Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

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	$508.22
Max. Negotiated Rate	$2,673.73
Rate for Payer: Aetna Commercial	$944.93
Rate for Payer: Aetna Medicare	$1,106.50
Rate for Payer: BCBS Complete	$533.63
Rate for Payer: BCBS Trust/PPO	$2,673.73
Rate for Payer: BCN Commercial	$1,165.98
Rate for Payer: Cash Price	$1,770.40
Rate for Payer: Cash Price	$1,770.40
Rate for Payer: Meridian Medicaid	$533.63
Rate for Payer: Priority Health Choice Medicaid	$508.22
Rate for Payer: Priority Health Cigna Priority Health	$1,438.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,189.02
Rate for Payer: Priority Health Narrow Network	$1,189.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$854.20
Rate for Payer: UHC Exchange	$854.20
Rate for Payer: UHCCP Medicaid	$508.22

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	$146.76
Max. Negotiated Rate	$1,116.83
Rate for Payer: Aetna Commercial	$317.13
Rate for Payer: Aetna Medicare	$247.50
Rate for Payer: BCBS Complete	$154.10
Rate for Payer: BCBS Trust/PPO	$1,116.83
Rate for Payer: BCN Commercial	$335.23
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Meridian Medicaid	$154.10
Rate for Payer: Priority Health Choice Medicaid	$146.76
Rate for Payer: Priority Health Cigna Priority Health	$321.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$365.37
Rate for Payer: Priority Health Narrow Network	$365.37
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$316.56
Rate for Payer: UHC Exchange	$316.56
Rate for Payer: UHCCP Medicaid	$146.76

PR PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY

Professional

Both

$2,657.00

Service Code	HCPCS 33020
Min. Negotiated Rate	$524.62
Max. Negotiated Rate	$1,727.05
Rate for Payer: Aetna Commercial	$1,108.60
Rate for Payer: Aetna Medicare	$1,328.50
Rate for Payer: BCBS Complete	$550.85
Rate for Payer: BCBS Trust/PPO	$745.96
Rate for Payer: BCN Commercial	$1,188.47
Rate for Payer: Cash Price	$2,125.60
Rate for Payer: Cash Price	$2,125.60
Rate for Payer: Meridian Medicaid	$550.85
Rate for Payer: Priority Health Choice Medicaid	$524.62
Rate for Payer: Priority Health Cigna Priority Health	$1,727.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,296.06
Rate for Payer: Priority Health Narrow Network	$1,296.06
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,126.90
Rate for Payer: UHC Exchange	$1,126.90
Rate for Payer: UHCCP Medicaid	$524.62

PR PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE

Professional

Both

$2,152.00

Service Code	HCPCS 19371
Min. Negotiated Rate	$462.00
Max. Negotiated Rate	$6,614.63
Rate for Payer: Aetna Commercial	$770.26
Rate for Payer: Aetna Medicare	$1,076.00
Rate for Payer: BCBS Complete	$485.10
Rate for Payer: BCBS Trust/PPO	$6,614.63
Rate for Payer: BCN Commercial	$1,043.82
Rate for Payer: Cash Price	$1,721.60
Rate for Payer: Cash Price	$1,721.60
Rate for Payer: Meridian Medicaid	$485.10
Rate for Payer: Priority Health Choice Medicaid	$462.00
Rate for Payer: Priority Health Cigna Priority Health	$1,398.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$967.60
Rate for Payer: Priority Health Narrow Network	$967.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$822.15
Rate for Payer: UHC Exchange	$822.15
Rate for Payer: UHCCP Medicaid	$462.00

PR PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX

Professional

Both

$916.00

Service Code	HCPCS 56810
Min. Negotiated Rate	$174.45
Max. Negotiated Rate	$1,892.90
Rate for Payer: Aetna Commercial	$320.71
Rate for Payer: Aetna Medicare	$458.00
Rate for Payer: BCBS Complete	$183.17
Rate for Payer: BCBS Trust/PPO	$1,892.90
Rate for Payer: BCN Commercial	$399.25
Rate for Payer: Cash Price	$732.80
Rate for Payer: Cash Price	$732.80
Rate for Payer: Meridian Medicaid	$183.17
Rate for Payer: Priority Health Choice Medicaid	$174.45
Rate for Payer: Priority Health Cigna Priority Health	$595.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$409.73
Rate for Payer: Priority Health Narrow Network	$409.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$296.71
Rate for Payer: UHC Exchange	$296.71
Rate for Payer: UHCCP Medicaid	$174.45

PR PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1Y

Professional

Both

$154.00

Service Code	HCPCS 99391
Min. Negotiated Rate	$45.89
Max. Negotiated Rate	$193.36
Rate for Payer: Aetna Commercial	$71.14
Rate for Payer: Aetna Medicare	$77.00
Rate for Payer: BCBS Complete	$48.18
Rate for Payer: BCBS Trust/PPO	$193.36
Rate for Payer: BCN Commercial	$141.72
Rate for Payer: Cash Price	$123.20
Rate for Payer: Cash Price	$123.20
Rate for Payer: Meridian Medicaid	$48.18
Rate for Payer: Priority Health Choice Medicaid	$45.89
Rate for Payer: Priority Health Cigna Priority Health	$100.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$146.80
Rate for Payer: Priority Health Narrow Network	$146.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$57.62
Rate for Payer: UHC Exchange	$57.62
Rate for Payer: UHCCP Medicaid	$45.89

PR PERIODIC PREVENTIVE MED EST PATIENT 12-17YRS

Professional

Both

$166.00

Service Code	HCPCS 99394
Min. Negotiated Rate	$61.08
Max. Negotiated Rate	$550.49
Rate for Payer: Aetna Commercial	$88.48
Rate for Payer: Aetna Medicare	$83.00
Rate for Payer: BCBS Complete	$64.13
Rate for Payer: BCBS Trust/PPO	$550.49
Rate for Payer: BCN Commercial	$120.73
Rate for Payer: Cash Price	$132.80
Rate for Payer: Cash Price	$132.80
Rate for Payer: Meridian Medicaid	$64.13
Rate for Payer: Priority Health Choice Medicaid	$61.08
Rate for Payer: Priority Health Cigna Priority Health	$107.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$107.90
Rate for Payer: Priority Health Narrow Network	$107.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$76.53
Rate for Payer: UHC Exchange	$76.53
Rate for Payer: UHCCP Medicaid	$61.08

PR PERIODIC PREVENTIVE MED EST PATIENT 1-4YRS

Professional

Both

$165.00

Service Code	HCPCS 99392
Min. Negotiated Rate	$53.49
Max. Negotiated Rate	$527.24
Rate for Payer: Aetna Commercial	$78.23
Rate for Payer: Aetna Medicare	$82.50
Rate for Payer: BCBS Complete	$56.16
Rate for Payer: BCBS Trust/PPO	$527.24
Rate for Payer: BCN Commercial	$151.49
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Meridian Medicaid	$56.16
Rate for Payer: Priority Health Choice Medicaid	$53.49
Rate for Payer: Priority Health Cigna Priority Health	$107.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$156.69
Rate for Payer: Priority Health Narrow Network	$156.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$67.29
Rate for Payer: UHC Exchange	$67.29
Rate for Payer: UHCCP Medicaid	$53.49

PR PERIODIC PREVENTIVE MED EST PATIENT 18-39 YRS

Professional

Both

$169.00

Service Code	HCPCS 99395
Min. Negotiated Rate	$61.08
Max. Negotiated Rate	$668.30
Rate for Payer: Aetna Commercial	$90.96
Rate for Payer: Aetna Medicare	$84.50
Rate for Payer: BCBS Complete	$64.13
Rate for Payer: BCBS Trust/PPO	$668.30
Rate for Payer: BCN Commercial	$123.60
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Meridian Medicaid	$64.13
Rate for Payer: Priority Health Choice Medicaid	$61.08
Rate for Payer: Priority Health Cigna Priority Health	$109.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$111.39
Rate for Payer: Priority Health Narrow Network	$111.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$76.53
Rate for Payer: UHC Exchange	$76.53
Rate for Payer: UHCCP Medicaid	$61.08

PR PERIODIC PREVENTIVE MED EST PATIENT 40-64YRS

Professional

Both

$182.00

Service Code	HCPCS 99396
Min. Negotiated Rate	$69.00
Max. Negotiated Rate	$972.60
Rate for Payer: Aetna Commercial	$98.74
Rate for Payer: Aetna Medicare	$91.00
Rate for Payer: BCBS Complete	$72.45
Rate for Payer: BCBS Trust/PPO	$972.60
Rate for Payer: BCN Commercial	$131.12
Rate for Payer: Cash Price	$145.60
Rate for Payer: Cash Price	$145.60
Rate for Payer: Meridian Medicaid	$72.45
Rate for Payer: Priority Health Choice Medicaid	$69.00
Rate for Payer: Priority Health Cigna Priority Health	$118.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$121.04
Rate for Payer: Priority Health Narrow Network	$121.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$86.59
Rate for Payer: UHC Exchange	$86.59
Rate for Payer: UHCCP Medicaid	$69.00

PR PERIODIC PREVENTIVE MED EST PATIENT 5-11YRS

Professional

Both

$152.00

Service Code	HCPCS 99393
Min. Negotiated Rate	$53.49
Max. Negotiated Rate	$624.98
Rate for Payer: Aetna Commercial	$78.23
Rate for Payer: Aetna Medicare	$76.00
Rate for Payer: BCBS Complete	$56.16
Rate for Payer: BCBS Trust/PPO	$624.98
Rate for Payer: BCN Commercial	$106.47
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Meridian Medicaid	$56.16
Rate for Payer: Priority Health Choice Medicaid	$53.49
Rate for Payer: Priority Health Cigna Priority Health	$98.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$95.16
Rate for Payer: Priority Health Narrow Network	$95.16
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$67.29
Rate for Payer: UHC Exchange	$67.29
Rate for Payer: UHCCP Medicaid	$53.49

PR PERIODIC PREVENTIVE MED EST PATIENT 65YRS& OLDER

Professional

Both

$196.00

Service Code	HCPCS 99397
Min. Negotiated Rate	$76.91
Max. Negotiated Rate	$977.36
Rate for Payer: Aetna Commercial	$103.72
Rate for Payer: Aetna Medicare	$98.00
Rate for Payer: BCBS Complete	$80.76
Rate for Payer: BCBS Trust/PPO	$977.36
Rate for Payer: BCN Commercial	$141.51
Rate for Payer: Cash Price	$156.80
Rate for Payer: Cash Price	$156.80
Rate for Payer: Meridian Medicaid	$80.76
Rate for Payer: Priority Health Choice Medicaid	$76.91
Rate for Payer: Priority Health Cigna Priority Health	$127.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$127.19
Rate for Payer: Priority Health Narrow Network	$127.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$97.06
Rate for Payer: UHC Exchange	$97.06
Rate for Payer: UHCCP Medicaid	$76.91

PR PERI-PX DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON

Professional

Both

$68.00

Service Code	HCPCS 93286
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$1,612.37
Rate for Payer: Aetna Commercial	$57.97
Rate for Payer: Aetna Medicare	$34.00
Rate for Payer: BCBS Complete	$9.62
Rate for Payer: BCBS Trust/PPO	$1,612.37
Rate for Payer: BCN Commercial	$67.44
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cash Price	$54.40
Rate for Payer: Meridian Medicaid	$9.62
Rate for Payer: Priority Health Choice Medicaid	$9.16
Rate for Payer: Priority Health Cigna Priority Health	$44.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$20.24
Rate for Payer: Priority Health Narrow Network	$20.24
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$28.10
Rate for Payer: UHC Exchange	$28.10
Rate for Payer: UHCCP Medicaid	$9.16

PR PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB

Professional

Both

$47.00

Service Code	HCPCS 93287
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$1,774.03
Rate for Payer: Aetna Commercial	$68.07
Rate for Payer: Aetna Medicare	$23.50
Rate for Payer: BCBS Complete	$14.31
Rate for Payer: BCBS Trust/PPO	$1,774.03
Rate for Payer: BCN Commercial	$78.19
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cash Price	$37.60
Rate for Payer: Meridian Medicaid	$14.31
Rate for Payer: Priority Health Choice Medicaid	$13.63
Rate for Payer: Priority Health Cigna Priority Health	$30.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$29.66
Rate for Payer: Priority Health Narrow Network	$29.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.25
Rate for Payer: UHC Exchange	$37.25
Rate for Payer: UHCCP Medicaid	$13.63

PR PERIRECTAL INJ SCLEROSING SOLUTION PROLAPSE

Professional

Both

$290.00

Service Code	HCPCS 45520
Min. Negotiated Rate	$25.99
Max. Negotiated Rate	$2,174.48
Rate for Payer: Aetna Commercial	$51.85
Rate for Payer: Aetna Medicare	$145.00
Rate for Payer: BCBS Complete	$27.29
Rate for Payer: BCBS Trust/PPO	$2,174.48
Rate for Payer: BCN Commercial	$240.43
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Meridian Medicaid	$27.29
Rate for Payer: Priority Health Choice Medicaid	$25.99
Rate for Payer: Priority Health Cigna Priority Health	$188.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$72.78
Rate for Payer: Priority Health Narrow Network	$72.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$46.03
Rate for Payer: UHC Exchange	$46.03
Rate for Payer: UHCCP Medicaid	$25.99

PR PERITONEAL LAVAGE W/WO IMAGING GUIDANCE

Professional

Both

$137.00

Service Code	HCPCS 49084
Min. Negotiated Rate	$68.50
Max. Negotiated Rate	$530.41
Rate for Payer: Aetna Commercial	$145.77
Rate for Payer: Aetna Medicare	$68.50
Rate for Payer: BCBS Complete	$72.02
Rate for Payer: BCBS Trust/PPO	$530.41
Rate for Payer: BCN Commercial	$155.40
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Meridian Medicaid	$72.02
Rate for Payer: Priority Health Choice Medicaid	$68.59
Rate for Payer: Priority Health Cigna Priority Health	$89.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$189.12
Rate for Payer: Priority Health Narrow Network	$189.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$132.65
Rate for Payer: UHC Exchange	$132.65
Rate for Payer: UHCCP Medicaid	$68.59

Know your out-of-pocket cost for care.

All Charges