Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGIOP

Professional

Both

$1,322.00

Service Code	HCPCS 36905
Min. Negotiated Rate	$275.84
Max. Negotiated Rate	$3,353.79
Rate for Payer: Aetna Commercial	$594.60
Rate for Payer: Aetna Medicare	$661.00
Rate for Payer: BCBS Complete	$289.63
Rate for Payer: BCBS Trust/PPO	$1,385.73
Rate for Payer: BCN Commercial	$3,353.79
Rate for Payer: Cash Price	$1,057.60
Rate for Payer: Cash Price	$1,057.60
Rate for Payer: Meridian Medicaid	$289.63
Rate for Payer: Priority Health Choice Medicaid	$275.84
Rate for Payer: Priority Health Cigna Priority Health	$859.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$684.46
Rate for Payer: Priority Health Narrow Network	$684.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$572.44
Rate for Payer: UHC Exchange	$572.44
Rate for Payer: UHCCP Medicaid	$275.84

PR PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH

Professional

Both

$887.00

Service Code	HCPCS 36904
Min. Negotiated Rate	$229.19
Max. Negotiated Rate	$2,663.30
Rate for Payer: Aetna Commercial	$493.49
Rate for Payer: Aetna Medicare	$443.50
Rate for Payer: BCBS Complete	$240.65
Rate for Payer: BCBS Trust/PPO	$1,699.01
Rate for Payer: BCN Commercial	$2,663.30
Rate for Payer: Cash Price	$709.60
Rate for Payer: Cash Price	$709.60
Rate for Payer: Meridian Medicaid	$240.65
Rate for Payer: Priority Health Choice Medicaid	$229.19
Rate for Payer: Priority Health Cigna Priority Health	$576.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$570.11
Rate for Payer: Priority Health Narrow Network	$570.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$456.05
Rate for Payer: UHC Exchange	$456.05
Rate for Payer: UHCCP Medicaid	$229.19

PR PERQ TRANSLUMINAL ANGIOPLASTY NATIVE/RECR COA

Professional

Both

$1,244.00

Service Code	HCPCS 33897
Min. Negotiated Rate	$362.10
Max. Negotiated Rate	$903.04
Rate for Payer: Aetna Commercial	$769.84
Rate for Payer: Aetna Medicare	$622.00
Rate for Payer: BCBS Complete	$380.20
Rate for Payer: BCN Commercial	$827.82
Rate for Payer: Cash Price	$995.20
Rate for Payer: Cash Price	$995.20
Rate for Payer: Meridian Medicaid	$380.20
Rate for Payer: Priority Health Choice Medicaid	$362.10
Rate for Payer: Priority Health Cigna Priority Health	$808.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$903.04
Rate for Payer: Priority Health Narrow Network	$903.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$779.05
Rate for Payer: UHC Exchange	$779.05
Rate for Payer: UHCCP Medicaid	$362.10

PR PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION

Professional

Both

$1,546.00

Service Code	HCPCS 22513
Min. Negotiated Rate	$219.77
Max. Negotiated Rate	$8,492.73
Rate for Payer: Aetna Commercial	$684.44
Rate for Payer: Aetna Medicare	$773.00
Rate for Payer: BCBS Complete	$341.07
Rate for Payer: BCBS Trust/PPO	$219.77
Rate for Payer: BCN Commercial	$8,492.73
Rate for Payer: Cash Price	$1,236.80
Rate for Payer: Cash Price	$1,236.80
Rate for Payer: Meridian Medicaid	$341.07
Rate for Payer: Priority Health Choice Medicaid	$324.83
Rate for Payer: Priority Health Cigna Priority Health	$1,004.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$773.97
Rate for Payer: Priority Health Narrow Network	$773.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$691.56
Rate for Payer: UHC Exchange	$691.56
Rate for Payer: UHCCP Medicaid	$324.83

PR PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ EACH

Professional

Both

$806.00

Service Code	HCPCS 22515
Min. Negotiated Rate	$57.48
Max. Negotiated Rate	$4,362.91
Rate for Payer: Aetna Commercial	$294.64
Rate for Payer: Aetna Medicare	$403.00
Rate for Payer: BCBS Complete	$144.92
Rate for Payer: BCBS Trust/PPO	$57.48
Rate for Payer: BCN Commercial	$4,362.91
Rate for Payer: Cash Price	$644.80
Rate for Payer: Cash Price	$644.80
Rate for Payer: Meridian Medicaid	$144.92
Rate for Payer: Priority Health Choice Medicaid	$138.02
Rate for Payer: Priority Health Cigna Priority Health	$523.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$328.21
Rate for Payer: Priority Health Narrow Network	$328.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$292.69
Rate for Payer: UHC Exchange	$292.69
Rate for Payer: UHCCP Medicaid	$138.02

PR PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR

Professional

Both

$1,444.00

Service Code	HCPCS 22514
Min. Negotiated Rate	$303.53
Max. Negotiated Rate	$8,451.68
Rate for Payer: Aetna Commercial	$638.90
Rate for Payer: Aetna Medicare	$722.00
Rate for Payer: BCBS Complete	$318.71
Rate for Payer: BCBS Trust/PPO	$3,205.12
Rate for Payer: BCN Commercial	$8,451.68
Rate for Payer: Cash Price	$1,155.20
Rate for Payer: Cash Price	$1,155.20
Rate for Payer: Meridian Medicaid	$318.71
Rate for Payer: Priority Health Choice Medicaid	$303.53
Rate for Payer: Priority Health Cigna Priority Health	$938.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$721.57
Rate for Payer: Priority Health Narrow Network	$721.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$644.15
Rate for Payer: UHC Exchange	$644.15
Rate for Payer: UHCCP Medicaid	$303.53

PR PERQ VERTEBROPLASTY UNI/BI INJECTION LUMBOSACRAL

Professional

Both

$1,057.00

Service Code	HCPCS 22511
Min. Negotiated Rate	$190.19
Max. Negotiated Rate	$2,669.64
Rate for Payer: Aetna Commercial	$541.34
Rate for Payer: Aetna Medicare	$528.50
Rate for Payer: BCBS Complete	$272.18
Rate for Payer: BCBS Trust/PPO	$190.19
Rate for Payer: BCN Commercial	$2,669.64
Rate for Payer: Cash Price	$845.60
Rate for Payer: Cash Price	$845.60
Rate for Payer: Meridian Medicaid	$272.18
Rate for Payer: Priority Health Choice Medicaid	$259.22
Rate for Payer: Priority Health Cigna Priority Health	$687.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$614.70
Rate for Payer: Priority Health Narrow Network	$614.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$542.51
Rate for Payer: UHC Exchange	$542.51
Rate for Payer: UHCCP Medicaid	$259.22

PR PERQ VERTEBROPLASTY UNI/BI INJX CERVICOTHORACIC

Professional

Both

$3,421.00

Service Code	HCPCS 22510
Min. Negotiated Rate	$275.20
Max. Negotiated Rate	$2,683.33
Rate for Payer: Aetna Commercial	$576.08
Rate for Payer: Aetna Medicare	$1,710.50
Rate for Payer: BCBS Complete	$288.96
Rate for Payer: BCBS Trust/PPO	$825.51
Rate for Payer: BCN Commercial	$2,683.33
Rate for Payer: Cash Price	$2,736.80
Rate for Payer: Cash Price	$2,736.80
Rate for Payer: Meridian Medicaid	$288.96
Rate for Payer: Priority Health Choice Medicaid	$275.20
Rate for Payer: Priority Health Cigna Priority Health	$2,223.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$652.87
Rate for Payer: Priority Health Narrow Network	$652.87
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$577.79
Rate for Payer: UHC Exchange	$577.79
Rate for Payer: UHCCP Medicaid	$275.20

PR PESSARY REUSABLE NONRUBBER

Professional

Both

$77.00

Service Code	HCPCS A4562
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$56.07
Rate for Payer: Aetna Commercial	$47.42
Rate for Payer: Aetna Medicare	$38.50
Rate for Payer: BCBS Complete	$30.80
Rate for Payer: BCN Commercial	$56.07
Rate for Payer: Cash Price	$61.60
Rate for Payer: Cash Price	$61.60
Rate for Payer: Priority Health Cigna Priority Health	$50.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$32.08
Rate for Payer: UHC Exchange	$32.08

PR PESSARY REUSABLE RUB ANYTYPE

Professional

Both

$77.00

Service Code	HCPCS A4561
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$50.05
Rate for Payer: Aetna Commercial	$19.09
Rate for Payer: Aetna Medicare	$38.50
Rate for Payer: BCBS Complete	$30.80
Rate for Payer: BCN Commercial	$22.57
Rate for Payer: Cash Price	$61.60
Rate for Payer: Cash Price	$61.60
Rate for Payer: Priority Health Cigna Priority Health	$50.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.91
Rate for Payer: UHC Exchange	$12.91

PR PHALANGECTOMY TOE EACH TOE

Professional

Both

$849.00

Service Code	HCPCS 28150
Min. Negotiated Rate	$182.12
Max. Negotiated Rate	$1,132.15
Rate for Payer: Aetna Commercial	$367.96
Rate for Payer: Aetna Medicare	$424.50
Rate for Payer: BCBS Complete	$191.23
Rate for Payer: BCBS Trust/PPO	$1,132.15
Rate for Payer: BCN Commercial	$607.43
Rate for Payer: Cash Price	$679.20
Rate for Payer: Cash Price	$679.20
Rate for Payer: Meridian Medicaid	$191.23
Rate for Payer: Priority Health Choice Medicaid	$182.12
Rate for Payer: Priority Health Cigna Priority Health	$551.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$431.01
Rate for Payer: Priority Health Narrow Network	$431.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$334.40
Rate for Payer: UHC Exchange	$334.40
Rate for Payer: UHCCP Medicaid	$182.12

PR PHARMACOLOGIC MANAGEMENT W/PSYCHOTHERAPY

Professional

Both

$85.00

Service Code	HCPCS 90863
Min. Negotiated Rate	$26.92
Max. Negotiated Rate	$1,062.41
Rate for Payer: Aetna Commercial	$31.40
Rate for Payer: Aetna Medicare	$42.50
Rate for Payer: BCBS Complete	$34.00
Rate for Payer: BCBS Trust/PPO	$1,062.41
Rate for Payer: BCN Commercial	$70.30
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$55.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$41.86
Rate for Payer: Priority Health Narrow Network	$41.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$26.92
Rate for Payer: UHC Exchange	$26.92

PR PHARYNGOPLASTY PLSTC/RCNSTV OPRATION PHARYNX

Professional

Both

$1,441.00

Service Code	HCPCS 42950
Min. Negotiated Rate	$509.50
Max. Negotiated Rate	$1,429.44
Rate for Payer: Aetna Commercial	$1,064.01
Rate for Payer: Aetna Medicare	$720.50
Rate for Payer: BCBS Complete	$534.98
Rate for Payer: BCBS Trust/PPO	$665.13
Rate for Payer: BCN Commercial	$1,175.76
Rate for Payer: Cash Price	$1,152.80
Rate for Payer: Cash Price	$1,152.80
Rate for Payer: Meridian Medicaid	$534.98
Rate for Payer: Priority Health Choice Medicaid	$509.50
Rate for Payer: Priority Health Cigna Priority Health	$936.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,429.44
Rate for Payer: Priority Health Narrow Network	$1,429.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$942.76
Rate for Payer: UHC Exchange	$942.76
Rate for Payer: UHCCP Medicaid	$509.50

PR PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE

Professional

Both

$196.00

Service Code	HCPCS 99195
Min. Negotiated Rate	$75.80
Max. Negotiated Rate	$587.47
Rate for Payer: Aetna Commercial	$110.88
Rate for Payer: Aetna Medicare	$98.00
Rate for Payer: BCBS Complete	$78.40
Rate for Payer: BCBS Trust/PPO	$587.47
Rate for Payer: BCN Commercial	$141.72
Rate for Payer: Cash Price	$156.80
Rate for Payer: Cash Price	$156.80
Rate for Payer: Priority Health Cigna Priority Health	$127.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$129.82
Rate for Payer: Priority Health Narrow Network	$129.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$75.80
Rate for Payer: UHC Exchange	$75.80

PR PHTFAC ARMS

Professional

Both

$255.00

Service Code	HCPCS 00079
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 PHTFAC CHEST/SHLD

Professional

Both

$128.00

Service Code	HCPCS 00077
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 PHTFAC FACE & NECK/ FL ARMS

Professional

Both

$255.00

Service Code	HCPCS 00076
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 PHTFAC FL LEGS

Professional

Both

$357.00

Service Code	HCPCS 00080
Hospital Revenue Code	990
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$232.05
Rate for Payer: Aetna Medicare	$178.50
Rate for Payer: BCBS Complete	$142.80
Rate for Payer: Cash Price	$285.60
Rate for Payer: Priority Health Cigna Priority Health	$232.05

PR PHTFAC HANDS

Professional

Both

$51.00

Service Code	HCPCS 00078
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 PHTFAC HEMANGIOMAS/WARTS

Professional

Both

$36.00

Service Code	HCPCS 00083
Hospital Revenue Code	990
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS Complete	$14.40
Rate for Payer: Cash Price	$28.80
Rate for Payer: Priority Health Cigna Priority Health	$23.40

PR PHTFAC NASAL VEIN

Professional

Both

$46.00

Service Code	HCPCS 00082
Hospital Revenue Code	990
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$29.90
Rate for Payer: Aetna Medicare	$23.00
Rate for Payer: BCBS Complete	$18.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Priority Health Cigna Priority Health	$29.90

PR PHTFAC SNGL PIGMENT

Professional

Both

$36.00

Service Code	HCPCS 00081
Hospital Revenue Code	990
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS Complete	$14.40
Rate for Payer: Cash Price	$28.80
Rate for Payer: Priority Health Cigna Priority Health	$23.40

PR PHYSICAL PERFORMANCE TEST/MEAS W/REPRT EA 15 MIN

Professional

Both

$54.00

Service Code	HCPCS 97750
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$708.45
Rate for Payer: Aetna Commercial	$24.69
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS Complete	$21.60
Rate for Payer: BCBS Trust/PPO	$708.45
Rate for Payer: BCN Commercial	$32.95
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Priority Health Cigna Priority Health	$35.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$77.25
Rate for Payer: Priority Health Narrow Network	$77.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$29.81
Rate for Payer: UHC Exchange	$29.81

PR PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASU

Professional

Both

$183.00

Service Code	HCPCS 93464
Min. Negotiated Rate	$55.81
Max. Negotiated Rate	$740.15
Rate for Payer: Aetna Commercial	$307.40
Rate for Payer: Aetna Medicare	$91.50
Rate for Payer: BCBS Complete	$58.60
Rate for Payer: BCBS Trust/PPO	$740.15
Rate for Payer: BCN Commercial	$319.60
Rate for Payer: Cash Price	$146.40
Rate for Payer: Cash Price	$146.40
Rate for Payer: Meridian Medicaid	$58.60
Rate for Payer: Priority Health Choice Medicaid	$55.81
Rate for Payer: Priority Health Cigna Priority Health	$118.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$121.94
Rate for Payer: Priority Health Narrow Network	$121.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$334.16
Rate for Payer: UHC Exchange	$334.16
Rate for Payer: UHCCP Medicaid	$55.81

PR PHYSIOL SUPPORT HARVEST ORGAN FROM BRAIN-DEAD PT

Professional

Both

$7.00

Service Code	HCPCS 01990
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.55
Rate for Payer: Aetna Medicare	$3.50
Rate for Payer: BCBS Complete	$2.80
Rate for Payer: Cash Price	$5.60
Rate for Payer: Priority Health Cigna Priority Health	$4.55

Know your out-of-pocket cost for care.

All Charges