Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR LOWER LID BLEPHAROPLASTY

Professional

Both

$1,836.00

Service Code	HCPCS 00531
Hospital Revenue Code	990
Min. Negotiated Rate	$734.40
Max. Negotiated Rate	$1,193.40
Rate for Payer: Aetna Medicare	$918.00
Rate for Payer: BCBS Complete	$734.40
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Priority Health Cigna Priority Health	$1,193.40

PR LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE

Professional

Both

$104.00

Service Code	HCPCS 20979
Min. Negotiated Rate	$40.52
Max. Negotiated Rate	$3,247.68
Rate for Payer: Aetna Commercial	$42.80
Rate for Payer: Aetna Medicare	$52.00
Rate for Payer: BCBS Complete	$41.60
Rate for Payer: BCBS Trust/PPO	$3,247.68
Rate for Payer: BCN Commercial	$82.58
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Priority Health Cigna Priority Health	$67.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$48.34
Rate for Payer: Priority Health Narrow Network	$48.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$40.52
Rate for Payer: UHC Exchange	$40.52

PR LT COMPRES BAND >=3"" <5""/YD

Professional

Both

$3.00

Service Code	HCPCS A6449
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Commercial	$1.63
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: BCN Commercial	$1.93
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.10
Rate for Payer: UHC Exchange	$1.10

PR LT COMPRES BAND <3""/YD

Professional

Both

$3.00

Service Code	HCPCS A6448
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna Commercial	$1.07
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: BCN Commercial	$1.27
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$0.73
Rate for Payer: UHC Exchange	$0.73

PR LT COMPRES BAND >=5""/YD

Professional

Both

$5.00

Service Code	HCPCS A6450
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna Commercial	$1.63
Rate for Payer: Aetna Medicare	$2.50
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: BCN Commercial	$1.93
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Priority Health Cigna Priority Health	$3.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.16
Rate for Payer: UHC Exchange	$1.16

PR LUX IR ABD/BACK

Professional

Both

$255.00

Service Code	HCPCS 00097
Hospital Revenue Code	990
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$165.75
Rate for Payer: Aetna Medicare	$127.50
Rate for Payer: BCBS Complete	$102.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Priority Health Cigna Priority Health	$165.75

PR LUX IR ARMS

Professional

Both

$128.00

Service Code	HCPCS 00095
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 LUX IR BUTTOCKS

Professional

Both

$153.00

Service Code	HCPCS 00098
Hospital Revenue Code	990
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$99.45
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS Complete	$61.20
Rate for Payer: Cash Price	$122.40
Rate for Payer: Priority Health Cigna Priority Health	$99.45

PR LUX IR CHEST

Professional

Both

$153.00

Service Code	HCPCS 00094
Hospital Revenue Code	990
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$99.45
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS Complete	$61.20
Rate for Payer: Cash Price	$122.40
Rate for Payer: Priority Health Cigna Priority Health	$99.45

PR LUX IR FACE & NECK

Professional

Both

$255.00

Service Code	HCPCS 00093
Hospital Revenue Code	990
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$165.75
Rate for Payer: Aetna Medicare	$127.50
Rate for Payer: BCBS Complete	$102.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Priority Health Cigna Priority Health	$165.75

PR LUX IR UP LEGS

Professional

Both

$255.00

Service Code	HCPCS 00096
Hospital Revenue Code	990
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$165.75
Rate for Payer: Aetna Medicare	$127.50
Rate for Payer: BCBS Complete	$102.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Priority Health Cigna Priority Health	$165.75

PR LYMPHANGIOTOMY/OTH OPRATIONS LYMPHATIC CHANNELS

Professional

Both

$930.00

Service Code	HCPCS 38308
Min. Negotiated Rate	$305.44
Max. Negotiated Rate	$945.36
Rate for Payer: Aetna Commercial	$570.91
Rate for Payer: Aetna Medicare	$465.00
Rate for Payer: BCBS Complete	$320.71
Rate for Payer: BCBS Trust/PPO	$635.54
Rate for Payer: BCN Commercial	$681.71
Rate for Payer: Cash Price	$744.00
Rate for Payer: Cash Price	$744.00
Rate for Payer: Meridian Medicaid	$320.71
Rate for Payer: Priority Health Choice Medicaid	$305.44
Rate for Payer: Priority Health Cigna Priority Health	$604.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$945.36
Rate for Payer: Priority Health Narrow Network	$945.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$497.41
Rate for Payer: UHC Exchange	$497.41
Rate for Payer: UHCCP Medicaid	$305.44

PR LYSIS/EXCISION PENILE POSTCIRCUMCISION ADHESIONS

Professional

Both

$521.00

Service Code	HCPCS 54162
Min. Negotiated Rate	$129.08
Max. Negotiated Rate	$1,225.13
Rate for Payer: Aetna Commercial	$255.52
Rate for Payer: Aetna Medicare	$260.50
Rate for Payer: BCBS Complete	$135.53
Rate for Payer: BCBS Trust/PPO	$1,225.13
Rate for Payer: BCN Commercial	$374.33
Rate for Payer: Cash Price	$416.80
Rate for Payer: Cash Price	$416.80
Rate for Payer: Meridian Medicaid	$135.53
Rate for Payer: Priority Health Choice Medicaid	$129.08
Rate for Payer: Priority Health Cigna Priority Health	$338.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$320.62
Rate for Payer: Priority Health Narrow Network	$320.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$236.65
Rate for Payer: UHC Exchange	$236.65
Rate for Payer: UHCCP Medicaid	$129.08

PR LYSIS INTRANASAL SYNECHIA

Professional

Both

$516.00

Service Code	HCPCS 30560
Min. Negotiated Rate	$96.70
Max. Negotiated Rate	$805.66
Rate for Payer: Aetna Commercial	$184.81
Rate for Payer: Aetna Medicare	$258.00
Rate for Payer: BCBS Complete	$101.54
Rate for Payer: BCBS Trust/PPO	$805.66
Rate for Payer: BCN Commercial	$479.88
Rate for Payer: Cash Price	$412.80
Rate for Payer: Cash Price	$412.80
Rate for Payer: Meridian Medicaid	$101.54
Rate for Payer: Priority Health Choice Medicaid	$96.70
Rate for Payer: Priority Health Cigna Priority Health	$335.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$212.27
Rate for Payer: Priority Health Narrow Network	$212.27
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$148.41
Rate for Payer: UHC Exchange	$148.41
Rate for Payer: UHCCP Medicaid	$96.70

PR LYSIS LABIAL ADHESIONS

Professional

Both

$492.00

Service Code	HCPCS 56441
Min. Negotiated Rate	$99.68
Max. Negotiated Rate	$488.15
Rate for Payer: Aetna Commercial	$179.27
Rate for Payer: Aetna Medicare	$246.00
Rate for Payer: BCBS Complete	$104.66
Rate for Payer: BCBS Trust/PPO	$488.15
Rate for Payer: BCN Commercial	$270.24
Rate for Payer: Cash Price	$393.60
Rate for Payer: Cash Price	$393.60
Rate for Payer: Meridian Medicaid	$104.66
Rate for Payer: Priority Health Choice Medicaid	$99.68
Rate for Payer: Priority Health Cigna Priority Health	$319.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$233.63
Rate for Payer: Priority Health Narrow Network	$233.63
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$158.53
Rate for Payer: UHC Exchange	$158.53
Rate for Payer: UHCCP Medicaid	$99.68

PR LYSIS OF ADHESIONS SALPINX/OVARY

Professional

Both

$2,428.00

Service Code	HCPCS 58740
Min. Negotiated Rate	$207.09
Max. Negotiated Rate	$1,578.20
Rate for Payer: Aetna Commercial	$1,075.71
Rate for Payer: Aetna Medicare	$1,214.00
Rate for Payer: BCBS Complete	$610.56
Rate for Payer: BCBS Trust/PPO	$207.09
Rate for Payer: BCN Commercial	$1,323.34
Rate for Payer: Cash Price	$1,942.40
Rate for Payer: Cash Price	$1,942.40
Rate for Payer: Meridian Medicaid	$610.56
Rate for Payer: Priority Health Choice Medicaid	$581.49
Rate for Payer: Priority Health Cigna Priority Health	$1,578.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,349.25
Rate for Payer: Priority Health Narrow Network	$1,349.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,001.56
Rate for Payer: UHC Exchange	$1,001.56
Rate for Payer: UHCCP Medicaid	$581.49

PR MA/EC CONTRACEPTIVEINJECTION

Professional

Both

$34.00

Service Code	HCPCS J1056
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$22.10
Rate for Payer: Aetna Medicare	$17.00
Rate for Payer: BCBS Complete	$13.60
Rate for Payer: Cash Price	$27.20
Rate for Payer: Priority Health Cigna Priority Health	$22.10

PR MAJOR RECONSTRUCTION CHEST WALL POSTTRAUMATIC

Professional

Both

$3,348.00

Service Code	HCPCS 32820
Min. Negotiated Rate	$878.56
Max. Negotiated Rate	$2,176.20
Rate for Payer: Aetna Commercial	$1,715.98
Rate for Payer: Aetna Medicare	$1,674.00
Rate for Payer: BCBS Complete	$931.51
Rate for Payer: BCBS Trust/PPO	$878.56
Rate for Payer: BCN Commercial	$1,919.52
Rate for Payer: Cash Price	$2,678.40
Rate for Payer: Cash Price	$2,678.40
Rate for Payer: Meridian Medicaid	$931.51
Rate for Payer: Priority Health Choice Medicaid	$887.15
Rate for Payer: Priority Health Cigna Priority Health	$2,176.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,831.62
Rate for Payer: Priority Health Narrow Network	$1,831.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,584.26
Rate for Payer: UHC Exchange	$1,584.26
Rate for Payer: UHCCP Medicaid	$887.15

PR MAKENA, 10 MG

Professional

Both

$3.00

Service Code	HCPCS J1726
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$20.24
Rate for Payer: Aetna Commercial	$19.41
Rate for Payer: Aetna Medicare	$1.50
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: BCBS Trust/PPO	$6.80
Rate for Payer: BCN Commercial	$6.80
Rate for Payer: Cash Price	$2.40
Rate for Payer: Cash Price	$2.40
Rate for Payer: Priority Health Cigna Priority Health	$1.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.24
Rate for Payer: UHC Exchange	$20.24

PR MAMMAPLASTY AUGMENTATION - GEL

Professional

Both

$4,937.00

Service Code	HCPCS 00261
Hospital Revenue Code	990
Min. Negotiated Rate	$1,974.80
Max. Negotiated Rate	$3,209.05
Rate for Payer: Aetna Medicare	$2,468.50
Rate for Payer: BCBS Complete	$1,974.80
Rate for Payer: Cash Price	$3,949.60
Rate for Payer: Priority Health Cigna Priority Health	$3,209.05

PR MAMMAPLASTY AUGMENTATION - SALINE

Professional

Both

$3,774.00

Service Code	HCPCS 00262
Hospital Revenue Code	990
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$2,453.10
Rate for Payer: Aetna Medicare	$1,887.00
Rate for Payer: BCBS Complete	$1,509.60
Rate for Payer: Cash Price	$3,019.20
Rate for Payer: Priority Health Cigna Priority Health	$2,453.10

PR MANIPLATN PALAR FASCIAL CRD POST INJ SINGLE CORD

Professional

Both

$410.00

Service Code	HCPCS 26341
Min. Negotiated Rate	$50.91
Max. Negotiated Rate	$354.49
Rate for Payer: Aetna Commercial	$102.17
Rate for Payer: Aetna Medicare	$205.00
Rate for Payer: BCBS Complete	$53.46
Rate for Payer: BCBS Trust/PPO	$354.49
Rate for Payer: BCN Commercial	$173.48
Rate for Payer: Cash Price	$328.00
Rate for Payer: Cash Price	$328.00
Rate for Payer: Meridian Medicaid	$53.46
Rate for Payer: Priority Health Choice Medicaid	$50.91
Rate for Payer: Priority Health Cigna Priority Health	$266.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$121.10
Rate for Payer: Priority Health Narrow Network	$121.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$95.50
Rate for Payer: UHC Exchange	$95.50
Rate for Payer: UHCCP Medicaid	$50.91

PR MANIPULATION ANKLE UNDER GENERAL ANESTHESIA

Professional

Both

$630.00

Service Code	HCPCS 27860
Min. Negotiated Rate	$106.71
Max. Negotiated Rate	$1,252.07
Rate for Payer: Aetna Commercial	$223.16
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS Complete	$112.05
Rate for Payer: BCBS Trust/PPO	$1,252.07
Rate for Payer: BCN Commercial	$240.92
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Meridian Medicaid	$112.05
Rate for Payer: Priority Health Choice Medicaid	$106.71
Rate for Payer: Priority Health Cigna Priority Health	$409.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$251.88
Rate for Payer: Priority Health Narrow Network	$251.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$201.37
Rate for Payer: UHC Exchange	$201.37
Rate for Payer: UHCCP Medicaid	$106.71

PR MANIPULATION ELBOW UNDER ANESTHESIA

Professional

Both

$716.00

Service Code	HCPCS 24300
Min. Negotiated Rate	$92.45
Max. Negotiated Rate	$691.55
Rate for Payer: Aetna Commercial	$567.74
Rate for Payer: Aetna Medicare	$358.00
Rate for Payer: BCBS Complete	$307.74
Rate for Payer: BCBS Trust/PPO	$92.45
Rate for Payer: BCN Commercial	$648.96
Rate for Payer: Cash Price	$572.80
Rate for Payer: Cash Price	$572.80
Rate for Payer: Meridian Medicaid	$307.74
Rate for Payer: Priority Health Choice Medicaid	$293.09
Rate for Payer: Priority Health Cigna Priority Health	$465.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$691.55
Rate for Payer: Priority Health Narrow Network	$691.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$439.55
Rate for Payer: UHC Exchange	$439.55
Rate for Payer: UHCCP Medicaid	$293.09

PR MANIPULATION FINGER JOINT UNDER ANES EACH JOINT

Professional

Both

$714.00

Service Code	HCPCS 26340
Min. Negotiated Rate	$108.30
Max. Negotiated Rate	$562.30
Rate for Payer: Aetna Commercial	$454.85
Rate for Payer: Aetna Medicare	$357.00
Rate for Payer: BCBS Complete	$251.16
Rate for Payer: BCBS Trust/PPO	$108.30
Rate for Payer: BCN Commercial	$528.26
Rate for Payer: Cash Price	$571.20
Rate for Payer: Cash Price	$571.20
Rate for Payer: Meridian Medicaid	$251.16
Rate for Payer: Priority Health Choice Medicaid	$239.20
Rate for Payer: Priority Health Cigna Priority Health	$464.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$562.30
Rate for Payer: Priority Health Narrow Network	$562.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$350.68
Rate for Payer: UHC Exchange	$350.68
Rate for Payer: UHCCP Medicaid	$239.20

Know your out-of-pocket cost for care.

All Charges