: BCN Commercial	$29.81
Rate for Payer: Cash Price	$30.40
Rate for Payer: Cash Price	$30.40
Rate for Payer: Priority Health Cigna Priority Health	$24.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$27.60
Rate for Payer: Priority Health Narrow Network	$27.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.55
Rate for Payer: UHC Exchange	$21.55

PR IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR

Professional

Both

$58.00

Service Code	HCPCS 96367
Min. Negotiated Rate	$23.20
Max. Negotiated Rate	$1,165.43
Rate for Payer: Aetna Commercial	$33.47
Rate for Payer: Aetna Medicare	$29.00
Rate for Payer: BCBS Complete	$23.20
Rate for Payer: BCBS Trust/PPO	$1,165.43
Rate for Payer: BCN Commercial	$42.02
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Priority Health Cigna Priority Health	$37.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$38.44
Rate for Payer: Priority Health Narrow Network	$38.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$33.47
Rate for Payer: UHC Exchange	$33.47

PR IV INJECTION TEST VASCULAR FLOW FLAP/GRAFT

Professional

Both

$230.00

Service Code	HCPCS 15860
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$10,615.31
Rate for Payer: Aetna Commercial	$116.64
Rate for Payer: Aetna Medicare	$115.00
Rate for Payer: BCBS Complete	$71.35
Rate for Payer: BCBS Trust/PPO	$10,615.31
Rate for Payer: BCN Commercial	$154.42
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Meridian Medicaid	$71.35
Rate for Payer: Priority Health Choice Medicaid	$67.95
Rate for Payer: Priority Health Cigna Priority Health	$149.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$142.68
Rate for Payer: Priority Health Narrow Network	$142.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$124.17
Rate for Payer: UHC Exchange	$124.17
Rate for Payer: UHCCP Medicaid	$67.95

PR IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS

Professional

Both

$40.00

Service Code	HCPCS 96368
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$1,117.88
Rate for Payer: Aetna Commercial	$22.34
Rate for Payer: Aetna Medicare	$20.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$1,117.88
Rate for Payer: BCN Commercial	$28.83
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Priority Health Cigna Priority Health	$26.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$26.69
Rate for Payer: Priority Health Narrow Network	$26.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.03
Rate for Payer: UHC Exchange	$20.03

PR IV ULTRASOUND,FIRST VESSEL

Professional

Both

$306.00

Service Code	HCPCS 37250
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 KETOROLAC TROMETHAMINE INJ

Professional

Both

$10.00

Service Code	HCPCS J1885
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Commercial	$0.50
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$0.11
Rate for Payer: BCN Commercial	$0.11
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	$0.83
Rate for Payer: UHC Exchange	$0.83

PR KO IMMOB CANVAS LONG PRE OTS

Professional

Both

$82.00

Service Code	HCPCS L1830
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$64.89
Rate for Payer: Aetna Commercial	$42.62
Rate for Payer: Aetna Medicare	$41.00
Rate for Payer: BCBS Complete	$32.80
Rate for Payer: BCN Commercial	$64.89
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Priority Health Cigna Priority Health	$53.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$45.19
Rate for Payer: UHC Exchange	$45.19

PR KYBELLA

Professional

Both

$612.00

Service Code	HCPCS 00086
Hospital Revenue Code	990
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$397.80
Rate for Payer: Aetna Medicare	$306.00
Rate for Payer: BCBS Complete	$244.80
Rate for Payer: Cash Price	$489.60
Rate for Payer: Priority Health Cigna Priority Health	$397.80

PR KYLEENA, 19.5 MG

Professional

Both

$877.00

Service Code	HCPCS Q9984
Min. Negotiated Rate	$350.80
Max. Negotiated Rate	$570.05
Rate for Payer: Aetna Medicare	$438.50
Rate for Payer: BCBS Complete	$350.80
Rate for Payer: Cash Price	$701.60
Rate for Payer: Priority Health Cigna Priority Health	$570.05

PR KYLEENA, 19.5 MG

Professional

Both

$1,472.00

Service Code	HCPCS J7296
Min. Negotiated Rate	$736.00
Max. Negotiated Rate	$1,351.89
Rate for Payer: Aetna Commercial	$1,101.70
Rate for Payer: Aetna Medicare	$736.00
Rate for Payer: BCBS Complete	$1,351.89
Rate for Payer: BCBS Trust/PPO	$1,118.44
Rate for Payer: BCN Commercial	$1,121.75
Rate for Payer: Cash Price	$1,177.60
Rate for Payer: Cash Price	$1,177.60
Rate for Payer: Meridian Medicaid	$1,351.89
Rate for Payer: Priority Health Choice Medicaid	$1,287.51
Rate for Payer: Priority Health Cigna Priority Health	$956.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,191.49
Rate for Payer: UHC Exchange	$1,191.49
Rate for Payer: UHCCP Medicaid	$1,287.51

PR KYPHECTOMY SINGLE OR TWO SEGMENTS

Professional

Both

$12,926.00

Service Code	HCPCS 22818
Min. Negotiated Rate	$145.43
Max. Negotiated Rate	$8,401.90
Rate for Payer: Aetna Commercial	$2,890.03
Rate for Payer: Aetna Medicare	$6,463.00
Rate for Payer: BCBS Complete	$1,451.04
Rate for Payer: BCBS Trust/PPO	$145.43
Rate for Payer: BCN Commercial	$3,130.47
Rate for Payer: Cash Price	$10,340.80
Rate for Payer: Cash Price	$10,340.80
Rate for Payer: Meridian Medicaid	$1,451.04
Rate for Payer: Priority Health Choice Medicaid	$1,381.94
Rate for Payer: Priority Health Cigna Priority Health	$8,401.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,277.58
Rate for Payer: Priority Health Narrow Network	$3,277.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,547.20
Rate for Payer: UHC Exchange	$2,547.20
Rate for Payer: UHCCP Medicaid	$1,381.94

PR LABYRINTHOTOMY TRANSCANAL

Professional

Both

$408.00

Service Code	HCPCS 69801
Min. Negotiated Rate	$79.88
Max. Negotiated Rate	$2,908.82
Rate for Payer: Aetna Commercial	$139.33
Rate for Payer: Aetna Medicare	$204.00
Rate for Payer: BCBS Complete	$83.87
Rate for Payer: BCBS Trust/PPO	$2,908.82
Rate for Payer: BCN Commercial	$336.70
Rate for Payer: Cash Price	$326.40
Rate for Payer: Cash Price	$326.40
Rate for Payer: Meridian Medicaid	$83.87
Rate for Payer: Priority Health Choice Medicaid	$79.88
Rate for Payer: Priority Health Cigna Priority Health	$265.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$181.41
Rate for Payer: Priority Health Narrow Network	$181.41
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$819.44
Rate for Payer: UHC Exchange	$819.44
Rate for Payer: UHCCP Medicaid	$79.88

PR LAIV3 VACCINE LIVE FOR INTRANASAL USE

Professional

Both

$69.00

Service Code	HCPCS 90660
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$44.85
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$34.50
Rate for Payer: BCBS Complete	$27.60
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.20
Rate for Payer: Priority Health Cigna Priority Health	$44.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$29.63
Rate for Payer: UHC Exchange	$29.63

PR LAIV4 VACCINE FOR INTRANASAL USE

Professional

Both

$32.00

Service Code	HCPCS 90672
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$29.64
Rate for Payer: Aetna Commercial	$27.79
Rate for Payer: Aetna Medicare	$16.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: BCBS Trust/PPO	$27.54
Rate for Payer: BCN Commercial	$27.54
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cash Price	$25.60
Rate for Payer: Priority Health Cigna Priority Health	$20.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$29.64
Rate for Payer: UHC Exchange	$29.64

PR LAM BX/EXC ISPI NEO IDRL IMED CERVICAL

Professional

Both

$8,260.00

Service Code	HCPCS 63285
Min. Negotiated Rate	$381.43
Max. Negotiated Rate	$5,369.00
Rate for Payer: Aetna Commercial	$3,380.35
Rate for Payer: Aetna Medicare	$4,130.00
Rate for Payer: BCBS Complete	$1,785.85
Rate for Payer: BCBS Trust/PPO	$381.43
Rate for Payer: BCN Commercial	$4,242.16
Rate for Payer: Cash Price	$6,608.00
Rate for Payer: Cash Price	$6,608.00
Rate for Payer: Meridian Medicaid	$1,785.85
Rate for Payer: Priority Health Choice Medicaid	$1,700.81
Rate for Payer: Priority Health Cigna Priority Health	$5,369.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,521.86
Rate for Payer: Priority Health Narrow Network	$4,521.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,027.55
Rate for Payer: UHC Exchange	$3,027.55
Rate for Payer: UHCCP Medicaid	$1,700.81

PR LAM BX/EXC ISPI NEO IDRL IMED THORACIC

Professional

Both

$8,278.00

Service Code	HCPCS 63286
Min. Negotiated Rate	$172.75
Max. Negotiated Rate	$5,380.70
Rate for Payer: Aetna Commercial	$3,337.98
Rate for Payer: Aetna Medicare	$4,139.00
Rate for Payer: BCBS Complete	$1,765.49
Rate for Payer: BCBS Trust/PPO	$172.75
Rate for Payer: BCN Commercial	$4,200.19
Rate for Payer: Cash Price	$6,622.40
Rate for Payer: Cash Price	$6,622.40
Rate for Payer: Meridian Medicaid	$1,765.49
Rate for Payer: Priority Health Choice Medicaid	$1,681.42
Rate for Payer: Priority Health Cigna Priority Health	$5,380.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,447.93
Rate for Payer: Priority Health Narrow Network	$4,447.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,996.06
Rate for Payer: UHC Exchange	$2,996.06
Rate for Payer: UHCCP Medicaid	$1,681.42

PR LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR

Professional

Both

$8,749.00

Service Code	HCPCS 63287
Min. Negotiated Rate	$174.34
Max. Negotiated Rate	$5,686.85
Rate for Payer: Aetna Commercial	$3,546.68
Rate for Payer: Aetna Medicare	$4,374.50
Rate for Payer: BCBS Complete	$1,871.73
Rate for Payer: BCBS Trust/PPO	$174.34
Rate for Payer: BCN Commercial	$4,448.24
Rate for Payer: Cash Price	$6,999.20
Rate for Payer: Cash Price	$6,999.20
Rate for Payer: Meridian Medicaid	$1,871.73
Rate for Payer: Priority Health Choice Medicaid	$1,782.60
Rate for Payer: Priority Health Cigna Priority Health	$5,686.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,740.24
Rate for Payer: Priority Health Narrow Network	$4,740.24
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,189.22
Rate for Payer: UHC Exchange	$3,189.22
Rate for Payer: UHCCP Medicaid	$1,782.60

PR LAM BX/EXC ISPI NEO IDRL SACRAL

Professional

Both

$6,285.00

Service Code	HCPCS 63283
Min. Negotiated Rate	$481.28
Max. Negotiated Rate	$4,085.25
Rate for Payer: Aetna Commercial	$2,457.79
Rate for Payer: Aetna Medicare	$3,142.50
Rate for Payer: BCBS Complete	$1,305.44
Rate for Payer: BCBS Trust/PPO	$481.28
Rate for Payer: BCN Commercial	$2,812.82
Rate for Payer: Cash Price	$5,028.00
Rate for Payer: Cash Price	$5,028.00
Rate for Payer: Meridian Medicaid	$1,305.44
Rate for Payer: Priority Health Choice Medicaid	$1,243.28
Rate for Payer: Priority Health Cigna Priority Health	$4,085.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,304.23
Rate for Payer: Priority Health Narrow Network	$3,304.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,185.50
Rate for Payer: UHC Exchange	$2,185.50
Rate for Payer: UHCCP Medicaid	$1,243.28

PR LAM BX/EXC ISPI NEO IDRL XMED CERVICAL

Professional

Both

$7,589.00

Service Code	HCPCS 63280
Min. Negotiated Rate	$499.24
Max. Negotiated Rate	$4,932.85
Rate for Payer: Aetna Commercial	$2,742.34
Rate for Payer: Aetna Medicare	$3,794.50
Rate for Payer: BCBS Complete	$1,446.34
Rate for Payer: BCBS Trust/PPO	$499.24
Rate for Payer: BCN Commercial	$3,442.59
Rate for Payer: Cash Price	$6,071.20
Rate for Payer: Cash Price	$6,071.20
Rate for Payer: Meridian Medicaid	$1,446.34
Rate for Payer: Priority Health Choice Medicaid	$1,377.47
Rate for Payer: Priority Health Cigna Priority Health	$4,932.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,672.19
Rate for Payer: Priority Health Narrow Network	$3,672.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,458.94
Rate for Payer: UHC Exchange	$2,458.94
Rate for Payer: UHCCP Medicaid	$1,377.47

PR LAM BX/EXC ISPI NEO IDRL XMED LUMBAR

Professional

Both

$8,001.00

Service Code	HCPCS 63282
Min. Negotiated Rate	$1,293.98
Max. Negotiated Rate	$5,200.65
Rate for Payer: Aetna Commercial	$2,559.02
Rate for Payer: Aetna Medicare	$4,000.50
Rate for Payer: BCBS Complete	$1,358.68
Rate for Payer: BCBS Trust/PPO	$1,388.14
Rate for Payer: BCN Commercial	$3,220.36
Rate for Payer: Cash Price	$6,400.80
Rate for Payer: Cash Price	$6,400.80
Rate for Payer: Meridian Medicaid	$1,358.68
Rate for Payer: Priority Health Choice Medicaid	$1,293.98
Rate for Payer: Priority Health Cigna Priority Health	$5,200.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,432.76
Rate for Payer: Priority Health Narrow Network	$3,432.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,290.54
Rate for Payer: UHC Exchange	$2,290.54
Rate for Payer: UHCCP Medicaid	$1,293.98

PR LAM BX/EXC ISPI NEO IDRL XMED THORACIC

Professional

Both

$7,432.00

Service Code	HCPCS 63281
Min. Negotiated Rate	$1,367.46
Max. Negotiated Rate	$4,830.80
Rate for Payer: Aetna Commercial	$2,712.92
Rate for Payer: Aetna Medicare	$3,716.00
Rate for Payer: BCBS Complete	$1,435.83
Rate for Payer: BCBS Trust/PPO	$1,388.14
Rate for Payer: BCN Commercial	$3,409.23
Rate for Payer: Cash Price	$5,945.60
Rate for Payer: Cash Price	$5,945.60
Rate for Payer: Meridian Medicaid	$1,435.83
Rate for Payer: Priority Health Choice Medicaid	$1,367.46
Rate for Payer: Priority Health Cigna Priority Health	$4,830.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,642.05
Rate for Payer: Priority Health Narrow Network	$3,642.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,430.13
Rate for Payer: UHC Exchange	$2,430.13
Rate for Payer: UHCCP Medicaid	$1,367.46

PR LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL

Professional

Both

$9,383.00

Service Code	HCPCS 63290
Min. Negotiated Rate	$213.43
Max. Negotiated Rate	$6,098.95
Rate for Payer: Aetna Commercial	$3,607.11
Rate for Payer: Aetna Medicare	$4,691.50
Rate for Payer: BCBS Complete	$1,903.26
Rate for Payer: BCBS Trust/PPO	$213.43
Rate for Payer: BCN Commercial	$4,523.57
Rate for Payer: Cash Price	$7,506.40
Rate for Payer: Cash Price	$7,506.40
Rate for Payer: Meridian Medicaid	$1,903.26
Rate for Payer: Priority Health Choice Medicaid	$1,812.63
Rate for Payer: Priority Health Cigna Priority Health	$6,098.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,819.87
Rate for Payer: Priority Health Narrow Network	$4,819.87
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,244.26
Rate for Payer: UHC Exchange	$3,244.26
Rate for Payer: UHCCP Medicaid	$1,812.63

PR LAM EXC/EVAC ISPI LESION OTH/THN NEO XDRL LUMBAR

Professional

Both

$5,418.00

Service Code	HCPCS 63267
Min. Negotiated Rate	$244.07
Max. Negotiated Rate	$3,521.70
Rate for Payer: Aetna Commercial	$1,771.05
Rate for Payer: Aetna Medicare	$2,709.00
Rate for Payer: BCBS Complete	$938.88
Rate for Payer: BCBS Trust/PPO	$244.07
Rate for Payer: BCN Commercial	$2,226.54
Rate for Payer: Cash Price	$4,334.40
Rate for Payer: Cash Price	$4,334.40
Rate for Payer: Meridian Medicaid	$938.88
Rate for Payer: Priority Health Choice Medicaid	$894.17
Rate for Payer: Priority Health Cigna Priority Health	$3,521.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,373.82
Rate for Payer: Priority Health Narrow Network	$2,373.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,590.56
Rate for Payer: UHC Exchange	$1,590.56
Rate for Payer: UHCCP Medicaid	$894.17

PR LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CERVICAL

Professional

Both

$5,819.00

Service Code	HCPCS 63265
Min. Negotiated Rate	$399.92
Max. Negotiated Rate	$3,782.35
Rate for Payer: Aetna Commercial	$2,154.82
Rate for Payer: Aetna Medicare	$2,909.50
Rate for Payer: BCBS Complete	$1,138.38
Rate for Payer: BCBS Trust/PPO	$399.92
Rate for Payer: BCN Commercial	$2,712.42
Rate for Payer: Cash Price	$4,655.20
Rate for Payer: Cash Price	$4,655.20
Rate for Payer: Meridian Medicaid	$1,138.38
Rate for Payer: Priority Health Choice Medicaid	$1,084.17
Rate for Payer: Priority Health Cigna Priority Health	$3,782.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,892.48
Rate for Payer: Priority Health Narrow Network	$2,892.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,931.99
Rate for Payer: UHC Exchange	$1,931.99
Rate for Payer: UHCCP Medicaid	$1,084.17

PR LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SACRAL

Professional

Both

$4,597.00

Service Code	HCPCS 63268
Min. Negotiated Rate	$312.75
Max. Negotiated Rate	$2,988.05
Rate for Payer: Aetna Commercial	$1,833.95
Rate for Payer: Aetna Medicare	$2,298.50
Rate for Payer: BCBS Complete	$1,005.75
Rate for Payer: BCBS Trust/PPO	$312.75
Rate for Payer: BCN Commercial	$2,272.28
Rate for Payer: Cash Price	$3,677.60
Rate for Payer: Cash Price	$3,677.60
Rate for Payer: Meridian Medicaid	$1,005.75
Rate for Payer: Priority Health Choice Medicaid	$957.86
Rate for Payer: Priority Health Cigna Priority Health	$2,988.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,544.43
Rate for Payer: Priority Health Narrow Network	$2,544.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,654.75
Rate for Payer: UHC Exchange	$1,654.75
Rate for Payer: UHCCP Medicaid	$957.86

Know your out-of-pocket cost for care.

All Charges