Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR PRO HEALTH VISION TESTING

Facility

$25.50

Service Code	CPT 99211
Hospital Charge Code	51000018
Hospital Revenue Code	510
Min. Negotiated Rate	$16.58
Max. Negotiated Rate	$25.50
Rate for Payer: Aetna Commercial	$22.95
Rate for Payer: ASR ASR	$24.74
Rate for Payer: ASR Commercial	$24.74
Rate for Payer: BCBS Trust/PPO	$20.78
Rate for Payer: BCN Commercial	$19.77
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cofinity Commercial	$23.97
Rate for Payer: Encore Health Key Benefits Commercial	$20.40
Rate for Payer: Healthscope Commercial	$25.50
Rate for Payer: Healthscope Whirlpool	$24.74
Rate for Payer: Mclaren Commercial	$22.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.68
Rate for Payer: Nomi Health Commercial	$20.91
Rate for Payer: Priority Health Cigna Priority Health	$16.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.44

PR PRO HEALTH VISION TESTING

Facility

$25.50

Service Code	CPT 99211
Hospital Charge Code	51000018
Hospital Revenue Code	510
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$119.69
Rate for Payer: Aetna Commercial	$22.95
Rate for Payer: Aetna Medicare	$12.75
Rate for Payer: ASR ASR	$24.74
Rate for Payer: ASR Commercial	$24.74
Rate for Payer: BCBS Complete	$10.20
Rate for Payer: BCBS Trust/PPO	$20.88
Rate for Payer: BCCCP Commercial	$21.87
Rate for Payer: BCN Commercial	$19.77
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cash Price	$20.40
Rate for Payer: Cofinity Commercial	$23.97
Rate for Payer: Encore Health Key Benefits Commercial	$20.40
Rate for Payer: Healthscope Commercial	$25.50
Rate for Payer: Healthscope Whirlpool	$24.74
Rate for Payer: Mclaren Commercial	$22.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.68
Rate for Payer: Nomi Health Commercial	$20.91
Rate for Payer: Priority Health Cigna Priority Health	$16.58
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$119.69
Rate for Payer: Priority Health Narrow Network	$95.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$22.44

PR PROHEALTH WORKSTATION EVAL

Facility

$102.00

Hospital Charge Code	98300182
Hospital Revenue Code	983
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: Aetna Medicare	$51.00
Rate for Payer: ASR ASR	$98.94
Rate for Payer: ASR Commercial	$98.94
Rate for Payer: BCBS Complete	$40.80
Rate for Payer: BCBS Trust/PPO	$83.53
Rate for Payer: BCN Commercial	$79.08
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cofinity Commercial	$95.88
Rate for Payer: Encore Health Key Benefits Commercial	$81.60
Rate for Payer: Healthscope Commercial	$102.00
Rate for Payer: Healthscope Whirlpool	$98.94
Rate for Payer: Mclaren Commercial	$91.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.70
Rate for Payer: Nomi Health Commercial	$83.64
Rate for Payer: Priority Health Cigna Priority Health	$66.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$89.37
Rate for Payer: Priority Health Narrow Network	$71.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.76

PR PROHEALTH WORKSTATION EVAL

Facility

$102.00

Hospital Charge Code	98300182
Hospital Revenue Code	983
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$91.80
Rate for Payer: ASR ASR	$98.94
Rate for Payer: ASR Commercial	$98.94
Rate for Payer: BCBS Trust/PPO	$83.12
Rate for Payer: BCN Commercial	$79.08
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cofinity Commercial	$95.88
Rate for Payer: Encore Health Key Benefits Commercial	$81.60
Rate for Payer: Healthscope Commercial	$102.00
Rate for Payer: Healthscope Whirlpool	$98.94
Rate for Payer: Mclaren Commercial	$91.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.70
Rate for Payer: Nomi Health Commercial	$83.64
Rate for Payer: Priority Health Cigna Priority Health	$66.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.76

PR PROLNG E/M BEFORE&/AFTER DIR CARE EA 30 MINUTES

Professional

Both

$121.00

Service Code	HCPCS 99359
Min. Negotiated Rate	$48.40
Max. Negotiated Rate	$295.85
Rate for Payer: Aetna Commercial	$52.40
Rate for Payer: Aetna Medicare	$60.50
Rate for Payer: BCBS Complete	$48.40
Rate for Payer: BCBS Trust/PPO	$295.85
Rate for Payer: BCN Commercial	$62.06
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Priority Health Cigna Priority Health	$78.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$48.91
Rate for Payer: Priority Health Narrow Network	$48.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$57.59
Rate for Payer: UHC Exchange	$57.59

PR PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR

Professional

Both

$242.00

Service Code	HCPCS 99358
Min. Negotiated Rate	$96.80
Max. Negotiated Rate	$157.30
Rate for Payer: Aetna Commercial	$109.68
Rate for Payer: Aetna Medicare	$121.00
Rate for Payer: BCBS Complete	$96.80
Rate for Payer: BCBS Trust/PPO	$147.73
Rate for Payer: BCN Commercial	$133.41
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Priority Health Cigna Priority Health	$157.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$117.12
Rate for Payer: Priority Health Narrow Network	$117.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$119.61
Rate for Payer: UHC Exchange	$119.61

PR PROLONGED EXTRACORPOREAL CIRCULATION INIT DAY

Professional

Both

$2,772.00

Service Code	HCPCS 33960
Min. Negotiated Rate	$1,108.80
Max. Negotiated Rate	$1,801.80
Rate for Payer: Aetna Medicare	$1,386.00
Rate for Payer: BCBS Complete	$1,108.80
Rate for Payer: Cash Price	$2,217.60
Rate for Payer: Priority Health Cigna Priority Health	$1,801.80

PR PROLONGED INPATIENT/OBSERVATION EM SVC EA 15 MIN

Professional

Both

$79.00

Service Code	HCPCS 99418
Min. Negotiated Rate	$24.92
Max. Negotiated Rate	$1,631.44
Rate for Payer: Aetna Commercial	$38.86
Rate for Payer: Aetna Medicare	$39.50
Rate for Payer: BCBS Complete	$26.17
Rate for Payer: BCBS Trust/PPO	$1,631.44
Rate for Payer: BCN Commercial	$56.68
Rate for Payer: Cash Price	$63.20
Rate for Payer: Cash Price	$63.20
Rate for Payer: Meridian Medicaid	$26.17
Rate for Payer: Priority Health Choice Medicaid	$24.92
Rate for Payer: Priority Health Cigna Priority Health	$51.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$52.50
Rate for Payer: Priority Health Narrow Network	$52.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$46.71
Rate for Payer: UHC Exchange	$46.71
Rate for Payer: UHCCP Medicaid	$24.92

PR PROLONGED OUTPATIENT E/M SERVICE EACH 15 MINUTES

Professional

Both

$66.00

Service Code	HCPCS 99417
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$1,097.28
Rate for Payer: Aetna Commercial	$32.84
Rate for Payer: Aetna Medicare	$33.00
Rate for Payer: BCBS Complete	$19.91
Rate for Payer: BCBS Trust/PPO	$1,097.28
Rate for Payer: BCN Commercial	$44.96
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Meridian Medicaid	$19.91
Rate for Payer: Priority Health Choice Medicaid	$18.96
Rate for Payer: Priority Health Cigna Priority Health	$42.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$39.94
Rate for Payer: Priority Health Narrow Network	$39.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.48
Rate for Payer: UHC Exchange	$37.48
Rate for Payer: UHCCP Medicaid	$18.96

PR PROLONGED SVC I/P OR OBS SETTING 1ST HOUR

Professional

Both

$303.00

Service Code	HCPCS 99356
Min. Negotiated Rate	$121.20
Max. Negotiated Rate	$196.95
Rate for Payer: Aetna Medicare	$151.50
Rate for Payer: BCBS Complete	$121.20
Rate for Payer: Cash Price	$242.40
Rate for Payer: Priority Health Cigna Priority Health	$196.95

PR PROLONGED SVC I/P OR OBS SETTING EA ADDL 30 MIN

Professional

Both

$160.00

Service Code	HCPCS 99357
Min. Negotiated Rate	$64.00
Max. Negotiated Rate	$104.00
Rate for Payer: Aetna Medicare	$80.00
Rate for Payer: BCBS Complete	$64.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Priority Health Cigna Priority Health	$104.00

PR PROLONGED SVC OUTPATIENT SETTING 1ST HOUR

Professional

Both

$233.00

Service Code	HCPCS 99354
Min. Negotiated Rate	$93.20
Max. Negotiated Rate	$151.45
Rate for Payer: Aetna Medicare	$116.50
Rate for Payer: BCBS Complete	$93.20
Rate for Payer: Cash Price	$186.40
Rate for Payer: Priority Health Cigna Priority Health	$151.45

PR PROLONGED SVC OUTPATIENT SETTING EA ADDL 30 MIN

Professional

Both

$173.00

Service Code	HCPCS 99355
Min. Negotiated Rate	$69.20
Max. Negotiated Rate	$112.45
Rate for Payer: Aetna Medicare	$86.50
Rate for Payer: BCBS Complete	$69.20
Rate for Payer: Cash Price	$138.40
Rate for Payer: Priority Health Cigna Priority Health	$112.45

PR PROLONG INPT EVAL ADD15 M

Professional

Both

$63.00

Service Code	HCPCS G0316
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$1,295.39
Rate for Payer: Aetna Commercial	$30.15
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS Complete	$25.20
Rate for Payer: BCBS Trust/PPO	$1,295.39
Rate for Payer: BCN Commercial	$45.94
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Priority Health Cigna Priority Health	$40.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$40.38
Rate for Payer: Priority Health Narrow Network	$40.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.26
Rate for Payer: UHC Exchange	$36.26

PR PROLONG OUTPT/OFFICE VIS

Professional

Both

$66.00

Service Code	HCPCS G2212
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$1,127.92
Rate for Payer: Aetna Commercial	$31.89
Rate for Payer: Aetna Medicare	$33.00
Rate for Payer: BCBS Complete	$20.58
Rate for Payer: BCBS Trust/PPO	$1,127.92
Rate for Payer: BCN Commercial	$38.06
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Meridian Medicaid	$20.58
Rate for Payer: Priority Health Choice Medicaid	$19.60
Rate for Payer: Priority Health Cigna Priority Health	$42.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$34.79
Rate for Payer: Priority Health Narrow Network	$34.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.48
Rate for Payer: UHC Exchange	$37.48
Rate for Payer: UHCCP Medicaid	$19.60

PR PROMETHAZINE HCL INJECTION

Professional

Both

$15.00

Service Code	HCPCS J2550
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna Commercial	$3.70
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: BCBS Trust/PPO	$0.30
Rate for Payer: BCN Commercial	$0.26
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Priority Health Cigna Priority Health	$9.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.97
Rate for Payer: UHC Exchange	$3.97

PR PROPH TX N/P/PLTWR W/WO METHYLMETHACRYLATE FEMUR

Professional

Both

$2,782.00

Service Code	HCPCS 27495
Min. Negotiated Rate	$1,112.80
Max. Negotiated Rate	$1,808.30
Rate for Payer: Aetna Commercial	$1,510.18
Rate for Payer: Aetna Medicare	$1,391.00
Rate for Payer: BCBS Complete	$1,112.80
Rate for Payer: BCBS Trust/PPO	$1,264.22
Rate for Payer: BCN Commercial	$1,655.15
Rate for Payer: Cash Price	$2,225.60
Rate for Payer: Cash Price	$2,225.60
Rate for Payer: Priority Health Cigna Priority Health	$1,808.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,735.21
Rate for Payer: Priority Health Narrow Network	$1,735.21
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,309.08
Rate for Payer: UHC Exchange	$1,309.08

PR PROPH TX N/P/PLTWR W/WO METHYLMETHACRYLATE TIBIA

Professional

Both

$2,148.00

Service Code	HCPCS 27745
Min. Negotiated Rate	$859.20
Max. Negotiated Rate	$2,619.31
Rate for Payer: Aetna Commercial	$1,016.22
Rate for Payer: Aetna Medicare	$1,074.00
Rate for Payer: BCBS Complete	$859.20
Rate for Payer: BCBS Trust/PPO	$2,619.31
Rate for Payer: BCN Commercial	$1,110.77
Rate for Payer: Cash Price	$1,718.40
Rate for Payer: Cash Price	$1,718.40
Rate for Payer: Priority Health Cigna Priority Health	$1,396.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,150.53
Rate for Payer: Priority Health Narrow Network	$1,150.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$867.20
Rate for Payer: UHC Exchange	$867.20

PR PROPH TX N/P/PLTWR W/WO MMA FEM NCK & PROX FEMUR

Professional

Both

$2,041.00

Service Code	HCPCS 27187
Min. Negotiated Rate	$816.40
Max. Negotiated Rate	$2,727.08
Rate for Payer: Aetna Commercial	$1,329.48
Rate for Payer: Aetna Medicare	$1,020.50
Rate for Payer: BCBS Complete	$816.40
Rate for Payer: BCBS Trust/PPO	$2,727.08
Rate for Payer: BCN Commercial	$1,461.15
Rate for Payer: Cash Price	$1,632.80
Rate for Payer: Cash Price	$1,632.80
Rate for Payer: Priority Health Cigna Priority Health	$1,326.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,533.19
Rate for Payer: Priority Health Narrow Network	$1,533.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,145.08
Rate for Payer: UHC Exchange	$1,145.08

PR PROPH TX W/WO METHYLMETHACRYLATE HUMERAL SHAFT

Professional

Both

$2,582.00

Service Code	HCPCS 24498
Min. Negotiated Rate	$557.36
Max. Negotiated Rate	$1,678.30
Rate for Payer: Aetna Commercial	$1,157.39
Rate for Payer: Aetna Medicare	$1,291.00
Rate for Payer: BCBS Complete	$1,032.80
Rate for Payer: BCBS Trust/PPO	$557.36
Rate for Payer: BCN Commercial	$1,274.47
Rate for Payer: Cash Price	$2,065.60
Rate for Payer: Cash Price	$2,065.60
Rate for Payer: Priority Health Cigna Priority Health	$1,678.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,337.80
Rate for Payer: Priority Health Narrow Network	$1,337.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$997.66
Rate for Payer: UHC Exchange	$997.66

PR PROPH TX W/WO METHYLMETHACRYLATE PROX HUMERUS

Professional

Both

$2,090.00

Service Code	HCPCS 23491
Min. Negotiated Rate	$185.93
Max. Negotiated Rate	$1,563.72
Rate for Payer: Aetna Commercial	$1,357.22
Rate for Payer: Aetna Medicare	$1,045.00
Rate for Payer: BCBS Complete	$836.00
Rate for Payer: BCBS Trust/PPO	$185.93
Rate for Payer: BCN Commercial	$1,490.47
Rate for Payer: Cash Price	$1,672.00
Rate for Payer: Cash Price	$1,672.00
Rate for Payer: Priority Health Cigna Priority Health	$1,358.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,563.72
Rate for Payer: Priority Health Narrow Network	$1,563.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,169.28
Rate for Payer: UHC Exchange	$1,169.28

PR PROPH TX W/WO METHYLMETHACRYLATE RADIUS

Professional

Both

$2,251.00

Service Code	HCPCS 25490
Min. Negotiated Rate	$824.93
Max. Negotiated Rate	$3,253.04
Rate for Payer: Aetna Commercial	$959.31
Rate for Payer: Aetna Medicare	$1,125.50
Rate for Payer: BCBS Complete	$900.40
Rate for Payer: BCBS Trust/PPO	$3,253.04
Rate for Payer: BCN Commercial	$1,060.92
Rate for Payer: Cash Price	$1,800.80
Rate for Payer: Cash Price	$1,800.80
Rate for Payer: Priority Health Cigna Priority Health	$1,463.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,114.92
Rate for Payer: Priority Health Narrow Network	$1,114.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$824.93
Rate for Payer: UHC Exchange	$824.93

PR PROSTATE CA SCREENING; DRE

Professional

Both

$35.00

Service Code	HCPCS G0102
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$1,420.07
Rate for Payer: Aetna Commercial	$8.94
Rate for Payer: Aetna Medicare	$17.50
Rate for Payer: BCBS Complete	$5.82
Rate for Payer: BCBS Trust/PPO	$1,420.07
Rate for Payer: BCN Commercial	$33.72
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cash Price	$28.00
Rate for Payer: Meridian Medicaid	$5.82
Rate for Payer: Priority Health Choice Medicaid	$5.54
Rate for Payer: Priority Health Cigna Priority Health	$22.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11.66
Rate for Payer: Priority Health Narrow Network	$11.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.24
Rate for Payer: UHC Exchange	$9.24
Rate for Payer: UHCCP Medicaid	$5.54

PR PROSTATECTOMY PERINEAL RAD W/BI PELVIC LYMPH EXC

Professional

Both

$3,657.00

Service Code	HCPCS 55815
Min. Negotiated Rate	$1,119.32
Max. Negotiated Rate	$2,781.23
Rate for Payer: Aetna Commercial	$2,262.59
Rate for Payer: Aetna Medicare	$1,828.50
Rate for Payer: BCBS Complete	$1,175.29
Rate for Payer: BCBS Trust/PPO	$1,908.22
Rate for Payer: BCN Commercial	$2,526.46
Rate for Payer: Cash Price	$2,925.60
Rate for Payer: Cash Price	$2,925.60
Rate for Payer: Meridian Medicaid	$1,175.29
Rate for Payer: Priority Health Choice Medicaid	$1,119.32
Rate for Payer: Priority Health Cigna Priority Health	$2,377.05
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,781.23
Rate for Payer: Priority Health Narrow Network	$2,781.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,138.23
Rate for Payer: UHC Exchange	$2,138.23
Rate for Payer: UHCCP Medicaid	$1,119.32

PR PROSTATECTOMY RETROPUBIC SUBTOTAL

Professional

Both

$3,341.00

Service Code	HCPCS 55831
Min. Negotiated Rate	$549.75
Max. Negotiated Rate	$2,171.65
Rate for Payer: Aetna Commercial	$1,213.98
Rate for Payer: Aetna Medicare	$1,670.50
Rate for Payer: BCBS Complete	$577.24
Rate for Payer: BCBS Trust/PPO	$1,886.03
Rate for Payer: BCN Commercial	$1,240.27
Rate for Payer: Cash Price	$2,672.80
Rate for Payer: Cash Price	$2,672.80
Rate for Payer: Meridian Medicaid	$577.24
Rate for Payer: Priority Health Choice Medicaid	$549.75
Rate for Payer: Priority Health Cigna Priority Health	$2,171.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,366.11
Rate for Payer: Priority Health Narrow Network	$1,366.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,143.51
Rate for Payer: UHC Exchange	$1,143.51
Rate for Payer: UHCCP Medicaid	$549.75

Know your out-of-pocket cost for care.

All Charges