Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR MENACWY-TT CONJ VACC SEROGROUPS ACWY FOR IM USE

Professional

Both

$184.00

Service Code	HCPCS 90619
Min. Negotiated Rate	$73.60
Max. Negotiated Rate	$200.38
Rate for Payer: Aetna Commercial	$159.10
Rate for Payer: Aetna Medicare	$92.00
Rate for Payer: BCBS Complete	$73.60
Rate for Payer: BCBS Trust/PPO	$168.36
Rate for Payer: BCN Commercial	$168.36
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: UHC All Payor (Choice/PPO) + Core	$200.38
Rate for Payer: UHC Exchange	$200.38

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

Professional

Both

$263.00

Service Code	HCPCS 90620
Min. Negotiated Rate	$105.20
Max. Negotiated Rate	$268.50
Rate for Payer: Aetna Commercial	$215.42
Rate for Payer: Aetna Medicare	$131.50
Rate for Payer: BCBS Complete	$105.20
Rate for Payer: BCBS Trust/PPO	$198.55
Rate for Payer: BCN Commercial	$198.55
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cash Price	$210.40
Rate for Payer: Priority Health Cigna Priority Health	$170.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$268.50
Rate for Payer: UHC Exchange	$268.50

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

Professional

Both

$184.00

Service Code	HCPCS 90621
Min. Negotiated Rate	$73.60
Max. Negotiated Rate	$228.31
Rate for Payer: Aetna Commercial	$183.17
Rate for Payer: Aetna Medicare	$92.00
Rate for Payer: BCBS Complete	$73.60
Rate for Payer: BCBS Trust/PPO	$165.84
Rate for Payer: BCN Commercial	$165.84
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: UHC All Payor (Choice/PPO) + Core	$228.31
Rate for Payer: UHC Exchange	$228.31

PR MEPERIDINE HYDROCHL /100 MG

Professional

Both

$10.00

Service Code	HCPCS J2175
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$7.52
Rate for Payer: Aetna Commercial	$7.52
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$1.87
Rate for Payer: BCN Commercial	$1.88
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	$6.02
Rate for Payer: UHC Exchange	$6.02

PR MEPERIDINE/PROMETHAZINE INJ

Professional

Both

$11.00

Service Code	HCPCS J2180
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$7.58
Rate for Payer: Aetna Commercial	$7.58
Rate for Payer: Aetna Medicare	$5.50
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	$7.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.79
Rate for Payer: UHC Exchange	$3.79

PR METATARSECTOMY

Professional

Both

$1,071.00

Service Code	HCPCS 28140
Min. Negotiated Rate	$274.34
Max. Negotiated Rate	$1,034.26
Rate for Payer: Aetna Commercial	$575.34
Rate for Payer: Aetna Medicare	$535.50
Rate for Payer: BCBS Complete	$288.06
Rate for Payer: BCBS Trust/PPO	$1,034.26
Rate for Payer: BCN Commercial	$830.26
Rate for Payer: Cash Price	$856.80
Rate for Payer: Cash Price	$856.80
Rate for Payer: Meridian Medicaid	$288.06
Rate for Payer: Priority Health Choice Medicaid	$274.34
Rate for Payer: Priority Health Cigna Priority Health	$696.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$653.37
Rate for Payer: Priority Health Narrow Network	$653.37
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$534.42
Rate for Payer: UHC Exchange	$534.42
Rate for Payer: UHCCP Medicaid	$274.34

PR METHYLPREDNISOLONE 20 MG INJ

Professional

Both

$10.00

Service Code	HCPCS J1020
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$7.25
Rate for Payer: Aetna Commercial	$7.25
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$1.79
Rate for Payer: BCN Commercial	$1.75
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$6.50

PR METHYLPREDNISOLONE 40 MG INJ

Professional

Both

$15.00

Service Code	HCPCS J1030
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna Commercial	$6.61
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: BCBS Trust/PPO	$3.27
Rate for Payer: BCN Commercial	$6.37
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$9.75

PR METHYLPREDNISOLONE 80 MG INJ

Professional

Both

$26.00

Service Code	HCPCS J1040
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$16.90
Rate for Payer: Aetna Commercial	$10.10
Rate for Payer: Aetna Medicare	$13.00
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: BCBS Trust/PPO	$5.37
Rate for Payer: BCN Commercial	$10.71
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Priority Health Cigna Priority Health	$16.90

PR METHYLPREDNISOLONE INJECTION

Professional

Both

$10.00

Service Code	HCPCS J2920
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$6.50
Rate for Payer: Aetna Commercial	$4.31
Rate for Payer: Aetna Medicare	$5.00
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS Trust/PPO	$3.17
Rate for Payer: BCN Commercial	$3.53
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Priority Health Cigna Priority Health	$6.50

PR METHYLPREDNISOLONE INJECTION

Professional

Both

$26.00

Service Code	HCPCS J2930
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$16.90
Rate for Payer: Aetna Commercial	$6.06
Rate for Payer: Aetna Medicare	$13.00
Rate for Payer: BCBS Complete	$10.40
Rate for Payer: BCBS Trust/PPO	$3.00
Rate for Payer: BCN Commercial	$2.84
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Priority Health Cigna Priority Health	$16.90

PR MGMT LVR HEMRRG CPLX SUTR WND/INJ

Professional

Both

$3,454.00

Service Code	HCPCS 47360
Min. Negotiated Rate	$331.24
Max. Negotiated Rate	$3,346.89
Rate for Payer: Aetna Commercial	$2,542.61
Rate for Payer: Aetna Medicare	$1,727.00
Rate for Payer: BCBS Complete	$1,260.27
Rate for Payer: BCBS Trust/PPO	$331.24
Rate for Payer: BCN Commercial	$2,732.20
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Meridian Medicaid	$1,260.27
Rate for Payer: Priority Health Choice Medicaid	$1,200.26
Rate for Payer: Priority Health Cigna Priority Health	$2,245.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,346.89
Rate for Payer: Priority Health Narrow Network	$3,346.89
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,252.59
Rate for Payer: UHC Exchange	$2,252.59
Rate for Payer: UHCCP Medicaid	$1,200.26

PR MGMT LVR HEMRRG EXPL WND DBRDMT COAGJ/SUTR

Professional

Both

$6,375.00

Service Code	HCPCS 47361
Min. Negotiated Rate	$1,921.90
Max. Negotiated Rate	$5,352.04
Rate for Payer: Aetna Commercial	$4,086.75
Rate for Payer: Aetna Medicare	$3,187.50
Rate for Payer: BCBS Complete	$2,018.00
Rate for Payer: BCN Commercial	$4,387.35
Rate for Payer: Cash Price	$5,100.00
Rate for Payer: Cash Price	$5,100.00
Rate for Payer: Meridian Medicaid	$2,018.00
Rate for Payer: Priority Health Choice Medicaid	$1,921.90
Rate for Payer: Priority Health Cigna Priority Health	$4,143.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,352.04
Rate for Payer: Priority Health Narrow Network	$5,352.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3,677.38
Rate for Payer: UHC Exchange	$3,677.38
Rate for Payer: UHCCP Medicaid	$1,921.90

PR MGMT LVR HEMRRG RE-EXPL WND RMVL PACKING

Professional

Both

$2,999.00

Service Code	HCPCS 47362
Min. Negotiated Rate	$910.36
Max. Negotiated Rate	$2,594.58
Rate for Payer: Aetna Commercial	$1,928.21
Rate for Payer: Aetna Medicare	$1,499.50
Rate for Payer: BCBS Complete	$955.88
Rate for Payer: BCN Commercial	$2,091.06
Rate for Payer: Cash Price	$2,399.20
Rate for Payer: Cash Price	$2,399.20
Rate for Payer: Meridian Medicaid	$955.88
Rate for Payer: Priority Health Choice Medicaid	$910.36
Rate for Payer: Priority Health Cigna Priority Health	$1,949.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,594.58
Rate for Payer: Priority Health Narrow Network	$2,594.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,722.00
Rate for Payer: UHC Exchange	$1,722.00
Rate for Payer: UHCCP Medicaid	$910.36

PR MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ

Professional

Both

$2,903.00

Service Code	HCPCS 47350
Min. Negotiated Rate	$873.51
Max. Negotiated Rate	$2,437.69
Rate for Payer: Aetna Commercial	$1,849.58
Rate for Payer: Aetna Medicare	$1,451.50
Rate for Payer: BCBS Complete	$917.19
Rate for Payer: BCBS Trust/PPO	$1,888.67
Rate for Payer: BCN Commercial	$1,994.78
Rate for Payer: Cash Price	$2,322.40
Rate for Payer: Cash Price	$2,322.40
Rate for Payer: Meridian Medicaid	$917.19
Rate for Payer: Priority Health Choice Medicaid	$873.51
Rate for Payer: Priority Health Cigna Priority Health	$1,886.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,437.69
Rate for Payer: Priority Health Narrow Network	$2,437.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,648.65
Rate for Payer: UHC Exchange	$1,648.65
Rate for Payer: UHCCP Medicaid	$873.51

PR MH PARTIAL HOSP TX UNDER 24H

Professional

Both

$259.00

Service Code	HCPCS H0035
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$268.86
Rate for Payer: Aetna Commercial	$268.86
Rate for Payer: Aetna Medicare	$129.50
Rate for Payer: BCBS Complete	$103.60
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cash Price	$207.20
Rate for Payer: Priority Health Cigna Priority Health	$168.35

PR MICRONEEDLING PIN ADB/THIGHS/BACK

Professional

Both

$459.00

Service Code	HCPCS 00108
Hospital Revenue Code	990
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$298.35
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: BCBS Complete	$183.60
Rate for Payer: Cash Price	$367.20
Rate for Payer: Priority Health Cigna Priority Health	$298.35

PR MICRONEEDLING PIN FULL FACE

Professional

Both

$408.00

Service Code	HCPCS 00105
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 MICRONEEDLING PIN NECK

Professional

Both

$153.00

Service Code	HCPCS 00107
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 MICRONEEDLING PIN UPPER OR LOWER FACE

Professional

Both

$255.00

Service Code	HCPCS 00106
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 MICRONEEDLING SCARS - UP TO 4 INCHES

Professional

Both

$51.00

Service Code	HCPCS 00109
Hospital Revenue Code	990
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$33.15
Rate for Payer: Aetna Medicare	$25.50
Rate for Payer: BCBS Complete	$20.40
Rate for Payer: Cash Price	$40.80
Rate for Payer: Priority Health Cigna Priority Health	$33.15

PR MICRONEEDLING TAT RMVL 4-6 SQ INCHES

Professional

Both

$459.00

Service Code	HCPCS 00122
Hospital Revenue Code	990
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$298.35
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: BCBS Complete	$183.60
Rate for Payer: Cash Price	$367.20
Rate for Payer: Priority Health Cigna Priority Health	$298.35

PR MICRONEEDLING TAT RMVL 6-9 SQ INCHES

Professional

Both

$306.00

Service Code	HCPCS 00123
Hospital Revenue Code	990
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 MICRONEEDLING TAT RMVL 9-12 SQ INCHES

Professional

Both

$204.00

Service Code	HCPCS 00124
Hospital Revenue Code	990
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$132.60
Rate for Payer: Aetna Medicare	$102.00
Rate for Payer: BCBS Complete	$81.60
Rate for Payer: Cash Price	$163.20
Rate for Payer: Priority Health Cigna Priority Health	$132.60

PR MICRONEEDLING TAT RMVL UP TO 2 SQ INCH

Professional

Both

$153.00

Service Code	HCPCS 00110
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

Know your out-of-pocket cost for care.

All Charges