Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR PENICILLIN G BENZATHINE INJ

Professional

Both

$10.00

Service Code	HCPCS J0561
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$43.21
Rate for Payer: Aetna Commercial	$40.21
Rate for Payer: Aetna Medicare	$30.01
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: BCBS MAPPO	$30.01
Rate for Payer: BCN Medicare Advantage	$30.01
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$43.21
Rate for Payer: Cofinity Commercial	$40.21
Rate for Payer: Health Alliance Plan Medicare Advantage	$30.01
Rate for Payer: Healthscope Commercial	$36.01
Rate for Payer: Healthscope Whirlpool	$36.01
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$31.51
Rate for Payer: Nomi Health Commercial	$36.01
Rate for Payer: PACE SWMI	$30.01
Rate for Payer: PHP Medicare Advantage	$30.01
Rate for Payer: Priority Health Cigna Priority Health	$6.50
Rate for Payer: Priority Health Medicare	$30.01
Rate for Payer: UHC Dual Complete DSNP	$30.01
Rate for Payer: UHC Medicare Advantage	$30.01
Rate for Payer: UHCCP DNSP	$30.01

PR PENILE PLETHYSMOGRAPHY

Professional

Both

$188.00

Service Code	HCPCS 54240
Min. Negotiated Rate	$75.20
Max. Negotiated Rate	$146.26
Rate for Payer: Aetna Commercial	$136.10
Rate for Payer: Aetna Medicare	$101.57
Rate for Payer: BCBS Complete	$75.20
Rate for Payer: BCBS MAPPO	$101.57
Rate for Payer: BCN Medicare Advantage	$101.57
Rate for Payer: Cash Price	$150.40
Rate for Payer: Cash Price	$150.40
Rate for Payer: Cofinity Commercial	$146.26
Rate for Payer: Cofinity Commercial	$136.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$101.57
Rate for Payer: Healthscope Commercial	$121.88
Rate for Payer: Healthscope Whirlpool	$121.88
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$106.65
Rate for Payer: Nomi Health Commercial	$121.88
Rate for Payer: PACE SWMI	$101.57
Rate for Payer: PHP Medicare Advantage	$101.57
Rate for Payer: Priority Health Cigna Priority Health	$122.20
Rate for Payer: Priority Health Medicare	$101.57
Rate for Payer: UHC Dual Complete DSNP	$101.57
Rate for Payer: UHC Medicare Advantage	$101.57
Rate for Payer: UHCCP DNSP	$101.57

PR PENIS CORRJ CHORDEE/1ST STAGE HYPOSPADIAS RPR

Professional

Both

$5,200.00

Service Code	HCPCS 54304
Min. Negotiated Rate	$714.22
Max. Negotiated Rate	$3,380.00
Rate for Payer: Aetna Commercial	$957.05
Rate for Payer: Aetna Medicare	$714.22
Rate for Payer: BCBS Complete	$2,080.00
Rate for Payer: BCBS MAPPO	$714.22
Rate for Payer: BCN Medicare Advantage	$714.22
Rate for Payer: Cash Price	$4,160.00
Rate for Payer: Cash Price	$4,160.00
Rate for Payer: Cofinity Commercial	$957.05
Rate for Payer: Cofinity Commercial	$1,028.48
Rate for Payer: Health Alliance Plan Medicare Advantage	$714.22
Rate for Payer: Healthscope Commercial	$857.06
Rate for Payer: Healthscope Whirlpool	$857.06
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$749.93
Rate for Payer: Nomi Health Commercial	$857.06
Rate for Payer: PACE SWMI	$714.22
Rate for Payer: PHP Medicare Advantage	$714.22
Rate for Payer: Priority Health Cigna Priority Health	$3,380.00
Rate for Payer: Priority Health Medicare	$714.22
Rate for Payer: UHC Dual Complete DSNP	$714.22
Rate for Payer: UHC Medicare Advantage	$714.22
Rate for Payer: UHCCP DNSP	$714.22

PR PENIS STRAIGHTENING CHORDEE

Professional

Both

$1,336.00

Service Code	HCPCS 54300
Min. Negotiated Rate	$534.40
Max. Negotiated Rate	$888.48
Rate for Payer: Aetna Commercial	$826.78
Rate for Payer: Aetna Medicare	$617.00
Rate for Payer: BCBS Complete	$534.40
Rate for Payer: BCBS MAPPO	$617.00
Rate for Payer: BCN Medicare Advantage	$617.00
Rate for Payer: Cash Price	$1,068.80
Rate for Payer: Cash Price	$1,068.80
Rate for Payer: Cofinity Commercial	$888.48
Rate for Payer: Cofinity Commercial	$826.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$617.00
Rate for Payer: Healthscope Commercial	$740.40
Rate for Payer: Healthscope Whirlpool	$740.40
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$647.85
Rate for Payer: Nomi Health Commercial	$740.40
Rate for Payer: PACE SWMI	$617.00
Rate for Payer: PHP Medicare Advantage	$617.00
Rate for Payer: Priority Health Cigna Priority Health	$868.40
Rate for Payer: Priority Health Medicare	$617.00
Rate for Payer: UHC Dual Complete DSNP	$617.00
Rate for Payer: UHC Medicare Advantage	$617.00
Rate for Payer: UHCCP DNSP	$617.00

PR PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS/PROPH

Professional

Both

$190.00

Service Code	HCPCS 94642
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$123.50
Rate for Payer: Aetna Medicare	$95.00
Rate for Payer: BCBS Complete	$76.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Priority Health Cigna Priority Health	$123.50

PR PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY

Professional

Both

$233.00

Service Code	HCPCS 92972
Min. Negotiated Rate	$93.20
Max. Negotiated Rate	$198.62
Rate for Payer: Aetna Commercial	$184.83
Rate for Payer: Aetna Medicare	$137.93
Rate for Payer: BCBS Complete	$93.20
Rate for Payer: BCBS MAPPO	$137.93
Rate for Payer: BCN Medicare Advantage	$137.93
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cofinity Commercial	$198.62
Rate for Payer: Cofinity Commercial	$184.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$137.93
Rate for Payer: Healthscope Commercial	$165.52
Rate for Payer: Healthscope Whirlpool	$165.52
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$144.83
Rate for Payer: Nomi Health Commercial	$165.52
Rate for Payer: PACE SWMI	$137.93
Rate for Payer: PHP Medicare Advantage	$137.93
Rate for Payer: Priority Health Cigna Priority Health	$151.45
Rate for Payer: Priority Health Medicare	$137.93
Rate for Payer: UHC Dual Complete DSNP	$137.93
Rate for Payer: UHC Medicare Advantage	$137.93
Rate for Payer: UHCCP DNSP	$137.93

PR PERCUTANEOUS TX MALAR AREA FRACTURE

Professional

Both

$916.00

Service Code	HCPCS 21355
Min. Negotiated Rate	$312.53
Max. Negotiated Rate	$595.40
Rate for Payer: Aetna Commercial	$418.79
Rate for Payer: Aetna Medicare	$312.53
Rate for Payer: BCBS Complete	$366.40
Rate for Payer: BCBS MAPPO	$312.53
Rate for Payer: BCN Medicare Advantage	$312.53
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cofinity Commercial	$450.04
Rate for Payer: Cofinity Commercial	$418.79
Rate for Payer: Health Alliance Plan Medicare Advantage	$312.53
Rate for Payer: Healthscope Commercial	$375.04
Rate for Payer: Healthscope Whirlpool	$375.04
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$328.16
Rate for Payer: Nomi Health Commercial	$375.04
Rate for Payer: PACE SWMI	$312.53
Rate for Payer: PHP Medicare Advantage	$312.53
Rate for Payer: Priority Health Cigna Priority Health	$595.40
Rate for Payer: Priority Health Medicare	$312.53
Rate for Payer: UHC Dual Complete DSNP	$312.53
Rate for Payer: UHC Medicare Advantage	$312.53
Rate for Payer: UHCCP DNSP	$312.53

PR PERCUTANEOUS VERTEBROPLASTY EA ADDL THRC/LMBR

Professional

Both

$719.00

Service Code	HCPCS 22522
Min. Negotiated Rate	$287.60
Max. Negotiated Rate	$467.35
Rate for Payer: Aetna Medicare	$359.50
Rate for Payer: BCBS Complete	$287.60
Rate for Payer: Cash Price	$575.20
Rate for Payer: Priority Health Cigna Priority Health	$467.35

PR PERCUTANEOUS VERTEBROPLASTY LUMBAR W/WO BNE BX

Professional

Both

$5,744.00

Service Code	HCPCS 22521
Min. Negotiated Rate	$2,297.60
Max. Negotiated Rate	$3,733.60
Rate for Payer: Aetna Medicare	$2,872.00
Rate for Payer: BCBS Complete	$2,297.60
Rate for Payer: Cash Price	$4,595.20
Rate for Payer: Priority Health Cigna Priority Health	$3,733.60

PR PERCUTANEOUS VERTEBROPLSTY THORACIC W/WO BONE BX

Professional

Both

$7,841.00

Service Code	HCPCS 22520
Min. Negotiated Rate	$3,136.40
Max. Negotiated Rate	$5,096.65
Rate for Payer: Aetna Medicare	$3,920.50
Rate for Payer: BCBS Complete	$3,136.40
Rate for Payer: Cash Price	$6,272.80
Rate for Payer: Priority Health Cigna Priority Health	$5,096.65

PR PERCUT DILATN RENAL TRACT

Professional

Both

$347.00

Service Code	HCPCS 50395
Min. Negotiated Rate	$138.80
Max. Negotiated Rate	$225.55
Rate for Payer: Aetna Medicare	$173.50
Rate for Payer: BCBS Complete	$138.80
Rate for Payer: Cash Price	$277.60
Rate for Payer: Priority Health Cigna Priority Health	$225.55

PR PERCUT INSERT KIDNEY CATH/DRAIN

Professional

Both

$365.00

Service Code	HCPCS 50392
Min. Negotiated Rate	$146.00
Max. Negotiated Rate	$237.25
Rate for Payer: Aetna Medicare	$182.50
Rate for Payer: BCBS Complete	$146.00
Rate for Payer: Cash Price	$292.00
Rate for Payer: Priority Health Cigna Priority Health	$237.25

PR PERC VERTEB AUGMENT/ KYPHOPLAST, EA ADD

Professional

Both

$505.00

Service Code	HCPCS 22525
Min. Negotiated Rate	$202.00
Max. Negotiated Rate	$328.25
Rate for Payer: Aetna Medicare	$252.50
Rate for Payer: BCBS Complete	$202.00
Rate for Payer: Cash Price	$404.00
Rate for Payer: Priority Health Cigna Priority Health	$328.25

PR PERC VERTEB AUGMENT/ KYPHOPLAST, LUMBAR

Professional

Both

$1,075.00

Service Code	HCPCS 22524
Min. Negotiated Rate	$430.00
Max. Negotiated Rate	$698.75
Rate for Payer: Aetna Medicare	$537.50
Rate for Payer: BCBS Complete	$430.00
Rate for Payer: Cash Price	$860.00
Rate for Payer: Priority Health Cigna Priority Health	$698.75

PR PERC VERTEB AUGMENT/ KYPHOPLAST, THOR

Professional

Both

$1,141.00

Service Code	HCPCS 22523
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$741.65
Rate for Payer: Aetna Medicare	$570.50
Rate for Payer: BCBS Complete	$456.40
Rate for Payer: Cash Price	$912.80
Rate for Payer: Priority Health Cigna Priority Health	$741.65

PR PEREYRA PX W/ANTERIOR COLPORRHAPHY

Professional

Both

$2,213.00

Service Code	HCPCS 57289
Min. Negotiated Rate	$758.08
Max. Negotiated Rate	$1,438.45
Rate for Payer: Aetna Commercial	$1,015.83
Rate for Payer: Aetna Medicare	$758.08
Rate for Payer: BCBS Complete	$885.20
Rate for Payer: BCBS MAPPO	$758.08
Rate for Payer: BCN Medicare Advantage	$758.08
Rate for Payer: Cash Price	$1,770.40
Rate for Payer: Cash Price	$1,770.40
Rate for Payer: Cofinity Commercial	$1,091.64
Rate for Payer: Cofinity Commercial	$1,015.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$758.08
Rate for Payer: Healthscope Commercial	$909.70
Rate for Payer: Healthscope Whirlpool	$909.70
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$795.98
Rate for Payer: Nomi Health Commercial	$909.70
Rate for Payer: PACE SWMI	$758.08
Rate for Payer: PHP Medicare Advantage	$758.08
Rate for Payer: Priority Health Cigna Priority Health	$1,438.45
Rate for Payer: Priority Health Medicare	$758.08
Rate for Payer: UHC Dual Complete DSNP	$758.08
Rate for Payer: UHC Medicare Advantage	$758.08
Rate for Payer: UHCCP DNSP	$758.08

PR PERICARDIOCENTESIS INITIAL

Professional

Both

$451.00

Service Code	HCPCS 33010
Min. Negotiated Rate	$180.40
Max. Negotiated Rate	$293.15
Rate for Payer: Aetna Medicare	$225.50
Rate for Payer: BCBS Complete	$180.40
Rate for Payer: Cash Price	$360.80
Rate for Payer: Priority Health Cigna Priority Health	$293.15

PR PERICARDIOCENTESIS SUBSEQUENT

Professional

Both

$450.00

Service Code	HCPCS 33011
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$292.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS Complete	$180.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Priority Health Cigna Priority Health	$292.50

PR PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED

Professional

Both

$495.00

Service Code	HCPCS 33016
Min. Negotiated Rate	$198.00
Max. Negotiated Rate	$322.44
Rate for Payer: Aetna Commercial	$300.05
Rate for Payer: Aetna Medicare	$223.92
Rate for Payer: BCBS Complete	$198.00
Rate for Payer: BCBS MAPPO	$223.92
Rate for Payer: BCN Medicare Advantage	$223.92
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cofinity Commercial	$322.44
Rate for Payer: Cofinity Commercial	$300.05
Rate for Payer: Health Alliance Plan Medicare Advantage	$223.92
Rate for Payer: Healthscope Commercial	$268.70
Rate for Payer: Healthscope Whirlpool	$268.70
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$235.12
Rate for Payer: Nomi Health Commercial	$268.70
Rate for Payer: PACE SWMI	$223.92
Rate for Payer: PHP Medicare Advantage	$223.92
Rate for Payer: Priority Health Cigna Priority Health	$321.75
Rate for Payer: Priority Health Medicare	$223.92
Rate for Payer: UHC Dual Complete DSNP	$223.92
Rate for Payer: UHC Medicare Advantage	$223.92
Rate for Payer: UHCCP DNSP	$223.92

PR PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY

Professional

Both

$2,657.00

Service Code	HCPCS 33020
Min. Negotiated Rate	$795.71
Max. Negotiated Rate	$1,727.05
Rate for Payer: Aetna Commercial	$1,066.25
Rate for Payer: Aetna Medicare	$795.71
Rate for Payer: BCBS Complete	$1,062.80
Rate for Payer: BCBS MAPPO	$795.71
Rate for Payer: BCN Medicare Advantage	$795.71
Rate for Payer: Cash Price	$2,125.60
Rate for Payer: Cash Price	$2,125.60
Rate for Payer: Cofinity Commercial	$1,145.82
Rate for Payer: Cofinity Commercial	$1,066.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$795.71
Rate for Payer: Healthscope Commercial	$954.85
Rate for Payer: Healthscope Whirlpool	$954.85
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$835.50
Rate for Payer: Nomi Health Commercial	$954.85
Rate for Payer: PACE SWMI	$795.71
Rate for Payer: PHP Medicare Advantage	$795.71
Rate for Payer: Priority Health Cigna Priority Health	$1,727.05
Rate for Payer: Priority Health Medicare	$795.71
Rate for Payer: UHC Dual Complete DSNP	$795.71
Rate for Payer: UHC Medicare Advantage	$795.71
Rate for Payer: UHCCP DNSP	$795.71

PR PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE

Professional

Both

$2,152.00

Service Code	HCPCS 19371
Min. Negotiated Rate	$683.82
Max. Negotiated Rate	$1,398.80
Rate for Payer: Aetna Commercial	$916.32
Rate for Payer: Aetna Medicare	$683.82
Rate for Payer: BCBS Complete	$860.80
Rate for Payer: BCBS MAPPO	$683.82
Rate for Payer: BCN Medicare Advantage	$683.82
Rate for Payer: Cash Price	$1,721.60
Rate for Payer: Cash Price	$1,721.60
Rate for Payer: Cofinity Commercial	$984.70
Rate for Payer: Cofinity Commercial	$916.32
Rate for Payer: Health Alliance Plan Medicare Advantage	$683.82
Rate for Payer: Healthscope Commercial	$820.58
Rate for Payer: Healthscope Whirlpool	$820.58
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$718.01
Rate for Payer: Nomi Health Commercial	$820.58
Rate for Payer: PACE SWMI	$683.82
Rate for Payer: PHP Medicare Advantage	$683.82
Rate for Payer: Priority Health Cigna Priority Health	$1,398.80
Rate for Payer: Priority Health Medicare	$683.82
Rate for Payer: UHC Dual Complete DSNP	$683.82
Rate for Payer: UHC Medicare Advantage	$683.82
Rate for Payer: UHCCP DNSP	$683.82

PR PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX

Professional

Both

$916.00

Service Code	HCPCS 56810
Min. Negotiated Rate	$259.54
Max. Negotiated Rate	$595.40
Rate for Payer: Aetna Commercial	$347.78
Rate for Payer: Aetna Medicare	$259.54
Rate for Payer: BCBS Complete	$366.40
Rate for Payer: BCBS MAPPO	$259.54
Rate for Payer: BCN Medicare Advantage	$259.54
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cofinity Commercial	$373.74
Rate for Payer: Cofinity Commercial	$347.78
Rate for Payer: Health Alliance Plan Medicare Advantage	$259.54
Rate for Payer: Healthscope Commercial	$311.45
Rate for Payer: Healthscope Whirlpool	$311.45
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$272.52
Rate for Payer: Nomi Health Commercial	$311.45
Rate for Payer: PACE SWMI	$259.54
Rate for Payer: PHP Medicare Advantage	$259.54
Rate for Payer: Priority Health Cigna Priority Health	$595.40
Rate for Payer: Priority Health Medicare	$259.54
Rate for Payer: UHC Dual Complete DSNP	$259.54
Rate for Payer: UHC Medicare Advantage	$259.54
Rate for Payer: UHCCP DNSP	$259.54

PR PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1Y

Professional

Both

$154.00

Service Code	HCPCS 99391
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$100.10
Rate for Payer: Aetna Medicare	$77.00
Rate for Payer: BCBS Complete	$61.60
Rate for Payer: Cash Price	$123.20
Rate for Payer: Priority Health Cigna Priority Health	$100.10

PR PERIODIC PREVENTIVE MED EST PATIENT 12-17YRS

Professional

Both

$166.00

Service Code	HCPCS 99394
Min. Negotiated Rate	$66.40
Max. Negotiated Rate	$107.90
Rate for Payer: Aetna Medicare	$83.00
Rate for Payer: BCBS Complete	$66.40
Rate for Payer: Cash Price	$132.80
Rate for Payer: Priority Health Cigna Priority Health	$107.90

PR PERIODIC PREVENTIVE MED EST PATIENT 1-4YRS

Professional

Both

$165.00

Service Code	HCPCS 99392
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$107.25
Rate for Payer: Aetna Medicare	$82.50
Rate for Payer: BCBS Complete	$66.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Priority Health Cigna Priority Health	$107.25

Know your out-of-pocket cost for care.

All Charges